The Management of Failed Spinal Operations
Waddell et al. (1980), painted a gloomy picture of the outcome for patients who have had multiple back operations. Little wonder that patients with persisting serious spinal problems are often given dire warnings about further operations, not only from no
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9.2. Investigation The cornerstone of management is to investigate these problems with great care and with compassion, before recommending further surgery. The surgeon must establish a good working relationship with the patient's general practitioner and physical therapist and call upon the expertise of other specialists with declared interests in this type of work when indicated. Before outlining a simple system for the analysis of failures after spinal operations, some general comments.should be made on the subject of investigations. Clinical neurological examination may be unrewarding in assessing the level or severity of nerve root or cauda equina lesions in patients who have had previous spinal surgery. This is especially true in those who have had multiple operations.
H. V. Crock, A Short Practice of Spinal Surgery © Springer-Verlag/Wien 1993
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The Management of Failed Spinal Operations
Radiological examinations which may be essential in helping to establish diagnoses and to plan further surgery in particular cases include: a) Motion studies of the spine.lnstability may require spinal fusion. b) Oblique views of the facet joints and intervertebral foramina.Unrecognized foraminal stenosis may require decompression. c) Antero-posterior and lateral tomograms in any case of failure following spinal fusion or canal exploration. Irregular laminal remnants or re-formed bone in scar tissue may require revision of canal decompression. d) Repeat myelography to demonstrate space-occupying lesions or arachnoiditis. e) Discography to plan the extent of spinal fusion. f) Computerized tomography, especially if reconstructed scans in three planes can be obtained. Offers a wide range of diagnostic information but does not necessarily supersede the use of a-e. g) MRI, especially with gadolinium enhancement, is probably the best investigation for demonstrating unrecognized disc lesions, epidural scarring or chronic inflammatory disorders. The analysis of individual cases of failed spinal operations may be facilitated by using the following classification: 1. Outright Failure
This group comprises patients who show no improvement or who become worse after the first operation. 2. Temporary Relief These patients may be free of symptoms for months or years after operation. 3. Failures in Spondylolisthesis These patients are considered separately because of special features of the pathological anatomy in this condition (see Chapter 5 and p. 305). 4. Infection
9.3. Outright Failure Failure is usually related to wrong diagnosis. Some pain and discomfort are to be expected after any spinal operation. Pain protracted over weeks may follow some operations in which adherent root sleeves have been tediously separated from disc tissue, yet a successful outcome can be predicted. Such special circumstances excluded, patients in this group can usually be identified soon after operation. They complain of pain which is more severe than is normally expected. Those with infections will have elevated temperatures and altered blood counts. T
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