Southwest Scoliosis and Spine Institute Revision Surgery

Southwest Scoliosis and Spine Institute Revision Surgery

Shawn Coker, watch his video had multiple spine fusion surgeries.  While he says they accomplished what they were supposed to do at the time, his condition continued to get worse.  Sadly, his spine caused him pain and forced him to lean forward constantly.

This made it difficult for Shawn, who had always been an active person, to walk for any kind of distance.  Also, he could not do things he loved, like traveling. After looking everywhere, he came to the Southwest Scoliosis and Spine Institute where he met with Dr. Hostin.  Dr. Hostin suggested revision surgery to correct the problem.

Recovery went much quicker than he expected, and within two weeks he was walking around better than before – without pain!

What is Revision Spine Surgery?

Revision spine surgery is a complex and specialized procedure aimed at addressing issues that arise after an initial spine surgery. Although initial spine surgeries are generally performed to alleviate pain, restore function, and correct spinal abnormalities, not all procedures yield lasting relief. For some patients, new or persistent symptoms develop after the first surgery, requiring additional intervention. Revision spine surgery corrects these issues, which may include mechanical instability, hardware complications, residual deformities, or nerve-related pain.

This paper provides a detailed overview of revision spine surgery, including indications, preoperative assessments, major types of procedures, expected outcomes, and the associated risks and complications.

Indications for Revision Spine Surgery

Revision spine surgery is not performed lightly due to its complexity, and it is typically considered only when conservative treatments are ineffective or when initial surgery results are unsatisfactory. Common indications include:

• Persistent or Recurrent Pain: Pain that remains or returns after initial surgery, indicating unresolved issues or new pathology.
• Non-Union or Pseudoarthrosis (Failed Fusion): When spinal bones meant to fuse fail to heal completely, leaving instability that can cause pain.
• Adjacent Segment Disease (ASD): Degeneration in spinal segments near the surgical site, often caused by the additional stress placed on these segments following fusion surgery.
• Hardware Failure or Complications: Metal components like screws, rods, or plates used in previous surgeries may break, loosen, or irritate surrounding tissue.
• Infection: Postoperative infections around the spine or hardware may necessitate removal and revision of the infected site.
• Residual or Progressing Deformity: In cases where the original surgery did not fully correct spinal deformity, revision surgery may be required to realign the spine properly.

Preoperative Assessment for Revision Surgery

Evaluating a patient for revision spine surgery involves a thorough diagnostic and preoperative process, given that revision surgeries carry higher risks and complexity than initial procedures.

• Imaging Studies: Advanced imaging techniques like X-rays, CT scans, and MRIs help visualize alignment, bone healing, hardware placement, and any new or unresolved spinal issues.
• Bone Health Assessment: Bone density scans evaluate bone strength, especially in older adults or individuals with conditions like osteoporosis, which may impact surgical decisions.
• Evaluation of Fusion Integrity: Special tests, such as a flexion-extension X-ray, assess movement at the fusion site, confirming if fusion failure is present.
• Physical and Functional Assessment: Understanding the extent of functional impairment and specific pain characteristics assists in selecting an appropriate surgical plan.
• Medical Optimization: Addressing health conditions such as diabetes, nutritional deficiencies, and smoking can improve healing and reduce surgical risks.

Major Types of Revision Spine Surgery

Several types of revision spine surgeries are performed, each designed to address specific complications or goals. The primary procedures include:

1. Hardware Removal or Replacement

• Indications: Hardware removal or replacement is recommended when hardware, such as screws, rods, or plates, is causing pain, irritation, or mechanical instability. It is also necessary if the hardware is broken or loosened.
• Procedure: During the revision, surgeons carefully remove or replace the hardware without damaging surrounding bone or tissue. Removal may be combined with other surgeries, such as fusion, to ensure stability is maintained. Imaging like CT scans or X-rays may guide the process to prevent complications.

2. Spinal Fusion Revision

• Indications: Revision fusion surgery is often necessary for patients experiencing non-union (pseudoarthrosis) or when additional stability is required in the spine.
• Procedure: The surgeon reattempts fusion by adding new bone grafts (either from the patient’s own body or from a donor) and sometimes enhancing the fusion site with bone growth stimulants, such as bone morphogenetic proteins (BMP). Revision fusion surgeries may be more extensive, covering more spinal levels or reinforcing previous fusion areas to increase stability.
• Expected Outcomes: When successful, revision fusion can improve stability and reduce pain, though additional levels of fusion may impact spinal mobility.

3. Decompression Procedures (Laminectomy, Discectomy, and Foraminotomy)

• Indications: Decompression procedures are used to relieve persistent nerve compression caused by spinal stenosis, herniated discs, or bone spurs, which were either missed or have recurred after the initial surgery.
• Procedures:
  • Laminectomy: Removal of the lamina (a part of the vertebral arch) to widen the spinal canal.
  • Discectomy: Removal of a portion of a herniated disc that is pressing on a nerve.
  • Foraminotomy: Enlargement of the foramen (nerve exit openings) to relieve nerve compression.
• Expected Outcomes: Decompression can offer substantial pain relief for patients with nerve compression, though it may need to be combined with other procedures, like fusion, to stabilize the spine.

4. Osteotomy for Deformity Correction

• Indications: Osteotomies are used for patients with residual or progressive spinal deformities, such as scoliosis or kyphosis, that were not adequately corrected in previous surgeries.
• Procedure Types:
  • Smith-Petersen Osteotomy (SPO): Involves cutting and removing a portion of the vertebrae to achieve spinal realignment.
  • Pedicle Subtraction Osteotomy (PSO): Removes a wedge of bone from a vertebra, allowing greater flexibility and realignment.
  • Vertebral Column Resection (VCR): Complete removal of a vertebra, typically reserved for severe, rigid deformities.
• Expected Outcomes: Osteotomies can significantly improve alignment and stability, though they are more extensive and carry higher risks.

5. Infection Management and Debridement

• Indications: Infection management becomes necessary when there is evidence of infection around the surgical site or hardware that does not respond to antibiotics alone.
• Procedure: Infected tissue and, if necessary, infected hardware are removed. In some cases, the surgery is staged—an initial surgery removes infected components, and subsequent surgeries address structural issues. Antibiotic treatment may continue postoperatively.
• Expected Outcomes: Infection management surgeries can successfully resolve infections but may require multiple interventions over time to ensure complete eradication.

Risks and Complications of Revision Spine Surgery

Revision spine surgery is inherently riskier than initial spine surgeries. Key risks include:

• Increased Infection Risk: The presence of scar tissue and longer operative times increase the likelihood of infection.
• Nerve Damage: Scar tissue from previous surgeries can complicate revision and increase the risk of nerve damage.
• Higher Risk of Blood Loss: The extent and complexity of revisions may lead to greater blood loss.
• Risk of Hardware Failure: Hardware may fail again, particularly if bone density is poor or if the structure does not support hardware placement well.
• Risk of Recurrent Non-Union: Achieving successful fusion can be more challenging in revision surgeries, especially in patients with poor bone quality or habits that inhibit bone healing, such as smoking.

Outcomes of Revision Spine Surgery

Success rates vary depending on the reason for revision, the patient’s health, and the complexity of the revision. Key outcomes include:

• Pain Relief: Many patients (70-80%) experience significant pain relief after successful revision surgery.
• Improved Function: Most patients report enhanced function, but outcomes depend on the extent and type of revision.
• Quality of Life Improvements: Many patients experience meaningful improvements in quality of life when revision surgery addresses the root cause of symptoms. However, the success rate is generally lower than in initial surgeries, and some patients may continue to experience symptoms.

Conclusion

Revision spine surgery is a critical option for patients with complications following their initial surgery, providing opportunities for pain relief, functional improvement, and spinal stability. While it carries higher risks and challenges, advances in surgical techniques and better understanding of spinal conditions have improved outcomes for many patients undergoing revision. As a tailored approach to each patient’s unique condition and needs, revision spine surgery has the potential to deliver significant relief and restore quality of life.

 Usually, within about three months after spine surgery, pain should not exist. However, in some cases (around 10-40%), an initial procedure might not produce the desired benefits and results. Doctors often refer to this as failed back surgery syndrome (FBS).  When this happens, doctors usually suggest revision spine surgery.

What Causes Failed Back Surgery Syndrome or FBS?

Despite the name, Failed Back Surgery Syndrome isn’t really a syndrome at all.  It refers to the presence of chronic issues after one or more back surgeries. There are a variety of causes, including certain disorders and diseases that can inhibit healing.  A few of those are as follows:

• Diabetes
• Autoimmune disorders
• Peripheral artery disease

Smokers are also at higher risk.  Cigarette smoking (and nicotine use in general) has been proven to inhibit and impair the healing process.  This occurs because nicotine constricts small blood vessels and capillaries.  This interferes with the body’s ability to heal and increases scar formation, and generally impedes successful bone fusion. In addition to pre-existing conditions like these, other problems can develop.  These problems occur months or even years after the initial surgery, and therefore, make revision surgery necessary.

Other common issues and injuries that lead to the need for revision spine surgery include:

• Recurring disc herniation(s)
• Flatback syndrome
• Failure of the spine to fuse properly
• Formation of scar tissue at the surgery site
• Post-surgical infection
• Failure of a spinal implant or hardware 
• Other changes unrelated to prior surgery

In many cases, these kinds of conditions develop as a result of normal wear and tear on the spine. However, those who conduct manual labor or who engage in contact sports or other rough activities may likely need more surgery.

Is Revision Spine Surgery the Only Method to Treat Failed Back Surgery?

In many cases, the doctors at Southwest Scoliosis and Spine Institute suggest non-surgical treatments.  Only after these treatments do not work will the doctors suggest revision surgery. This is because our doctors believe that surgery is a last resort due to the risks involved.

Non-surgical treatment includes things like:

• Medications 
• Physical therapy
• Exercise therapy
• Steroid injections (ESIs)

Even though non-surgical treatment is the preferred starting point. Doctors may suggest immediate revision spine surgery if you have any of the following conditions:

• Serious nerve-related pain or weakness, shooting pains, and numbness – especially in the legs
• Bowel and bladder problems
• Spinal instability 
• Broken or displaced spinal rods & screws that could damage nerves or vascular structures
• Spinal infection

Surgical Treatments for Failed Back Surgery

If your doctor says that more surgery is necessary, the goal is to reduce or stop the pain and allow you to return to life as normal.

To do this, revision spine surgeries fall into one of two categories: decompression surgery or stabilization surgery. In some cases, decompression and stabilization are performed at the same time.

Decompression Surgery

Common decompression surgeries include:

• The removal of a herniated or damaged disc that is pressing on the spinal cord or nerves.
• The surgeon enlarges the opening(s) between the affected vertebrae through which the nerve roots exit the spine.
• Involve partial or complete removal of the lamina, which is the rear portion of the vertebrae.

The goal of any decompression surgery is to relieve pressure on the spinal cord and nerves, but this surgery alone may lead to more problems by causing spinal instability when creating added space between your vertebrae. This added space allows the vertebrae to move more freely than they should, and this can make your spine less stable. If a decompression surgery threatens the stability of your spine, your surgeon will also perform a stabilization procedure during the same surgery.

Stabilization Surgery

The primary surgery to stabilize the spine is a spinal fusion, which limits any abnormal motion or range of motion between vertebrae. This prevents the vertebra from moving too much or moving out of place, which can cause them to put pressure on the spinal cord and nerves.

By fusing together two or more vertebrae, usually with a bone graft, a spinal fusion procedure allows the vertebrae to grow together, or fuse. Because this takes some time, a spinal fusion is typically held in place with rods and screws that support the healing bone and allow your spine to fuse properly.

How do Doctors Determine if a Patient Needs Revision Surgery?

To properly test for and diagnose a patient with FBS, the doctors at Southwest Scoliosis and Spine Institute perform a number of tests that are needed to discover what caused the initial surgery or surgeries to fail and then determine the best way to fix the issue.

Evaluations and testing always start with a thorough examination, during which the doctor will carefully go over your medical history with the patient. Next, they will utilize state-of-the-art imaging EOS to get an accurate model of your entire spine.

Diagnostic imaging options may include:

• X-ray imaging to check the spine and ensure that any implanted hardware is intact
• CT scans to determine if vertebrae have fused properly and check for things like fractures
• MRI scans to detect nerve or disc problems
• EMG to study nerve functions
• Bone scans to rule out the possibility of infection

Once these tests have been performed, our team of experts will review the findings to diagnose the problem and determine the best possible course of treatment. The doctor will then sit down with the patient to discuss all of the options available, as well as answer any questions they may have.

Revision Spine Surgery Recovery

Depending on the exact procedure and the reason for revision surgery, recovery times for each patient will vary. However, most surgeries will require the patient to stay in the hospital for several days to allow their Surgeon and team of doctors to monitor them and ensure there are no problems. Key aspects of recovery include:

1. Pain Management: Pain following revision surgery can be significant, and patients may require medications and gradual weaning off narcotics.
2. Physical Therapy: Rehabilitation is critical to help patients regain strength and mobility while protecting the surgical site. Therapy often begins with gentle exercises, progressing to more active forms as healing allows.
3. Lifestyle Adjustments: Patients may need to limit certain activities permanently, especially if their revision surgery included extensive fusion levels.

After the surgery, patients get fitted with a brace or collar to help keep their spine stable during recovery, and during the first few weeks, the doctors will restrict their activities.

However, as healing progresses, the patient will slowly resume normal activities again. That’s why physical therapy after surgery is so important and should begin as soon as possible to help regain strength and movement.

Depending on the nature of the revision spine surgery, recovery times vary between six weeks and three months, with a full recovery usually in six months.

The exception is that some revision spine surgeries occur using minimally invasive techniques, in which the surgery is done by making small incisions with specialized instruments. This method causes less damage to the muscles and tissues around the spine and involves a much quicker recovery time as compared to open surgical methods.

Southwest Scoliosis and Spine Institute Specializes in Treating Complex Spine Conditions and Revision Surgery

If you think you may need revision spine surgery, it’s critical to consult a doctor who is skilled in performing these kinds of complex procedures – especially if it’s the result of earlier surgery.

At our practice, our board-certified, fellowship-trained orthopedic surgeons have performed more than 5,900 successful spine surgeries, helping more than 100,000 patients. Richard Hostin, MD, Devesh Ramnath, MD, Ishaq Syed, MD, Shyam Kishan, MD, and Kathryn Wiesman, MD have the expertise and surgical skills necessary to diagnose and treat the most complex spine cases and revision surgeries.

If you have been told that there is no hope, call us at the Southwest Scoliosis and Spine Institute. We have offices in Dallas, Plano, and Frisco, Texas.  Our phone number is 214-556-0555 or you can use our contact page to ask for an appointment.

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Verywell Health: Spine Revision Surgery
National Institute of Health: Spine Revision Surgery