Revision Spine Surgery
Overview
Revision spine surgery is done in a patient who has previously undergone a spine surgery that has not met the expectations of the patient or the surgeon. Revision spine surgeries are usually performed on prior surgeries of the neck or the lower back. The revision of spine surgeries is usually more complicated than primary spine surgery.
In the cervical region, a failed cervical disc replacement surgery is usually corrected with revision surgery. Revision spine surgery of the cervical or lumbar region is also indicated in patients with re-herniation of the intervertebral disk, infection of the prior surgery, or failure of the hardware inserted during the prior surgery. The patients may also present with adjacent level degeneration and pseudoarthrosis.
Status post L3 to L5 fusion with adjacent segment degeneration of L2-3 and L5-S1 on X-ray.
There may be a failure of fusion of the adjacent vertebrae that may lead to loosening of the internal hardware and degenerative changes in the adjacent segments. The failure of fusion may be due to the patient’s co-morbid conditions such as diabetes mellitus, immune disorders, chemotherapy, or kidney failure. These conditions may lead to poor healing of the fusion surgery.
Chronic smokers have a decreasing healing capacity, and continued smoking after the primary surgery leads to inadequate healing and subsequent failure. The failed fusion of the vertebrae and loosened implants may cause worsening of the spinal stenosis.
In patients with failed fusion and loosened implants, revision surgery is performed to remove the failed implants and replace them with new implants. The fusion is also freshened by adding bone grafts.
In some cases, the primary surgery may have been inadequately performed or incorrectly performed leading to continued or worsening symptoms. In such cases, the revision surgery is performed for adequate relief. Revision spine surgery is also performed in cases of the instability of the spine after primary surgery, excessive scar formation after primary surgery, and flatback syndrome after lower back surgery.
Failed back surgery syndrome
A failed back surgery syndrome is the persistence of the chronic symptoms of pain after one or more surgeries of the spine. The failed back surgery syndrome occurs when the outcome of the surgery is not as expected by the patient or the surgeon.
Spine surgery performed in patients in whom the surgery was not indicated or poor patient selection is the most common cause of failed back surgery. Other causes of failed spine surgery include patients with an incorrect/incomplete initial diagnosis, wrong procedure/technique, chronic smokers, and patients with immune-suppressing co-morbid diseases. Postoperative complications such as a dural tear, infection, or hematoma may lead to failed back syndrome.
Time of appearance of symptoms
An early appearance of symptoms immediately after surgery or within 2-3 weeks after surgery may most commonly result from a wrong level of surgery, inadequate diagnosis, or procedure. The symptoms appearing after one month up to a period of six months may result from graft or implant failure or from recurrent disc herniation. After six months, symptoms may result from recurrent stenosis at the same or a different level or from excessive scar tissue formation.
Transition syndrome results from the instability of the segments adjoining the fused segment in surgery. The additional stress on the adjoining segment due to the successful fusion of diseased level may result in accelerated degenerative changes in the adjoining level.
Diagnosis
The diagnosis of failed back surgery requires a thorough examination by the physician. Blood investigations may be required to rule out infection. Radiological tests include X-rays as an initial investigation which are usually followed by MRI. CT scans provide a better picture of the bony structures compared to an X-ray.
Management
Conservative management is initially tried in the form of pain medications, physical therapy, heat/cold therapy, etc. Other minimally invasive techniques such as spinal cord stimulation, epidural injections, percutaneous adhesion-lysis, and spine endoscopy may be tried for pain relief.
Revision surgery is reserved for spine instability and nerve root compression syndrome. Revision may also be performed to correct the balance of the spine. The revision surgery usually involves the extraction of the hardware from previous surgery, freshening of the one margins, and insertion of new bone graft and hardware.
Rod holding forceps and clamps
Various types of rod benders
The images above show various types of instruments used in posterior spinal fusion which may be used for revision surgery. The rods are used to stabilize the spinal segments and are tightened over the pedicle screws. The rods may be contoured to a required shape during the surgery to achieve maximum stability using the rod benders.
Do you have more questions?Â
How is a patient evaluated for revision spinal surgery?
Evaluation includes a thorough medical history, physical examination, and imaging studies like X-rays, MRI, or CT scans to assess the condition of the spine and any complications from the initial surgery.
How long is the recovery time after revision spinal surgery?
Recovery can take several weeks to months, depending on the extent of the surgery and the individual patient’s healing process. Physical therapy is often required to aid recovery.
What is the success rate of revision spinal surgery?
Success rates vary, but many patients experience significant improvement. However, outcomes can be less predictable than with primary surgery, depending on the reason for revision and the patient’s overall health.
Will I need physical therapy after revision spinal surgery?
Yes, physical therapy is usually recommended to help restore function, strengthen muscles, and improve spinal stability after surgery.
What can I do to prepare for revision spinal surgery?
Preparation includes discussing all medications with your surgeon, stopping certain drugs that could increase bleeding, and following any preoperative instructions given by your medical team.
Are there alternatives to revision spinal surgery?
Depending on the specific condition, alternatives might include conservative treatments like physical therapy, medications, or minimally invasive procedures. However, in cases of hardware failure, significant instability, or infection, surgery may be necessary.
How do I know if my symptoms are due to the failure of my initial surgery?
Symptoms like recurrent pain, neurological deficits, or changes in mobility may indicate issues with the initial surgery. A thorough evaluation by your surgeon is necessary to determine the cause.
What types of imaging studies are used to assess the need for revision surgery?
X-rays, MRI, and CT scans are commonly used to evaluate the spine’s condition, check for hardware issues, and identify any new or unresolved problems.
Is revision spinal surgery more painful than the first surgery?
Pain levels vary, but revision surgery can sometimes result in more postoperative discomfort due to the complexity of the procedure and the presence of scar tissue.
What are the chances of needing another surgery after a revision procedure?
While the goal is to address all issues during the revision, some patients may require further surgeries, especially if complications arise or new spinal problems develop.
Can revision surgery address all the issues from the initial procedure?
While revision surgery aims to correct previous issues, it may not resolve all problems, especially if there is significant scar tissue or if the original condition has progressed.
What should I expect during the recovery period?
Expect a gradual recovery process involving rest, limited activity, pain management, and physical therapy. Follow-up visits with your surgeon will be necessary to monitor your progress.
Will I have any restrictions after revision spinal surgery?
Yes, patients typically have activity restrictions, such as avoiding heavy lifting, bending, or twisting, during the initial recovery phase. These restrictions will gradually be lifted as you heal.
How can I reduce the risk of complications after revision spinal surgery?
Follow your surgeon’s postoperative instructions carefully, attend all follow-up appointments, avoid smoking, maintain a healthy diet, and engage in recommended physical therapy.
What are the potential long-term outcomes of revision spinal surgery?
Long-term outcomes vary, but many patients experience pain relief and improved function. However, some may have ongoing symptoms or require further treatment.
Is it possible to prevent the need for revision spinal surgery?
While not all cases can be prevented, proper patient selection, careful surgical technique, and adherence to postoperative care can reduce the likelihood of requiring revision surgery.
How does scar tissue affect revision spinal surgery?
Scar tissue can complicate revision surgery by making it more difficult to access the surgical site and increasing the risk of complications like nerve damage or dural tears.
What is adjacent segment disease, and how is it related to revision spinal surgery?
Adjacent segment disease occurs when the segments of the spine above or below a fusion develop degenerative changes due to altered biomechanics. This condition may require revision surgery if symptoms become significant.
What questions should I ask my surgeon before undergoing revision spinal surgery?
Key questions include asking about the specific reasons for revision surgery, potential risks and benefits, the expected recovery process, the likelihood of success, and how the surgery will address your current symptoms.
Dr. Suhirad Khokhar
My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.
I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.
My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.
