Search

Proven to be a successful treatment modality for several chronic pain conditions including Failed Back Surgery Syndrome, spinal cord stimulation (SCS) has many benefits as both a cost-effective and reversible technique. Prior to permanent implantation technique of the device, trial placement is performed to establish expected benefit. Lead location, stimulation parameters, and power source selection are optimized on a case-by-case basis. A recent addition to the growing field of neuromodulation, SCS is a promising new technology with many additional applications yet to be fully elucidated.

Item does not contain fulltext Dorsal root ganglion stimulation (DRG-S) has shown promise as a treatment for low back pain. The traditional anterograde placement of DRG-S leads can be challenging in patients with anatomical changes from prior back surgery. We describe an "outside-in" placement technique of DRG-S leads in 4 patients with histories of multiple lumbar surgeries, which made the traditional anterograde placement not feasible. At long-term follow-up, the patients experienced substantial pain relief and improvement in quality of life, with no complications. The outside-in lead placement technique may be an efficacious alternative to the traditional techniques in patients with anomalous anatomy from prior surgery.

Failed Back surgery syndrome or persistent low back pain following lumbar surgery is a known complication of lumbosacral spine surgery. The incidence of FBSS ranges from 5% to 10% postlumbosacral surgery. It is characterized by disabling pain resistant to usual analgesic and physiotherapy. Epidural fibrosis is found to be the most common cause of FBSS. Various treatment modalities such as spinal canal stimulation, epidural corticosteroids injection, Non steriodal antiinflammatory drugs, opioids, and repeat surgery have been tried for the management of FBSS, but none of them have shown a promising result. The second surgery in such patients has a poor success rate of only 30%–35%. 15%–20% patients even reported worsening of symptoms after a second surgery. Gabapentin which is an analog of gamma-aminobutyric acid has shown good results in few studies in reducing pain in patients with failed back surgery syndrome FBSS. Few case reports and randomized control trials published in recent past has shown good efficacy of gabapentin in reducing low back pain as well as leg pain associated with failed back surgery syndrome FBSS. To conclude, gabapentin can be tried in a patient with FBSS, but its efficacy needs to be established with a large multicentric study.

Study design An Internet-based assessment of websites using recognized score systems. Objective To assess the quality, content, and readability of online information for failed back spinal surgery (FBSS). Summary of background data A significant amount of patients still suffer from chronic or recurrent back pain with or without radicular symptoms after spinal surgery. More and more patients use the Internet to find health-related information. Low-quality or inaccurate information may not only misleading patients but also have a negative impact on the trust between patients and physicians. Methods The terms "chronic pain after spinal surgery," "chronic pain after back surgery," "failed back surgery syndrome," "post spinal surgery syndrome," and "post laminectomy syndrome" were entered into three search engines (Google, Yahoo!, and Bing). The first 25 websites from each search were reviewed. The quality, content, and readability of each website were evaluated using DISCERN score, FBSS-specific content score, and the Journal of the American Medical Association (JAMA) benchmark criteria, the first two score systems were assessed by three reviewers independently. The Flesch-Kincaid grade level (FKGL) was used to assess the readability. Each website with or without the Health on the Net Code (HONcode) was also recorded. Results Seventy-two websites were analyzed in our study. The average DISCERN score for all websites was 35.26 ± 11.45, indicating the quality of the websites was poor. The DISCERN score of physician websites was 31.25 ± 9.08, lower than that of media (36.50 ± 0.71, P = 0.017) and commercial websites (42.55 ± 10.93, P = 0.045). The mean FBSS-specific content score was 9.58 ± 3.90 out of maximum 25. We failed to find any difference of FBSS-specific content score among different type of website. Websites with HONcode certification were associated with higher DISCERN score, FBSS-specific content score, and JAMA benchmark criteria score than non-certified websites. The mean FKGL was 12.19 ± 2.20, and none of the websites' FKGL was lower than the six grade level. Conclusion The quality and content of available online information for FBSS were poor. The readability of online information in our results showed a significantly higher reading level than the sixth-grade level recommended by the AMA and NIH. Level of evidence 4.

Background Patients with failed back surgery syndrome (FBSS) experience chronic back pain following spinal surgery, and effective treatment is difficult because of multiple contributing factors. Case presentation Here we report a case involving a 72-year-old woman who experienced recurrent low back pain after undergoing two back surgeries. She was treated with erector spinae plane (ESP) block, which affected the dorsal rami of the spinal nerves from T12 to L5. Pain relief lasted for approximately 10 h after the initial block, and successful low back pain relief was achieved after a total of three trials. Conclusions ESP block, which is an easy and safe procedure, can be used to treat FBSS-associated low back pain.

Item does not contain fulltext BACKGROUND AND AIMS: Persistent low back pain after initially successful surgery that is not attributed to structural deficits is called failed back surgery syndrome (FBSS). When conservative and minimal invasive therapy fail, the recommended treatment is spinal cord stimulation (SCS). Because epidural fibrosis can be a contributing factor in the majority of FBSS patients, lumbosacral epiduroscopic lysis of adhesions may be considered as a less invasive alternative treatment option. We hypothesized that the use of epiduroscopic lysis of adhesions could reduce the need for SCS. METHODS: A pilot study was performed in 35 consecutive patients with FBSS who underwent epiduroscopic lysis of adhesions. SCS was considered if epiduroscopic lysis of adhesions gave less than 50% global perceived effect (GPE) improvement after 15 months of follow-up. The GPE was measured 1 week and 6 months after the procedure. RESULTS: Over a period of 69 months, 35 patients were included. After 15 months of follow-up, 43% of patients required SCS. Eight of the 15 patients who reported no short-term improvement needed SCS; those patients had severe epidural fibrosis. One week after epiduroscopic lysis of adhesions, 34%, 23%, and 43% of patients reported GPE improvement of > 50%, 20% to 50%, and < 20%, respectively. After 6 months, 5 patients were lost to follow-up, and 30%, 17%, and 16% of patients reported improvement of > 50%, 20% to 50%, and < 20%, respectively. CONCLUSIONS: In this pilot study we observed a reduced need for SCS when lumbosacral epiduroscopic lysis of adhesions was used for patients with FBSS and magnetic resonance imaging-proven adhesions. These observations justify the evaluation of both treatment options in a prospective observational trial.

The patient is a 53-year-old male with T3N2c squamous cell carcinoma of the left supraglottis who is now 4 weeks into a 7-week course for radiation and chemotherapy. He presents with constant, uncontrolled throat pain described as burning and shooting. He remarks that this began shortly after the onset of his radiation therapy and chemotherapy treatments. Of note, the patient does have a history of chronic pain secondary to failed back surgery treated with tricyclic antidepressants and low-dose opiates.

We present an up-to-date summary of the scientific evidence on (1) the diagnostic value of neural blockade in radiculopathy, peripheral neuropathic pain, and complex regional pain syndrome; (2) the therapeutic value of neural blockade on peripheral trauma-related neuropathic pain, herpes zoster, postherpetic neuralgia, lumbosacral and cervical radiculopathy, failed back surgery syndrome with prominent radicular symptoms, complex regional pain syndrome, trigeminal neuralgia, and painful diabetic and other peripheral neuropathies; and (3) the efficacy of neural destructive techniques and pulse radiofrequency on postherpetic neuralgia, cervical and lumbosacral radiculopathy, and sympathetically maintained pain. The evidence for efficacy is, at the best, moderate, and is often limited or conflicting.

Objectives Spinal cord stimulation (SCS) for patients with failed back surgery syndrome (FBSS) show variable results and limited to moderate evidence. In the last years the stimulation of high frequency (HF) has been considered as a better alternative in this pathology for its supposed benefits compared to the stimulation with conventional frequency (CF). To compare in one year follow-up, the efficacy of high-frequency SCS (HF) versus conventional frequency SCS (CF) on the patients with FBSS. Design Prospective, Randomized blind trial. Setting Academic University Pain Medicine Center. Subject Seventy eight patients with FBSS diagnosis based on internationally recognized criteria, and refractory to conservative therapy for at least 6 months, have been initially recruited, and. Methods Sixty subjects met the eligibility criteria and were randomized and scheduled for the trial phase.The patients were randomly assigned in either, one of the two groups: CF SCS or HF SCS. Within the study methods, special attention was paid to standardizing patient programming, so that these parameters would not impact the results.The trial period was considered successful if there was ?50% reduction in the NRS from baseline. Results A total of 55 subjects successfully completed all assessments during one year follow-up. Change patterns in scores do not differ based on high versus conventional frequency, with significant global average reduction at 1 year similarly for both groups. Among all the items included in the Short Form-12 questionnaire (SF-12), only the variations in the social function score between the instants t1 and t2 are somewhat higher in the high frequency group. Conclusion The evolutionary pattern of the different parameters studied in our patients with FBSS does not differ according to their treatment by spinal stimulation, with conventional or high frequency, in one year follow-up.

Background: The spine surgeons have been combining anterior and posterolateral fusion (circumferential fusion) as the final solution to treat spinal disorders and many have been using it to treat failed back surgery syndrome (FBSS). In present study, we analyzed and compared the clinical and radiological outcomes in patients with transpedicular screw fixation and intervertebral autogenous posterior iliac crest bone graft or in patients with transpedicular screw fixation and intervertebral B-Twin system for FBSS with a follow-up period of 10 years after the surgery. Materials and Methods: This study was a retrospective case study performed on 55 patients with FBSS. Clinical and radiological changes were compared between the two groups of patients on the basis of improvement of back pain, radicular pain, and work capacity. Outcome was measured in terms of Oswestry Low Back Pain Disability Index, and the changes in pain and function were documented every year from before surgery until 2012. We analyzed the evolution of 55 cases of FBSS those underwent segmental circumferential posterior fusions from June 2001 to February 2003, operated by a single surgeon and followed up during 10 years until February 2012. The patients were divided into 2 groups: In 25 patients, posterolateral fusions with Legacy™ (Medtronic, Inc. NYSE: MDT) screws and intersomatic autogenous posterior iliac crest bone graft was performed, and, in 30 patients, posterolateral fusions with the same screws and intersomatic fusion B-Twin (Biomet Spain Orthopaedics, S.L.) system was performed. In all cases, we used posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) approach for intervertebral graft, and the artrodesis was supplemented at intertransverse level with Autologus Growth Factor (AGF-MBA INCORPORADO, S.A.). The outcome was measured in terms of Oswestry Low Back Pain Disability Index, and the changes in pain and function were documented every year and compared from before surgery to the final follow-up visit. Preoperative and postoperative scores were available for all patients. Results: The average age of these patients was comparable in both groups (mean age 42.6 versus 50.2 years). The average follow-up period was 200.6 months in the first group (screws and intersomatic bone) and 184.4 months in the second group (screws and B-Twin). In the autologus bone graft group, the CT scan and Rx study revealed loss of height of intervertebral space between 25% and 45% of 24 h postoperative height of intervertebral operated disc, and the patients continued to lose the height until 20 months after the surgery. In the B Twin group, the CT scan and Rx study revealed a loss of height of the intervertebral level of 8-12% over a period of 9 months follow-up, followed by stability. A total of 31 patients (55%) had improved Oswestry Low Back Pain Disability Index >40% of the total possible points, although this did not reflect in PSI or return to work rate. Conclusions: The patients with rigid fixation do well in terms of correction of lumbar lordosis, but they do not do well in terms of recurrence of pain. Furthermore, they need some kind of intervention to control pain after the first year after surgery. In patients in whom bone graft is used, although they do not maintain and sustain the lumbar lordosis in the long term, they have less recurrence of pain with less chances of intervention for pain control.

Introduction: Spinal cord stimulation is a safe and effective procedure applied for medically intractable neuropathic pain and failed back surgery syndrome. Recently, a novel stimulation paradigm was developed, called burst stimulation consisting of intermittent packets of closely spaced high-frequency stimuli. The design consists of 40 Hz burst mode with 5 spikes at 500 Hz per burst, with a pulse width of 1ms and 1ms interspike interval delivered in constant current mode. Methods and Materials: A retrospective analysis is performed looking at 102 patients from 2 neuromodulation centers, 1 in Belgium and 1 in the Netherlands. This consisted of 2 groups, 1 group who had become failures to tonic (conventional) stimulation and 1 group who still responded to tonic stimulation. All patients were switched from tonic to burst stimulation and the amount of responders as well as the amount of pain suppression was assessed. Results: Overall burst stimulation was significantly better than tonic stimulation and baseline. On average the pain on numeric rating scale (NRS) improved from 7.8 at baseline to 4.9 with tonic to 3.2 with burst stimulation. For the Belgian and Dutch centers combined, 62.5% of nonresponders to tonic stimulation did respond to burst stimulation, on average, with 43% pain suppression. Most responders to tonic further improved with burst stimulation; on average, pain suppression improved from 50.6% to 73.6.3%. The results (from both centers) did not differ for the amount of obtained pain suppression, only for the amount of responders, which could be related to the different profile of the 2 participating centers. Conclusions: Burst seems to be significantly better than tonic stimulation. It can rescue an important amount of nonresponders to tonic stimulation and can further improve pain suppression in responders to tonic stimulation.

Single cohort study of patients undergoing revision fusion for lumbar pseudoarthrosis.To assess the 2-year comprehensive costs of revision arthrodesis for lumbar pseudoarthrosis at our institution and determine the associated cost per quality-adjusted life year (QALY) gained in this patient population.The proportion of lumbar spine operations involving a fusion procedure has increased over the past 2 decades. Similarly, there has been a corresponding increase in the incidence and prevalence of pseudoarthrosis. However, the cost-effectiveness of revision surgery for pseudoarthrosis-associated back pain has yet to be examined.Forty-seven patients undergoing revision instrumented arthrodesis for pseudoarthrosis-associated back pain were included. Two-year total back-related medical resource utilization, missed work, and health-state values (QALYs, calculated from EuroQuol 5D with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost) and patient and care-giver work-day losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). The mean total 2-year cost per QALY gained after revision surgery was assessed.The mean (±SD) duration of time between prior fusion and development of symptomatic pseudoarthrosis was 2.69±3.09 years. None of the patients developed symptomatic pseudoarthrosis after 2 years of revision surgery. A mean cumulative 2-year gain of 0.35 QALYs was reported. The mean (±SD) total 2-year cost of revision fusion was $41,631±$9691 (surgery cost: $23,865±$270; outpatient resource utilization cost: $4885±$2301; indirect cost: $12,879±$8171). Revision instrumented arthrodesis was associated with a mean 2-year cost per QALY gained of $118,945.Revision arthrodesis was associated with improved 2-year quality of life in patients with pseudoarthrosis-related back pain. Nevertheless, in our experience revision surgery was shown to be marginally cost-effective at $118,945 per QALY gained.

The preoperative identification of lumbar foraminal stenosis (LSFS) is important because a lack of recognition of this clinical entity is often associated with failed back surgery syndrome. Although magnetic resonance imaging (MRI) is widely used, and is considered by many as an appropriate tool for studying spine pathologies, there is limited data to suggest that MRI examinations are sufficiently sensitive or specific for the diagnosis of LSFS. There is a paucity of literature on the diagnostic performance of the combination of conventional diagnostic imaging methods. The purpose of this study is to determine the characteristics of conventional diagnostic imaging for symptomatic lumbar foraminal stenosis.The characteristics of conventional diagnostic imaging of LSFS (X-ray, computed tomography (CT) and MRI) were assessed in 68 patients in whom the site of the stenosis was confirmed by means of selective decompression surgeries.Measurement of the foraminal width and height on CT imaging of the diseased side was significantly less than that on the intact side in the LSFS group. The grading scale for facet joint arthritis on the diseased side was significantly higher than that on the intact side in the LSFS group. The prevalence of the vacuum phenomenon and stage of intervertebral disk (IVD) pathology were higher in the L5-S1 spine of the LSFS group (95.2%) compared with the lumbar spinal canal stenosis (LCS) group (21.1%). MRI study revealed that the prevalence of Type 3 Modic changes was significantly higher in the LSFS group (39.3%) compared with the LCS group (7.7%).Our study demonstrates combination of conventional imaging techniques, to improve the detection of symptomatic foraminal stenosis.

The solution to the failed back syndrome will come from the surgeon who masters the technology, the pathology and the surgery and who understands the patient. The back is normally dynamic and the failed back is no longer dynamic. The multimodality approach has validity and requires attention to the brain as well as the local pain site. Neuro-augmentation is a variable but critical component of pain control. Welfare systems that promote disability may undermine successful therapy. Solutions to great problems usually come from men who are passionate, observing and skilful.

Introduction Low back surgery, including as many type of spine procedures as the multitude of failed back surgery syndrome (FBSS) etiologies, is not always the answer for patients with chronic low back pain. Paradoxically, although a patient is considered to present FBSS because he has already undergone spinal surgery, any new symptom in the back or deterioration of back pain must not be immediately attributed to FBSS, but could be related to another cause independently of the initial mechanical problem. The aim of this paper is to extensively review the potential back pain generators in FBSS patients and to discuss their respective roles and interactions in back pain pathophysiology. Methods Literature searches included an exhaustive review of 643 references and 74 book chapters updated by searching the major electronic databases from 1930 to August 2013. Results Nociceptive fibres innervating any of the back anatomical structures can all play a part in the pathogenesis of the low back pain component in FBSS. The main spinal pain generators are not only myofascial syndrome or muscle spasm but also the facets, the disc complex or a sagittal imbalance and should therefore be carefully reviewed. Only after these steps and appropriate imaging, would it be justified to irremediably diagnose the patient with a refractory chronic condition, requiring no further spine surgery and to propose “palliative” pain treatment options. Conclusion Clinical investigations of the low back pain component in FBSS patients should be based on meticulous dissection of all potential triggers that could be a source of the nociceptive pain characteristics and possibly amenable to further aetiological treatment. Clinicians should therefore refine pain management strategies to ensure that the chronic nature of the pain becomes the guiding principle for multidisciplinary assessement.

Study DesignRetrospective analysis.ObjectiveTo test the hypothesis that failed back surgery syndrome (FBSS) patients and nonsurgical back pain (NSBP) patients respond differently on psychological measures and differ in pain medication usage.Summary of background dataThe study was part of an inter disciplinary outpatient functional restoration program. There were 121 participants—42 with FBSS and 79 with NSBP—who participated in a multidisciplinary pain evaluation.MethodsA chart review was performed and interventions were not applicable. The outcome measures for the study include: the beck depression inventory (BDI), pain disability index (PDI), statetrait anxiety inventory (STAI), multidimen sional pain inventory pain severity (MPIPS) subscale and medication quantification scale III (MQS-III).ResultsPearson's correlation analyses of all patients com bined (28 FBSS and 39 NSBP) revealed significant relationships between MQS-III and BDI (r = 0.388, p < 0.01) and STAI (r = 0.323, p < 0.05). A significant correlation was found between MQS-III and STAI (r = 0.536, p < 0.05) among the NSBP patients. The MQS-III was significantly correlated with BDI (r = 0.536, p < 0.05) and MPI-PS t-scores (r = 0.356, p < 0.05) among the 40 NSBP patients. Independent ttests of mean BDI, PDI, STAI, MPIPS, and MQS-III scores revealed no significant group differences.ConclusionResults suggest that while there is differing cor relation between FBSS and NSBP groups in pain medication use and psychometrics, the mean difference of quantity of pain medications used and scores on psychometric measure ments in these groups are not different. While presurgical psychometrics and pain medication usage were not available for our FBSS patients, our results support that medication quantification with psychological prescreening before surgical intervention for back pain patients may help to limit the number of failed back surgeries. Thus, future research including pre and postsurgical psychological functioning, physical functioning, and pain medication usage is suggested.Gallizzi MA, Gagnon CM, Blizzard DJ, Stanos SP. Failed Back Surgery Syndrome and Back Pain Patients: Medications They use and How They relate to Their Emotional and Physical Functioning. The Duke Orthop J 2015;5(1):53-57.

Objective Spinal cord stimulation can be effectively used in the treatment of low back pain and extremity pain in failed back surgery syndrome. Ideal targets for stimulation corresponding to paresthesia overlap in the low back versus the extremities may differ in cranial-caudal location. Materials and Methods We present here a technical report of three cases demonstrating a technique to place anterograde and retrograde epidural paddles through a single laminotomy. Results Using this technique we were able to cover five spinal levels in each patient, and different stimulation programs at different levels created paresthesia overlap in back versus lower extremity in those patients. Conclusion Dual paddle placement through a single laminotomy may be a reasonable option for select patients where coverage of anatomically-separated pain regions is necessary. This technique can be performed in most patients without significantly increased morbidity.

Objective: Failed back syndrome is a common clinical syndrome that is seen after lumbar disc herniation operations. In this study, we planned to investigate the effects of gabapentin in the treatment of failed back syndrome. Material and Methods: The study included 47 patients who had been operated on because of LDH. They were divided into two groups. Group 1 (n=24) had been treated with gabapentin (300 mgr-3000 mgr/daily) and a lumbar exercise program, and Group 2 (n=23) received only the home exercise program. Patients were assessed by means of range of motion, Schober test, straight leg test, and pain and functional capacity. Pain was evaluated by visual analog scale and neuropathic pain scale. Functional capacity was assessed by Oswestry scale. Assessments were done before and after first and third month of the therapy. Results: The mean age of the patients was 48.7±12.3 (24-81) years. In Group 1, 16 patients (70%) had been operated on at the L4-L5 level, and in Group 2, 10 patients (44%) had been operated on at the L4-L5 level. There was a statistically significant improvement in Oswestry scale scores in Group 1 and Group 2 (p 0.05). Conclusion: Gabapentin treatment was found to be effective, especially for functional capacity and pain, in failed back syndrome patients.

To investigate the effects of local and systemic administration of methyl palmitate on the formation of epidural fibrosis.Twenty-eight rats were randomly divided into four equal groups (control, Spongostan, local methyl palmitate and orally methyl palmitate) and laminectomy was performed between T11 and L1 in all rats. Local methyl palmitate (300 mg/kg) was applied with Spongostan; methyl palmitate (300 mg/kg) was given orally three times per week on different days for a total period of 4 weeks. Four weeks later, the vertebral column from T9 to L3, including the paraspinal muscles and epidural scar tissue, was removed en bloc and epidural fibrosis and arachnoidal involvement was graded and evaluated histopathologically. Kruskal-Wallis and Pearson Chi-Square test were used for statistical analysis. A statistically significant p-value was determined as p0.05.The grading of epidural fibrosis was lower at a statistically significant level in orally-administrated methyl palmitate groups compared to the control and spongostan groups (p0.05).The findings of this study show that oral methyl palmitate decreases the formation of epidural fibrosis and that this effect of methyl palmitate could be mediated by reducing the functions of inflammatory cells such as macrophages, neutrophils and fibroblasts, including anti-inflammatory and antioxidant effects.

The failed back surgery syndrome (FBSS) is a severe, long-lasting, disabling and relatively frequent (5-10%) complication of lumbosacral spine surgery. Wrong level surgery, inadequate surgical techniques, vertebral instability, recurrent disc herniation, and lumbosacral fibrosis are the most frequent causes of FBSS. The results after repeated surgery on recurrent disc herniations are comparable to those after the first intervention, whereas repeated surgery for fibrosis gives only 30-35% success rates, and 15-20% of the patients report worsening of the symptoms. MRI has allowed a differentiation between these two pathologies for selection of different therapies. Gadolinium enhanced MR is at present the single most sensitive and specific imaging modality available to the neuro radiology imager for the evaluation of the post operative lumbosacral spine in the patient presenting with FBSS. Medical imaging specialists and clinicians need to better understand the origins and means of avoiding the FBSS, to more clearly focus the post operative imaging evaluation and to more successfully link the clinical diagnosis and the imaging findings with optimised patient therapy.

Background: The optimal treatment of failed back surgery syndrome (FBSS) is controversial. Limited studies have demonstrated the satisfactory outcomes of percutaneous adhesiolysis in FBSS, which can be performed as a 1 day or 3 days procedure. In the current randomized clinical trial, we compared the clinical and functional outcomes of these 2 techniques. Methods: In this study, 60 patients with FBSS were randomly assigned into 2 equal groups: 1 day group and 3 days group. Before and at 4 and 12 weeks after the procedure, pain intensity was measured using visual analogue scale (VAS). The Oswestry disability index (ODI) was also completed. Pain reduction of 50% or more was defined as treatment success. Results: Significant pain relief and ODI improvement were obtained in the 2 groups with adhesiolysis (P < 0.001). However, pain intensity remained the same before and at 4 and 12 weeks after adhesiolysis. ODI score was significantly lower in 1 day group in the 1 month visit (P < 0.001). Treatment was successful in 76.7% and 83.3% of the patients in 1 day and 3 days groups, respectively (P = 0.519). Conclusions: Adhesiolysis is an effective treatment for pain relief and functional improvement in FBSS. The results of 1 day and 3 days procedures are comparable. Based on these findings, the authors recommend using 1 day technique, which can potentially decrease the patients' discomfort, hospital stay, and cost of treatment.

Objectives: To evaluate the short-term outcome of a 3-in-1 procedure including percutaneous facet radiofrequency, percutaneous spinal fixation and steroid with hyaluronidase enzyme injection versus percutaneous spinal fixation alone for cases with failed back surgery syndrome (FBSS).Patients and methods: The study included 50 patients who had had previous spinal surgery since a mean duration of 39.7 ± 8.5 months and developed recurrent back pain since a mean duration of 10 ± 2.1 months. Patients were randomly allocated into two groups; group A underwent percutaneous spinal fixation only and group B underwent the 3-in-1 procedure. Outcome was evaluated at the end of six months postoperatively (PO) using a pain numeric rating scale (NRS), the Oswestry Disability Index (ODI) and Odom’s criteria for evaluation of surgical outcome with evaluation of patients’ satisfaction by outcome.Results: All patients showed progressive decrease of NRS pain and ODI scores compared with preoperative scores. However, patients in group B showed significantly lower postoperative NRS pain scores and ODI with significantly higher frequency of patients having had > 50% reduction of both scores compared with patients in group A. PO analgesic consumption rate in both groups was significantly lower than the preoperative rate with a significant reduction of mean total scoring compared with preoperative scoring. The frequency of patients who found the provided therapeutic procedure satisfactory and its outcome good-to excellent was significantly higher among patients in group B compared with group A.Conclusion: Short-term outcomes of the applied 3-in-1 procedure are promising for improvement of symptoms secondary to FBSS and may ultimately prove to be recommended as the therapeutic modality for such a challenging clinical problem.Keywords: failed spinal surgery, percutaneous facet radiofrequency, percutaneous spinal fixation

Failed back surgery syndrome (FBSS) is complex and recurrent chronic pain after spinal surgery. Several important patient and surgery related risk factors play roles in development of FBSS. Inadequate selection of the candidates for the spinal surgeries is one of the most crucial causes. The guidelines suggest that conservative management featuring pharmacologic approaches and rehabilitation should be introduced first. For therapy-refractory FBSS, spinal cord stimulation (SCS) is recommended in selected patients. Treatment efficacy for FBSS has increased over the years with the majority of patients experiencing pain relief and reduced medicinal load. Improved quality of life can also be achieved using SCS. Cost-effectiveness of SCS still remains unclear. However evidence for SCS role in FBSS is controversial, SCS can be beneficial for carefully classified patients.

A systematic review.A systematic literature review of the clinical data from prospective studies was undertaken to assess the efficacy of spinal cord stimulation (SCS) in the treatment of failed back surgery syndrome (FBSS) in adults.For patients with unrelenting back pain due to mechanical instability of the spine, degenerative disc disease, spinal injury, or deformity, spinal surgery is a well-accepted treatment option; however, even after surgical intervention, many patients continue to experience chronic back pain that can be notoriously difficult to treat. Clinical evidence suggests that for patients with FBSS, repeated surgery will not likely offer relief. Additionally, evidence suggests long-term use of opioid pain medications is not effective in this population, likely presents additional complications, and requires strict management.A systematic literature review was performed using several bibliographic databases, prospective studies in adults using SCS for FBSS were included.SCS has been shown to be a safe and efficacious treatment for this patient population. Recent technological developments in SCS offer even greater pain relief to patients' refractory to other treatment options, allowing patients to regain functionality and improve their quality of life with significant reductions in pain.N/A.

The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients' clinical history (observing "red flags"), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.

To evaluate clinical outcomes and complications of extreme lumbar interbody fusion (XLIF) in spinal revision surgery comparing our data with the available literature evidence about other fusion techniques. Retrospective analysis of patients underwent revision surgery with XLIF as interbody fusion technique. Demographic, comorbidity, surgical data, clinical results, and intraoperative and postoperative complications were recorded. 36 patients, with a minimum follow-up of 28 ± 11.5 months, were included in the analysis. 41 levels were fused with XLIF. The mean number of previous spine surgery was 1.5 ± 0.7. Mean improvement in back pain and leg pain on VAS was 5.6 ± 1.4 (p

Surgery of lumbar disc herniation is most common procedure in neurosurgical practice. However poor outcomes, recurrent disc herniation and recurrence of low back and leg pain which affect quality of life, are still challenging. Lumbar spine instability develops as a result of a gradual degenerative process and lumbar segmental instability is one of main reason of failed back surgery. Presence of lumbar segmental instability or potential secondary instability after surgery should not be overlooked. Accurate preoperative evaluation of patients with lumbar disc herniation needs to understand biomechanics of spinal stability and predict possible result of postoperative instability. Thus failure of treatment modalities can be avoided.

Background: Chronic low back and leg pain is a disabling condition, affecting, in most cases, older patients with congenital or acquired spinal stenosis or patients with failed back surgery syndrome. Spinal cord stimulation has been introduced as an effective therapeutic option for those patients who have previously been operated without significant clinical benefits, or for all those patients who are ineligible for traditional surgery. Methods: We report our experience with ten patients treated with spinal cord stimulation plus medication and physical therapy between November 2014 and September 2015. Inclusion criteria were: previous surgical treatments for lumbar stenosis and metameric instability and persistent or ingravescent disabling low back and leg pain, with a mean duration of symptoms of at least 18 months. A visual analog scale (VAS) was employed for back and leg pain, and the Oswestry Disability Index (ODI) score was determined, and findings were analyzed after 6 months. Findings: No intra- or postoperative complication was recorded. The mean VAS score for back pain decreased from 7.5 to 2.9, while leg VAS decreased from 8.2 to 3.0. Analysis of ODI values showed evident improvement in daily life activities, ranging from a median value of 75.7% to 32.7 % after the stimulation. Conclusion: Spinal cord stimulation has a recognized impact on the pain and on the quality of life of patients with failed back surgery syndrome.

Introduction. This observational study was designed to evaluate the efficacy of ultramicronized palmitoylethanolamide (um-PEA) (Normast®) administration, as add-on therapy for chronic pain, in the management of pain-resistant patients affected by failed back surgery syndrome. Methods. A total of 35 patients were treated with tapentadol (TPD) and pregabalin (PGB). One month after the start of standard treatment, um-PEA was added for the next two months. Pain was evaluated by the Visual Analogue Scale (VAS) at the time of enrollment (T0) and after one (T1), two (T2), and three (T3) months. Results. After the first month with TDP + PGB treatment only, VAS score decreased significantly from 5.7±0.12 at the time of enrollment (T0) to 4.3 ± 0.11 (T1) (p<0.0001); however, it failed to provide significant subjective improvement in pain symptoms. Addition of um-PEA led to a further and significant decrease in pain intensity, reaching VAS scores of 2.7 ± 0.09 (T2) and 1.7 ± 0.11 (T3, end of treatment) (p<0.0001) without showing any side effects. Conclusions. This observational study provides evidence, albeit preliminary, for the efficacy and safety of um-PEA (Normast) as part of a multimodal therapeutic regimen in the treatment of pain-resistant patients suffering from failed back surgery syndrome.

Item does not contain fulltext Spinal cord stimulation is an effective treatment modality for refractory neuropathic pain conditions, but the placement of leads can be challenging due to unforeseen anatomical variations. We used a retrograde C7-T1 approach to place a lead at the bottom of T8 in a patient suffering from failed back surgery syndrome. We were able to achieve adequate stimulation in her lower back and legs, which resulted in significant reduction in pain intensity during the spinal cord stimulation trial. Cervical retrograde placement of leads may represent an alternative method for successful placement of percutaneous leads in patients with abnormal anatomy due to thoracic postsurgical changes.

Spinal cord stimulation (SCS) is a reliable clinical option for treatment of refractory chronic pain. It is known to be effective method for treating sympathetic pain, failed back surgery syndrome, and complex regional pain syndrome etc. The devices and implantation techniques for SCS are already highly developed and continuously improving, but there are some complications that can not be corrected easily. Lead migration is the most common complication after SCS. It can cause failure of SCS that can make discomfort to patients. Here we describe our experience of lead migration in implanted SCS which was inserted to a patient with complex regional pain syndrome patient.

This article describes the costs and risk factors for failed back surgery syndrome and reviews the diagnosis and treatment strategies commonly used to address this syndrome. The purpose of this review is to describe some of the treatment pitfalls associated with these approaches from a physiatric perspective.

PubMed ID: 24374200 The formation of epidural fibrosis adjacent to the dura mater is a complex multi-step process that is associated with a marked reduction in tissue cellularity and the excessive deposition of extracellular matrix components. Extensive epidural fibrosis is a major cause of post-laminectomy syndrome. Decorin strongly inhibits fibrosis formation in various tissues via blockade of transforming growth factor-?1. The aim of this study was to investigate the effects of a topical application of decorin on the formation of epidural fibrosis in a rat laminectomy model. Twenty-four female Wistar albino rats (250-350 g) were equally and randomly divided into three groups (control, spongostan and decorin). Laminectomy was performed between the L3 and L5 levels in all rats. The dura mater was directly exposed to spongostan soaked with saline (2 cc/kg) or decorin (100 ?g/kg). Four weeks later, the laminectomized spine of the rats was completely removed between the L3 and L5 levels. The extent of the epidural fibrosis and arachnoidal involvement was histopathologically evaluated and graded. Our data revealed that epidural fibrosis was significantly reduced in the group treated with decorin compared to the spongostan and control groups (P

Epiduroscopy is a minimally invasive diagnostic and therapeutic technique that was introduced in clinical practice in early 1990s. We have performed a systematic review of side effects and complications reported in literature. Troubleshooting to prevent or reduce complications has been proposed. Dural puncture and fluid injection overpressure were the main causes of complications. According to the published evidence, conventional epiduroscopy is a safe procedure with no mortality and little morbidity.

Failed back surgery syndrome refers to persistent back pain following back surgery. The optimal course of treatment for this syndrome varies according to the patient and the etiology of the pain. This study describes the application of a treatment algorithm for failed back surgery syndrome, focusing on the use of epiduroscopy, a novel technique that is useful for diagnosis and treatment of this syndrome. Diagnoses and treatment success after one year of follow-up are reported., BACKGROUND: Failed back surgery syndrome (FBSS) is a major clinical problem. Different etiologies with different incidence rates have been proposed. There are currently no standards regarding the management of these patients. Epiduroscopy is an endoscopic technique that may play a role in the management of FBSS. OBJECTIVE: To evaluate an algorithm for management of severe FBSS including epiduroscopy as a diagnostic and therapeutic tool. METHODS: A total of 133 patients with severe symptoms of FBSS (visual analogue scale score ≥7) and no response to pharmacological treatment and physical therapy were included. A six-step management algorithm was applied. Data, including patient demographics, pain and surgical procedure, were analyzed. In all cases, one or more objective causes of pain were established. Treatment success was defined as ≥50% long-term pain relief maintained during the first year of follow-up. Final allocation of patients was registered: good outcome with conservative treatment, surgical reintervention and palliative treatment with implantable devices. RESULTS: Of 122 patients enrolled, 59.84% underwent instrumented surgery and 40.16% a noninstrumented procedure. Most (64.75%) experienced significant pain relief with conventional pain clinic treatments; 15.57% required surgical treatment. Palliative spinal cord stimulation and spinal analgesia were applied in 9.84% and 2.46% of the cases, respectively. The most common diagnosis was epidural fibrosis, followed by disc herniation, global or lateral stenosis, and foraminal stenosis. CONCLUSIONS: A new six-step ladder approach to severe FBSS management that includes epiduroscopy was analyzed. Etiologies are accurately described and a useful role of epiduroscopy was confirmed.

Failed back surgery syndrome (FBSS) is a challenging problem. One treatment advocated to treat FBSS is epidural lysis of adhesions (LOA). The results of studies examining LOA for FBSS have been mixed, but are limited because no study has ever sought to identify factors associated with outcomes.We performed this multicenter, retrospective study in 115 patients who underwent LOA for FBSS (n = 104) or spinal stenosis (n = 11) between 2004 and 2007. Twenty-seven demographic, clinical, and procedural variables were extracted from medical records and correlated with the outcome, defined as ≥50% pain relief lasting ≥1 month. Univariable analysis was performed, followed by multivariable logistic regression.Overall, 48.7% (95% confidence interval [CI], 39.3%-58.1%) of patients experienced a positive outcome. In univariable analysis, those who had a positive outcome were older (mean age 64.1 years; 95% CI, 59.7-68.6 vs 57.2; 95% CI, 53.0-61.4 years; P = 0.02), while higher baseline numerical rating scale pain scores were associated with a negative outcome (mean 6.7 years; 95% CI, 6.0-7.3 vs 7.5; 95% CI, 6.9-8.0; P = 0.07). Use of hyaluronidase did not correlate with outcomes in univariable analysis (odds ratio [OR], 1.2; 95% CI, 0.6-2.5; P = 0.65). In multivariable analysis, age ≥81 years (OR, 7.8; 95% CI, 1.4-53.7), baseline numerical rating scale score ≤9 (OR, 4.4; 95% CI, 1.4-16.3, P = 0.02), and patients on or seeking disability or worker's compensation (OR, 4.4; 95% CI, 1.1-19.5, P = 0.04) were significantly more likely to experience a positive outcome.Considering our modest success rate, selecting patients for epidural LOA based on demographic and clinical factors may help better select treatment candidates. Procedural factors such as the use of hyaluronidase that increase risks and costs did not improve outcomes, so further research is needed before these become standard practice.

To evaluate the cost-effectiveness of spinal cord stimulation (SCS) and conventional medical management (CMM) compared with CMM alone for patients with failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), peripheral arterial disease (PAD), and refractory angina pectoris (RAP).Markov models were developed to evaluate the cost-effectiveness of SCS vs CMM alone from the perspective of a Canadian provincial Ministry of Health. Each model followed costs and outcomes in 6-month cycles. Health effects were expressed as quality-adjusted life years (QALYs). Costs were gathered from public sources and expressed in 2012 Canadian dollars (CAN$). Costs and effects were calculated over a 20-year time horizon and discounted at 3.5% annually, as suggested by the National Institute of Clinical Excellence. Cost-effectiveness was identified by deterministic and probabilistic sensitivity analysis (50,000 Monte-Carlo iterations). Outcome measures were: cost, QALY, incremental net monetary benefit (INMB), incremental cost-effectiveness ratio (ICER), expected value of perfect information (EVPI), and strategy selection frequency.The ICER for SCS was: CAN$ 9,293 (FBSS), CAN$ 11,216 (CRPS), CAN$ 9,319 (PAD), CAN$ 9,984 (RAP) per QALY gained, respectively. SCS provided the optimal economic path. The probability of SCS being cost-effective compared with CMM was 75-95% depending on pathology. SCS generates a positive INMB for treatment of pain syndromes. Sensitivity analyses demonstrated that results were robust to plausible variations in model costs and effectiveness inputs. Per-patient EVPI was low, indicating that gathering additional information for model parameters would not significantly impact results.SCS with CMM is cost-effective compared with CMM alone in the management of FBSS, CRPS, PAD, and RAP.