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Spinal cord stimulation (SCS) targets structures of the dorsal column and dorsal horn of the spinal cord with electrical impulses, thereby, modulating pain perception. For chronic pain patients, e.g., in failed back surgery syndrome (FBSS), the aim is to achieve pain relief and enable patients to improve their quality of life.Failed back surgery syndrome, complex regional pain syndrome (CRPS) type I and II, therapy-refractory ischemic pain, neuropathic pain syndromes (e.g., phantom limb pain).Identification of degenerative alterations as the cause of pain; untreated mental illness.A two-stage implantation technique is performed. Initially, after percutaneous implantation of epidural leads a trial period with stimulation by an external pulse generator is evaluated. Following verification of pain relief, a subcutaneous internal pulse generator is implanted.Early mobilization and adjustment of stimulation parameters.In all, 19 consecutive patients with FBSS were treated by high frequency SCS (HF-SCS) and included in a prospective prognostic study. In 18 patients, an internal pulse generator (IPG) for HF-SCS was permanently implanted. Therapy success was assessed using the Oswestry Disability Index (ODI), visual analogue pain scale (VAS) and painDetect questionnaire. Neuropathic pain of the legs versus the back (median values: VAS leg 71 mm, VAS back 69 mm) was dominant in the patients at a preoperative mean ODI of 63%. With HF-SCS therapy, a pronounced pain reduction was seen and persisted in the follow-up after 6 months (VAS leg 18 mm, VAS back 24 mm). The ODI showed an improvement to a mean of 24% after 6 months.OPERATIONSZIEL: Durch die Spinal-Cord-Stimulation (SCS) werden Strukturen der Hinterstränge und Hinterhörner des Rückenmarks mittels elektrischer Impulse stimuliert und dadurch wird die Schmerzwahrnehmung moduliert. Ziel ist es, bei chronischen Schmerzpatienten, z. B. bei Failed-Back-Surgery-Syndrom (FBSS), das Schmerzniveau zu reduzieren und betroffenen Patienten eine verbesserte Lebensqualität zu ermöglichen.Failed-Back-Surgery-Syndrom, komplex regionales Schmerzsyndrom (CRPS) Typ I und II, therapierefraktärer Ischämieschmerz, neuropathische Schmerzsyndrome (z. B. Phantomschmerz).Chirurgisch sanierbare Schmerzursache, nicht behandelte psychische Erkrankung.Zweizeitige Implantationstechnik. Beginn mit der Testphase nach perkutaner Implantation von epiduralen Elektroden und Stimulation durch externen Pulsgenerator. Bei Schmerzreduktion Implantation eines subkutanen internen Pulsgenerators zur Dauerstimulation.Frühfunktionelle Mobilisation und ggf. Anpassung der Stimulationsparameter.Es wurden 19 konsekutive Patienten mit FBSS mittels Hochfrequenz-SCS (HF-SCS) behandelt und in eine prospektiv prognostische Studie eingeschlossen. Bei 18 Patienten wurde ein implantierbarer Pulsgenerator (IPG) zur HF-SCS permanent implantiert. Der Therapieerfolg wurde mittels Oswestry Disability Index (ODI), visueller Analogschmerzskala (VAS) und painDetect-Fragebogen erfasst. Bei den Patienten dominierten neuropathische Schmerzen der Beine gegenüber dem Rücken (Mittelwerte: VAS Bein 71 mm, VAS Rücken 69 mm) bei präoperativem mittlerem ODI von 63 %. Unter der HF-SCS zeigte sich eine deutliche Schmerzreduktion und persistierte auch im Follow-up nach 6 Monaten (VAS Bein 18 mm, VAS Rücken 24 mm). Im ODI zeigte sich eine Verbesserung auf einen Mittelwert von 24 % nach 6 Monaten.

Post-nucleotomy syndrome includes all existing sequelae after surgical nucleotomy for the resection of a lumbar disc herniation, such as axial lumbar back pain and persisting radiculopathy.To describe underlying pathologies and to determine operative treatment options.Extensive literature research was carried out on Medline.Various devices and approaches have been developed in the last decades. Nonetheless, surgical and non-surgical therapy of post-nucleotomy syndrome remains complex and frequently fails.Better studies providing a better level of evidence for each sub-entity of post-nucleotomy syndrome are required.

Unfortunately, 10-40 % of patients still experience pain after spinal surgery. There are many reasons for the patients' complaints. If no identifiable cause, such as a recurrent disc herniation, is visible, this is referred to as failed back surgery syndrome. However, this definition includes a variety of possible underlying causes of the pain, which result in just as many different therapeutic approaches. In addition to pharmacological, behavioral and physical therapy, also neuromodulation techniques can be offered; the best known method is spinal cord stimulation (SCS). The following article describes evidence-based studies with regard to the beneficial treatment of failed back surgery syndrome with conventional tonic SCS and new developments in spinal cord stimulation addressing the treatment of chronic refractory back pain.

Failed back surgery syndrome (FBSS) is a frequent complication (15-40 %) of lumbar disc surgery and is rarely successfully treated by surgery with the exception of a re-prolapse associated with radicular pain. Multimodal pain treatment, however, is indicated by a lack of pathoanatomical correlates, unclear cause and psychosocial risk factors.This review describes a standardized non-operative treatment starting with broad interdisciplinary clarification by medical, psychological and physiotherapeutic means (assessment).If the conditions for multimodal pain therapy are met, the OPS 8‑918-procedure can be applied to avoid chronic developing pain. In doing so, the already issued quality standards and guidelines for documentation should be respected.

As a rule, postoperative imaging is carried out after spinal interventions to document the exact position of the implant material.Imaging is absolutely necessary when new clinical symptoms occur postoperatively. In this case a rebleeding or an incorrect implant position abutting a root or the spinal cord must be proven. In addition to these immediately occurring postoperative clinical symptoms, there are a number of complications that can occur several days, weeks or even months later. These include the failed back surgery syndrome, implant loosening or breakage of the material and relapse of a disc herniation and spondylodiscitis.In addition to knowledge of the original clinical symptoms, it is also important to know the operation details, such as the access route and the material used.In almost all postoperative cases, imaging with contrast medium administration and corresponding correction of artefacts by the implant material, such as the dual energy technique, correction algorithms and the use of special magnetic resonance (MR) sequences are necessary.In order to correctly assess the postoperative imaging, knowledge of the surgical procedure and the previous clinical symptoms are mandatory besides special computed tomography (CT) techniques and MR sequences.

The purpose of the study was to present a reliable instrument with easy application to assess the outcome and improvement of therapy in patients with radicular symptoms of the lumbar spine.Data from patients who underwent microdiscectomy because of lumbar radicular symptoms were collected and analyzed and interviews were performed using the well-known North American Spine Society (NASS) lumbar spine questionnaire (17 items) before and after the intervention. In addition patient data including comorbidities were collected. By calculating effect size (ES) and standardized response mean (SRM) for each item of the questionnaire, the questions with the highest change before and after the intervention could be selected.A total of 139 patients undergoing microdiscectomy for lumbar radicular symptoms due to a disc herniation were included in the analysis. Concerning the three dimensions pain, neurological symptoms and impairment of activities in daily life, the questions with best predictive value (high ES and SRM) were selected. According to their clinical relevance eight questions of the NASS questionnaire were finally selected for the short form.This short, significant and easy to use questionnaire is in our opinion a useful instrument to assess the course of patients with radicular back pain and especially to measure and monitor the outcome of therapeutic interventions, in addition to conventional clinical diagnostics and examinations. This novel instrument could be a useful tool for improving quality assurance in conventional and interventional pain management of these patients.

Postoperative imaging after spinal surgery is usually performed to document the correct positioning of implants or to rule out complications if patients still suffer from pain after surgery. Depending on the question various imaging modalities can be used all of which have benefits and limitations. Conventional X-ray is used for the documentation of the correct positioning of spinal implants, stability (olisthesis) and during follow-up to rule out fractures or instability of the implants, whereas soft tissue changes cannot be completely assessed. Besides these indications, imaging is usually performed because of ongoing symptoms (pain for the most part) of the patients. Soft tissue changes including persistent or recurrent herniated disc tissue, hematoma or infection can best be depicted using magnetic resonance imaging (MRI) which should be performed within the immediate postoperative period to be able to distinguish physiological development of scar tissue from inflammatory changes in the area of the surgical approach. Often imaging alone cannot differentiate between these and imaging can therefore only be considered as an adjunct. Computed tomography is the modality of choice for the evaluation of bony structures and an adjunct of new therapies such as image-guided application of cement for kyphoplasty or vertebroplasty.

Aside from the surgical technique used, the development of peri- and postoperative pain and impairments in patients following intervertebral disk surgery is also determined to a crucial extent by psychological factors. Based on a systematic literature review, we checked whether evidence-based recommendations could be deduced on how to take into account psychological risk factors in back surgery in order to avoid postoperative complications, such as failed back surgery syndrome. The current state of research suggests three groups of risk factors: (1) negative psychological factors, (2) preexisting pain chronification, and (3) psychological disorders. In the case of elective intervertebral disk surgery, these factors should therefore be determined and identified preoperatively and taken into account in the indication for surgery. Multimodal treatments could conceivably prove to be more effective, or else psychological pain management therapy might be considered prior to surgery so as to avoid postoperative complications. If surgery is medically unavoidable despite existing risk factors, postoperative treatment should incorporate psychological pain management therapy at an early stage in the context of a multidisciplinary approach.