Single and Multi-Disc Prolapse, Disc Sequestration, Vascular Hemorrhage, Single and Multi level Canal Stenosis, Failed Back Surgical Syndrome, Arachnoiditis, Associated Neuropathy, Secondary Infection, Injury recurrence

Additional information and links after the Media Files

• http://www.brainandspinalcord.org/blog/2009/10/12/how-great-are-the-risks-from-lumbar-spinal-fusion-surgery/

• Back Facts

• HyperMED Spinal Case Studies

• HyperMED - Advantages Spinal Hyperbaric Oxygenation

• HyperMED/QLD Study - HBOT promotes Osteoblasts response.pdf

HyperMED UPDATE  Jinah Kim

 

HyperMED UPDATE  Rose Batty - Failed Back Surgical Syndrome

 

HyperMED UPDATE Greg Bound – Acute neck injury requiring 3-level disc removal and block spinal fusion

HyperMED UPDATE Minnie Veljkovic – Chronic back and leg pains (canal stenosis; large facet joint cyst)

• HyperMED UPDATE Massive L5/S1 disc sequestration - 12.0mm prolapse; S1 compression

• HyperMED UPDATE Cervical spinal stenosis - Myelopathy 

• HyperMED UPDATE Chronic Low Back and sciatica pain - L5/S1 Disc prolapse/sequestration

• HyperMED UPDATE Failed Back Surgery - L5/S1 Laminectomy, residual prolapsed disc (7.0mm), massive scar formation

• HyperMED UPDATE Chronic Back Pain - Advanced Canal Stenosis

FAILED BACK SURGERY

We all know someone who has had a back operation and certainly someone who has a bad back. Some operations are successful however at HyperMED we focus on the cases that go wrong! Invariably most back suffers continue to suffer residual problems after a back operation and are often worse after the initial procedure.

Functional MRI (flexion - extension MRI ) post surgical demonstrating continuing structural instability.

‘Low-back pain is the most common health problem for men and women between 20 and 50 years of age, resulting in 13 million doctor visits in the US annually, with significant costs to society in terms of lost time from work and direct and indirect medical expenses. Degeneration of lumbar intervertebral discs is a major cause of low back complaints, an irreversible occurrence with no currently available treatment. Furthermore, various 'surgical procedures can accelerate disc degeneration’. Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Bohseidai, Isehara, 259-1193, Japan. [J Orthop Sci. 2005;10(1):112-8].

Back Surgery may be inevitable; but should be as the absolute LAST RESORT when all avenues of conservative approaches have been exhausted. Surgery is typically an attempt to alleviate the level of radiating pain (arm and or leg pain) and is NOT remotely aimed at the underlying reason the problem emerged in the first place! Surgery does not address the continuing cycle of degeneration which is often accelerated after surgery. [J Orthop Sci. 2005;10(1):112-8.]

Patients often describe a ‘honeymoon’ period after their back operation. Several months or even several years can pass with everything ‘rosy’ until something ‘triggers’ the pain again. Additional MRIs invariably reveal continuing degenerative instability with many individuals undertaking more complex surgery in an attempt to stabilise and fuse what has become a mess!

If you suffer a bad back – have you had an MRI?

Most individuals with a bad back start the journey with the usual approach of basic pain medication, massage, physio, chiro, acupuncture, pilates and if they don’t work – epidural injections, heavier medications and eventually a specialist referral who recommends an MRIs invariably just prior to surgery!

Plain film X-rays are the typical kindergarten approach to investigation – good for fractures but not much else! CAT Scans also have limited value and do not fully reveal the pathogenesis of the deeper disc and spinal cord structures which is better evaluated with an MRI. In addition CAT Scans result in radiation exposure that we can do without!  

There is no radiation with MRI and at a cost of several hundred dollars; an MRI is the most cost effective way to determine the exact state and history of your spine including disc, spinal cord and exiting nerves. This provides a clear and concise determination as to what is the most effective treatment suitable for your specific condition.

What is the underlying cause of back pain?

Managing Low Back Pain (3rd Edition); William H. Kirkaldy-Willis, MA, MD, LLD (Hon), FRCS (E and C), FACS, FICC (Hon), Emeritus Professor and Head, Department of Orthopaedic Surgery, University of Saskatchewan College of Medicine; Royal University Hospital, Saskatoon, Saskatchewan, Canada;

Kirkaldy-Willis details the ischemic model of back pain describing the "degenerative cascade" associated with degenerative disc disease. ‘Structures within the spine have a very poor and often inadequate blood supply. There is minimal blood supply to the disc, and blood is what brings healing nutrients and Oxygen to damaged structures in the body. This means that the spinal disc lacks any significant reparative powers. Unlike muscles, which have good blood supply, once a spinal disc is injured it cannot repair itself.’ Kirkaldy-Willis [Managing Low Back Pain] 

What is the Advantage of Hyperbaric Oxygenation for disc related pathology?

• HBOT targets ‘zones of ischemia’ (areas of tissue and bone with retarded blood supply and nutritional status), facilitating new capillary network support and increasing blood supply (neovascularisation), reducing swelling and inflammation and promoting metabolism and immune system responses overcoming underlying infectious agents.

                         Before HBOT                                                                            After HBOT

Mr. SM has suffered chronic back and leg pain for years. He is a builder and spent most of his working life involved with heavy lifting. He has consulted virtually every form of therapy over the years ranging from massage, chiropractic, physiotherapy, and naturopathy; received ongoing medical supervision taking anti-inflammatory and muscle relaxants.  

MRIs over a 2-years period; revealed continued structural instability and progressive neurological symptoms and eventually after increasing episodes of acute and debilitating pain he was referred to several surgeons and orthopedic specialists who all recommended discectomy and spinal fusion.  

As a last attempt to avoid surgery he decided to attend HyperMed (Melbourne Hyperbaric and the Spinal Rehabilitation Group) for intensive HBOT combined with appropriate physical therapy including direct electrical stimulated acupuncture. After 3-weeks of intensive HBOT a re-take of his MRI reveals considerable reduction of the sequestrated disc and reduction of both the compressive effects on both the lower cord and exiting nerve roots. His condition remains stable! 

It is easy to see that the problems associated with chronic back problems and ‘failed back surgery’ are enormous. How can this happen? Are there really so many failed surgeries? Can failed surgery be avoided? Can failed surgery be corrected? Can it be avoided completely?

Once a patient receives a diagnosis of ‘failed back surgery’, they are frequently labelled as ‘hopeless’ and ostracized not only by the medical community but also by their fellow workers, employers, friends and even family members. Many lose their sense of identity, direction, the ability to cope and the drive to go on.

Most failed back operations can be avoided, and are usually caused by a very well meaning surgeon operating on the wrong patient for the wrong indication. Removal of the disc and lamina may assist the patient’s leg pain in the short term, but frequently complicates the long-term condition of the patient, since it precipitates further narrowing and hastens the overall degenerative process.

Laminectomy and or discectomy is reported to be 90% effective in relieving pain radiating below the knee in patients disabled by severe pain. However, the big problem is to then determine what additional instability is imposed by the surgeon’s knife because of removing vital structures in an attempt to alleviate the immediate radiating pain and the fact that the region is rendered vulnerable to the potential of opportunistic infection.

Microscopic discectomy for the removal of extruded disc fragments has also been reported to be a successful procedure. However, this procedure can also result in incomplete extraction of the fragment material or lead to recurrent disc herniation. Unfortunately, the incidence of post surgical scarring, infection, accelerated discogenic complications and spinal canal compromise is high.

Patients having undergone such procedures and now experiencing ongoing and recurrent pain require extensive diagnostic investigation, including gadolinium enhanced MRI scans, radioisotope bone scans and in many cases myelo-disco-CT scans for further diagnosis. Further surgery is often extremely complex, with significant ongoing disability.

Surgical ‘block’ spinal stabilisation for spinal cord problems often precipitates a degenerative cascade of spinal and related structures with a high incidence of secondary segmental disc herniation. It would take an entire volume to discuss this incredibly complicated subject.

Failed back surgery is a fact. You cannot avoid the issue of back problems by just getting a ‘crack’, massage and stretch or by going to the gym. Many treatments and exercise programs recommended with good intentions often contribute to the underlying structural condition because correct investigation was not initially conducted.

Our recommendations are that any person suffering ongoing or recurrent back and related problems be reviewed by an appropriate doctor and have current investigations, including functional loading X-rays performed of the area. If the condition persists, MRI investigation may be required to accurately determine the underlying problem and then an appropriate treatment strategy will need to be implemented. 

If the patient also suffers additional symptoms that appear to be unrelated including chronic fatigue, migratory joint and musculoskeletal pains then investigation should include PCR DNA screen for opportunistic infection and co-factors.

• Long-term Steroid complications

• New Fractures Occur Sooner in Adjacent Vertebrae Following Vertebroplasty

• Updates/Post Op Instability spinal.pdf

• Effectiveness of hyperbaric oxygen therapy in the treatment of complex regional pain syndrome

• Transplantation of mesenchymal stem cells embedded in to the intervertebral disc: a potential therapeutic model for disc degeneration

• Intervertebral disc cell therapy for regeneration: mesenchymal stem cell implantation in rat intervertebral discs

• New strategies for disc repair: novel preclinical trials

• Is the Chiropractic Subluxation Theory a Threat to Public Health?

• The potential role of mesenchymal stem cell therapy for intervertebral disc degeneration: a critical overview

• Stem cell regeneration of the nucleus pulposus

• Bone mesenchymal stem cells transplanted into rabbit intervertebral discs can increase proteoglycans

• New Fractures Occur Sooner in Adjacent Vertebrae Following Vertebroplasty

• Magnetic resonance imaging of hyperbaric oxygen treated rats with spinal cord injury: preliminary studies

• The effect of hyperbaric oxygen therapy on spinal fusion: using the model of posterolateral intertransverse fusion in rabbits

• Effectiveness of hyperbaric oxygen therapy in the treatment of complex regional pain syndrome

• A new treatment modality for fibromyalgia syndrome: hyperbaric oxygen therapy

• Magnetic resonance imaging of hyperbaric oxygen treated rats with spinal cord injury: preliminary studies

Onesti ST (Neurologist. 2004 Sep;10(5):259-64) stated that ‘Failed Back Syndrome (FBS) is a well-recognized complication of surgery of the lumbar spine. It can result in chronic pain and disability, often with disastrous emotional and financial consequences to the patient. Many patients have traditionally been classified as ‘spinal cripples’ and are consigned to a life of long-term narcotic treatment with little chance of recovery.  

The issue of chronic pain associated with failed spinal surgery was reported as far back as in 1994. The publication; Spine featured an article: Outcome of lumbar fusion in Washington State workers' compensation (Franklin 1994).  

Franklins et al. covered a large, population-based cohort of workers in the Washington State workers' compensation system who received lumbar fusion between August 1, 1986 and July 31, 1987 to determine work disability status, reoperation rate, and patient satisfaction.  

Most patients reported that back pain (67.7%) was worse and overall quality of life (55.8%) was no better or worse than before surgery.  

Conclusion: Outcome of lumbar fusion performed on injured workers was worse than reported in published case series. Prospective studies should be conducted to determine the biologic indications that might lead to improved outcomes in this disabled population.

• Etiology of long-term failures of lumbar spine surgery

Waguespack A, Schofferman J, Slosar P, Reynolds J. SpineCare Medical Group, San Francisco Spine Institute, Daly City, California, USA. Pain Med. 2002 Mar;3(1):18-22 

BACKGROUND: Patients who do not improve after lumbar surgery may be given the nonspecific label of failed back surgery syndrome (FBSS). Since 1981, there has not been a quantitative assessment of the etiologies of FBSS despite major improvements in surgical techniques and diagnostic testing.  

PURPOSE: To define the causes of FBSS seen in a referral-based spine center.

STUDY DESIGN AND METHODS: Retrospective review of 181 consecutive charts of patients seen at a single spine center because of continued pain after lumbar surgery performed elsewhere. Evaluation was individualized based on history and physical examination and included x-rays, CT scans, MRI, selective nerve root injections, discography, and psychiatric evaluation.

PATIENT SAMPLE: There were 101 men and 80 women; mean age was 47 years.  

There were 118 patients with one prior surgery, 52 with two, 6 with three, and 5 with four. Mean interval from the last prior surgery to the first clinic visit was 33 months.  

RESULTS: A predominant diagnosis could be established in 170 of 181 (94%) patients, included foraminal stenosis (29%), painful disc(s) (17%), pseudarthrosis (14%), neuropathic pain (9%), instability (5%), and psychological problems (3%).  

CONCLUSION: We were able to establish a predominant diagnosis in 94% of our patients. Foraminal stenosis remains the leading cause of FBSS, but painful discs are also common. Recurrent disc herniation is seen less often than in the past, and there is increased recognition of neuropathic pain. Knowledge of the potential causes of FBSS leads to a more efficient and cost-effective evaluation of these patients.