Still having Pain after Spine Surgery?

Posted on November 30, 2015 | by Dr. Shim

Statistically, most people do improve with spine surgery. Unfortunately, some people do not improve, and a few are worsened.

As a Spine Surgeon, I know many patients want a guarantee of improvement after surgery. The truth is, THERE CAN NEVER BE A GUARANTEE. Surgeons can only give chances of success. As I tell my patients, you have an X percent chance of improvement after surgery. I will also let you know my definition of improvement is based on how you are feeling before surgery. If your pre surgery pain level is 8/10 or more, and your after surgery pain is 3/10 or less, that is an improvement. As a surgeon, I would consider that an excellent improvement. Prior to surgery, I would counsel you that the goal of surgery is a reduction of pain by 60%. Because your expectations are properly set, you should be satisfied with a pain level of 3/10 or less. If your expectation was to be pain free, you will be disappointed, and may even feel you are worsened, as it does not meet your expectations.

Beyond disappointments due to lack of proper expectations, there are other reasons why some Spine Surgery is not successful. Let’s just look at the most simplest of spine surgeries, the standard Lumbar Discectomy.

For properly selected patients, there is an expectation that greater than 90% will improve after surgery. For the 5-10% that do not improve, the reasons why can be difficult to identify. A small percentage of patients do have postoperative complications such as infection, or medical complications due to their heart, or lungs. Let us assume we have ruled out those reasons for a poor outcome. The general reasons people do not improve are the following:

Residual pressure on the nerves by other disk fragments or bone spurs. Often times large fragments of disk herniations are removed, but there can be additional fragments that may not be visualized. For some patients, there can also be narrowing of the space for the nerves secondary to bone spurs that may continue to cause a pincher effect on the nerves.
Surgery may have helped that particular disk, or bone spur, but there may be other disk herniations or bone spurs that contributed, or was the primary cause of the nerve irritation.
The nerve itself has been compressed so long, that there is a permanent change to that nerve. This can explain the residual pain, tingling and weakness associated with patients who had seemingly successful surgery, with normal appearing post operative diagnostic studies.
Discectomy and decompression surgery may have caused a development of an instability pattern to the spine. The disk is a ligament which holds the spine bones in proper position to each other. Sometimes, disk herniations occur because the ligament function of the disk is no longer working. While the disk is removed in hopes of reducing the pincher effect on the nerve, if the real reason for the pain is abnormal bone movement (instability), removing the herniated disk, and the necessary removal of some of the tissues and bone to achieve that removal can actually increase the instability. If this is the real reason for the pain, a stabilization procedure may be the only solution to the continued pain.
Patients with medical problems such as diabetes, or a neuropathy could have continued pain despite what appears to be a successful discectomy surgery. Patients with certain medical conditions must understand that their underlying medical problem may compromise the results of surgery.
If a person has good resolution of pain, then has sudden recurrence of pain after a period of time, there is a concern that another piece of disk material herniated again. The other possibility is a break of the spine area called the pars interarticularis secondary to the weakening of that area while the disk material is exposed. Usually, these causes are identified by post operative diagnostic studies such as MRI’s, X-rays, and CT scans.

If you do have continued back and leg pain after discectomy surgery, please see your Surgeon. If there is a mis match in expectations, that a good discussion about the expected goals and residual discomfort should help you understand your disappointment.

If there is little improvement, or worsening of complaints, you may need additional diagnostic studies to make sure you do not have some of the above causes of pain. If the studies are not revealing, you may have residual pain that may improve with other modalities such as medications, therapy or injections.