By Ian D. Connolly, MD, MS, Massachusetts General Hospital
John H. Shin, MD, Massachusetts General Hospital
What is it?
The field of spine surgery has seen tremendous advancements over the past few decades, benefitting a multitude of patients. As far as we’ve come, the fact remains that some patients do not get better. Failed neck surgery syndrome is a condition where a patient experiences persistent pain following one or more neck surgeries. It is closely related to a broader term known as failed back surgery syndrome which generally refers to recurrent pain after one or more surgeries on the lower back.
Neck and back pain are often multifactorial and very complex. There are a number of reasons why pain could persist following spine surgery. These reasons can be grouped into preoperative, operative, and postoperative factors. Preoperative factors could include psychological and social factors or improper patient selection for surgery (i.e. wrong indication for surgery). Operative factors could include inadequate decompression, instability of the spinal segments from excessive decompression (i.e. too much structural bone removed), or even incorrect level surgery. Postoperative factors may involve recurrent disc herniations, adjacent segment disease where the level above a spinal fusion undergoes degeneration from newly introduced stress from the fusion and restricted movement, or new imbalance in sagittal spinal alignment. In some cases, epidural fibrosis or scarring can form which can put pressure on or even tether the spinal nerves.
How is it diagnosed and treated?
The evaluation of failed neck surgery begins with a detailed history and clinical examination. Basic labs may be ordered to rule out inflammation or infection. Postoperative imaging studies such as MRI, CT, or standing flexion and extension x-rays are typically obtained to rule out structural causes of persistent pain. If a structural cause is identified, additional spine surgery may be an option after a thorough workup that does not reveal any other causes. In general, the success rate of a repeat surgery in cases of failed neck surgery syndrome is lower than the initial surgery. The risks and benefits should be carefully weighed since repeat surgery often has diminishing returns.
In the absence of compelling indications for reoperation, the management of failed neck surgery syndrome relies on an interdisciplinary team-based approach involving the spine surgeon, primary care physician, pain management team, and physical therapy team. Non-steroidal anti-inflammatory drugs (NSAIDs) possibly in conjunction with neuropathic pain medications such as gabapentin or pregabalin may be prescribed. The use of opioids remains controversial and is usually reserved as a short course generally in the postoperative period. Cervical epidural steroid injections may also provide pain relief by reducing swelling and inflammation around the nerves. Patients may also need to engage in physical therapy to improve flexibility and strengthen core muscles. Some studies have supported the use of cognitive behavioral therapy in improving chronic neck pain scores. Another emerging treatment option in some cases of recurrent neuropathic pain from failed neck surgery syndrome is cervical spinal cord stimulator implantation. This option should be reserved after exhausting other conservative measures as data supporting its widespread use remains limited.
Take home message
In summary, failed neck surgery syndrome remains a challenging clinical entity for both physicians and patients. Its underlying causes are numerous and approach to management requires a broad workup. Repeat surgery should be carefully considered in cases with a clear structural etiology that correlates with the location and type of pain being experienced. Patients benefit from a multidisciplinary approach to chronic pain management.
