Dr David Johnson – Brain and Spinal Neurosurgeon

Never before has back pain been so widely discussed, and it’s management so hotly contested. Social media platforms like Twitter, Facebook, Instagram, and commercial television programs lately are all buzzing about the ‘boring’ topic of Chronic Low Back Pain. Even our own Pain Medicine Faculty of the Australian and New Zealand College of Anaesthetists is lending its unqualified “expert” view to “advise doctors not to refer patients with mechanical or axial low back pain for spinal surgery”, as quoted in 14 February 2018 Australian Newspaper.⁽⁵⁾

In the March 2018 edition of Surgical News, an article described stem cell research and 9.4 Tesla Magnetic Resonance Imaging’s ability to demonstrate blood vessels and nerve fibres growing in degenerate and compromised lumbar discs…and how this may be the “cause” of chronic low back pain. The article sadly makes no link between the obvious disconnect between imaging features of degeneration and the manifestation of back pain symptoms.¹¹

The Lancet Back Pain series in March 2018, presented a more than doubling of DALYs (Disability-Adjusted Life Years) from Low Back Pain between 1990 and 2015, which followed on from the World Health Organisation’s Musculoskeletal Fact Sheet (February 2018), announcing that Low Back Pain is the single leading cause of disability globally and is not a condition restricted to old age.^2,3

Upon review of Australian Commision on Safety and Quality in Health Care spinal surgery data, Australian Bureau of Statistics population data and epidemiological studies on the prevalence of the condition of Chronic Low Back pain, it becomes apparent that a condition of “Failed Back Pain Rehabilitation Syndrome” clearly exists.^12,13,14,15 There is a profound lack of commentary and discussion about the existence of this syndrome despite the statistics that estimate annually 1.5 million people qualify as having chronic low back pain failing to respond to non surgical management. A meager 745 individuals receive surgical intervention for their chronic back pain symptoms in the form of “non decompressive” lumbar fusion. If neural decompression with fusion surgery is analysed, the proportion of surgical management still only increases to 4915 per annum. Those who under go decompression in conjunction with fusion are unlikely to reflect patients suffering from purely chronic axial low back pain as surgical fusion is indicated as part of the management of symptomatic neural compression. None the less the substantial disproportion between surgically and non surgically managed back pain profoundly reflects “Failed Back Pain Rehabilitation”.

Figure 1. Referenced and extrapolated from Prevalence of chronic low back pain: systematic review, Australian Commission on Safety and Quality in Health Care, Australian Bureau of Statistics 12,13,14,15

Regardless of this “elephant in the room” statistic recent government policy from the Department of Health and Aging, guided by the “Choosing Wisely Australia” Advisory Panel consisting of membership from the Pain Medicine Faculty of the Australian and New Zealand College of Anaesthetists, with out spinal surgery representation, is in no uncertain terms moving towards greater restriction on spinal surgery accessibility and surgeon involvement in the care of patients with, yet to be defined, “uncomplicated” axial chronic low back pain.^9,10

It’s conjectural that such an “uncomplicated” condition exists. Describing a chronic disabling condition of epidemic proportions as such is a blatant oxymoron. Also, one must accept that any form of pain is merely a symptom and not an acceptable diagnosis or disease label. Peer reviewed literature and the context of these proposed government policy changes reflect a fundamental misunderstanding of the condition of “Back Pain” with the term repeatedly being used interchangeably and incorrectly, to represent both a disease and symptom.

It is hard to imagine how guidelines that attempt to restrict spinal surgical assessment of patients with chronic back pain will have any favorable outcome either clinically or economically when the statistics glaringly reveal that the orders of magnitude massive majority of patients with low back pain symptoms never receive surgical input. They constitute the patients repeatedly consuming resources and chronically suffering from the condition of Failed Back Pain Rehabilitation Syndrome.¹⁵

Establishing the condition or diagnosis of “Failed Back Pain Rehabilitation Syndrome is important because it shifts accountability which is currently lacking back onto the countless methodologies of the pain management, physical therapy and rehabilitation industry.^1,4,17

With the prevalence of Back Pain increasing and reaching the number one cause of global disability, treatment methods that hide behind a fake veil of perceived safety, affordability and effectiveness should no longer be acceptable, especially when they are in fact dangerous as they delay commencement of effective therapy and potentiate central sensitization, costly in the order of billions and clearly ineffective.^2,3,15,17,18

Additional importance in recognising the diagnosis of Failed Back Pain Rehabilitation Syndrome is to establish a cause for “Failed Back Surgery Syndrome”, currently having nebulous explanations.^7,8 Surgeons also have to be accountable for these poor out comes, so an understanding of “why we fail” is critical for surgeons.¹ The often drawn conclusion for the failed outcome is poor patient selection. This leaves surgeons perplexed because they reflect on prior similar clinical experience where patients have had successful out comes. The true discriminator for failure clearly remains elusive because “Failed Back Pain Rehabiliation Syndrome” has not yet been recognized as a diagnosis.

Intuitively every patient would prefer to avoid major stabilising spinal surgery for their chronic low back pain symptoms. Anecdotally but well appreciated, is that the vast majority of surgeons consultation time with patients is spent explaining why surgery is not indicated for their symptoms.

Patients and surgeons may embark on a surgical treatment path because of “Failed Back Pain Rehabiliation Syndrome” and the diagnostic acumen of the surgeon concluded that the structural integrity of the spine has been compromised to the point that a surgical structural repair will carry benefits out weighing risks for the patients over all condition.

One would consider this to be a logical paradigm of management but it becomes unstuck when we know that chronic back pain symptoms persist after what is deemed “successful” lumbar spinal stabilisation surgery, in up to fifty percent of cases. Despite the fact that surgery, short of rare intraoperative complications goes to perfectly to plan, the poor outcome is ironically labeled “Failed Back Surgery Syndrome”, discussed widely in the same peer reviewed literature that does not describe “Failed Back Pain Rehabilitation Syndrome”.⁸

Where is the disconnect? How is it possible with all things hypothetically controlled, for the surgeon to see two patients with the same compromised structural integrity such as a disrupted L5/S1 disc and perform the same operation such as an L5/S1 Anterior Lumbar Interbody fusion and achieve success in one patient and “failure” in the other?

In order to answer this it’s important for surgeons to conceptualise that there is no such thing as Back Pain Surgery.⁷ Pain is not a lesion that can be excised or fused. Chronic Back Pain is the symptomatic result of a Functional Disease. Spinal surgery for chronic back pain symptoms can only ever resolve compromised spinal structure that occurs secondary to a yet poorly described and unmanaged Functional Disease. Expecting an isolated structural remedy like surgery to reverse a Functional Disease is going to be unrewarding, no different to a structural frontal lobectomy failing to aid a functional disease like migraine.

A unifying answer to this is “Failed Back Pain Rehabilitation Syndrome”.

Effective “Functional” rehabilitation is always required after “Structural” surgical repair in order to address the primary Functional Disease that created the secondary structural break down and activation of the multitude of spine region nociceptive and inflammatory pathways that surgeons will refer to as pain generators. At a tertiary level, many patients will display Central Sensitisation which represents physiological maladaptive and dysfunctional pain generation that has no possibility of resolving, until the Primary Functional Disease that triggered the cascading progressive pathophysiology which manifests in “Chronic Axial Back Pain” symptoms, is arrested.

If the patient or applied rehabilitation does not eliminate the Functional Disease that was the primary cause of the activation of nociceptive and inflammatory pain pathways then it is logical and not at all unexpected that a patient will continue to suffer chronic pain after “successful” spine surgery and paradoxically be labeled with Failed Back Surgery Syndrome, recalling that spinal stabilization surgery has no influence on a functional disease and merely addresses structural integrity.

It becomes essential for surgeons operating on and managing patients with back pain to be discerning about the rehabilitation methodology that is applied to their patients if a successful out come is to be obtained.

Being discerning about effective rehabilitation and avoiding “Failed Back Pain Rehabilitation Syndrome” requires a paradigm shift in understanding of a primary Functional Disease driving secondary structural break down and pain.

If we consider that the primary Function of the musculoskeletal system, with the spine being no exception is movement, then a dysfunction will necessarily involve corrupted movement. Hence we can propose confidently with this paradigm that Movement Dysfunction is the Primary Functional Disease that drives secondary compromised structural integrity and pain generator activation.

Surgery addresses the secondary structural deficits but the patient must absolutely restore Functional Movement proficiency, either independently or with guidance from their Functional Movement focused rehabilitation.

This paradigm shift and model for the condition of Chronic Low Back Pain is supported by and explains important observations.

Modern industrialized society actively suppresses Movement Proficiency, behaving like a domestic cage to its occupants – us. This explains the increasing rates of back pain in industrialized nations. It explains the disconnect between degeneration of the spinal integrity that is unavoidable with age and manifestation of back pain symptoms.¹¹

The presence of Movement Dysfunction will in time potentiate pain and disability in a younger individual with minimal degeneration as their functional capacity falls below their functional demand.

Conversely an elderly individual living a non industrialized lifestyle and maintaining Movement Proficiency will experience no pain or disability despite the expected spinal degeneration of age as both individuals necessarily try to meet their required functional demand. The alternative is a maladapting by reducing the functional demand of their life below their compromised functional capacity. This is clearly observed in clinical practice.

If the rehabilitation methodology is controlled, would we not expect similar outcomes from the application of the same surgery for the same structural pain generators? The answer which is in reality obviously no, clearly supports a Movement Dysfunction paradigm because unless the rehabilitation methodology uniformly and specifically targets restoring Movement Proficiency then any other type of rehabilitation methodology such as exercise therapy or core strengthening is going to be “hit or miss”. Patients will have a highly variable propensity to naturally restore their movement proficiency regardless of their improved core strength or improved fitness style of rehabilitation. Having a strong core does not mandate skillful movement during activities of daily living, explaining the perplexing variable out come from similar surgery and similar patient selection by the same surgeon.

With out a Movement Proficiency focused approach, the Failed Rehabilitation becomes causation for a poor outcome with a core strengthened, fitter patient moving poorly with persisting pain. Alternatively and fortuitously for the patient, Failed Rehabilitation is only association for a good outcome, where by the patient independently re-acquired skillful movement regardless of the misdirected rehabilitation. It is not unreasonable to agree that some patients are naturally better movers than others, just like some people are better at different sporting or artistic movements than others.

Designing rehabilitation that focuses distinctively and specifically on eliminating the Functional Movement Disease means defining Movement Proficiency for the conceptual “Sport of Life” that we are all active participants in. For this we can turn to the anatomical form and function of our musculoskeletal system and derive movement points of performance for the “Sport of Life”:

1. Neutral spine awareness
2. For our stacked vertebral body support strut, once oriented in predominantly a horizontal plane
3. Hip centric rotation
4. For our ball and socket hip joint
5. Posterior kinetic chain driven movement
6. For conditioning of our powerful posteriorly located musculo-ligamentous tissues which critically aid in maintaining the posteriorly located spine and points 1. And 2. listed above.
7. Unloaded knee positioned movement
8. Default movement that is anterior chain dominant or that loads the knees such as kneeling as opposed to Olympic squatting compromises 1. and 3. eventually progressing to greater amounts of lumbar spine centric rotation that the spinal form is not adapted to.
9. Movement proficiency limited range of motion
10. For maintaining quality of Movement not quantity. Movement proficiency will be compromised if we exceed our musculo-skeletal range of motion capability. The Central Nervous System driven motor pattern that drives proficient movement over a short range is identical to that which drives the same movement over a wide range. In order to acquire the desired more functional wider range of motion, skillful central nervous system motor patterns must be rehabilitated first.

The paradigm shift effective rehabilitation is therefore targeting Central Nervous System driven motor patterns manifesting in skillful and qualitatitive Functional Movement proficiency. Distinctive and contrasting to existing methods which focus on peripheral, quantitative and structural targets of the musculo-skeletal system such as strengthening, stretching and fitness, amounting to “Failed Back Pain Rehabilitation”. If these skillful movement points of performance become default for activities of daily living then they will serve as a sound Functional Movement Proficiency Rehabilitation foundation to build Functional Capacity upon.

Building Functional Capacity to exceed Functional Demand is the ultimate goal to reversing maladaptive responses that patients demonstrate in the face of chronic pain and disability, such as not engaging in minimal physically demanding activities or ceasing employment. All of which lead to ever increasing reduction in functional capacity, more pain and consequently the cyclic entrenchment of the disease of Movement Dysfunction. The inevitable development of maladaptive pain pathways recognized as central sensitization will ensue.¹⁶

The logical step is to apply effective rehabilitation universally to all patients. This rehabilitation must incorporate a paradigm shift in thinking with reversal of the Functional Movement Disease which is a sound model for the development of down stream structural break down and secondary Back Pain symptoms with activation of pain generating pathways.

This model remains robust regardless of whether or not spinal surgery is incorporated into management because surgery merely represents a stepping stone to giving patients the potential to regain Movement Proficiency after repair of structural spinal integrity. Leaving out the effective functional rehabilitation after surgery exposes patients to poor outcomes and the misinterpreted label of Failed Back Surgery Syndrome.

If we are going to make a clinical and economic difference to the enormous burden that the symptoms of back pain have on our society, we need to acknowledge and reverse Failed Back Pain Rehabilitation Syndrome and implement a paradigm shift in understanding the Disease of Movement Dysfunction which causes Back Pain symptoms.

References:

1. Johnson D, Hanna J. Why we fail, the long-term outcome of lumbar

fusion in the Swedish Lumbar Spine Study. Spine Journal: Official

Journal of the North American Spine Society 2017;17(5):754.

2. World Health Organisation Musculoskeletal conditions fact sheet

[Internet]. 2018 From: http://www.who.int/mediacentre/factsheets/

musculoskeletal/en/ Accessed 13 April 2018.

3. Lancet series on low back pain [Internet] 2018 From: http://www.

thelancet.com/series/low-back-pain?utm_campaign=tlwbackpain18

Accessed 13 April 2018.

4. Cochrane Reviews Back Pain Management

http://www.cochranelibrary.com/topic/Orthopaedics%20%26%20trauma/Back%20disorders/Non-specific%20low%20back%20pain/

5.”The Australian” Newspaper. Health Waste: spinal fusion added to the list. Wednesday 14 February 2018

https://www.theaustralian.com.au/

6. Murphy K. Major International Science Prize For Neurosurgery Trainee. Royal Australasian College of Surgeons Surgical News. 2018 March;19(2):48-

7. Johnson D. Back Pain Surgery Doesn’t Exist But Do Not Refuse To Fuse. Royal Australasian College of Surgeons Surgical News. 2018 May;19(4):22-3.

8. Zafeer Baber Z, Erdek M. Failed back surgery syndrome: current perspectives. J Pain Res. 2016; 9: 979–987

9. Australian Governemnt Department of Health. Spinal Surgery.

http://health.gov.au/internet/main/publishing.nsf/Content/DCA37AF837D2C3D0CA25827700826A27/$File/Spinal-surgery.pdf

10. Choosing Wisely Australia.
    Faculty of Pain Medicine, ANZCA: tests, treatments and procedures clinicians and consumers should question. Do not refer axial lower back pain for spinal fusion surgery. http://www.choosingwisely.org.au/recommendations/fpm.

11. Brinjikji A, Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic Literature Review of Imaging Features of Spinal Degeneration In Asymptomatic Populations. AJNR Am J Neuroradiol.2015 Apr;36(4):811-6.

12. Rodrigo Dalke Meucci,I Anaclaudia Gastal Fassa,II and Neice Muller Xavier Faria. Prevalence of chronic low back pain: systematic review. Rev Saude Publica. 2015; 49: 1

13. Australian Commision on Safety and Quality in Health Care. Lumbar Spinal Fusion Hospitalisations 18 Years and Over. https://www.safetyandquality.gov.au

14. Australian Beureau of Statistics. Population. http://www.abs.gov.au/Population

15. Walker B, Muller R, Grant W. Low back pain in Australian adults: the economic burden. Asia Pac J Public Health. 2003;15(2):79-87

16. Sanzarello I, Merlini L, Rosa MA, Perrone M, Frugiuele J, Borghi R, Faldini C. Central sensitization in chronic low back pain: A narrative review. J Back Musculoskelet Rehabil.2016 Nov 21;29(4):625-633

17. van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo

R, Koes BW. A systematic review on the effectiveness of

physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal 2011 Jan;20(1):19-39.