Patients involved in worker's compensation, tort litigation or other compensation systems tend to fare more poorly after surgery. Surgery for spinal stenosis usually has a good outcome, if the surgery is done in an extensive manner, and done within the first year or so of the appearance of symptoms. Oaklander and North define the Failed Back Syndrome as a chronic pain patient after one or more surgical procedure to the spine.
They delineated these characteristics of the relation between the patient and the surgeon:. In the absence of a financial source for disability or worker's compensation, other psychological features may limit the ability of the patient to recover from surgery. Some patients are simply unfortunate, and fall into the category of "chronic pain" despite their desire to recover and the best efforts of the physicians involved in their care. Lumbar total disc replacement was originally designed to be an alternative to lumbar arthodesis fusion. The procedure was met with great excitement and heightened expectations both in the United States and Europe.
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In late , the first lumbar total disc replacement received approval from the U. More experience existed in Europe. Since then, the initial excitement has given way to skepticism and concern. The role of artificial or total disc replacement in the treatment of spinal disorders remains ill-defined and unclear. Patient expectations may be distorted. A younger age was predictive of a better outcome in several studies. Prior spinal surgery has mixed effects on disc replacement. It has been reported to be negative in several studies.
Many failed back patients are significantly impaired by chronic pain in the back and legs. Many of these will be treated with some form of electrical stimulation. This can be either a transcutaneous electrical nerve stimulation device placed on the skin over the back or a nerve stimulator implanted into the back with electrical probes which directly touch the spinal cord. Also, some chronic pain patients utilize fentanyl or narcotic patches. These patients are generally severely impaired and it is unrealistic to conclude that application of neurostimulation will reduce that impairment.
For example, it is doubtful that neurostimulation will improve the patient enough to return to competitive employment. Neurostimulation is palliative. Success is defined as a relative decrease in pain. The results of several studies showed significant improvement for patients with failed back surgery who were managed with chiropractic care.
In a groundbreaking Canadian study, Waddell et al. They concluded that workers who undergo spinal surgery take longer to return to their jobs. Once two spinal surgeries are performed, few if any ever return to gainful employment of any kind. After two spinal surgeries, most people in the worker's comp system will not be made better by more surgery. Most will be worse after a third surgery. Episodes of back pain associated with on the job injuries in the worker's compensation setting are usually of short duration.
It has been hypothesized that job dissatisfaction and individual perception of physical demands are associated with an increased time of recovery or an increased risk of no recovery at all. A Finnish study of return to work in patients with spinal stenosis treated by surgery found that: 1 none of the patients who had retired before the operation returned to work afterward.
Women's and men's working capacity do not differ after lumbar spinal stenosis operation. If the aim is to maximize working capacity, then, when a lumbar spinal stenosis operation is indicated, it should be performed without delay. Therefore, after such an extensive surgical procedure, re-education of patients for lighter jobs could improve the chances of these patients returning to work. In a related Finnish study, a total of patients operated on for lumbar spinal stenosis during the period was re-examined and evaluated for working and functional capacity approximately 4 years after the decompressive surgery.
The ability to work before or after the operation and a history of no prior back surgery were variables predictive of a good outcome. Before the operation 86 patients were working, patients were on sick leave, and patients were retired. After the operation 52 of the employed patients and 70 of the unemployed patients returned to work.
None of the retired patients returned to work. Ability to work preoperatively, age under 50 years at the time of operation and the absence of prior back surgery predicted a postoperative ability to work. A report from Belgium noted that patients reportedly return to work an average of 12 to 16 weeks after surgery for lumbar disc herniation. However, there are studies that lend credence to the value of an earlier stimulation for return to work and performance of normal activities after a limited discectomy.
At follow-up assessment, it was found that no patient had changed employment because of back or leg pain. The sooner the recommendation is made to return to work and perform normal activities, the more likely the patient is to comply. Patients with ongoing disabling back conditions have a low priority for return to work.
The probability of return to work decreases as time off work increases.
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In Belgium, the medical advisers of sickness funds have an important role legally in the assessment of working capacity and medical rehabilitation measures for employees whose fitness for work is jeopardized or diminished for health reasons. The measures are laid down in the sickness and invalidity legislation.
They are in accordance with the principle of preventing long-term disability. It is apparent from the authors' experience that these measures are not adapted consistently in medical practice. Most of the medical advisers are focusing purely on evaluation of corporal damage, leaving little or no time for rehabilitation efforts. In many other countries, the evaluation of work capacity is done by social security doctors with a comparable task. In a comprehensive set of studies carried out by the University of Washington School of Medicine , it was determined that the outcome of lumbar fusion performed on injured workers was worse than reported in most published case series.
This increase in metal usage was associated with a greater risk of complication without improving disability or re-operation rates. The identification of tumor necrosis factor-alpha TNF as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with FBSS. Specific and potent inhibitors of TNF became available in the U. These treatments are still experimental. If chronic pain in FBSS has a chemical component producing inflammatory pain, then prior to additional surgery it may make sense to use an anti-inflammatory approach.
Often this is first attempted with non-steroidal anti-inflammatory medications, but the long-term use of Non-steroidal anti-inflammatory drugs NSAIDS for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicity; and NSAIDs have limited value to intervene in TNF-mediated processes.
A report from Spain noted that the investigation and development of new techniques for instrumented surgery of the spine is not free from conflicts of interest. The influence of financial forces in the development of new technologies and its immediate application to spine surgery, shows the relationship between the published results and the industry support. Authors who have developed and defended fusion techniques have also published new articles praising new spinal technologies. The author calls spinal surgery the "American Stock and Exchange" and "the bubble of spine surgery".
The scientific literature doesn't show clear evidence in the cost-benefit studies of most instrumented surgical interventions of the spine compared with the conservative treatments. It has not been yet demonstrated that fusion surgery and disc replacement are better options than the conservative treatment. It's necessary to point out that at present "there are relationships between the industry and back pain, and there is also an industry of the back pain". Nonetheless, the "market of the spine surgery" is growing because patients are demanding solutions for their back problems.
The tide of scientific evidence seems to go against the spinal fusions in the degenerative disc disease, discogenic pain and in specific back pain. After decades of advances in this field, the results of spinal fusions are mediocre. New epidemiological studies show that "spinal fusion must be accepted as a non proved or experimental method for the treatment of back pain". The surgical literature on spinal fusion published in the last 20 years establishes that instrumentation seems to slightly increase the fusion rate and that instrumentation doesn't improve the clinical results in general.
We still are in need of randomized studies to compare the surgical results with the natural history of the disease, the placebo effect, or conservative treatment. The European Guidelines for lumbar chronic pain management show "strong evidence" indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper posterolateral fusion without instrumentation. Recently, the literature published in this field is sending a message to use "minimally invasive techniques"; - the abandonment of transpedicular fusions.
Surgery in general, and usage of metal fixation should be discarded in most cases.
Cherkin et al. There were twice the number of surgeons per capita in the United States compared to the United Kingdom. Numbers were similar to Sweden. Despite having very few spinal surgeons, the Netherlands proved to be quite aggressive in surgery. Sweden, despite having a large number of surgeons was conservative and produced relatively few surgeries. The most surgeries were done in the United States. In the UK, more than a third of non-urgent patients waited over a year to see a spinal surgeon. In Wales, more than half waited over three months for consult.
Lower rates of referrals in the United Kingdom was found to discourage surgery in general. Fee for service and easy access to care was thought to encourage spinal surgery in the United States, whereas salaried position and a conservative philosophy led to less surgery in the United Kingdom. There were more spinal surgeons in Sweden than in the United States. However, it was speculated that the Swedish surgeons being limited to compensation of 40—48 hours a week might lead to a conservative philosophy.
There have been calls for a more aggressive approach to lumbar surgery in both the United Kingdom and Sweden in recent years. From Wikipedia, the free encyclopedia.
Main article: Arachnoiditis. This section is empty. You can help by adding to it. November Archived from the original on Retrieved 10 Sep Bibcode : PLoSO.. Sep Pain Med. Recent United States trends and regional variations". A clinical follow-up of surgical and non-surgical treatment". Acta Orthop. Attempted meta-analysis of the literature". A meta-analysis of literature —".
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Regarding the pain intensity at the final follow-up, we found a reduced general mean in the visual analog scale from 7. A peridural catheter for spinal infusion of a morphine and lidocaine solution was placed in thirteen patients; all of them had a MPS, being considered refractory after a rehabilitative treatment attempt.
The outcome was excellent in 4 Treatment cost, compensation, and lost productivity are high. The patients' mean age at pain onset was In most cases, the course is favorable, even when no care measures are taken. In In our series, preoperative pain was severe, with a 7. In only According to Hanley et al. The numbers of spine surgeries to relieve pain have steadily grown in the United States, with thousand operations in , , in reaching , in 12 , with 80 thousand cases of failed back surgery pain syndrome per year According to Deyo and Tsiu 9 , the main reason for an increasing number of laminectomies is the growing number of surgeons operating the spine in each country.
Poor outcome of operative treatment might result from an incorrect diagnosis. Among the identified causes for low back pain, the following could be highlighted: rheumatic conditions, primary or secondary spine tumors, vascular conditions, hematological abnormalities, endocrine conditions, pelvic or abdominal viscus diseases endometriosis, ovarian cyst torsion, pelvic inflammatory disease, prostatitis, cystitis, pancreatopathy, nefropathy, kidney disease, peptic ulcer, urinary tract, biliary or duodenal conditions , mechanical abnormalities herniated intervertebral disk, articular facet injury, segmental instability or sacroiliac joint instability , systemic conditions fibromyalgia, myositis, autoimmune or immune-allergic diseases , psychiatric diseases and other conditions hip joint disease, trochanteric bursa injury, polyradiculoneuritis, meningeal irritation signs Because of the great number of possibilities, the high surgical therapeutic failure rate is justifiable in care provided to these patients, but it also indicates there must be a more judicious semiologic evaluation.
Surgeries that do not meet the indication criteria to treat a herniated disk can result in maintenance or worsening of pain and preoperative deficits. A herniated disk misinterpreted as a cause for low back pain is the most common reason for indicating spine surgeries that progress to a post-laminectomy chronic pain syndrome with an early onset postoperatively. This is partly due to overvaluing the anatomical findings not related to the low back pain that are shown in imaging studies, but those usually do not warrant the pain and the surgical intervention Boden et al.
Therefore imaging studies can confirm a herniated disk clinical diagnosis, but they are not the main determinants for indicating a surgery, since asymptomatic herniated disks are so commonly seen 2. Even in symptomatic conditions, there is a progressive absorption of the herniated disk fragment, a phenomenon accompanied by symptom improvement in most cases This means the indication criteria for diskectomy, represented by a cauda equina syndrome, marked acute or progressive motor deficit or lumbosciatic pain occurrence and evident radiculopathy, characterized by sensory, motor and deep tendon reflexes deficits over one or more nerve root territory, nerve root irritation evidence, translated as a positive straight leg raising maneuver and consistent imaging study findings 20 in patients achieving no improvement after symptomatic drug therapy with physical medicine measures during a period of over 6 to 12 weeks 20,21 , are not always met.
Only Among them, residual or relapsed herniations, spinal instability, post-vertebral fixation pseudarthrosis, articular facet abnormalities, spinal canal stenosis, meningocele and pseudomeningocele are highlighted In no patient of ours a spinal instability or residual herniation was found. In addition to the diskectomy, a spinal fixation and fusion was proposed However, there is little evidence the spinal fusion is useful in patients with no actual spinal instability 7.
This occurred in 5. Postoperative imaging of a residual disk herniation does not imply this is necessarily the cause for a persisting pain, as postoperative imaging studies often show similar abnormalities in individuals whether they are symptomatic or not Peridural scar occurring after a laminectomy is a frequent postoperative finding. However, epidural fibrosis is often shown on CT scan or MRI postoperatively in cases there is no pain 8. The patients included in our study had undergone up to 4 surgical lumbar spine surgical procedures with no improvement; the mean was 1.
Many patients undergoing further operations to treat persisting or residual pain get frustrated. There is evidence that MPS is involved in low back pain genesis or maintenance However, MPS diagnosis is frequently disregarded Many lumbar muscles affected by MPS and the operative injury would result in pain worsening. Although physiatrically speaking lumbar and gluteal muscle MPS is considered the most important cause for low back pain, bone, tendinous, nerve, disk and bursa conditions are still valued as symptom causes The muscle fiber injury is not necessarily a cause for pain, since in patients with primary degenerative conditions, as in Duchenne muscular dystrophy, there is a disruption in a large amount of myofibrils and the sarcoplasmic reticulum, but there is no pain, suggesting MPS symptoms result from nonstructural muscle fiber changes or dysfunctions The main electrophysiological abnormality seems to be a neuromuscular dysfunction in the motor endplate.
The energy crisis theory postulates there is an increased calcium concentration in the sarcoplasm due to a sarcoplasmic reticulum, sarcolemma and or muscle cell membrane disruption. The sarcoplasmic reticulum function is storing and releasing ionized calcium, which activates contractile elements and causes sarcomere shortening.
Sustained sarcomere contraction results in increased metabolism, causes localized ischemia and generates a localized energy crisis. The combination of electrophysiological and histopathological theories generated the neuromuscular endplate multiple dysfunction concept. The potentials recorded as spontaneous activity or spikes in trigger points would result in abnormal acetylcholine release by the nervous ending.
Acetylcholine release would accentuate depolarization and calcium release from the sarcoplasmic reticulum, causing sarcomere contraction and small-caliber vessel compression. Increased depolarization due to acetylcholine release and sarcomere contraction would cause increased energy demand, which, if associated with hypoxia resulting from reduced muscle blood flow, would then cause the energy crisis.
This energy crisis generates metabolites which sensitize nociceptores and referred pain from trigger points The abnormalities in nerve fibers responsible for supplying the muscle could cause localized muscle contraction and MPS The referred pain from the trigger point is due to a sensory neuron sensitization in the spine cord posterior horn and may have a distribution similar to that in the radiculopathic pain. This referred pain associates with tingling and numbness The ages of patients included in the study when firstly seen at the Pain Center ranged from 28 to 76 years mean age, The mean symptom length was 96 months and the mean pain intensity was 8.
The postoperative pain was also shown more severe than the preoperative pain. The chronic pain treatment should involve a multidisciplinary team and pharmacological, physiatric, psychotherapeutic, and neuroanesthesic procedures; functional neurosurgical procedures should be performed if required Myofascial trigger point treatment consists of using analgesic drugs, psychotherapeutic agents, muscle relaxant drugs, refrigerant vapor, dry needling, local anesthetic injection and stretching, as well as correction of causal or perpetuating factors The failed back surgery pain syndrome evaluation and management is challenging for the medical team.
Analgesic drugs and physical medicine provide major improvement in most cases. The pain intensity in post-laminectomy syndrome is worse than the herniated disk preoperative pain. The injection of myofascial trigger points and opiate infusion into the lumbar spine compartment can be required in refractory pain cases. Merskey NB. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms prepared by the International Association for the Study of Pain.
Etiology and evaluation of the failed back surgery outcome. Neurosurg Q. High levels of inflammatory phospholipase A2 activity in lumbar disc herniations. Spine ; Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology? Deyo RA. Back surgery-who needs it? N Engl J Med. Back pain revisited newer thinking on diagnosis and therapy.
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