Failed Back Syndrome or Post-laminectomy Syndrome is a condition characterized by persistent pain following back surgeries. Laminectomy is a spine operation to remove the portion of the vertebral bone called the lamina. Pain, in the sense of physical pain, is a typical sensory experience that may be described as the unpleasant awareness of a noxious stimulus or bodily harm Laminectomy is a spine operation to remove the portion of the vertebral bone called the lamina.

Failed back syndrome (FBS), more commonly referred to as "failed back surgery syndrome" (FBSS), refers to chronic back and/or leg pain that occurs after back (spinal) surgery. ^[1][2] Multiple factors can contribute to the onset or development of FBS. Contributing factors include but are not limited to residual or recurrent disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness and spinal muscular deconditioning. Hypermobility (also called double-jointedness, hypermobility syndrome or hyperlaxity) describes Joints that stretch farther than is normal Fibrosis is the formation or development of excess fibrous Connective tissue in an organ or tissue as a reparative or reactive process as opposed to a formation of Fibrous In the fields of Psychology and Psychiatry, the terms depression or depressed refer to both expected and pathologically chronic or severe Anxiety is a physiological and psychological state characterized by Cognitive, Somatic, Emotional and Behavioral components Insomnia is a symptom of a sleeping disorder characterized by persistent difficulty falling asleep or staying asleep despite the opportunity Deconditioning is adaptation of an organism to less demanding environment or alternatively the decrease of physiological adaptation to normal conditions An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease. Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Autoimmune diseases arise from an overactive Immune response of the body against substances and tissues normally present in the body Peripheral vascular disease (PVD also known as peripheral artery disease (PAD or peripheral artery occlusive disease (PAOD is a collator for all Diseases Smoking is a risk for poor recovery from such an operation as is anything that constricts the blood vessels.

Common symptoms associated with FBS include diffuse, dull and aching pain involving the back and/or legs. Abnormal sensibility may include sharp, pricking, and stabbing pain in the extremities. The term “post-laminectomy syndrome” is used by some doctors to indicate the same condition as failed back syndrome.

The treatments of post-laminectomy syndrome include physical therapy, minor nerve blocks, transcutaneous electrical nerve stimulation (TENS), behavioral medicine, non-steroidal anti-inflammatory (NSAID) medications, membrane stabilizers, antidepressants, spinal cord stimulation, and intracathecal morphine pump. Behavioral Medicine is an Interdisciplinary field of Medicine concerned with the development and integration of Psychosocial, Behavioral Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAID s or NAID s, are drugs with Analgesic, Antipyretic and in higher An antidepressant is a Psychiatric medication used for alleviating major depression or Dysthymia ('milder' depression Spinal Cord Stimulator (SCS or Dorsal Column Stimulator (DCS is an implantable Medical device used to treat chronic pain of neurologic origin Use of epidural steroid injections has been shown to decrease the frequency and intensity of the pain. The targeted anatomic use of a potent anti-inflammatory anti-TNF therapeutic is an emerging treatment option for patients with severe back or neck disc-related pain associated with FBSS (see below).

In the past two decades there has been a dramatic increase in fusion surgery in the U. S. : in 2001 over 122,000 lumbar fusions were performed, a 22% increase from 1990 in fusions per 100,000 population, increasing to an estimate of 250,000 in 2003, and 500,000 in 2006. ^[3][4][5] In 2003, the national bill for the hardware for fusion alone was estimated to have soared to $2. 5 billion a year. ^[4] A single screw that goes into the spine may sell for $1,000. ^[5] In 2004, the average hospital bill, excluding professional fees was $34,000 for fusion surgery; if one adds the fee of the surgeon, the assistant surgeon, and the anesthesiologist, one can easily see how fusion surgery alone generates billions of dollars per year in fees for hospitals and surgeons. ^[6]

With these increasing numbers of operations, one would expect the incidence of FBSS to also have increased. In contrast to the representation that “spine surgery is no more than 95% predictive of a successful result”, other sources document a success rate as low as 49%, depending upon the evaluation criteria used. ^[7] Other forms of spinal surgery are less invasive than spinal fusion; one such operation is laminectomy, performed more than 250,000 times per year in the U. Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to combine two or more Vertebrae. Laminectomy is a spine operation to remove the portion of the vertebral bone called the lamina. S. ^[8] But even this less invasive form of surgery is not uniformly successful; approximately 30,000-40,000 laminectomy patients obtain either no relief of symptomatology or a recurrence of symptoms. Laminectomy is a spine operation to remove the portion of the vertebral bone called the lamina. ^[9] Another less invasive form of spinal surgery, percutaneous disc surgery, has reported revision rates as high as 65%. ^[10] It is no surprise, therefore, that FBSS is a significant medical concern which merits further research and attention by the medical and surgical communities.

Contents 1 Etiology of the Failed Back Surgery Syndrome 2 Treatment 3 Emerging Treatment Options 4 References 5 External links 5.1 General Interest

Etiology of the Failed Back Surgery Syndrome

For patients with continued severe pain following spinal surgery the surgeon's first responsibility is to rule out a serious treatable cause of pain: infection, tumor, fracture, spinal instability, or abscess. An infection is the detrimental Colonization of a host Organism by a foreign Species. See also Cancer A tumor or tumour is the name for a swelling or lesion formed by an abnormal growth of cells (termed neoplastic A fracture is the (local separation of an object or material into two or more pieces under the action of stress. An abscess (abscessus is a collection of Pus (dead Neutrophils) that has accumulated in a cavity formed by the tissue on the basis of an infectious process If present, these causes are usually ferreted out early-on. Surgeons will argue that the etiology of FBSS "can be poor patient selection, incorrect diagnosis, suboptimal selection of surgery, poor technique . . . and/or recurrent pathology", as well as including "failure to achieve surgical goals". ^[11] Commonly, however, causes of continued pain are difficult to unequivocally identify, and the patient suffers from chronic pain, not readily amenable to surgical intervention. Chronic pain is defined as Pain that persists longer than the temporal course of natural healing associated with a particular type of injury or disease process ^[12][13] For those contemplating more surgery additional complications must be considered. Complications of spinal fusion surgery may include instrument failure, bone-donor site infection or chronic pain; neural injuries, pulmonary embolus, infections, vascular complications (rare but potentially catastrophic), failure to achieve a solid fusion, and blindness. Pulmonary embolism (PE is a blockage of the Pulmonary artery or one of its branches usually occurring when a venous Thrombus (blood clot from a vein Blindness is the condition of lacking Visual perception due to Physiological or Neurological factors ^[6]

For patients with continued pain after surgery which is not due to the above complications or conditions, interventional pain physicians speak of the need to identify the "pain generator" i. e. the anatomical structure responsible for the patient's pain. Obviously, to be effective, the surgeon must operate on the correct anatomic structure; however it is often not possible to determine the source of the pain. ^[12][13] The reason for this is that many patients with chronic pain often have disc bulges at multiple spinal levels and the physical examination and imaging studies are unable to pinpoint the source of pain. Chronic pain is defined as Pain that persists longer than the temporal course of natural healing associated with a particular type of injury or disease process ^[12] In addition, spinal fusion itself, particularly if more than one spinal level is operated on, may result in “adjacent segment degeneration”. Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to combine two or more Vertebrae. ^[14] This is thought to occur because the fused segments may result in increased torsional and stress forces being transmitted to the intervertebral discs located above and below the fused vertebrae. Intervertebral discs (or intervertebral fibrocartilage) lie between adjacent vertebrae in the spine. ^[14] This pathology is one reason behind the development of artificial discs as a possible alternative to fusion surgery. But the fusion surgeons would argue that spinal fusion is more time-tested, and artificial discs contain metal hardware that is unlikely to last as long as biological material without shattering and leaving metal fragments in the spinal canal. Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to combine two or more Vertebrae.

Another highly relevant consideration is the increasing recognition of the importance of “chemical radiculitis” in the generation of back pain. Back pain (also known " dorsalgia " is Pain felt in the back that usually originates from the Muscles Nerves Bones ^[15] A primary focus of surgery is to remove “pressure” or reduce mechanical compression on a neural element: either the spinal cord, or a nerve root. The spinal cord is a long thin tubular bundle of Nerves that is an extension of the Central nervous system from the brain and is enclosed in and protected A nerve root is the initial segment of a Nerve leaving the Central nervous system. But it is increasingly recognized that back pain, rather than being solely due to compression, may instead entirely be due to chemical inflammation. ^{[16][17] [18][15]} In the past five years increasing evidence has pointed to a specific inflammatory mediator of this pain. ^[19][20] This inflammatory molecule, called tumor necrosis factor-alpha (TNF), is released not only by the herniated or protruding disc, but also in cases of disc tear (annular tear), by facet joints, and in spinal stenosis. Tumor necrosis factor ( TNF, cachexin or cachectin and formally known as Tumor necrosis factor-alpha) is a Cytokine involved in systemic Tumor necrosis factors (or the TNF-family) refers to a group of Cytokines family that can cause Apoptosis. Spinal stenosis is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves ^{[15][21][22][23]} In addition to causing pain and inflammation, TNF may also contribute to disc degeneration. Tumor necrosis factors (or the TNF-family) refers to a group of Cytokines family that can cause Apoptosis. ^[24] If the cause of the pain is not compression, but rather is inflammation mediated by TNF, then this may well explain why surgery might not relieve the pain, and might even exacerbate it, resulting in FBSS. Tumor necrosis factors (or the TNF-family) refers to a group of Cytokines family that can cause Apoptosis.

Treatment

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 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. Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAID s or NAID s, are drugs with Analgesic, Antipyretic and in higher ^[13] An alternative often employed is the injection of cortisone into the spine adjacent to the suspected pain generator, a technique known as “epidural steroid injection”. ^[25] Although this technique began more than a decade ago for FBSS, the efficacy of epidural steroid injections is now generally thought to be limited to short term pain relief in selected patients only. ^[26] In addition, epidural steroid injections, in certain settings, may result in serious complications. ^[27] Fortunately there are now emerging new methods that directly target TNF. ^[28] These TNF-targeted methods represent a highly promising new approach for patients with chronic severe spinal pain, such as those with FBSS. ^[28] Ancillary approaches, such as rehabilitation, physical therapy, anti-depressants, and, in particular, graduated exercise programs, may all be useful adjuncts to anti-inflammatory approaches. An antidepressant is a Psychiatric medication used for alleviating major depression or Dysthymia ('milder' depression ^[13] In addition, more invasive modalities, such as spinal cord stimulation, may offer relief for certain patients with FBSS, but these modalities, although often referred to as “minimally invasive", require additional surgery, and have complications of their own. ^[29][30]

Emerging Treatment Options

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. Tumor necrosis factor ( TNF, cachexin or cachectin and formally known as Tumor necrosis factor-alpha) is a Cytokine involved in systemic Tumor necrosis factors (or the TNF-family) refers to a group of Cytokines family that can cause Apoptosis. Specific and potent inhibitors of TNF became available in the U. Tumor necrosis factors (or the TNF-family) refers to a group of Cytokines family that can cause Apoptosis. S. in 1998, and were demonstrated to be potentially effective for treating sciatica in experimental models beginning in 2001. Sciatica is a set of symptoms including Pain that may be caused by general compression and/or irritation of one of five nerve roots that give rise to the Sciatic nerve ^[31][32][33] Targeted anatomic administration of one of these anti-TNF agents, etanercept, a patented treatment method,^[34] has been suggested in published pilot studies to be effective for treating selected patients with chronic disc-related pain and FBSS. Etanercept (Enbrel is a Recombinant -DNA drug made by combining two proteins (a fusion protein ^[28][35] The scientific basis for pain relief in these patients is supported by the most current review articles. ^[36][37] In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation, thereby enabling more accurate localization of the "pain generators" responsible for symptom production.

References

External links

General Interest

• New York Times Back Pain

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