Failed Back Surgery Syndrome

//Failed Back Surgery Syndrome
Failed Back Surgery Syndrome 2016-11-17T09:50:55+00:00

What Is Failed Back Surgery Syndrome?

Failed back surgery syndrome refers to a condition whereby patients have persistent pain or develop new pain after undergoing spinal surgery. Various spinal surgeries are utilized to treat numerous conditions of the spine. These surgical procedures include laminectomies, discectomies, spinal stenosis decompression, and spinal fusion procedures, among others. Despite advances in surgical technology, the rates of failed back surgery have remained unchanged, and unfortunately, some patients experience debilitating pain after spinal surgery.

Patients with failed back surgery syndrome may report an initial relief of symptoms; however, they will typically start to report an increase in pain around three to six months after surgery. Typical symptoms of failed back surgery syndrome include a diffuse, dull ache in the back or legs. Additionally, abnormal sensation including pricking and stabbing may be felt in the extremities.

Causes Of Failed Back Surgery Syndrome

The etiology of failed back surgery can be attributed to a number of factors, including poor patient selection, incorrect diagnosis, suboptimal selection of surgical intervention, poor surgical technique, and failure to achieve surgical goals, as well as recurrent pathology.

The most common cause of failed back surgery syndrome is most likely poor patient selection. Various studies have found that psychological disturbances can be related to poor spinal surgery outcomes. Additionally, poor surgical outcomes are associated with patients who exhibit abnormal pain behaviors and those who have clinical depression or anxiety, as well as those who are receiving workers’ compensation or who are involved in litigation.

Another cause of failed back surgery is incorrect or incomplete diagnosis. A poor surgical outcome may occur if intraspinal pathology was misdiagnosed prior to surgical intervention. Failure to identify the definitive source of pain may result in a mismatch of surgical procedures, resulting in ongoing pain after surgery, as the problem was not correctly addressed.

Surgical error is another cause of failed back surgery. The most common type of spinal surgical error is wrong-level discectomy. Other errors include failing to identify the correct level of spinal stenosis or incorporating the wrong spinal levels for fusion procedures. Additionally, selecting a surgery that inadequately addresses all of the patient’s symptoms may result in a poor outcome.

Even when the patient’s underlying issue is accurately identified and the appropriate procedure is selected, if the surgery is incompletely or inappropriately performed, poor outcomes can result. Furthermore, if complications arise, they must be identified and treated quickly to avoid further damage.

Recurrence of symptoms after spinal surgery may be the result of an ongoing degenerative disease process, or an alteration in biomechanics caused by spinal surgery. Recurrent disc herniation occurs in about 5% to 15% of patients; with almost half occurring at a new level, or on the other side. Furthermore, transition syndrome can occur when the stability of a fusion spinal segment increases the load to adjacent spinal segments, accelerating disc degeneration. Formation of scar tissue around the spinal nerve root after surgery can also result in persistent pain after surgery.

Treatment For Failed Back Surgery Syndrome

Treatment of patients presenting with symptoms of failed back surgery syndrome should begin with a detailed history, focused physical examination, and carefully selected diagnostic tests. The evaluation of a patient with symptoms of failed back surgery syndrome should identify symptoms, rule out extraspinal causes, identify a specific spinal etiology, in addition to assessing the patient’s psychological state.

Medication may be necessary to alleviate some of the patient’s pain. Medications may include analgesic and anti-inflammatory medications, including non-steroidal anti-inflammatory drugs (NSAIDs). Additionally, some patients may be prescribed opioids for short-term pain relief. Furthermore, certain antidepressants medications may be prescribed.

Physical therapy, chiropractic care, transcutaneous electrical nerve stimulation (TENS), and electroacupuncture may also be recommended as complementary treatments for patients suffering with failed back surgery syndrome. Epidural steroid injections, nerve blocks, and trigger point injections may also be suggested to help alleviate a patient’s pain. Epidural steroid injections consist of injecting a corticosteroid, combined with a local anesthetic, into the epidural space of the affected area. Nerve blocks consist of injecting medication close to or directly into a nerve root to help block pain signals. Trigger point injections involve injecting medication directly into a trigger point to help relieve pain.

If the pain associated with failed back surgery syndrome does not respond to initial pain management therapies, spinal cord stimulation may be recommended. This therapy involves implanting stimulating electrodes in the epidural space and implanting a small electrical pulse generator near the spine that is connected with conducting wires. These devices usually have a remote control. Spinal cord stimulation delivers small, electrical impulses to the spinal cord to help control chronic pain.

While not all therapies may provide complete relief of symptoms, physicians will help to design the best treatment plan to help eliminate as much pain as possible. A combination of treatment options usually provides the best possible treatment outcomes.

Conclusion

Low back pain is a common condition, affecting millions of adults in the United States. Often, patients resort to surgery to help manage their symptoms; however, spinal surgery is not always effective. Failed back surgery syndrome is a relatively common condition that results in persistent or new pain after spinal surgery. There are various causes of failed back surgery syndrome, ranging from poor patient selection to poor surgical technique.

Patients presenting with symptoms of failed back surgery syndrome need to be thoroughly evaluated in order to determine the underlying cause of their pain. There are various treatment options that can be offered to patients with this condition, ranging from conservative treatments to slightly more invasive options. Optimal treatment outcomes are usually seen with a combination of treatment therapies. Patients should discuss their symptoms with their physicians to determine an appropriate treatment plan for their condition.

References

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  3. Hwang M, Heo K, Cho H, Shin B, et al. Electroacupuncture as a complement to usual care for patients with non-acute pain after back surgery: a study protocol for a pilot randomised controlled trial. BMJ Open. 2015;5(2):e007031.
  4. Kumar K, Raylor RS, Jacques L, Eldabe S, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicenter randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007;132(1,2):179-188.
  5. Smith HS. Current Therapy In Pain. Philadelphia: Saunders/Elsevier, 2009. 323-331.
  6. Taylor RS. Spinal cord stimulation in complex regional pain syndrome and refractory neuropathic back and leg pain/failed back surgery syndrome: results of a systematic review and meta-analysis. Journal of Pain and Symptom Management. 2006;31(4):S13-S19.
  7. Tharmanathan P, Adamson J, Ashby R, Eldabe S. Diagnosis and treatment of failed back surgery syndrome in the UK: mapping of practice using a cross-sectional survey. British Journal of Pain. 2012;6(4):142-152.
  8. Vleggeert-Lankamp CL, Arts MP, Jacobs WCH, Peul WC. Failed back (surgery) syndrome: time for a paradigm shift. British Journal of Pain. 2013;7(1):48-55.

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