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Failed back surgery syndrome
Abstract
A review of the etiology, clinical, radiological, differential diagnosis and management goals of failed back surgery syndrome is presented.
... There was a large body of lower-level studies that were not assessed for quality. This included 1 scoping review [31], 1 narrative review [32], 14 case series [33][34][35][36][37][38][39][40][41][42][43][44][45][46], 23 case reports , and 2 commentaries [70,71]. Ten of the case reports described 53 cases following discectomy, 16 reports described MMT in 143 cases post-laminectomy, 16 reports described MMT care for 67 cases after fusion, 1 report discussed post-surgical treatment in 8 cases after artificial disc replacement, and 1 report discussed care in 3 cases following implantation of spinal cord stimulators. ...
... In a scoping review of lumbar surgery perioperative rehabilitation, Marchand et al. found that passive and active hip and knee flexion exercises reduced time to independent mobility and return-to-work. Commentaries by Walker [70] and Shapiro [71] discussed complications related to, and the role of manipulation for, individuals with FBSS. ...
Background
The purpose was to identify, summarize, and rate scholarly literature that describes manipulative and manual therapy following lumbar surgery.
Methods
The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was registered with PROSPERO. PubMed, Cochrane Database of Systematic Reviews, ICL, CINAHL, and PEDro were searched through July 2019. Articles were screened independently by at least two reviewers for inclusion. Articles included described the practice, utilization, and/or clinical decision making to post surgical intervention with manipulative and/or manual therapies. Data extraction consisted of principal findings, pain and function/disability, patient satisfaction, opioid/medication consumption, and adverse events. Scottish Intercollegiate Guidelines Network critical appraisal checklists were utilized to assess study quality.
Results
Literature search yielded 1916 articles, 348 duplicates were removed, 109 full-text articles were screened and 50 citations met inclusion criteria. There were 37 case reports/case series, 3 randomized controlled trials, 3 pilot studies, 5 systematic/scoping/narrative reviews, and 2 commentaries.
Conclusion
The findings of this review may help inform practitioners who utilize manipulative and/or manual therapies regarding levels of evidence for patients with prior lumbar surgery. Following lumbar surgery, the evidence indicated inpatient neural mobilization does not improve outcomes. There is inconclusive evidence to recommend for or against most manual therapies after most surgical interventions.
Trial registration
Prospectively registered with PROSPERO (#CRD42020137314). Registered 24 January 2020.
... The original scale consists of 21 items, including symptoms and attitudes with intensities ranging from 0 to 3. The sum of the scores for each item reveals the intensity of the depression: values below 10 signify the absence of depression or the presence of mild depression, values between 10 and 18 signify mild to moderate depression, values between 19 and 29 signify moderate to severe depression, and values between 30 and 63 signify severe depression. For the measurement of anxiety, the sum of the items indicates the intensity as minimal (up to 10), mild (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20), moderate (20-30) or severe (31-63). ...
... As many as one-third of the patients undergoing surgery for the correction of lumbar disc conditions experience recurrent postoperative symptoms [16]. Walker [17] states that 20-40 % of the patients undergoing lumbar surgery will not experience benefits from the procedure and that the condition will worsen in 1-10 %. The high prevalence in our study was perhaps due to inaccurate indications for surgery, in which the preoperative pain may have been attributed to disc herniations despite the other possible differential diagnoses. ...
Background and objectives:
Although not well known, post-laminectomy syndrome (PLS) is an important cause of chronic back pain, which may lead to decreased quality of life, disability and psychological disorders. This study aimed to evaluate the clinical characteristics and prevalence of PLS, to estimate its impact on the quality of life and to determine its association with anxiety, depression and disability in patients at public hospitals in São Luís, MA.
Methods:
Cross-sectional, descriptive and analytical study. Eighteen patients characterized as having PLS were selected, and their clinical, epidemiological and psychological characteristics, their quality of life and their levels of physical fitness were evaluated through clinical evaluations, Beck questionnaires, the Short Form-36 (SF-36), the Rolland-Morris questionnaire and the Douleur Neurophatique 4 questions. The multidimensional pain evaluation was performed using the McGill Pain Questionnaire.
Results:
The prevalence of post-laminectomy pain was 60 %. Most of the patients assessed in this study were male and received a family income of up to minimum wage; their mean age was 45 years. All of the patients presented with chronic, intense pain that had lasted an average of 7.22 years. The prevalence of neuropathic pain was 89.9 %. The physical appearance and functional capacity domains of the SF-36 were classified as unsatisfactory in 94.4 and 83.3 % of the patients, respectively. None of the patients exhibited high levels of physical fitness. The average score was 21.33 for anxiety and 18.88 for depression. There was a strongly positive and significant relationship between the anxiety and depression scores. Additionally, there was a moderately positive and significant relationship between the disability and anxiety scores. Regarding the correlation between the pain intensity and the quality of life, there was a moderately significant relationship between the patients' mental health and their vitality.
Conclusion:
PLS exhibits a high prevalence and significance, and it causes high levels of morbidity in patients. Furthermore, PLS features intense levels of pain, reduced quality of life and greater physical and occupational disability.
... [3] FBSS is now considered a constellation of symptoms and has a varied etiology. [4,5] In a recent study, Baber and Erdek [4] have described the current thinking in FBSS. The etiology was tabulated into preoperative and postoperative causes. ...
Post spinal surgery syndrome(PSSS) has always been considered only for the pain it causes. However, many other neurological deficits do happen after lower back surgery. The aim of this review is to look into the various other neurological deficits that could happen after a spinal surgery. Using the keywords, foot drop, cauda equina syndrome, epidural hematoma, nerve and dural injury in spine surgery, the literature was searched. Out of the 189 articles obtained, the most important were analyzed. The problems associated with spine surgery have been published in the literature but are much more than the failed back surgery syndrome and cause more discomfort to the patients. To bring about a more sustained and collective awareness and understanding of these complications following spinal surgery, we encompassed all these complications under the heading of PSSS.
... The term "failed back surgery syndrome" (FBSS) has been introduced decades ago to cover any painful conditions in patients who did not achieve satisfying results after spinal surgery [21,22,28,44,45,49]. Although the term FBSS has been criticized for being too unspecific and several studies have shown that a variety of conditions may underlie "FBSS", this label is still used widely in common practice [4,5,8,11,13,15,17,19,23,24,29,34,38,39,41]. ...
Background
The term failed back surgery syndrome (FBSS) has been criticized for being too unspecific and several studies have shown that a variety of conditions may underlie this label. The aims of the present study were to describe the specific symptoms and to investigate the primary and secondary underlying causes of FBSS in a contemporary series of patients who had lumbar spinal surgery before.Methods
We used a multilevel approach along three different axes defining symptomatic, morphological, and functional pathology dimensions.ResultsWithin the study period of 3 years, a total of 145 patients (74 f, 71 m, mean age 51a, range 32–82a) with the external diagnosis of FBSS were included. Disk surgery up to 4 times and surgery for spinal stenosis up to 3 times were the commonest index operations. Most often, the patients complained of low back pain (n = 126), pseudoradicular pain (n = 54), and neuropathic pain (n = 44). Imaging revealed osteochondrosis (n = 61), spondylarthrosis (n = 48), and spinal misalignment (n = 32) as the most frequent morphological changes. The majority of patients were assigned at least to two different symptomatic subcategories and morphological subcategories, respectively. According to these findings, one or more functional pathologies were assigned in 131/145 patients that subsequently enabled a specific treatment strategy.ConclusionsFBSS has become rather a vague and imprecisely used generic term. We suggest that it should be avoided in the future both with regard to its partially stigmatizing connotation and its inherent hindering to provide individualized medicine.
... In addition to evaluating for hardware failure, they are useful in the diagnosis of spondyloarthropathies, tumor, infection, sequestrated fragment, and postoperative scar or fibrosis formation. 103 Intravenous contrast application is recommended in patients previously operated upon for disk herniation to help delineate postoperative scar tissue (epidural fibrosis) from herniated material. 104 Chiropractic Manipulation. ...
Objective:
The purpose of this narrative review was to describe the most common spinal fusion surgical procedures, address the clinical indications for lumbar fusion in degeneration cases, identify potential complications, and discuss their relevance to chiropractic management of patients after surgical fusion.
Methods:
The PubMed database was searched from the beginning of the record through March 31, 2015, for English language articles related to lumbar fusion or arthrodesis or both and their incidence, procedures, complications, and postoperative chiropractic cases. Articles were retrieved and evaluated for relevance. The bibliographies of selected articles were also reviewed.
Results:
The most typical lumbar fusion procedures are posterior lumbar interbody fusion, anterior lumbar interbody fusion, transforaminal interbody fusion, and lateral lumbar interbody fusion. Fair level evidence supports lumbar fusion procedures for degenerative spondylolisthesis with instability and for intractable low back pain that has failed conservative care. Complications and development of chronic pain after surgery is common, and these patients frequently present to chiropractic physicians. Several reports describe the potential benefit of chiropractic management with spinal manipulation, flexion-distraction manipulation, and manipulation under anesthesia for postfusion low back pain. There are no published experimental studies related specifically to chiropractic care of postfusion low back pain.
Conclusions:
This article describes the indications for fusion, common surgical practice, potential complications, and relevant published chiropractic literature. This review includes 10 cases that showed positive benefits from chiropractic manipulation, flexion-distraction, and/or manipulation under anesthesia for postfusion lumbar pain. Chiropractic care may have a role in helping patients in pain who have undergone lumbar fusion surgery.
Background and Purpose
Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events.
Methods
Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events.
Results
Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria.
Conclusion
There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.
Background:
Post-laminectomy syndrome is a common cause of dissatisfaction after endoscopic interlaminar approach. Our aim was to evaluate the efficacy and safety of our two newly designed instruments for laminotomy, a dural protector attached to the scope and a knot pusher for water-tight suturing of the incidental dural tears.
Material and methods:
This was a multicenter evaluation. Efficacy was quantified as the pre-to-postoperative improvement in pain (visual analog scale), disability (Oswestry Disability Index), patient satisfaction (modified MacNab score), and length of hospital stay. Safety was quantified by the incidence and location of dural tears, rate of revision, and radiological outcomes. Outcomes were evaluated between the control (before instrument development) and experimental (after instrument development) groups.
Results:
There was a significant improvement in leg pain in the experimental group (p = 0.03), with greater patient satisfaction in the control group (p < 0.01). There was no incidence of dural tears in the area of the traversing and exiting nerve roots in the experimental group. Water-tightness of sutures was confirmed radiologically.
Conclusion:
The novel dural protector and the knot pusher for water-tight sutures improved the efficacy and safety of decompression and discectomy; however, a prolonged operative time was a drawback.
Failed back surgery syndrome (FBSS) is defined as persistent or recurring low back pain following one or more spine surgeries. It is part of the worldwide epidemic of chronic pain which is estimated to affect 37 % of the general adult population with a 60–80 % lifetime prevalence. These numbers are only projected to rise as our elderly population expands, demonstrating the extent to which chronic low back pain impacts our society. The etiology of FBSS is driven by a complex relationship of not only biological and psychological factors, but also social and economic. These factors can be broken down into pre-, intra-, and postoperative categories. It is essential, however, that the correct procedure be selected for the appropriately screened and properly diagnosed patient. A thorough history and physical exam along with advanced imaging including MRI with gadolinium, flexion/extension X-rays, and CT can be beneficial in helping to diagnose FBSS.
This report describes the treatment of 3 patients with previous spinal fusion surgery who had subsequently regressed to their previous levels of pain and disability.
Three patients with chronic intractable pain presented to a private integrative medicine clinic for manipulation under anesthesia (MUA) evaluation. All 3 patients had previously had lumbar spine fusion surgery for intervertebral disk herniation. All surgeries were performed at least 2 years before clinical presentation. Patients had plateaued with other conservative pain management strategies before seeking MUA treatment.
The patients were evaluated for MUA. The patients received a serial MUA over 3 consecutive days by trained chiropractic and osteopathic physicians. Outcome assessments used for each patient included a quadruple numerical pain rating scale and functional rating index. Patients completed a course of post-MUA physiotherapy and rehabilitation lasting 8 weeks immediately after the serial MUA. Clinical improvements were observed in all 3 outcome assessments after the MUA, the post-MUA therapy, and were essentially maintained 1 year after conclusion of treatment.
Three patients with failed back surgery were treated conservatively using MUA by trained chiropractic and osteopathic physicians followed by 8 weeks of post-MUA therapy. Pain and disability outcomes all improved immediately following treatment.
A considerable number of patients complain about pain after lumbar surgery. The spinal dura mater has been debated as a possible source of this pain. However, there is no information if laminectomy influences the nociceptive sensory innervation of the dura. Therefore, we quantitatively evaluated the density of SP- and CGRP-immunopositive nerve fibers in the dura mater lumbalis in an animal model of laminectomy. Twelve adult Lewis rats underwent laminectomy, in six of them the exposed dura was covered by an autologous fat graft. Further six animals without surgical treatment served as controls. Six weeks after surgery, the animals were perfused and the lumbar dura was processed immunohistochemically for the detection of CGRP- and SP-containing nerve fibers. In controls, the peptidergic nerve fibers were found predominantly in the ventral but rarely in the dorsal dura mater lumbalis. After laminectomy, the density of SP- and CGRP-immunopositive neurons significantly increased in ventral as well as in dorsal parts of the dura. Axonal spines could be observed in some cases at the site of laminectomy. The application of autologous fat grafts failed to inhibit the significant increase in the density of peptidergic afferents. Thus, we have provided the first evidence that laminectomies induce an increase in the density of putative nociceptive SP- and CGRP-immunopositive neurons in the lumbar dura mater ascribable to an axonal sprouting of fine nerve fibers. This effect was not prevented by using autologous fat grafts. It is conceivable that the neuronal outgrowth of nociceptive afferents is a cause of low back pain observed after lumbar surgery.
In the United States, approximately two thirds of all patients enrolled in chronic pain centers suffer from the failed back syndrome. Neurosurgeons perform 100,000 operations for lumbar disc disease every year, and orthopedic surgeons perhaps perform a similar number.6 It is estimated that between 20% and 40% of these operations are unsuccessful and result in the failed back syndrome. Dr. William Sweet, former Professor and Chairman of Neurosurgery at the Massachusetts General Hospital, has estimated that, in contrast, only approximately 10% of patients enrolled in European pain clinics suffer from the failed back syndrome.7 The reasons for this discrepancy are likely to be multiple, including, perhaps, Europeans’ greater stoicism and a less supportive acceptance of disability and non-productivity.
Seventy-two patients having chronic back pain, representative of high-risk demographic and personality populations, received a broad range of therapeutic modalities designed around the theme of self-regulation. The self-regulation principle was used in: (1) biofeedback training for teaching self-regulated muscle relaxation; (2) psychological counseling emphasizing self-control techniques for the management of stress and anxiety, including assertion training; (3) patient-regulated medication program; (4) patient involved case conferences; (5) physical therapy program emphasizing reconditoning; (6) comprehensive vocational rehabilitation services; (7) a series of educational lectures; (8) a therapeutic milieu designed for relaxation, recreation and socialization. Utilizing a success criteria of functional physical activity at discharge (average length of stay, 45 days) and levels of vocational restoration (employable, in training, or employed at 30 days postdischarge), 57 of the patients demonstrated unimpaired physical functioning levels and 59 of the patients were at success levels of vocational restoration.
The major objectives of spinal surgery are to relieve pain, improve function, and correct deformity. The surgical strategies to meet these objectives are decompression of neural elements or surgical stabilization by arthrodesis. This article analyzes spinal fusion from the perspective of indications, the broad principles of surgical technique, the results that can be obtained, and the complications of the procedure.
Records of 575 patients operated on for the first time for lumbar disc herniation have been reviewed. Four to 17 years after the operation 371 (65%) patients answered a questionnaire on number of reoperations, working capacity, lumbar or sciatic pain as well as necessity of treatment. Of these, 255 (70%) still complained of back pain, and 83 (23%) of this group complained of constant heavy pain; 172 patients (45%) have a residual sciatica; 131 (35%) are still under some kind of treatment; 47 (14%) patients are receiving a disability pension. Repeat operations were performed in 17%. Based on the criteria given by Spine Update 1984 as related to justified or unjustified indication there was no statistical difference in long-term results concerning the above-mentioned criteria of success. The so-called justified indication for disc herniation neurosurgery does not necessarily imply a good long-term result. In the preoperative investigation, not only symptoms and neurological signs, but also the socially and personally defined career of the illness are of importance. The patients with complaints, mainly those receiving a pension, are psychologically conspicuous and show more psychopathological features as monitored by MMPI than the patients without complaints after surgery. Psychological assessment should increasingly be used in the preoperative evaluation, especially in patients who do not present an absolute indication for neurosurgical intervention.
The biomechanical effects of discectomy on the motion behavior of whole lumbar spine are investigated using a Selspot II system. Fresh human ligamentous specimens were potted at the sacrum and clinically relevant loads (flexion/extension, right/left lateral bending, and right/left axial torsion moments) applied through a loading frame attached rigidly to the topmost vertebra of the specimen. The resulting three-dimensional motions of each vertebra for the intact specimen were recorded. The specimen was injured sequentially on the right side of the L4-5 level: partial laminectomy, partial facetectomy, subtotal discectomy, and total discectomy. The motion behavior of the specimen after each injury was recorded. The results of the injured tests were normalized with respect to the corresponding intact results. The normalized data for eight specimens were pooled for statistical analysis. Subtotal discectomy induced significantly less motion at the injury site than total discectomy, in all loading modes. At L3-4, the motion segment above the injury level, anteroposterior translation in flexion and lateral translation in left lateral bending show significant increases irrespective of the amount of nucleus excised. The clinical relevance of these findings are discussed.
An animal experimental study was performed to investigate prevention of scar formation under lumbar laminectomy by using new biodegradable interposing materials-- polylactic acid (PLA) foam and membrane. The experimental animals consisted of 32 dogs, 16 control and 16 experimental. The experimental surgery consisted of L5 or L6 complete laminectomy and covering of the laminectomy defect with the experimental materials. The same procedure but without the covering of the laminectomy defect was performed on the control group animals. Animals were sacrificed at varying intervals (2-52 weeks) and the lumbar spines were evaluated with histologic preparations. The PLA membrane is found to be a promising material for prevention of scar tissue extension and adhesion after laminectomy but has a problem of marginal fitting. PLA foam is found to behave as a scaffold for scar tissue extension and adhesion onto the nerve. Other foamy materials such as gelatin foam or avitane are probably behaving similarly, causing scar tissue extension and adhesion. The new materials were found to be completely biocompatible and slowly biodegradable. A combined use of posteriorly convexed stiff PLA membrane and marginal gap filler with PLA foam may provide solutions for both prevention of scar tissue extension and adhesion and prevention of postlaminectomy spinal stenosis.
An interinstitutional study on the failed back surgery syndrome (FBSS) has determined that failure to recognize or adequately treat lateral stenosis of the lumbar spine with resultant nerve irritation and/or compression comprised the primary etiology in 57% to 58% of patients. Other common causes were recurrent or persistent disk herniation and lumbosacral adhesive arachnoiditis. The diagnosis of stenosis was made either by high-resolution CT scan of the lumbar spine or by directly testing lateral canal and for animal patency at the time of surgery. It is now appreciated that the process of degenerative disk disease, particularly when enhanced by diskectomy, results in progressive loss of intervertebral disk volume and predisposes to future ipsilateral or contralateral lateral spinal stenosis. Degenerative disk disease is ultimately a bilateral process and therefore surgical exposure should be bilateral. The direct and indirect costs of FBSS to patients and to society as well as the toll in human suffering are very high. This is particularly a matter of concern when it is realized that for many FBSS patients, surgery could have been avoided in the first place by preventive care or by innovative conservative treatment. When surgery is indicated, adequate diagnostic tests and the execution of appropriate procedures based upon this information should largely prevent the failed back surgery syndrome.
Post-operative instabilityafterdecompression forlumbarspinalstenosis
- K- Johnsson
- E Willner
- S Johnsson
Johnsson K-E., Willner S., Johnsson K. Post-operative instabilityafterdecompression forlumbarspinalstenosis.Spine. Vol 11, No 2.1986. pp. 107-110.