Spine surgery, stem cells, Richard rooney, Seattle

1. Why back surgery fails?
Richard C Rooney, MD, FACS
rrooney@seattlespinegroup.com

2. Surgical Decision Making
• Much more problematic than infections or
technical errors
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3. In this example, the surgeon states ‘discogenic back pain’. By
definition discogenic means it is caused from the disc. The patient
may have back pain along with radicular (nerve) pain from nerve
compression but it would not be discogenic low back pain it would
simply be low back pain. Without a fundamental understanding of the
problem, it is unlikely the physician will arrive at satisfactory solutions.
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4. Why back surgery fails
• 55 y/o woman with back pain without
radiclopathy
• Spondylolisthesis
• Obese
• No improvement with PT, chiropractor, Pilates,
no relief with ESI’s
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6. MRI
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S1 transitional vertebrae, spontaneous
reduction of spondylolisthesis while
laying down for the MRI.
Spondylolisthesis was evident on
standing Xray.
With multiple degenerative discs, it is
impossible to discern where the pain
generator.
In this setting, unless the goal of
surgery is to decompress a nerve and
relieve sciatic pain (radiculopathy)
there is no reasonable chance of back
pain relief since any of the 5
degenerative discs could be causing
the low back pain.
Unfortunately, the surgeon thought he
knew better.

7. • Underwent L5-S1 minimally invasive
decompression and fusion (TLIF)
– ‘Minimally Invasive Specialist’
– Leg pain post op…no leg pain pre-op
– Worse low back pain post op
– 10 months post op absolutely no better
– Sent to ‘Pain Specialist’ for chronic pain and ‘failed
back’.
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8. Post Op MRI
Expected changes
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9. Post Op CT scan
Interbody spacer ‘cage’ (red
rectangle) sitting in the canal
S1 pedicle screw in the canal
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10. Yellow defines the canal, the screws obviously intrude into the canal
where the nerve roots are located
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11. So does the cage (red oval)
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12. • This patient was essentially abandoned by her
surgeon with a diagnosis of ‘failed back
syndrome’.
• The failure was in the surgical planning as well
as the execution.
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13. Patient DL 84y/o male
Pt with metastatic renal cell cancer
(kidney cancer)
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15. Patient followed up 1 year after surgery with severe
back pain. He had loosening of the screws (halo
images around the screws to the right).
The cancer is seen in L2 as well as L5 and S1 at the
bottom. It is the white color inside the bone.
The patient had widespread metastasis. Why
selectively choose one region to operate on?
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Normal appearing bone
White color is metastatic bone
White color is metastatic bone

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19. Surgeon didn’t understand the
type of cancer involved
This particular cancer was not osteolytic which
means the bone was eroded. When the bone
erodes, it gets weaker and instrumentation like
this may help to support the spine.
Instead, this patient had osteoblastic metastasis
which means that the bone is denser and will not
collapse and thus does not need support with
screws and rods.
Had the surgeon understood this, they would
have potentially avoided a surgery which has
served him no benefit and at the age of 84 years
old, this type of surgery carries significant risks.
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20. 1-9-13
• SW
• 55 y/o woman
• Leg and back pain
• Grade 1-2 spondy
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21. X-ray in prone position. Yellow arrow indicates
challenging angle to access L5-S1 disc space.
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22. The red line indicates surgeon’s line of sight. Seeing the back of
L5 is blocked in large part by S1. As a result, he chose an
anterior fusion at L5-S1.
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23. In this Xray of the patient supine, the yellow arrow shows the
angle in which the disc must be addressed anteriorly.
Unfortunately, the surgeon didn’t recognize that the angle is
so steep that the anterior bony pelvis was in the way.
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24. 2-8-13
The cage protrudes significantly into
the abdomen and the curved fixation
plate is not even in the anterior of the
S1 body.
No reduction of L5 on S1 was not
possible either. Since there is no
significant contact between the bone
graft and vertebral body endplates,
the fusion possibilities are limited.
The pedicle screws in L5 are also not
beyond the pedicle into the body and
the angle was limited by the angle of
L5 from the posterior approach.
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25. 6-14-13
• 4 months later
• Loose screws
• Leg pain the same as
preop
• Back pain worse
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26. 8-20-13
• Revision by original surgeon
• Awkward position of screws
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27. 9-20-13
• 1 month post op from revision
• Screw failure of right L4 screw
– Upper right screw on right image, the rod disengaged the screw
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28. • Revised
• Interbody support
• Reduction of spondylolisthesis
• Rigid internal fixation
• Leg and back pain resolved
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29. • Imperative that surgeon understands the
anatomy, the etiology and physiology of the
disease that they are treating.
• Thanks for your attention
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30. Which surgeon?
• Fellowship Trained
• Board Certified
• Experienced
• Diligent about the literature
• Second opinion
• rrooney@seattlespinegroup.com
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31. Questions?
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