Interventional Pain Management for Failed Back Surgery Syndrome

Abstract

Patients who suffer from the condition known as failed back surgery syndrome (FBSS) present to the offices of physicians, surgeons, and pain specialists alike in overwhelming numbers. This condition has been defined as persistent back and/or leg pain despite having completed spinal surgery. As lumbar surgery continues to grow in prevalence, so will the number patients suffering from FBSS. It is important for physicians treating this population to expand their knowledge of FBSS etiologies and appropriate diagnostic imaging modalities, combined with confirmatory diagnostic injections, and proper technique for interventional pain procedures. In doing so, the physician may adequately be prepared to manage these complex cases in the future, ideally with the support of stronger evidence. Management begins with a systematic evaluation of common FBSS etiologies such as new‐onset stenosis, recurrent herniated nucleus pulposus (HNP), epidural fibrosis, pseudarthrosis, and others. History and physical may be supplemented by imaging including X‐ray, magnetic resonance imaging, or computed tomography myelography. Certain diagnoses may be confirmed with diagnostic procedures such as intra‐articular injections, medial branch blocks, or transforaminal nerve root blocks. Once an etiology is determined, a multidisciplinary approach to treatment is most effective. This includes exercise or physical therapy, psychological counseling, medication, and interventional procedures. The most invasive treatment option, short of revision surgery, is spinal cord stimulation. This intervention has a number of studies demonstrating its efficacy and cost‐effectiveness in this population. Finally, revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.

Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series

“…4 Postsurgical continued pain (PSCP) sends patients to the offices of physicians, surgeons, and pain specialists alike in overwhelming numbers. 5 Although surgery for radiculopathy caused by herniated lumbar disk and symptomatic spinal stenosis shows improved short-term benefit compared with nonsurgical care, the benefits diminish long term.…”

Is Once Failed Back Surgery, Always Failed Back Surgery? A Relative Success of Surgical Intervention in a Patient with Failed Back Surgery on Intrathecal Morphine Pump

“…Pain specialist input is playing a crucial role for management of such difficult to treat patients. When final step in analgesic ladder is reached without a satisfactory pain control and all other interventions including physical therapy complementary techniques [5] are tried and failed, an IT morphine pump implant may be considered [2,6]. Even in the presence of such device, co-medication with one or combination of different classes of analgesics may still be necessary.…”

“…It is assumed that every patient that is on the chronic pain pathway does not have surgical target anymore and/or the surgical armamentarium has been tried and exhausted and failed. Such patients are assumed to have almost no potential to benefit from yet another operation hence non-surgical modalities are recruited [2]. Pain specialist input is playing a crucial role for management of such difficult to treat patients.…”

“…Implanted cord stimulators and intrathecal pumps, represent the last resort for pain control in carefully selected patients when non-surgical modalities have been exhausted [1,2]. Patients with these devices, therefore, are generally considered as non-surgical candidates by definition.…”

Management for failed back surgery syndrome: three-in-one procedure versus percutaneous spinal fixation alone

“…In these cases, RF is the preferred procedure due to its effectiveness over time and lack of complications. 7 RF neurotomy has been useful for treatment of lumbar facet syndrome and sacroiliac joint pain. Despite gradual loss of efficacy, at 2 years 40% of patients maintained a 50% reduction of pain intensity.…”