Workup for Failed Back Syndrome

• Orthopeadic Chief Resident at Thomas

Jefferson University Hospital and the
Rothman Institute
• Administrative and Academic Chief
Resident 2010-2011
• Interest:
• Spine Surgery
• Medical Illustrations
• Medical education
• Medical Leadership – Emergent Leader Physician
Chadi Tannoury, MD • Enjoys Arts, Music, Martial Arts, Travel,
Social Networking
• Contact: chadi.tannoury@gmail.com
Failed Back Surgery Syndrome:
The Workup

Chadi Tannoury, M.D.

Thomas Jefferson University Hospital
& The Rothman Institute
S.P.I.N.E. Meeting – Lebanon June 2010
 Disclosure

*Disclosure of Financial Interest

The author have not received nothing of value from or does not own stock (or stock
options) in a commercial company or institution related directly or indirectly to the subject
of this topic.
 !!Failed Surgery!!
 Patient:  Surgeon:
 Anxiety  Anxiety
 Repeat Surgery  Hit to the Ego

 Pain  Revision Sx

 Debilitation  Technical diff

 Poor Outcome  Grief !!!!

Failure… what failure?
FBSS:
 Unresolved symptoms

 New Symptoms
 What caused the “Perfect”
surgery to Fail?
 Bad Patient selection
 Incorrect Diagnosis
 Inappropriate surgery
 Technical errors
 Nonunion of the fusion
 Imbalance
 Missed pathology
 Arachnoiditis
 Progression of disease
Poor Pt Selection
 Intrinsic Pathological x
 MMPI: Psych disturb
 Hysteria, hypochodriasis
 Depression, Anxiety

 Workman’s compensat’
 Non-compliance
Incorrect/Incomplete Diagnosis
 Failure to address:
Foramin/lat recess
stenosis
 Unnecess Rx: Asymp
Radiog findings
 Misdiagnosis: conj NR
– Far lat HNP
 Wrong Surgical Procedure
 Wrong Level
 Poor Technique:
 Battered NR syndrome
 Iatrogenic Instability

 Inappropriate hardware
placement
 Progressive Disease
 Recurrent Sx:
 Ongoing DDD
 Recurrent HNP (5-15%)

 Scar formation – NR
tethering
 Adjacent DD (35%)
 Workup
 Careful Thorough Evaluation
 Results of Revision Surgery:
Poorer than index surgery
 Etiologies:
 R/o Non-spinal causes
 Psychological Sources

 Spinal workup
 History
 Symptoms relation to index surgery
 Review of Med Records / OR Reports /
Imagings:
 Wrong level surgery vs. Incorrect initial diagnosis
 ROS – Social hx:
 Identify co-morbidities: Somatizat’ – Addictions –
Depression – Personality disorders
 Constitutional Sx: Malig vs. Infections
 Physical Examination
 Non-Organic Physical Findings (Waddell signs):
 Superficial or non-anatomic distribution of symptoms
 Over-reaction to stimuli
 Pain out of proportion – to non painful stimuli
• > 2 above  Strongly predicts Poor Outcome
Waddell Spine 1980
 Standard Tests: Posture, Gait, Tenderness, ROM, NR
tension signs, NeuroExam, Hips/knee
 Imaging
 Biplanar Standing Rad:
 Site of Surgery
 Balance
 Progressive Degeneration
 Flex/ext Rad (post Fusion):
 Instability
 Hardware Loosening/ subsidence
 SI joints eval – Hip/Knee eval
 ICBG site: r/o pelvic frx
Standing 36” Radiog
 Imaging – Cont’d
 MRI: w-w/out Gad
 Enhancement (scar) vs.
Nonenhancement (recurr HNP)
 Post op infection?!
 Imaging Cont’d
 CT Myelo: if MRI is contraindicated
 Assess fusion vs. Pseudarthrosis
 Hardware placement – Loosening
/Subsidence
 Electrodiagnostic Studies
 EMG, NCV
 Rarely Indicated
 Evaluate extra-spinal etiologies:
 Peripheral neural compression
 Peripheral Neuropathy
 Laboratory Tests
 ESR, CRP:
 Nonspecific
 Eval for Occult Infx in Pts w diffrt quality LBP

 CRP returns to Nl in 14 days postop, ESR later

 Good Indicators: response to treatment

 Psychological Assessment
 Psychological distress measurement:
 MMPI: high scores  Poor outcome
(Minnesota Multi-phasic Personality Inventory) Wiltse’75, Spengler’80

 Pts w h/o Chronic pain: Referral to a

Psychologist/Psychiatrist can be helpful
 Pts with Depression + Sleep disturbances:
should be treated before and after surgery
 Diagnostic Blocks
 Selective Nerve Root Blocks:
 Help Confirm culprit level
 ~ Predict outcomes of surgery
 Provocative diskography:
 Controversial use
 Help localize Adjacent segment disease
 Diagnostic Facet Blocks:
 Used to Identify painful transitional motion segments
 Expectations
 For some diagnosis:
 Recurr HNP – Pseudarth – Adjacent SD 
Revision Surgery GRATIFYING
 Arachnoiditis – epid/perin Fibrosis  Spinal cord
Stimulation SUCCESSFUL
 Chronic Pain: Preop screening by a Psychologist 
Help avoid additional Surg in pts high risk for
unfavorable outcomes!
 Best Management = Prevention
 Pre-surgical thorough Assessment:
 Good Indications
 PE: Red Flags (Waddell sings – Pain Behavior, etc..)
 At Surgery: Correct Level
 After decompression: adequate Foraminal decomp
 After fusion: Inspect Hardware for misplacement
 If Complications happen: Rx Promptly + Aggressively – Do
Not Delay!!!