What are the most common causes of the failed (surgical) back?
• The diagnosis was wrong. Therefore, even if the surgical treatment was technically flawless, the patient must be regarded as having never been treated for the presenting signs and symptoms and requires a thorough reassessment with generation of a new treatment plan.
• The diagnosis was correct, but the treatment was technically flawed or inappropriate.
• Whether or not the diagnosis was correct, something new has happened—perhaps an immediate or late consequence of treatment or an unrelated but intercurrent complication. This situation usually occurs when two or more pain-generating mechanisms coexist. For example, in disc herniation removal of disc material improves radicular symptoms but fails to address the mechanical pain produced by spinal instability after the herniation.
• A complication of diagnosis or treatment has arisen such as arachnoiditis, injury to a nerve root, or disc space infection.
• No preoperative counseling has been given. Physicians must discuss and in some instances negotiate with patients a plan of postsurgical treatment, stressing patient participation in functional restoration and dispelling unrealistic expectations of complete restoration to normal.