Adjacent Segment Disease And Spinal Instability The Key To Treatment May Be Spinal Ligaments
An October 2021 paper published in the European Federation of National Associations of Orthopaedics and Traumatology Open Review examined who was at higher risk for developing adjacent segment degeneration following a spinal fusion. This is what they wrote: Spinal fusion is the most widely accepted treatment for lumbar disc degenerative disease. However, it has been associated with adjacent segment degeneration as a potential long-term sequel, especially in those with preoperative risk factors, which may cause aberrant stress forces in these segments and lead to adjacent-level degeneration. Adjacent segment pathology can include adjacent segment degeneration and adjacent segment disease, although a clear and consensual definition of adjacent segment disease is missing. In most studies, adjacent segment degeneration is defined as radiographic changes in the intervertebral discs adjacent to the surgically treated levels, whereas adjacent segment disease is defined as the pathologic process associated with disc degeneration leading to clinical symptoms, such as radiculopathy, stenosis, and instability.
We have taken you on a journey throughout this article to show the current options that are most commonly prescribed. We are now going to continue with the discussion of Prolotherapy.
The Growing Use Of Medical Marijuana For Failed Back Surgery Syndrome Pain
Increasingly, medical marijuana and cannabinoids are being used to manage painand people who suffer from FBSS may find that it helps ease their chronic back or neck pain.
According to the National Institute on Drug Abuse, medical marijuana is the use of the whole, unprocessed marijuana plant or its extracts to treat pain and other symptoms.¹While many U.S. states have legalized medical marijuana, the U.S. Food and Drug Administration does not approve or recognize marijuana for medicinal purposes.
However, the FDA has approved two cannabinoids to treat two rare forms of epilepsy . These cannabinoids, dronabinol and nabilone, are available as a pill.
More research showing that medical marijuanas benefits outweigh its risks may lead to new uses for medical marijuana and perhaps open the door to FDA approval. Photo Source: 123RF.com.
While only two cannabinoids are approved by the FDA for narrow treatment uses, the cannabinoids THC and cannabidiol may also provide pain-relieving benefits. Moreover, some research has suggested that medical marijuana legalization had led to fewer opioid prescriptions and deaths.¹
Optimizing The Management And Outcomes Of Failed Back Surgery Syndrome: A Proposal Of A Standardized Multidisciplinary Team Care Pathway
Failed back surgery syndrome is a major, worldwide health problem that generates considerable expense for healthcare systems. A number of controversial issues concerning the management of FBSS are regularly debated, but no clear consensus has been reached. This pitfall is the result of lack of a standardized care pathway due to insufficient characterization of underlying pathophysiological mechanisms, which are essential to identify in order to offer appropriate treatment, and the paucity of evidence of treatment outcomes. In an attempt to address the challenges and barriers in the clinical management of FBSS, an international panel of physicians with a special interest in FBSS established the Chronic Back and Leg Pain Network with the primary intention to provide recommendations through consensus on how to optimize outcomes. In the first of a series of two papers, a definition of FBSS was delineated with specification of criteria for patient assessment and identification of appropriate evaluation tools in order to choose the right treatment options. In this second paper, we present a proposal of a standardized care pathway aiming to guide clinicians in their decision-making on how to optimize their management of FBSS patients. The utilization of a multidisciplinary approach is emphasized to ensure that care is provided in a uniform manner to reduce variation in practice and improve patient outcomes.
2. Materials and Methods
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Failed Back Surgery Syndrome
Failed back syndrome or failed back surgery syndrome refers to a condition in which a patient has undergone back surgery with a poor outcome. Patients with FBSS are a diverse group, with complex and varied etiologies and pain sources. They also vary with regard to their clinical complaints and psychological status. Patients with FBSS typically experience a decrement in their functional capacity, morale, and productivity. They are also more vulnerable to developing psychosocial problems and addiction to pain medication. In the aftermath of an unsuccessful surgery, and faced with mounting physical and psychological problems, many FBSS patients seek treatment from chronic pain centers. In the United States, approximately two-thirds of all patients enrolled in chronic pain centers suffer from FBSS.
How Is Failed Back Surgery Syndrome Diagnosed
The spine care specialist may perform the following tests and assessments to properly diagnose the condition.
- The doctor may initially perform a physical, neurologic and orthopedic examination. This is to evaluate the patients mobility, identify the affected spine area, and assess the strength and sensation of the site.
- For a detailed recount of the symptoms, the physician may ask for the patients medical history to identify the main cause of the condition.
- To further confirm the diagnosis, an imaging test such as X-ray and magnetic resonance imaging , is required to complete the assessment. A CT scan may be used if an MRI cannot be utilized.
Some other diagnostic test, such as electromyography , or Nerve Conduction Studies , may also be required alongside diagnostic injections. This is to detect the exact source of pain and to come up with the best treatment plan for the patient.
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Multidisciplinary Approach To Address Pain
Your doctor may use a multidisciplinary approach to address your pain and limitation in function, this means that instead of relying on one treatment , he or she may recommend a mix of therapies that comprehensively address different aspects of your pain. Your doctor may use one or more of the following therapies:
- refer you to a physical therapy and rehabilitation program.
- refer you to a behavioral health professional to address mental and emotional health.
- Your doctor may prescribe medications to help you manage your pain, this may include non-steroidal anti-inflammatory drugs, oral steroids, antidepressants, nerve-pain medications, and muscle relaxants.
How Dr Lowenstein Can Help
There are both conservative and minimally invasive surgical treatment options for patients who suffer from FBSS. Usually, orthopedic surgeons exhaust conservative treatments first and only opt for surgery if absolutely necessary. In more severe cases, doctors may skip this initial step and immediately recommend revision spine surgery. This may include an additional spinal fusion or a facet joint rhizotomy, depending upon your unique case. It is important to communicate your symptoms with your doctor to receive the best possible treatment.
Examples of conservative treatment include:
- Physical therapy
- Pain medication
- Medically advised exercises
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Recurrence Of Back Or Leg Pain After Surgery Is A Well
Doctors in the United Kingdom wrote in The Journal of Bone and Joint Surgery:
Recurrence of back or leg pain after discectomy is a well-recognized problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success.The debate around which procedure is the most effective for these patients remains controversial.
- Note that the above study cites a 28% rate of post-surgical pain.
- The researchers also note that controversy exists over the best revision surgery for pain after surgery.
- Their conclusion is that surgeons may as well choose the least invasive surgery since theres no one revision surgery that is better than the other.
As mentioned above, surgery of any kind interferes can cause harm to soft tissue, revision surgery is likely not the best answer. Non-surgical treatments for spinal instability should be explored.
What Are The Disastrous Results In Failed Back Surgery Patients
For patients, fixing one problem but causing the same problem to appear in another area of the spine can be seen as disastrous results. Disastrous result is a term used by doctors in Mexico who investigated patients diagnosed with Failed Back Surgery Syndrome.
In their research they noted:
The majority of the cases in one group had a previous diagnosis of lumbar stenosis whereas disc herniation was the main diagnosis in the group number.
- The main reason for failed back surgery in the stenosis group was a technical error during surgery .
- In group 2 the disc herniation group -misdiagnosis was highly prevalent .
Therefore disastrous results could be seen arising from surgical error, and MRI misinterpretation.
Research appearing in the journal, Seminars in Musculoskeletal Radiology, lists potential complications following spinal fusion which could confuse the interpretation of the MRI for doctors who are trying to see why the patient is suffering from post-surgical pain.
Radiologists are told to look for specific complications related to the use of spinal instrumentation that include incorrectly positioned instrumentation and failure of spinal fusion, leading to instrumentation loosening or breakage. This is in addition to leakage of cerebrospinal fluid, infection, and continued disc herniation.
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How To Fix Failed Back Syndrome
When your back hurts, surgery can seem like the last besthope. If youve triedwithout successnonsurgical treatment such as rest,physical therapy or corticosteroid shots, surgery may be the last resort.Surgery to fix a herniated disc or spinal stenosis is safe and effective. Butwhat happens when an operation doesnt help, or even makes it worse?
It can happen. Theres even a name for it: failed backsyndrome. It is also known as post-laminectomy syndrome and failed back surgery syndrome. Not only does your backstill hurt, but also you feel like youre right back where you started.
But dont lose hope. At Edison Spine Center, youll have options for treatment even if a previous spine surgery has proven ineffective. Heres what you need to know about failed back syndrome, how it happens and what you can do to reduce your risk.
What Is Failed Back Surgery Syndrome And What Are My Treatment Options
What Is Failed Back Surgery Syndrome and What Are My Treatment Options?
If you have been suffering from back pain and have tried more conservative treatments without relief, then you may have decided to opt for a back surgery like a spinal fusion, laminectomy, or discectomy. Many patients find their pain much improved following such a procedure, but many other patients do not obtain symptom relief.
For those patients who continue to suffer from back pain following surgery, their condition is labeled as failed back surgery syndrome. One study found that almost 50 percent of people who undergo a spinal procedure will continue to experience back pain the success rate falls to 30 percent, then 15 percent and finally 5 percent for each subsequent back surgery.
Why Do Back Surgeries Fail So Often?
It is estimated that as many as 80,000 people in the U.S. annually undergo a back procedure but find no pain relief. There are many reasons why this is such a common outcome with most related to the complexity and sensitivity of this part of our bodies.
Among the most common reasons for failed back surgery syndrome include complications related to the procedure. In many cases, the spinal fusion procedure proceeded just as intended which resulted in pain relieffor a period of time. However, losing a joint in your spine puts additional strain on other areas that will begin to start hurting.
Treatment Options after Failed Back Surgery
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Types Of Pain Caused By Failed Back Surgery Syndrome
After failed back surgery, patients may experience one or more of the following types of pain:
- Chronic pain, or significant pain that lasts more than 12 weeks.
- Nociceptive pain, which is dull or sharp pain around the incision site.
- Neuropathic pain, which is caused by damage to the nerves or spinal cord may be accompanied by numbness, burning, tingling, weakness, and other unusual sensations.
- Radicular pain, or pain that radiates from one part of the body to another.
Pain Management For Failed Back Surgery Syndrome
Back pain can impact daily life, and for some, surgery may be the only route to bring pain relief. However, a percentage of patients continue to experience pain after surgery. Over time, ongoing back pain can cause a person to suffer from physical disability, and even psychosocial and financial issues. Failed back surgery syndrome happens when patients have ongoing post-operative pain in spite of their spine surgery to correct their diagnosed back problem. For spine surgeons, the key to helping FBSS patients feel better is to use all the diagnostic tools at their disposal to find the underlying cause of their pain so it can be corrected, which may or may not include additional back surgery.
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The Causes Of Failed Back Surgery Syndrome
To reduce the risk of failed back surgery syndrome, patients should choose operations that have a high degree of success and ensure the correct lesion is identified beforehand.
Causes of FBSS include:
Operating on the wrong lesion
Fusion surgery considerations, such as failure to fuse or implant the level above or below the fusion deteriorates and causes pain.
Lumbar decompression back surgery considerations, such as recurrent spinal stenosis or disc herniation, inadequate decompression of a nerve root, preoperative nerve damage that fails to heal after surgery, and nerve damage caused by surgery.
Scar tissue considerations, such as formation of scar tissue around the nerve root.
Postoperative rehabilitation, which refers to additional pain from a secondary source.
Pharmacotherapy And Spinal Interventions In Failed Back Surgery Syndrome
If further surgery has been ruled out, then the analgesic regimen should be optimised. Although there are case reports published that report the effectiveness of gabapentin in postoperative epidural fibrosis after spinal surgery,24 a large randomised controlled trial published recently failed to show efficacy of pregabalin in neuropathic pain associated with radiculopathy.25 Overall the efficacy of gabapentinoids seems borderline at best for neuropathic pain, i.e. effect size is small and accompanied by side effects in many patients. Strong opioids for chronic pain are being re-evaluated because the side effects from the long-term use of strong opioids including immune suppression, endocrine suppression, reduced libido and an overall detrimental effect on the quality of life are becoming well known.2628 There is concern that mortality may be increased in patients with chronic pain who are using strong opioids in high dosages to control pain, though the exact contribution of opioids to increased mortality is not yet clear. Pharmacological treatment options are helpful only in a minority of patients with FBSS.2931
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Indications For Spinal Surgery
Surgery represents an important treatment option for physicians in managing chronic back pain, especially conditions that are intractable to more conservative interventions. Except for emergency situations, surgery is only undertaken after attempting less invasive procedures. The most common conditions for which surgery is recommended are disc bulge, disc herniation, and disc disruption spinal stenosis, spondylosis, spondylolisthesis, and failed back surgery syndrome.
Psychological Screening For Surgery
Thus, it is clear that psychological screening is a critical component of the pre-surgical evaluation process. A psychological screening for surgery helps the physician and patient prevent FBSS. Psychosocial factors have been shown to affect surgery outcome. Though physicians are sometimes aware of blatant chemical dependency, psychopathology, or secondary gain issues in their patients, they often miss the less obvious psychosocial problems that may make the difference between a successful and unsuccessful surgery outcome.²² Consideration of psychological factors in concert with physical factors, such as characteristics of the herniation and duration of illness, lead to the most accurate predictions about those patients who will benefit from surgery and those who will not. A psychological evaluation allows the surgeon/physician to improve treatment outcomes by screening out patients likely to have a poor outcome and providing necessary psychological/ emotional assistance prior to surgery, if needed. An evaluation also identifies those patients who are likely to experience medication addiction or compliance difficulties, and who may end up being problem patients for the treating physician.
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When Your Condition Is Failed Back Surgery Syndrome
Failed back surgery syndrome refers to chronic back or neck pain, with or without extremity pain, that can occur if a spine surgery does not achieve the desired result.
Contributing factors to pain that returns following spine surgery include but are not limited to recurrent disc herniation, further degeneration causing pressure on a spinal nerve, altered joint mobility, scar tissue around or within the nerves, muscle de-conditioning, facet joint degeneration, or sacroiliac joint degeneration.
Common symptoms associated with Failed Back Syndrome include diffuse, dull, and aching pain involving the back and/or legs. Patients may also complain of sharp, pricking, burning, or stabbing pain in the extremities.
The physician will review the treatment history, particularly the type of surgery done and for what reason. Particular attention is paid to the result of the surgery and how the patients symptoms have evolved following the surgery. A physical examination will also be done. X-rays, MRI and computed tomography , or myelogram-CT may be ordered.
Treatment for failed back surgery syndrome may include physical therapy, nerve blocks, medications, injections, or a chronic pain management program. If the pain is possibly coming from the facet or sacroiliac joints, chiropractic care may be recommended.
Once You Find Out What Went Wrong What Are The Next Steps
Dr. Rashbaum: Sometimes well do injection therapy to help us figure out where the pain is coming from. We need to determine if the pain now is mechanical facet joint pain, mechanical disc degeneration, or painful disc syndrome. Above all, we dont give up on these patients. We do whatever is needed to re-investigate, because the important issue with FBSS is that time is of the essence.
Pain is a signal that something is wrong. Its like taking our hand off the hotplate. If we leave our hand on the hotplate too long, then that pain can go from being an acute signal to chronic indolent pain. Over time, it becomes a disease called Disease. The longer we live with pain thats unabated, the more we suffer psychosocial, financial, and physical issues. We also lose conditioning.
So the message is, that if the patient doesnt do well with the planned surgery, figure out what went wrong. Get your ego out of the way and say, “Okay, this is what happened, this is what I need to do.” And that becomes the most important thing in trying to rectify the situation. The single most important thing for failed back surgery syndrome is to do the right surgery on the right patient at the right time, and execute it in the right way. Simple.
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