General
- Aka
- Fail back surgery syndrome
Definition
- Christelis et al 2021: Chronic axial pain and/or radicular symptoms of spinal origin has or has not been caused by spinal surgery, or who have not undergone any spinal surgery.
Numbers
- Estimated to be anywhere between 10% and 40% following spinal surgery for disc-related pathologies
- Four out of five are unable to work
- The quality of life is reported to be worse than in other common chronic pain conditions
Classification
- Type 1: Post spinal surgery
- Type 2: without spinal surgery
- i.e. self resolved disc but with resultant pain.
Clinical presentation
- 2 types
- Predominant neuropathic buttock pain and leg pain
- Treatment conventional SCS
- Predominant neuropathic back pain
- Treatment
- High-frequency SCS,
- Dorsal root ganglion stimulation,
- Peripheral nerve field stimulation or complex surgical paddle leads
- Burning pain
- Is characteristic of neuropathic pain secondary to nerve damage and includes complex regional pain syndrome.
- This type of pain is best treated with neuropathic agents and referral to a pain specialist.
- Neuromodulation in the form of spinal cord stimulation may also be considered.
- PainDETECT
- Function: a screening tool to detect neuropathic pain components in persons with chronic low back pain
Investigation
- MRI
- Look for
- Postoperative discitis
- A screening tool to detect neuropathic pain components in persons with chronic low back pain[Residual disc herniation needs to be differentiated from epidural scarring, as this has implications for further treatment options.
- New or recurrent lateral disc prolapse should be ruled out if the patient presents with a new onset of symptoms and signs of a radicular nature.
- Foraminal stenosis is one of the most common causes of persistent back pain following surgery.
Management
- Bio-psycho-social assessment by MDT
- Pain physician
- Neuropsychologist
- Medication
- Oral
- Baron 2010: large randomised controlled trial published recently failed to show efficacy of pregabalin in neuropathic pain associated with radiculopathy.
- Overall the efficacy of Gabapentinoids seems borderline at best for neuropathic pain,
- Injections
- Transforaminal epidural steroid injection
- Efficacy of interlaminar lumbar or caudal epidural steroid injections in FBSS is not as well established as for acute lumbar radicular pain
- Modulation
- Neuromodulation should not be considered as a ‘last-ditch’ effort but should be offered early in the management plan.
- Chemical
- Pharmacological management by various routes including
- Intrathecal drug delivery systems.
- Implantation usually follows a trial and a careful assessment of the trial results.
- The management of patients on large doses of opioids before trial also varies (some wean off the opioids, some reduce the dose by half and some continue high-dose opioids during the trial process).
- There is considerable variation in the use of ITDDS by neuromodulation units.
- Bolus
- Infusion
- A patient with an ITDDS requires long-term regular follow-up for regular pump refills, and to identify and solve potential problems which may arise in relation to efficacy, side effects related to drugs delivered through the pump and neurological or endocrine issues arising as a result of this treatment.
- Agents
- Morphine
- Ziconotide
- Baclofen
- Outcome
- Although there may be benefits from an ITDDS in some patients with FBSS, there is limited consensus on long-term efficacy, safety and cost-effectiveness.
- Electrical
- Spinal cord stimulator
- Mainly for neuropathic buttock pain and leg pain
- Kumar et al 2007
- N=100
- Spinal cord stimulation plus conventional medical management (SCS group)
- Conventional medical management alone (CMM group) for at least 6 months.
- With predominant leg pain of neuropathic radicular origin
- Outcome
- 50% or more pain relief in the legs occurred in
- 24 SCS patients (48%)
- 4 CMM patients (9%) (p < 0.001)
- (32%) had experienced device-related complications
- In selected patients with FBSS, SCS provides better pain relief and improves health-related quality of life and functional capacity compared with CMM alone
- North 2005: SCS is more effective than reoperation as a treatment for persistent radicular pain after lumbosacral spine surgery
- High-frequency spinal cord stimulation:
- Indication
- FBSS with a predominant lower back pain component.
- A frequency of about 5000–10,000 Hz is used.
- A major advantage is that patients do not have to rely on the perception of paraesthesia in the affected area.
- There are no efficacy, cost-effectiveness or safety data from a randomised controlled trial or comparison with conventional SCS in relation to the long-term use of this technology.
- Dorsal root ganglion stimulation:
- A specially designed lead is placed around the dorsal root ganglion, via the epidural space, and this produces pleasant paraesthesia in a dermatome or part of it.
- The major advantages seem to be that there is no change in perception of paraesthesia with posture, and it is possible to target dermatomes which would otherwise be difficult to target with conventional SCS (foot, groin etc.) without overspill of paraesthesia into other dermatomes.
- There are minimal long-term data regarding efficacy, safety and cost-effectiveness.
- Peripheral nerve field stimulation:
- Specially designed leads have been approved for this use, especially for treating the neuropathic back pain component of FBSS.
- Use of this technique, in combination with conventional SCS or alone, has been published with impressive results in case series.
- However, cost-effectiveness and long-term efficacy are not established.
- Surgical
- Facet joint denervation
- Cognitive–behavioural rehabilitation.
- Postoperative complications
- The term does not imply negligence, more that the patient has persistent pain beyond what is expected, and that this may be incapacitating and prevent return to work.
- When a poor surgical outcome is encountered, three questions should be asked:
- Was this the correct operation?
- For example, decompression alone in a patient with degenerative spondylolisthesis experiencing increasing back pain postoperatively.
- Was it the correct diagnosis?
- For example, performing lumbar surgery in the context of hip and knee pathology or cervical surgery in the context of shoulder pathology or coexisting ulnar or median nerve neuropathy.
- Medical conditions such as diabetes, vasculitis, and nutritional deficiency resulting in neurological dysfunction should always be borne in mind.
- Was this the correct management for this particular patient?
- For example, it is important to assess the patient’s level of motivation, expectations, psychological well- being, and be aware of potential secondary gains and litigation.
- This algorithm may aid in reflective practice, however, there will be occasions when poor outcomes are beyond the control of the clinician.
- Recurrent or ongoing axial and radicular pain may be due to
- Residual compression (retained disc and osteophytes)
- Recurrent disc herniation
- Adjacent segment disease
- Peridural scar formation and fibrosis
- Postoperative discitis (infective and aseptic)
- Pseudomeningocele formation
- Epidural haematoma
- Arachnoiditis
- Permanent nerve root injury
- Operative damage following retraction or inadvertent durotomy, conjoined nerve roots (compression at an adjacent level to that operated)
- Progressive spondylosis and instability
- Failure to appreciate sagittal imbalance resulting in muscular fatigue and deformity
- Coexisting myofascial syndrome
- Complex regional pain syndrome
- It is important to ascertain the nature of pain
- Sagittal imbalance
- (Flat back/ lumbar kyphosis) is corrected through the action of the back extensors and increased pelvic tilt resulting in pain and fatigue.
- Pain can be incapacitating, and deformity can have psychosocial implications secondary to poor self image and deficient horizontal gaze.
- Correction of fixed deformity can be achieved through aggressive surgical techniques, such as the
- Smith– Peterson osteotomy
- Pedicle subtraction osteotomy.
Made with Bullet