CASE REPORTS

A Novel Treatment Combination for Failed

Back Surgery Syndrome, With a 41-Month
Follow-Up: A Retrospective Case Report
Gianni F. Maddalozzo, PhD, FACSM, a, b Kristine Aikenhead, DC, c
Vani Sheth, PT, b and Michelle N. Perisic, DC b

ABSTRACT

Objective: The purpose of this retrospective case report was to describe chiropractic management of a patient with
failed back surgery syndrome.
Clinical Features: A 45-year-old woman presented 2 years after L4-L5 and L5-S1 fusion surgery with low back and
sciatic pain. Her physical exam included a positive straight leg raise and diminished lower-extremity reflexes and
muscle strength. The patient’s magnetic resonance imaging showed right disc bulging and annular tearing at L2-L3
and L3-L4 disc bulging with foraminal impingement.
Intervention and Outcome: A total of 52 treatments were provided over 28 weeks consisting of multidirectional
functional decompression (FD) unweighted gait training, core exercises while in FD, strengthening exercises on a
vibration platform, and supine spinal FD with vibration and chiropractic spinal manipulative therapy. Over the course
of treatment, the patient noted gradual improvement in function (Oswestry Disability Index) and pain (Numeric Rating
Scale), with a reduction in pain medications. Follow-up of 41 months posttreatment revealed an Oswestry Disability
Index score of 0 and Numeric Rating Scale score of 0, and the patient no longer was using any pain medication.
Conclusion: After a course of care, the patient in this study reported resolution of symptoms, decrease in pain
medications, and improvement of function. (J Chiropr Med 2018;17:256-263)
Key Indexing Terms: Low Back Pain; Failed Back Surgery Syndrome

INTRODUCTION stimulation, (4) injection therapy, and (5) surgery. 2-23

Patients who had surgery between 1990 and 1993 reported a
Failed back surgery syndrome (FBSS) is a term used to
19% cumulative incidence of reoperation during the subse-
describe persistent or recurrent back or radiating leg pain
quent 11 years. After fusion surgery, 62.5% of reoperations
after anatomically successful spinal surgery. 1 Treatment of
were associated with a diagnosis suggesting device complica-
FBSS can be challenging for health care practitioners.
tion or pseudarthrosis, 2 with the likelihood of reoperation after
Treatment options for FBSS include the following: (1) a lumbar spine operation being substantial. 2-7 As a result of the
medications, (2) exercise or manipulation, (3) spinal cord
poor outcomes of subsequent surgeries, 2-7 surgery is not a
recommended treatment 6 for FBSS. 6,8
a
School of Biological and Population Health Sciences, Oregon Pharmaceuticals and injection therapy appear to have
State University, Corvallis, Oregon.
b
limited efficacy on FBSS, 9-15 and limited information exists
Illinois Back Institute, Wheaton, Illinois on the benefits of exercise, manipulation, or physical therapy
c
Clinical Sciences, National University of Health Sciences,
Lombard, Illinois. for the treatment of FBSS. 16 Surgical implantation of a spinal
Corresponding author: Gianni F. Maddalozzo, PhD, FACSM, cord stimulation device has been shown to be promising for
315 S Naperville Road, Wheaton, IL 60187. Tel.: +1 541 602 6595. the treatment of FBSS, 17,18 but success rates are only at the
(e-mail: gfmadd@illinoisback.com). 50% to 75% range. 19 These statistics demonstrate a need for
Paper submitted April 26, 2017; in revised form January 2, effective, noninvasive therapies for FBBS.
2018; accepted March 21, 2018.
1556-3707 Some evidence suggests that lumbar traction may provide
© 2018 National University of Health Sciences. a stabilizing effect on intervertebral movements 20 and reduce
https://doi.org/10.1016/j.jcm.2018.03.007 pressure in the nucleus pulposus of herniated discs. 21 Lumbar
Journal of Chiropractic Medicine Maddalozzo et al 257
Volume 17, Number 4 Failed Back Surgery Syndrome, Traction, Vibration

traction may improve lower back mobility 22 while providing The patient reported that medication and traditional physical
proper mechanical alignment essential for joint function. 23 therapy failed to reduce her pain meaningfully. The orthopedic
The purpose of this retrospective case report is to describe a surgeon suggested a second surgery, which the patient refused.
therapeutic approach that was used for a patient with FBSS. The patient reported constant pain that affected her ability to
The treatment combined spinal functional decompression take part in leisure activities, made her physically dependent on
(FD) (traction) on a vibration table; seated mechanical FD others for help, and impaired her ability to perform activities of
(lumbar traction) with exercise; multidirectional treadmill gait daily living or hold down a job. The patient reported she had
training with FD; manipulation of the cervical, thoracic, and contemplated suicide and was under the care of a psychologist.
lumbar spine; and whole-body vibration. Table 1 provides a list of the medications at intake.
The patient’s Oswestry Disability Index (ODI) score was
Case Report 50%, demonstrating severe disability. Her Numeric Rating
A 45-year-old African-American woman reported inter- Scale (NRS) was 8 of 10 (severe pain, classified as disabling);
mittent low back pain “off and on since age 17,” when she fell and she was unable to perform activities of daily living owing
and fractured her coccyx. For this initial injury, the patient to pain in the low back, right and left gluteal areas, and right
sought chiropractic spinal manipulative therapy (SMT), and and left lower extremities. The exam revealed a well-nourished
then continued care for low back pain 6 to 8 times per year for woman, height 182.25 cm, weight 77.27 kg, and body mass
25 years, which was moderately effective until 2008. index 23.3 kg/m 2. She demonstrated a positive straight leg
At that time, the patient noted an increase in pain for raise bilaterally, a positive Kemp’s test bilaterally, and a
unknown reasons, and the SMT was no longer effective. There positive sitting root (Bechterew’s) test bilaterally. Muscle
had been no trauma or change to precipitate the worsening. The strength testing of the quadriceps, gluteal, hamstring, and
patient reported having received 3 epidural injections over the psoas muscles were graded 4 of 5 bilaterally. Lower-extremity
period of 4 months to treat bulging discs, without lasting relief. reflexes were 1 bilaterally, and lumbar ranges of motion
The patient reported starting a course of treatment with hydro- generally were reduced (Table 2). An MRI of the lumbar spine
codone along with acetaminophen, while also receiving spinal performed March 18, 2011, concluded the following: L2-L3
manipulations 3 times per week for 3 months without relief of disc bulge with posterocentral annular tearing; L3-L4 disc
pain. The patient reported that in 2009 she presented to her bulge with small right foraminal protrusion, which minimally
orthopedic surgeon, and magnetic resonance imaging (MRI) of displaced the right L3 dorsal root ganglion; L4-5 and L5-S1
the lumbar spine was obtained. An MRI revealed disc herni- discectomy and posterior fusion; and left L4 hemilaminotomy.
ations, and the patient then underwent spinal fusion surgery. The diagnoses of post-spinal surgery syndrome, disc hernia-
The patient stated that symptoms were improved for 3 months tion, and radiculopathy were made.
after surgery. Shortly after her return to work, however, the back The patient was seen for 52 visits over 8 months and was
pain returned. She then began treatment with opioid pharma- generally compliant, attending 81% of her scheduled
cotherapy and traditional physical therapy for 3 months at 3 treatment sessions (Table 3). Each treatment session lasted
times per week at Central DuPage Hospital in Winfield, Illinois. 90 minutes and was modified to patient tolerance. Therapy

Table 1. General Clinical Characteristics Including ODI and NRS Scores Plus Medications
41-Month Follow-up
Characteristic Intake Week 4 Week 8 Week 12 Week 16 Week 20 Week 24 Week 28 Posttreatment
ODI raw score 25 22 21 19 15 22 6 4 0

ODI percentage 50 44 42 38 30 22 12 8 0

ODI change in points from baseline 0 3 4 6 10 14 19 21 25

ODI decrease % change in score from intake 0 6 8 12 20 28 38 42 50

NRS 8 8 7 6 5 3 2 1 0

Hydrocodone-acetaminophen 10/325 6/d 0 0 6/d 6/d 4/d 4/d 2/d No medication

Fentanyl 50 mcg/hr Transd Patch 1/d 1/d 1/d 0 0 0 0 0 No medication

Pregabalin (300 mg/d) 1/d 1/d 1/d 1/d 1/d 1/d 1/d 1/d No medication

Sertraline (50 mg) 1/d 1/d 1/d 1/d 1/d 1/d 1/d 1/d No medication
NRS, Numeric Rating Scale; ODI, Oswestry Disability Index.
258 Maddalozzo et al Journal of Chiropractic Medicine
Failed Back Surgery Syndrome, Traction, Vibration December 2018

Table 2. Physician Medical Outcome Assessments of Patient at 8-Week Intervals

Medical Exam Baseline Week 8 Week 16 Week 24 End of Care
Quad ST 4 Bilateral 4 Bilateral 4 Bilateral L5 R4 L5 R5

Glute ST 4 Bilateral 4 Bilateral 4 Bilateral L5 R4 L5 R5

Hamstring ST 4 Bilateral 4 Bilateral 4 Bilateral L5 R4 L5 R5

Psoas ST 4 Bilateral 4 Bilateral 4 Bilateral L5 R4 L5 R5

Lumbar flexion 70 80 85 90 90

Lumbar extension 5 15 20 25 25

Right rotation 20 20 20 20 20

Left rotation 20 20 20 20 20

Right lateral flexion 20 22 24 32 34

Left lateral flexion 20 20 22 28 30

Straight leg raise + RT side + Bilateral + Bilateral + Bilateral - Bilateral

Sitting root + Bilateral + Bilateral - Bilateral - Bilateral - Bilateral

Sacroiliac compression + Bilateral + Bilateral - Bilateral - Bilateral - Bilateral

Kemp test + Bilateral + Bilateral - Bilateral - Bilateral - Bilateral

Patellar reflex 1 Bilateral 1 Bilateral 1 Bilateral L2 R1 L2 R1

Achilles reflex 1 Bilateral 1 Bilateral 1 Bilateral L2 R2 L2 R2

Hip flexion 70 Bilateral 70 Bilateral 80 Bilateral 80 Bilateral 90 Bilateral

Ankle dorsi flexion 10 Bilateral 15 Bilateral 20 Bilateral 30 Bilateral 30 Bilateral

was progressed each month after a patient reevaluation or starting speed of 0.7 mph and progressing to 1.4 mph, and
assessment. The patient received all of the interventions backward (3 minutes) with a starting speed of 0.7 mph and
listed in this section on each visitation for treatment. progressing to 1.3 mph (Fig 1).

Multidirectional Treadmill Gait Training With Functional Decompression Seated Functional Decompression in Pneumatic Chair
Equipment included a treadmill, pneumatic FD station, While seated, FD was applied, starting with 40% and
and compressor, which allow the patient to rotate 360 degrees progressing to 60% of the patient’s body weight by the 15th
while walking under FD. Functional decompression was treatment as she was able to tolerate more FD. While under
applied to make the exercise tolerable, starting with 40% and FD, the patient was able to perform core strengthening and
progressing to 80% of the patient’s body weight by the 15th stability exercises; scapular stabilization exercises; isolated
treatment as she was able to tolerate more FD. The patient back extensions; and exercises to improve strength and
walked forward (8 minutes) with a starting speed of 1.0 mph mobility in the cervical, upper thoracic, and abdominal
progressing to 1.6 mph laterally (2 minutes each side), with a regions for 3 minutes each. The patient was secured tightly

Table 3. Treatment Schedule and Compliance

Treatment History Weeks: 0-12 Weeks: 13-24 Weeks: 25-28
Number of treatments 3/wk 2/wk 1/wk

Compliance 28/36 treatments 20/24 treatments 4/4 treatments

Compliance percentage (%) 72.2 83.3 100

Journal of Chiropractic Medicine Maddalozzo et al 259
Volume 17, Number 4 Failed Back Surgery Syndrome, Traction, Vibration

Fig 1. Multidirectional treadmill gait training with functional decompression.

in the chair using Velcro straps around her waist and thighs Vibration Table With FD Plus Exercise
to lock the pelvis in place (Fig 2). This restraint system While lying supine on the vibration FD table (0.6-1.2
isolated sagittal plane movements to the lumbar spine while mm at 30 Hz), 4 lever arms were used to create directional
preventing other muscle groups (eg, hamstrings, gluteus) FD to the patient’s spine. The vibration platform ran for
from contributing to the exercises being performed on the 180-second intervals with 30 seconds of rest. Functional
FD chair. decompression started with 30% and progressed to 50% of
In addition, the patient remained seated for 8 minutes the patient’s body weight by the 15th treatment as she was
while FD was applied, starting with 80% and progressing to able to tolerate more FD. The axial FD was applied with
100% of the patient’s body weight by the 15th treatment as emphasis on the patient’s right side (Fig 3).
she was able to tolerate more FD weight. No additional
exercises were performed during this time (Fig 2).
Vibration Platform Plus Exercise
While standing on a vibration platform, the patient
performed functional strengthening and stability and
balance exercises, including physioball wall squats, full
body squats, clam shells, and lunges. Additional exercises
also were prescribed to address the muscle strength and
endurance deficits and improve core strength and flexibility
for all major muscle groups.

Manual Chiropractic Adjustments

Chiropractic SMT was applied to improve mobility to all
spinal levels according to palpation findings on that visit.

Outcome
After 52 treatments, the patient’s ODI score was 8%,
demonstrating minimal disability and improved overall
function. Her NRS score was 1, indicating minimal pain
(Table 1). In addition, improvements were seen with muscle
strength, lumbar flexion and extension ranges of motion, and
reflexes (Table 2), as well as a decrease in pharmaceuticals for
pain management (Table 1). At 41 months posttreatment, the
patient’s ODI and NRS scores were 0, and she no longer was
Fig 2. Seated functional decompression in pneumatic chair. taking any pain or depression medications (Table 1). The
260 Maddalozzo et al Journal of Chiropractic Medicine
Failed Back Surgery Syndrome, Traction, Vibration December 2018

Fig 3. Vibration table with functional decompression plus exercise.

patient reported a return to regular intimacy with her husband addition, poor back extensor muscle endurance is a predictor
and was able to partake in a normal social life. The patient no of low back pain occurrence 32 and long-term chronic low
longer felt dependent on others, improving her relationships back pain (CLBP) 33 and affects neuromuscular recruitment
and re-establishing her role within her family. The patient and control of the spine. 25,26 Isolated core exercises while in
easily was able to perform daily tasks and return to work FD allowed this patient to perform core and thoracic exercises
without issue. The patient provided consent for publication of while actively stabilizing the pelvis, thus helping her in the
her case report and signed an informed consent form. long term with improved muscular endurance and a
successful return to activities of daily living.
Functional decompression as a treatment for CLBP has
been suggested to accomplish the following: (1) increase the
DISCUSSION disc height, 26 (2) stretch the ligaments and muscles of the
To our knowledge, this is the first time this combination spine, 25 (3) create separation of the facets of the apophyseal
of therapeutic approaches has been presented in the joints, 24 and (4) improve synaptic plasticity on dopaminergic
literature. It appeared that FD allowed this deconditioned neurons and fibers in an animal model. 34 Functional
patient to perform exercises that she otherwise may not decompression in this case also was applied to provide relief
have been able to perform. Functional decompression of pain while having the patient perform exercises designed to
creates distraction to increase the intervertebral space, strengthen and stabilize the core while stabilizing the pelvis.
tensing of the posterior longitudinal vertebral ligament, and It has been suggested that exercising with the pelvis firmly
vacuum effect to draw the disc protrusion inward toward the stabilized forces the lumbar spine to move against resistance. 35
defined intervertebral space. 21,24-27 Functional decompres- Exercises that do not require pelvic stabilization do not
sion in combination with gait training and core stabilization encourage meaningful exercise movements because the
exercises, functional exercises, vibration with exercise, and patient’s natural tendency is to protect the lumbar area from
SMT decreased pain and improving function in this patient. participating in meaningful exercise movements. This results
Back pain is more common among people who are not in failure to improve the patient’s core strength and consequent
physically fit. Weak back and abdominal muscles may not CLBP. 35 Pelvic stabilization while performing abdominal and
properly support the spine. 28 The patient presented in this lumbopelvic musculature 36 exercises was accomplished in
study was deconditioned when she first started treatment. this patient by teaching the patient to draw in her navel
Thus, a strategy was developed to focus on both her disc approximately 30%, 37 and bracing 38,39 while performing
issues and lack of muscular strength and endurance. abdominal and lumbopelvic musculature exercises.
Increasing the strength and endurance of the core muscles Multidirectional treadmill gait training with FD may
was critical to alleviating and preventing lower back pain have allowed this patient, who had limitations of weight-
while providing stability to the trunk region. 29,30 bearing resulting from her CLBP, to exercise pain-free.
The flexor and extensor muscles that stabilize the spine are Walking on a treadmill has been reported to improve
often weak in individuals with lower back pain, as was the walking speed and symmetry of walking compared with
case with this patient. The back extensor muscles, especially walking on the ground. 24,34,40 Thus, walking on a treadmill
the erector spinae group, provide posterior stability for the while in FD may lead to pain relief owing to functional gait
vertebral column. 31 According to several studies, a relation- improvement. In addition, sideways walking has been
ship exists between decreased strength and endurance of these shown to improve balance and walking abilities and reduces
muscles and chronic low back pain because low back pain has asymmetrical weight bearing on the lower limbs, while
been prevented by strengthening of these muscles. 21,30 In placing the patient in a position of good posture. 41
Journal of Chiropractic Medicine Maddalozzo et al 261
Volume 17, Number 4 Failed Back Surgery Syndrome, Traction, Vibration

Vibration therapy has been shown to acutely increase CONCLUSION

muscle activation during exposure, 42,43 resulting in post-
This case study describes the resolution of symptoms
activation potentiation 42 and improvement of muscular
and improvement of function in a patient with FBSS using a
performance. 42 Zaidell et al 44 have suggested that the tonic
multimodal approach, at the conclusion of treatment and at
vibration reflex is operative during vibration therapy
41-month posttreatment follow-up.
because antagonist musculature is being vibrated simulta-
neously. Furthermore, Cholewicki et al 45 has reported that
antagonistic trunk muscle coactivation is necessary to
provide mechanical stability to the lumbar spine around a FUNDING SOURCES AND CONFLICTS OF INTEREST
neutral posture, resulting in an increased response to an
increase of axial load on the spine. Thus, agonist– No funding sources or conflicts of interest were reported
antagonist muscle coactivation resulting from vibration for this study.
therapy may have improved the patient’s motor control
strategy to improve joint stability and movement accuracy.
Further, vibration therapy plus functional decompression CONTRIBUTORSHIP INFORMATION
may improve lumbar extension strength and both static and
dynamic balance, all of which are needed to maintain a Concept development (provided idea for the research):
neutral spine position. Both traction and vibration therapy G.F.M.
have been associated with decreasing pain in patients with Design (planned the methods to generate the results): G.F.M.
lower back pain. Recently, Wang et al 46 reported that Supervision (provided oversight, responsible for orga-
traction applied to patients while lying on a table in nization and implementation, writing of the manuscript):
combination with 12 Hz of vibration was effective in G.F.M., K.A., V.S., M.N.P.
reducing muscle fatigue of the lumbar erector spinae. Data collection/processing (responsible for experiments,
Motion palpation and range-of-motion findings for this patient management, organization, or reporting data): G.F.M.
patient demonstrated decreased segmental mobility contrib- Literature search (performed the literature search): G.F.M.
uting to decreased lumbar range of motion. Cramer et al Writing (responsible for writing a substantive part of the
(2013) lists reasons for facet joint hypomobility as “inactiv- manuscript): G.F.M., K.A., V.S., M.N.P.
ity; injury; or repetitive, asymmetric motions (eg, assembly Critical review (revised manuscript for intellectual
line work)” resulting in “normal or increased movement of content, this does not relate to spelling and grammar
some of the [facet joints] while chronically loading others.” 47 checking): G.F.M., K.A., V.S., M.N.P.
Loaded joints become hypomobile, and fibrous adhesions
develop in the hypomobile joints, further reducing normal
motion. 47 Gapping of the facet joints, achieved through
spinal manipulative therapy, breaks up intra-articular adhe- Practical Applications
sions and increases the motion of the segment. 47 Spinal • This case study suggests that chronic low
manipulative therapy assists in reestablishing normal range of back pain as a result of failed back surgery
motion, thereby reducing pain and improving functional syndrome can be managed.
capacity. 47 The SMT within the therapeutic protocol • Exercises done with vibration therapy plus
described in this study allowed the patient to achieve functional decompression combined with
improved joint mobility by gapping the facet joints and multidirectional unweighted treadmill gait
breaking up joint adhesions. Promotion of normal range of training and functional decompression supine
motion, pursued especially in chiropractic therapy, along traction may be an effective intervention to
with the therapeutic approach used in this study may have restore function and quality of life.
promoted healing in the disc periphery by stimulating cells,
boosting metabolite transport, and preventing further adhe-
sions from forming while prompting pain relief. 48

Limitations
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