Failed Back Surgery Syndrome
What is failed back surgery syndrome (post laminectomy pain syndrome)?
Failed back surgery syndrome (FBSS) denotes persistent low back pain with or without leg pain (“sciatica”) despite prior spine surgery. For example, a patient suffers a lumbar disc herniation with radiculopathy that caused significant low back and lower limb pain with associated numbness and tingling. The patient tries medications, physical therapy, and lumbar epidural steroid injections, but continues to experience significant pain. As such, spine surgery is performed to treat the disc herniation and decompress the nerve. In many cases, this allows for a significant improvement in a patient’s pain. Unfortunately, there are cases in which, despite good surgical technique, the patient continues to experience persistent pain. The incidence of FBSS is estimated to be 10-40% of patients who undergo lumbar spine surgery.
What causes failed back surgery syndrome (post laminectomy pain syndrome)?
There are a many different potential etiologies of FBSS that may include, but are not necessarily limited to, progressive disease (new disc herniation, spondylolisthesis), epidural fibrosis, surgical complications, development of myofascial pain, poor surgical candidate selection, and inadequate decompression.
How is failed back surgery syndrome (post laminectomy pain syndrome) diagnosed?
Similar to other spine conditions, the diagnosis of FBSS includes a thorough history and physical examination. Additional testing with imaging (x-ray, CT, MRI) and electrodiagnostic studies (EMG/NCS) may be recommended. Finally, diagnostic procedures such as medial branch blocks, sacroiliac joint injections, or provocative lumbar discography may be utilized to more precisely rule in or rule out potential sources of low back pain such as the facet joints, sacroiliac joints, or intervertebral discs.
How is failed back surgery syndrome (post laminectomy pain syndrome) treated?
Initial treatment options may include analgesic medications, physical therapy, or chiropractic. Trials of epidural steroid injections or pulsed radiofrequency of dorsal root ganglion can also be considered. If the patient has tried typical conservative measures but has not noted significant improvement in pain and function, a spinal cord stimulator trial can then be considered.
Spinal Cord Stimulator
A spinal cord stimulator (SCS) is a non-surgical, minimally invasive treatment for failed back surgery syndrome (FBSS) that uses electrical impulses to block specific nerves of the spinal cord that transmit pain. It consists of a pacemaker-like battery pack called a generator and thin wires called leads. Together, the generator and leads produce electrical signals that stimulate specific nerves of the spinal cord which mask or modify pain signals before reaching the brain, thus greatly diminishing a person’s interpretation and perception of pain.
SCS may be used for patients who have chronic pain conditions despite trials of treatment options such as medications, physical therapy, chiropractic, injections, and even surgery. Indications for use of SCS include chronic low back or neck pain with or without limb pain such as failed back surgery syndrome (post-laminectomy pain syndrome). It may also be used for patients with chronic nerve pain conditions such as complex regional pain syndrome (CRPS), painful peripheral polyneuropathy, or painful diabetic neuropathy. Finally, SCS may be used for those patients with chronic pain who may not be surgical candidates or those who wish to avoid surgery altogether.
If a patient is deemed to be a good candidate for a SCS, Dr. Best will discuss performing a trial first. During a SCS trial, the epidural space is accessed using an introducer needle and x-ray (fluoroscopic) guidance just like an epidural steroid injection. However, rather than instilling steroid through the needle, a very small and thin wire (spinal cord stimulator lead) is inserted into the epidural space and gradually advanced to the mid-thoracic region. The other end of the leads exit the skin at the site oof introducer needle placement and connected to the generator which will be secured to the patient’s flank area during the 5–7-day trial period. During this 5–7-day period, the patient has the opportunity to test out the SCS technology and get a sense of whether it helps to significantly decrease pain and improve function. The patient then returns to Dr. Best’s clinic to discuss the result of the SCS trial. During the follow up visit in clinic, the SCS trial leads are removed and, if successful, the patient may choose to have the spinal cord stimulator permanently placed. When a SCS is placed on a permanent basis, all components of the leads are once again placed in the epidural space and advanced to the mid-thoracic region; however, they are then tunneled under the skin and connected to the generator which is sitting in a subcutaneous pocket created with a small incision.
The common goals when considering the use of SCS include significantly decreasing pain, decreasing need for and use of pain medication, and improvement in overall function.
At a Glance
Dr. Craig Best
- Harvard Fellowship-Trained Interventional Spine & Sports Medicine Specialist
- Double Board-Certified in Physical Medicnie & Rehabilitation and Pain Medicine
- Assistant Professor of Physical Medicine & Rehabilitation and Orthopedic Surgery
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