People who have already had back sugery SummaryAmong
all the ailments of the back, surgery is indicated in less than 1% of the cases.
As in all surgery, that of the spine entails a series of risks, but they decrease
when only patients for whom surgery is strictly recommended are intervened. There
are various reasons why a person may feel pain after an operation. The most frequent
are vertebral instability, rejecion of implanted material, loss of muscle mass,
postsurgical fibrosis and discitis. Before commiting to an operation, one must
be certain that all the criteria for its advisibility are met.
After the
operation, it is importanta to take care of the back (exercise, stay active, follow
the rules for a healthy posture and general health) and to adopt a positive mental
attitude. If the surgery is not effective or if the pain reappears after some
time, the doctor must be consulted. It can usually be treated effectively.
Technological progress has perfected surgical
instruments and procedures. As a result, mortality and morbidity rates due to
surgery of the vertebral spine are now very low. For example, scientific studies
have demonstrated that the risk of infection or hemorrhage in a first operation
on the intervertebral disc is lower than 1%, although this proportion increases
in older patients or when it is not the first disc operation. The
characteristics of the patients receiving the surgery and their longterm evolution
have been analyzed. As a result, those situations for which surgery is truly effective
and indicated have been determined. Among all of the ailments of the back, surgery
is recommended in less than 1% of the cases. In
one section of this site, the surgical
techniques commonly used are explained. In another section, the various ailments
of the vertebral spine which could require surgery are presented, as well
as the criteria for intervention. In most of the cases
in which surgery has not yielded the desired outcome, the operation was in fact
not indicated. Less often, the failure is due to an inappropriate surgical procedure,
and only rarely, to a technical error during the operation. Nonetheless,
even when the most appropriate techniques are used correctly and the surgery is
truly necessary, pain can persist or reappear after the operation. In this section
of the Web of the Back, the following issues are discussed:
 Causes
of pain after the operation
After an operation, pain
can occur due to the following causes: a)
Pain due to the operation itself b)
Ineffectiveness of the intervention c)
Complications from the intervention d)
Pain unrelated to the intervention
a) Pain due to the operation
itself Surgery is in itself an aggression, since tissue
is cut and sewn. As such, it can cause discomfort, though
the discomfort tends to disappear spontaneously within a period of time. The most
frequent discomforts are: Pain around the surgical wound. Alterations
in sensitivity (numbness or pins and needles, feeling of cold or cramps, etc.)
in the area operated on or in the limb which previously hurt (the leg in the case
of low back surgery or the arm in the case of cervical surgery). Lessening
or loss of reflexes in the limb which hurt before the intervention. In some cases,
the loss of reflexes is not due to the operation but rather to a prior compression
of the nerve, and may be unrecoverable. On these occasions, the loss of reflexes
is not a cause for concern and does not alter the patient's life in any way (in
fact, some healthy people do not have reflexes and that does not cause them any
problem). The less aggressive the
surgical procedure, the less intense and persistent the discomfort afterward.
Thus, for example, after a microdiscectomy,
the pain is very slight or nonexistent, while after arthrodesis,
the pain is greater. When necessary, pain can and should
be treated with medications, usually, analgesics. In fact, they are taken almost
as a matter of course after spinal surgery. Alterations in sensitivity tend to
disappear by themselves. In the rare event that these alterations are painful,
the doctor can study the appropriateness of other medications or treatments. b)
Pain due to the ineffectiveness of the intervention In
this case, the pain appears immediately after the operation (as soon as the effect
of the analgesia wears off), and its characteristics and localization are identical
to those existing before the surgery. Given the meticulous
preparation and high qualifications of surgeons, it is very rare that an operation
fails because of a technical error in surgery. In the case of interventions for
disc hernia,
sometimes the pain persists after the operation because a fragment of disc has
remained and is still compressing the nerve. But the most
common reason for pain to persist after surgery is that the operation was not
correctly prescribed. In that case, the doctor should assess very carefully the
need for a new intervention (almost never recommended). Normally, treatment will
be based on other
procedures. c) Pain due to
a complication in the operation The most frequent
complications are postsurgical
vertebral instability, the rejection
of or problems arising from the material which is sometimes implanted during the
operation, the loss of
muscle mass, postsurgical
fibrosis, or discitis.
Postsurgical vertebral instability.
Postoperative vertebral instability consists of the lack of fixation between the
vertebrae as a result of a damaged intervertebral
disc or facet
joint. In this case, the unstable vertebra slips over the one below it during
certain movements above all when flexing the spine forward. Instability
can appear after a laminectomy
in which bone is extracted or broken in order to reach the facet joints, so these
joints cease to be stable. Sometimes, these joints are overloaded when the space
separating the vertebrae is much reduced due to the original injury to the disc
or because a large part of its contents had to be extracted during the operation. Immediately
after this kind of surgery, some instability is normal for a period of time until
the bone is consolidated. For that reason, instability is only diagnosed as the
source of the pain when it lasts longer than the expected period. Traditionally,
vertebral instability is thought to produce pain in the area of the vertebral
spine and not irradiated pain to the leg or the arm and it appears with movement
typically, on walking or flexing the spine forward. But different studies have
demonstrated that a degree of instability can exist in the lumbar spine in persons
who do not experience pain, so that some experts question instability as the cause
of the problems and rather attribute these pains to insufficient strength of the
muscles. For that reason, they recommend exercise and not surgery to develop the
muscles and resolve the instability. Certain criteria
have been set to determine in each specific case whether the instability is severe
enough to require surgery. To make this assessment, the degree of displacement
of the vertebrae during movement must be quantified, taking x-rays
of the patient standing, front and profile. The x-rays are first taken with the
patient straight and afterward in postures of greatest possible flexion (that
is to say, with the patient bending the spine forward as far as possible) and
extension (with the patient arching the spine backwards as far as possible). The
x-rays taken in this way provide the means to study whether a vertebra has slipped
over the one below it. This displacement is then measured in millimeters. If it
exceeds the established limits, the possibility of a surgical intervention can
be considered. When vertebral instability is shown to be
the cause of the pain and exercise is not sufficient to control it, a fixation
is usually performed, which consists of surgically fixing the unstable vertebra
to the next vertebra, above or below it.
Rejection of or problems derived from implanted material. In arthrodesis,
two vertebrae are fixed to each other. To do this, one can use bone graft from
the patient or place screws, plates, or other elements called "prostheses".
While it is not common, these prostheses can be rejected by the patient's
organism or give rise to some problem or other (for example, they move
or penetrate too deeply). In these cases, the patient feels pain in the area operated
on, and there could be inflammation and even fever. The rejected material often
becomes infected, so it is sometimes difficult to know whether the discomfort
and the fever are caused by the rejection or the infection. An x-rays
allows one to see the implanted material and if there are signs that it is being
rejected. A blood analysis
shows if there are signs of infection. If it is proven that the material is being
rejected, is infected or is causing problems, the patient must be operated on
again and the material extracted. The
loss of muscle mass. Surgery means cutting and sewing tissue. The more aggressive
the surgery, the more tissues are cut and sewn. Furthermore, in some operations,
such as arthrodesis,
a period of relative physical inactivity must be observed afterward in order for
the bone graft to take. All of this could mean a loss of muscle mass, especially
if the patient's muscles before the operation were not very strong. For this reason,
and although the operation was successful upon resuming normal activity, the patient
could experience back pain which bears no direct relation to the surgery. Instead,
and because of the loss of muscle mass, the remaining muscles are more easily
overloaded. In this case, pain appears to be caused by
muscle overload. Usually, such pain is different, both in its characteristics
and its localization, from the pain that motivated the operation. It tends to
affect the back area, although it can extend to the arm (if cervical segments
are affected) or to the leg (if the lumbar segments are affected). Once
it appears, pain can be perpetuated by a reflex
mechanism. To prevent this, muscle condition should be recovered after the
operation by appropriate exercise. Another section of this site describes the
most effective exercises
to increase strength, resistance and elasticity. But a doctor must establish which
exercises are specifically indicated or counterindicated in each specific case. Pain
of this kind can also be treated effectively with different procedures, which
are described in the treatment
section of this site. Clearly, it is not necessary to operate on the patient again
and it is not recommended, as it could be counterproductive.
Postoperative fibrosis. Postoperative fibrosis consists of the excessive
scarring of the tissues cut during the operation. (It is described in detail in
a section
in this site).
Discitis. Discitis is the infection of the intervertebral
disc. This infection occurs in less than 1% of the operations for disc
hernia. Given the standardized conditions of asepsis under which surgery is
performed, discitis usually has its origin in bacteria which was already present
in the patient before. It is rare for this infection to be caused by an external
contamination. When discitis occurs, a very intense pain appears in the operated
area, normally with fever although not always. It is diagnosed by means of the
patient's clinical history
and magnetic
resonance imaging. If discitis is shown to exist, the patient must be operated
on again immediately, so that the surgical space is cleaned, the germ causing
the infection identified and the appropriate antibiotics administered. d)
Pain unrelated to the intervention Surgery is very effective
in resolving the specific problem for which it is prescribed, but it has an effect
only on the area operated. Clearly, it is not a guarantee that the rest of the
spine or the muscles that form the back will always function perfectly. Once
a patient has been successfully operated on, he or she runs the same risk as any
other person of having back pains again. For this reason, even after a perfectly
indicated and performed surgical intervention, pains could appear due to causes
other than those that prompted the operation, or to a recurrence of the initial
problem. When this occurs, the pain that prompted the operation disappears
and after a period without any problems, pain arises which could be identical
if it is a repetition of the problem for which the patient underwent surgery or
different if it is another. In these cases, preventive
measures, diagnosis
and treatment
are the same as for subjects who have not been operated on before.
Risks
and complications of surgery.Scientific
studies show that mortality as a result of vertebral surgery is close to zero,
and that the risk of infection during a first operation on the intervertebral
disc is approximately 1%, though this risk increases with older patients and when
it is not the first disc operation. In any event, its advisability in each case
depends on the specific patient's history and condition, such as his or her general
state of health or immune system. Another risk in surgery is postoperative
fibrosis. While its occurrence depends primarily on the way each individual scars
and heals, it is generally acknowledged that the less aggressive the surgery and
the less bleeding during the operation, the lower the risk of fibrosis. The
less aggressive the surgery and the less it affects the vertebral bone, the lower
the risk that vertebral
instability will occur. In the case of operated disc hernias,
a new hernia could appear in the same segment operated on (a relapse). The
main risk is that the operation does not yield satisfactory results. Numerous
scientific studies show that less than 40% of patients with disc hernia but without
clear signs of nerve compression on physical
examination or by electromyogram
obtain satisfactory outcomes from surgery. These
studies show that the main cause for surgical failure comes from operating on
patients who should not have undergone surgery and that the stricter the selection
of patients referred for surgery, the better the results. For this reason, it
is essential that all patients who are going to be operated on really meet the
criteria for it. In the section of this site describing the ailments
of the vertebral spine, the criteria for surgical intervention for each ailment
are presented. Furthermore, complications found in any surgical
intervention can arise (due to problems with anesthesia, postsurgical tromboembolism,
etc.) even though the necessary measures are taken as a matter of course to avoid
or reduce them to the maximum.
Care
of the back after an operationFrom
the moment the surgeon discharges the patient from the hospital, it is necessary
to adopt the same preventative
measures followed by people who have never been operated on. Some of these
measures are especially important: a)
Exercise. b)
Remain physically active. c)
Follow the rules for a healthy posture. d)
Adopt a healthy mental attitude. e)
Follow the recommendations for general health.
a) Exercise Scientific
studies show that exercise is effective in lowering the risk of back pain, as
well in diminishing pain and improving the degree of mobility and autonomy for
those who already suffer back pain. Exercise helps improve
strength, resistance, coordination and flexibility of the muscles involved in
the back's functioning. This is especially important for people who have been
operated on, since they tend to lose muscle tone whether due to the operation
itself, bed rest or as a consequence of the pain suffered before being operated
on. To prevent back pain, a healthy person should do specific
exercises or different kinds of sports swimming is one of the most highly recommended,
especially the "crawl" and "back stroke". Nonetheless, one
should always consult a doctor before beginning any program of physical exercise
or sport. A section of this site lists and describes the most effective exercises
to increase strength, resistance or flexibility of the muscles used in the back.
A doctor must determine which specific exercises should be done and with what
intensity and progress. b) Remain
physically active A sedentary lifestyle increases
the risk of back pain, and bed rest increases the risk that this pain lasts longer.
On the other hand, being physically active lowers the
risk of back pain. Even if pain does appear, staying as physically active as possible
has been shown to shorten its duration and to reduce the risk of recurrence in
the future. For that reason, as soon as the surgeon orders
the discharge, it is important that the patient operated on resume his or her
usual activities (progressively), avoid bed rest, and remain as active as is possible.
c) Follow the rules for a healthy
posture The rules for a healthy posture show how
to perform daily activities so that they do not overload the back. A section in
this site describes the rules for a healthy
posture, applicable to household activities as well as to work, sports and
leisure. d) Adopt a healthy mental attitude People
with an evasive attitude toward back pain have a higher risk of its lasting longer
and reappearing. This attitude is characterized by the following:
Believe mistakenly that the pain reflects the existence
of a structural injury to the vertebral spine. Reduce
their physical activity because they are afraid of the pain and even stop working
as a result. Have a catastrophic attitude toward the
future: believe, mistakenly, that the pain is going to limit their quality of
life forever. Abuse medication, especially painkillers. On
the other hand, the symptoms do not last as long and are less likely to reappear
among people who maintain a healthy mental attitude and confront the pain. This
attitude includes the following: Believe
that the pain is not the result of an injury, but rather is a muscle problem.
Stay active and continue working, avoiding only those activities which the pain
specifically prevents them from doing. Trust that the
pain is going to get better with time and, when that is not the case, adapt to
it without it conditioning their life. Do not take medication,
or only rarely and for a short time when the discomfort gets worse. e)
Follow the recommendations for general health The
back forms part of the whole organism, therefore the recommendations for achieving
a healthy life contribute indirectly to the improvement of the health of the back.
Basically, these recommendations consist of eliminating
those avoidable risks which have been shown to increase the likelihood of back
pain: being overweight, smoking, suffering anxiety, etc.
What
to do if there is no improvement after the operationBefore
all else, one must consult the surgeon who performed the operation so that he
or she can appraise the situation. The patient can also consider the advisability
of asking for a second opinion from another doctor. When
surgery of the vertebral spine has failed, other treatments can be assessed. This
site includes a section on all of the treatments
used for back pain and their indications, risks and the scientific effectiveness
of each. In general, pain surgery, pain units, neuroreflexotherapy, psychological
support, or multidisciplinary rehabilitation programs can help in these cases.
What
to do if the pain reappears after the operationWhen
pain appears after the operation, one must consult the doctor. The fact of having
undergone surgery does not necessarily mean that the pain is due to the operation
especially if it was followed by a period without pain. So the first thing the
doctor must do is assess the situation, make a detailed clinical
history and physical examination and evaluate the advisability of requesting
a supplementary test
to determine the cause of the pain. If the episodes of
pain appearing after an operation are sporadic, it is not always necessary to
go to the doctor immediately. In most cases, the episode disappears in less than
7 days, almost independently of the treatment used. Meanwhile, and to shorten
the episode, it is important to avoid bed rest, stay as active and mobile as possible
temporarily postponing only those activities which produce or aggravate the pain
and limit medication
intake, especially analgesics,
to those times when the pain is most intense. If the pain
is different in its characteristics or localization, or if it doesn't improve
after a few days, one should see the doctor. In the immense majority of cases,
pain can be treated satisfactorily with medication,
neuroreflexotherapy,
exercise
or other nonsurgical
treatments. The fact of having been operated on does not mean that all future
episodes of pain require a new operation. |
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