A Brighter Outlook on Spinal Revision Surgery

Date: February 15, 2013

Khaled Kebaish’s studies have shown that many of his patients do just as well following revision surgeries as they do with the initial ones.

photo by Keith Weller

If you look up “complex spine surgery” on the Internet, you’re likely to find a generic statement that describes it as any sort of modern surgery to treat degenerative spine disease or spinal infections, fractures or instabilities.

Khaled Kebaish, an orthopaedic surgeon at Johns Hopkins who specializes in complex spine surgery, treats patients with all of these problems, but to him, the term “complex spine” is, well, a little more complex.

“It’s all relative,” Kebaish says. “The spine itself is complex, but ‘complex spine’ really encompasses the more severe deformities. For example, I may have a patient with a severe spine curvature who’s been operated on before, but I have to redo the surgery because the first one was unsuccessful.” This type of surgery is very complex and requires a higher level of expertise.

Indeed, 70 percent of Kebaish’s operations are revision surgeries—many for patients with severe scoliosis, kyphosis or spondylolisthesis—and 10 percent to 15 percent are to treat primary spinal tumors. “Sometimes a revision is required to correct the original problem and also to correct problems that arose as a result of the initial surgery,” Kebaish says. “Some physicians look at revision surgery as a hot potato, since these patients are considered to have a high rate of complications and, often, bad outcomes.”

However, Kebaish, who has presented several research papers comparing outcomes of primary spine surgeries with outcomes of revisions, says this labeling is misplaced. “Our studies show that patients undergoing revision surgery do just as well as patients who have had the initial surgery,” he says. “In fact, the outcome for revision patients is a bit better in some of the study tools we use to assess their function. And the complication rate isn’t significantly higher.”

“I think the question is, ‘Does spine surgery work?’ It clearly starts with making the right diagnosis, having the right operation, hopefully by the right surgeon who has the required knowledge and expertise to treat this particular problem. Under those circumstances, you expect to have a good outcome, even if an initial surgery has failed. You go back and figure out why it failed and try to correct the reason for the failure, and take the appropriate steps to prevent it from happening again.” 

All these considerations are significant in preventing “failed back surgery syndrome,” a term used to describe a patient who continues to experience pain after back surgery. “Some believe that if the surgery fails to relieve the patient’s pain, you should just send the patient away,” he says. “Unfortunately, as a result, a lot of patients may not get treated appropriately or often get referred for symptomatic pain management when there’s actually a clear and correctable problem.”

On the other hand, some of these patients should not have had surgery in the first place. “Normal disk wear-and-tear happens in almost everyone with advancing age,” says Kebaish. “By the time you’re 50, you will have some changes in your disks and spinal joints.” And this wear-and-tear isn’t always amenable to treatment with surgery, he adds. “You have to consider both the patient’s symptoms and what’s on the MRI, and figure out what the real problem is and how to correct it. The disk changes that we see on MRIs and X-rays are not always causing the problem. You want to treat the patient, not the MRI or the radiographs. If you treat the test only, the surgeon and the patient will end up very disappointed.”