approach to failed back surgery syndrome (fbss ) agrasen hospital gondia vidarbha dr sandeep c...

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Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India drsandeep123@gmail.com

www.drsandeepagrawal.com www,agrasenortho.com

Failed Back Surgery Syndrome(FBSS)

SYNOVIAL CYST

FBSS

• Failed back surgery syndrome

Numbers of spine surgery increasing !

Surgical results not always successful

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Failed Back Surgery SyndromeFBSS is a term applied to a heterogeneous group of individuals who share only one characteristic - continued back and/or extremity pain following one or more spinal operations 15% of patients will experience persistent or recurrent symptoms Spectrum of abnormalities ranging from purely organic to purely psychological, but in most cases consists of a physiological abnormality complicated by psychological factors FBSS is perhaps the prototypical example of chronic pain as a biopsychosocial disorder

Failed back surgery syndrome • Definition: the results of re-operation did not differ

significantly from those of initial surgery !

• Etiology: – Recurrent disc herniation – Segmental instability – Spinal stenosis – Infection

Failed back surgery syndrome • No improvement • Getting worse • Recurrence after a period of pain relief !

• Wrong diagnosis • Inadequate treatment

– Wrong level or side – Inadequate decompression or stabilization

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Failed Back Patient ProfilePain and suffering often disproportionate to any identifiable disease process Depression Physical deconditioning Inappropriate use of physician-prescribed medications Superstitious beliefs about bodily functions Failure to work or perform expected physical and cognitive activities No active medical problems that can be remediated with the expectation of relief of pain

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The “Ds” of FBSS

Disuse

Deconditioning

Drug misuse

Dependence

Depression

Disability

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9% – 28% of the population suffers from moderate to severe chronic non-cancer pain

American Pain Society (2002); Chronic pain in America: roadblocks to relief

Chronic Pain – Scope of the Problem

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Pain TypesNOCICEPTIVE PAIN

results from ongoing activation of mechanical, thermal, or chemical nociceptors typically opioid-responsive eg. pain related to mechanical instability

!NEUROPATHIC PAIN

spontaneous or evoked pain that occurs in the absence of ongoing tissue damage typically opioid-resistant*** eg. pain secondary to nerve root injury

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Neuropathic Pain

Pain in absence of ongoing tissue damage Pain in an area of sensory loss Paroxysmal or spontaneous pain Characteristics of pain: burning, pulsing, stabbing Allodynia, hyperalgesia, or dysesthesias Delay in onset following injury Presence of major neurological deficit Poor response to opioids

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Biopsychosocial Model of Pain

Pain Behavior

Suffering

Pain

Nociception

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Failed Back Surgery Syndrome Surgical Complications

Disk space infection

Iatrogenic instability

Nerve root injury

Retained disk fragment

Recurrent disk herniation

Inadequate decompression

Complications of fusion and instrumentation

Adhesive arachnoiditis

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CLASSIFICATION OF FAILURE

■ No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy

1) Wrong pre-operative diagnosis 2) Technical error

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■ No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy 1) Wrong pre-operative diagnosis

1) Tumor 2) Infection 3) Metabolic Disease 4) Psychosocial 5) Discogenic pain (IDD,IDR) 6) Decompression done too late for disc

sequestration

CLASSIFICATION OF FAILURE

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CLASSIFICATION OF FAILURE

■ No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy 2) Technical error

1) Missed level or levels 2) Failure to perform adequate decompression

1) Missed fragment including foraminal disc 2) Failure to recognize canal stenosis 3) Conjoined nerve root

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Failed Back Surgery Syndrome Physician Decision Making

Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection

Problems of re-operation • Poor landmarks of anatomy • Wrong level • Neural injury • Blood loss • Longer op time • Difficulty in instrumentation • Inadequate bone graft

F.B.S.S.

History taking Neuro. exam Image study

Psychosocial evaluation

Specific diagnosis

Mechanical causes Non-mechanical causes

Appropriate surgery Medical tx

Rehabilitation Psycho. tx

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Most common cause of failed back syndrome is poor

judgment on the part of the physician. Surgery prescribed as a last resort, with a hope and a prayer that it might

alleviate the pain.

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CLASSIFICATION OF FAILURE

!■ Temporary relief but recurrence of pain

1) Early recurrence of symptoms (within weeks) 1) Infection 2) Meningeal cyst 3) Juxtafacet cyst

1) Synovial cyst 2) Ganglion cyst

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JUXTAFACET (JFC) CYSTS :

■ Term originated by Kao et al in 1974

■ First reported by von Gruker in 1880 during autopsy

■ First diagnosed clinically in 1968

CYSTS ADJACENT TO THE FACET

JOINT, OR ARISING FROM THE

LIGAMENTUM FLAVUM

Kao C.C., Winkler S.S., Turner J.H: Synovial Cyst of Spinal Facet. J Neurosurg 41:372-6,1974. Kao C.C., Uihlein A., Bickelr W.H: Lumbar Intraspinal Extradural Ganglion Cyst. J Neurosurg 29:168-72,1968.

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TYPES

■ SYNOVIAL CYSTS (those having a synovial

lining membrane)

■ GANGLION CYSTS (those lacking lining

membrane)

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ETIOLOGY

Unknown Possibilities

Synovial fluid extrusion from the joint Latent growth of a developmental rest Myxoid degeneration and cyst formation in collagenous connective tissue Increased motion plays a role in some cases

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IMAGINGPRE OPERATIVE TI 8 WEEKS POST OP T1

SYNOVIAL CYST

SYNOVIAL CYST

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IMAGING

PRE OPERATIVE T2 8 WEEKS POST OP T2

HYPERTOPHIED LIGAMENT

STENOSED LATERAL RECESS

HYPERTOPHIED JOINT

DECOMPRESSED CANAL

SYNOVIAL CYST

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CLASSIFICATION OF FAILURE

!■ Temporary relief but recurrence of pain

2) Mid-term (within weeks to months) ■ Recurrent disc prolapse ■ Battered root ■ Arachnoiditis ■ Patient expectations

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Battered root syndrome

The permanent radiculopathy caused by surgical trauma was first called the battered root problem by Bertrand in 1975. It is the reappearance of radicular pain after the relief of sciatica by operation. The pain is constant, burning, increased by motion or Valsalva. At that time rhizotomy was suggested as the treatment. Since it is considered now as a type of peripheral neuropathy, the treatment shifted to spinal cord stimulation (SCS).

!Bertrand G. The battered root problem Orthop Clin North Am. 1975 Jan;6(1):305-10

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Arachnoiditis

Arachnoiditis is a disease of the spine which results in the clumping or sticking of nerve roots together inside the spinal fluid. The nerves adhere together therefore the technical name of the condition is "adhesive arachnoiditis". Arachnoiditis occurs intradurally whereas peridural fibrosis occurs extradurally in the epidural space.

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Arachnoiditis

The most common causes of arachnoiditis are meningitis, spine surgery and trauma. A cause for which there are a few case reports in the literature are epidural steroid injections . Epidural analgesia not cause. The incidence of arachnoiditis after spine surgery in patients undergoing re-operation for pain ranges from 3.5% to 16%

Ribeiro C, Reis FC Findings and outcome of revision lumbar disc surgery J Spinal Disord 1999 Aug;12(4):287-92 and Lumbar arachnoiditis Acta Med Port 1998 Jan;11(1):59-65.

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CLASSIFICATION OF FAILURE

!■ Temporary relief but recurrence of pain

3) Longer-term failures (within months to years) 1) Recurrent stenosis or development of lateral

stenosis from disc space collapse 2) Instability

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Disc space collapse

A number of relapses are due to disc space collapse. Although the disc height is often decreased in the preoperative patient with a herniated nucleus pulposus, it is an exceedingly common occurrence following surgical discectomy. Disc space narrowing is very important in terms of decreasing the size of the neural foramina and altering facet loading and function. The entire process predisposes to the development of hypertrophic changes of the articular processes.

Hanley EN, Shapiro DE. The development of low-back pain after excision of a lumbar disc. J Bone Joint Surg 1989;71A:719-721 Schneck CD. The anatomy of lumbar spondylosis. Clin Orthop 1985;193:20-37. .

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Evaluation of the Patient with FBSS

Detailed pain history including prior treatments and MOST IMPORTANTLY the outcome of each !Obtain appropriate imaging studies (including those on which surgical decisions were based)

!Attempt to establish the underlying cause of the pain; however……….

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Pain HistoryWhere is it located?

Does the pain radiate?

When did it start and under what circumstances?

What is the quality of the pain?

What is the severity of the pain (VAS scores)

What factors make it worse?

What factors make it better?

Are there associated symptoms?

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Pain HistoryEffect of pain on sleep

Medications taken for pain

Health professionals consulted

Patient’s beliefs concerning the cause of pain

Expectations of outcome of treatment

Family expectations

Pain reduction required for “reasonable activities

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Treatment HistoryWhat therapies have been tried and what were the outcomes?

Physical therapy Injections ▪ Epidural steroids, nerve root blocks, facet blocks, etc

Medication history What drugs? Dose? How long? Effect?

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Imaging StudiesStatic plain radiographs

Spinal alignment Flexion/extension views

Instability Computed tomography (CT)

Bony surgical defects Hardware placement Fusion mass

Magnetic resonance imaging (MRI) Soft tissue and neural structures

Radionuclide imaging Technetium99 bone scan Indium111 WBC scan

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Post-operative Causes of Back PainDeconditioning Trauma

Muscle spasm Wrong level fused

Myofascial pain Insufficient levels fused

Spinal instability Pseudomeningocele

Diskogenic pain Graft donor site pain

Facet arthropathy Psychosocial factors

Infection

Pseudarthrosis

Loose hardware

Arachnoiditis

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Post-operative Causes of Leg Pain

Retained disk fragment Arachnoiditis

Recurrent HNP Synovial cyst

Far lateral disk Root sleeve meningocele

Lateral recess stenosis Loose hardware

Inadequate decompression Facet fracture

Wrong level decompressed Psychosocial factors

Nerve root injury

Retained foreign body

Epidural fibrosis

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Goals of Chronic Pain Management in Patients with FBSS

Functional improvement Functional improvement Functional improvement!!!

Improvement in physical activities and exercise tolerance Reduction in narcotic use Reduction in healthcare consumption Return to work Pain reduction

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Common Features of Multidisciplinary Pain Management

Physical therapy and rehabilitation Medication management Patient education about pain and body function Psychological treatments Coping skills training Vocational assessment Therapies targeted toward improving the likelihood of return to work Surgical interventions for selected patients

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Multidisciplinary Pain Clinic Personnel

Physicians Neurosurgeon Orthopedic surgeon Anesthesiologist Neurologist Physiatrist Internal medicine Psychiatrist Addictionologist

Nurses Psychologists

Physical Therapist Occupational Therapist Vocational counselor Social worker Dietician Recreational staff Administrative support staff

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Electrophysiological StudiesEMG is likely of greater utility in FBSS than in primary low back pain and sciatica !Greatest use is for establishing the presence of a peripheral neuropathy !May be helpful for defining a feigned neurological deficit !Rarely using in decision-making regarding treatment

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Diagnostic BlockadeRationale is straightforward In practice, it is much more complicated Specificity may be low Single blocks (positive or negative) have a high error rate Placebo controls provide the most accurate information Multiple blocks using different agents

BLOCKS ARE ADJUNCTS AND SHOULD NEVER BE SUBSTITUTED FOR SOUND CLINICAL JUDGEMENT !

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Facet Block

Blockade of the innervation of the facet joint will relieve pain in some patients with facet disease

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Facet BlockRarely useful in patient with FBSS

Transitional facet disease above a fused level !

Anatomy obliterated and accurate block not possible !Blockade of pseudarthrosis may sometimes be useful

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Selective Nerve Root BlockMust be done accurately to provide any useful information !One root at a time !Small volume of local anesthetic without steroids !Confirm the presence of an adequate block !Confirm findings on repetitive blocks

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Anticonvulsant Agents (AEDS)

Similarities in pathophysiology of neuropathic pain and epilepsy !All AEDS ultimately act on ion channels !Efficacy of AEDS most clearly established for neuropathic conditions characterized by episodic lancinating pain !Most clinical studies have focused on DPN and PHN !Use of AEDS in patients with FBSS is nearly entirely empiric

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Antidepressant Analgesics

Relieves all components of neuropathic pain !Clear separation of analgesic and antidepressant effects !Although other agents (eg anti-epileptics)) may be regarded as 1st line therapy over antidepressants, there is no good evidence for this practice !More selective agents are either less effective or not useful (serotonergic, noradrenergic)

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CorticosteroidsUseful in the short term for treatment of radicular pain !Limited role in the long-term treatment of FBSS !Epidural or transforaminal steroids for selected patients

Cochrane Review (Nelemans, et al., 2002) Most trials included patients with radicular pain No significant difference in pain relief after 6 weeks or 6 months between ESI and placebo

Adjacent instability( Case )• Well-defined spondylolisthesis • Dynamic instability with Slippage > 4 mm Angle change > 10° on flexion and extension views

Risk factors --- not clearly defined • Implant rigidity • Bone grafting technique • Gender • Age • Decompression beyond fused

level • Posterior complex !

• Biomechanical factors

Procedures • Decompression

– Through adjacent virgin site to stenosis – Medial facetectomy

• Extension of PLF with autograft • Instrumentation

– Old screws ! new screws with larger diameter – TPS through virgin pedicles of adjacent segment

Best treatment is prevention

• Preservation of segmental stability during decompression

• Avoidance of violating adjacent joint during instrumentation

• As short fusion as possible • Preservation of intact posterior complex

Results of multiple operated back is still favorable

Right diagnosis Right patient Right surgery Right surgeon

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