Failed Back Surgery Syndrome (1) (2) and references in article 1 about FBSS.
Definition. Failed back surgery syndrome is a broadly defined diagnosis usually attributed to persistent or renewed pain after previous back surgery. The “failed” in the FBSS diagnosis does not refer to any potential failure of the surgeon, such as through an incorrect surgical indication, technique, or level. It refers to not achieving the intended objective of the spinal surgery, that is pain reduction, possibly due to the absence of a surgically treatable cause. Therefore, the term postsurgical pain syndrome would be more appropriate.141 Usually, there has to be some form of nerve compression caused by degenerative defects, such as spinal disk herniation, benign stenosis, ligamentum flavum hypertrophy, or spondylolisthesis. In this guideline, the term “FBSS” applies to patients who have undergone 1 or more lumbosacral operations, or who have found no reduction of pain or a comparable level of pain has returned within, for example, 1 year. As a rule, the patient has no underlying problem that could successfully be treated surgically and which would further reduce the chance for success with repeated surgery.141
Epidemiology. Reported estimates of the incidence/ prevalence vary drastically, ranging from anywhere up to 40% of the number of surgical patients.142–145
Pathophysiology. There are definite indications that certain pathophysiological factors play a role. The indications are categorized as such: residual or relapse HNP or recurrent disk herniation, nerve damage, spinal canal stenosis, postoperative infection, epidural fibrosis, and/or adhesive arachnoiditis. Also, there is convincing evidence that certain psychological and environmental factors, such as smoking, play a role in the risk for developing FBSS.146–149
Diagnosis. The patient’s medical history and physical examination, including appropriate imaging (X-ray, CT, MRI), are the main cornerstones for diagnostics. FBSS is a diagnosis of exclusion, which is different from the other diagnoses that fall under the category of uncomplicated degenerative spinal pain. Consultation with a spinal surgeon is needed to rule out surgically treatable causes.
Invasive Treatment Recommendations
Of the several invasive pain treatments available for FBSS, we investigated (A) epiduroscopy and (B) spinal cord stimulation. In the search for the effectiveness of invasive treat- ment in FBSS, we identified 22 papers. After the selection procedure, no papers fulfilled the inclusion criteria to formulate a scientific conclusion. More details on the search strategy are described in the Guideline literature site of the Erasmus Medical Center (www.erasmusmc.nl/pijn/guidelineliterature). The task force developed recommendations based on the remaining considerations.
A) Epiduroscopy
After the selection procedure, no papers fulfilled the inclusion criteria to formulate a scientific conclusion. One RCT 150 of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain showed significant pain relief and functional recovery remaining after some months. Serious complications are described due to pressure increase in the epidural space during the epiduroscopy. Based on the lack of a scientific conclusion and on these other considerations, the task force developed the following recommendation: Epiduroscopy can be a treatment option for patients with FBSS for whom conservative therapy has provided insufficient or no effect. This treatment option is preferably administered study-related (because there is not enough and/or conflicting evidence, and benefits are clearly balanced with risk and burdens, to give a clear recommendation for practice).
B) Spinal Cord Stimulation
After the selection procedure, no papers fulfilled the inclusion criteria to formulate a scientific conclusion. No placebo-controlled studies can be performed with the recently available stimulation paradigms. Two prospective randomized comparative trials clearly show a positive effect of spinal cord stimulation on leg pain in FBSS.143,151 Based on the lack of a scientific conclusion and these other considerations, the task force developed the following positive recommendation for practice (because effectiveness is demonstrated in various RCTs, and the benefits clearly outweigh the risks and burdens): Neuromodulation is recommended for patients with FBSS who have pronounced leg pain and for whom conservative therapy has provided insufficient or no effect.
1. Itz CJ, Willems PC, Zeilstra DJ, Huygen FJ. Dutch Multidisciplinary Guideline for Invasive Treatment of Pain Syndromes of the Lumbosacral Spine. Pain practice : the official journal of World Institute of Pain. 2015.
2. Hooten WM, Cohen SP, Rathmell JP. Introduction to the Symposium on Pain Medicine. Mayo Clinic proceedings. 2015;90(1):4-5.
The most intruiging problem in western Medicine related tot our lifestyle: back pain. .
FBSS syndrome must be understood as a cascade of failing treatments where the first one who did a surgical procedure was not aware of any lifestyle dependant factor that brings the lumboscaral spine to early detoriation or degeneration: malalignement in the sagital plane, or "bad posture" . If there is no understanding of the cause of "DDD" or herniated disc and the first surgery is done without proper lifestyle changes or well established conservative means by the surgeon himself initiated and controlled, and the first surgery is not based on true knowledge , why this spine is hurting so much, all next steps in case of failure can potentially be harmfull either.
With full assessment of spinal form ( posture) and spinal mobilitiy related to almost ever present neuromuscular thightness in low back patients it is possible to prevent most unnessary primary procedures. Proper explanation of the found relation of the state of posture and neuromuscular rigidity to patients is ( in my opinion) half of the treatment. Proper lifestyle advises, certainly to avoid bad sitting postures o sitting too long is a next step. A tsunami of problems is coming out of the generations that are raised in an almost complete sedentary lifestyle.
Excersisetherapy to improve posture, improve muscular unbalance and stretch all the thight or contracted structures is a merely used treatment in hospital surroundings. If you are on your way to the OR, nobody will stop this.
Paincontingent treatment modalities by paindoctors ( Painmedicine??) do miss the biomechanical and neuromechanical knowledge that is needed to understand this evergrowing (global) socioeconomic burden of disease. Prevention is the only solution that gives no collateral damage as in FBSS.