Elsevier

Neurochirurgie

Volume 61, Supplement 1, March 2015, Pages S66-S76
Neurochirurgie

Rapport : Douleurs lombaires postopératoires
Optimal medical, rehabilitation and behavioral management in the setting of failed back surgery syndromePrise en charge médicale, comportementale et réadaptative dans le cadre des lombo-radiculalgies postopératoires

https://doi.org/10.1016/j.neuchi.2014.09.002Get rights and content

Abstract

Introduction

Failed back surgery syndrome (FBSS) constitutes a constellation of symptoms grouped together and attributed to prior surgical intervention. Clinicians often poorly understand the heterogeneity of this condition combined with the etiological factors responsible for its development. Therefore, it would follow that an algorithmic treatment approach to patients diagnosed with this syndrome might pose challenges. The clinical work-up of the patient involves history, examination and appropriate diagnostic imaging as well as behavioral assessment.

Materials and methods

We sought to conduct a narrative review of the available literature focused on the medical, rehabilitative and behavioral treatment of FBSS. To that end, we conducted a literature search using PubMed (through March 2013). We focused on studies published over the last 20 years. Only English language articles were included. Search terms included “failed back surgery syndrome”, “FBSS”, “failed back syndrome”, and “post-laminectomy syndrome”. Studies included in our review focused on randomized controlled trials (RCTs), prospective cohort studies, and case series (retrospective and prospective). Studies were organized by intervention (e.g. medical management, physical therapy and rehabilitation, and psychosocial) and presented to emphasize the quality of evidence (e.g. RCTs, prospective studies, etc.).

Conclusion

Overall, the literature provides very limited guidance on the comprehensive management of patients suffering from FBSS. There are rehabilitative interventions and behavioral protocols that demonstrate promise. Pathways based on medication management remain difficult to clearly define.

Résumé

Introduction

Les lombo-radiculalgies postopératoires (LRPO) représentent une constellation de symptômes attribués à une intervention rachidienne préalable. Bien souvent, les cliniciens ne font qu’effleurer leur hétérogénéité et ont du mal à reconnaître l’existence de facteurs étiologiques indéniables. Par conséquent, il paraît clair que la mise en place d’un consensus prônant une approche thérapeutique algorithmique chez les patients diagnostiqués de ce syndrome relève du défi. La prise en charge clinique du patient souffrant de LRPO chroniques implique la prise en considération de son histoire clinique, son examen et un diagnostic d’imagerie approprié, associés à une évaluation comportementale.

Matériel et méthode

Cet article propose une revue exhaustive de la littérature ciblée sur les traitements médicaux, la réadaptation et rééducation physique, ainsi que la prise en charge comportementale des LRPO. Pour cela, nous avons mené une recherche bibliographique en utilisant principalement PubMed (jusqu’en mars 2013). Nous nous sommes focalisé sur les études publiées ces 20 dernières années. Seuls les articles en langue anglaise ont été inclus. Les termes recherchés ont été « failed back surgery syndrome », « FBSS », « failed back syndrome », et « post-laminectomy syndrome ». Les études incluses dans cette revue n’étaient que des essais randomisés contrôlés, des études de cohorte prospectives, et des séries de cas (rétrospectives et prospectives). L’analyse de ces études a été organisée par type d’interventions (cf. soins médicaux, thérapie physique et rééducation, et prise en charge psychosociale) et est aussi présentée sous forme de tableaux pour faire ressortir la qualité des preuves, de manière synthétique (cf. essais randomisés contrôlés, études prospectives, etc.).

Conclusion

Globalement, l’analyse de la littérature ne fait ressortir que des recommandations très limitées, pour nous aider dans la compréhension et l’optimisation de la prise en charge des patients souffrant de LRPO. Certaines pistes dans les techniques de rééducation et les protocoles d’analyse comportementales semblent prometteuses. Un schéma organisationnel clair reste difficile à définir pour la prise en charge de ces patients.

Introduction

Failed back surgery syndrome (FBSS) is a diverse and complex array of symptoms involving persistent or recurrent chronic pain after one or more surgical procedures on the lumbosacral spine, which results in functional failure of the back, as opposed to failure of treatment or surgery [1]. In the United States, where spine surgery exceeds 300,000 operations per year, 10–40% of lumbar spine operations result in FBSS [1]. Patients with FBSS are a diverse group, with varied etiologies [2]. Patients may present with chronic back pain, extremity pain, or both. Back pain is often described as diffuse, dull, or aching; extremity pain as sharp, pricking, burning, or stabbing. FBSS patients may also experience weakness and spasm in the limbs, numbness and, possibly, bladder and bowel difficulties [2]. Patients with FBSS have a low quality of life (QoL) and high psychological morbidity and are frequent users of health services [3], [4], [5]. The term “FBSS” does not identify a cause or give clues to appropriate management [6]. Further, such a term may leave the impression of a lack of precision in diagnosis and treatment [7].

A standardized treatment algorithm for FBSS does not currently exist, although several groups have proposed different management strategies for this syndrome [8]. One reason for the lack of a standardized management algorithm for FBSS patients may be due to its many possible causes (Table 1). Identification of any one FBSS etiology may involve a unique diagnostic approach: diagnosis of epidural fibrosis might require CT plus epiduroscopy, while a comprehensive psychosocial evaluation might be required to diagnose a psychological etiology. Further, many FBSS patients have a combination of nociceptive and neuropathic pain. It is therefore important to distinguish between these subtypes, as the treatment approach is different for each [2]. Terminology has also been heterogeneous, with different groups referring to FBSS as “failed back syndrome”, “post-laminectomy syndrome” or “rebound radicular syndrome” [1], [9], [10].

Another reason for the absence of a standardized management approach to the FBSS patient is the paucity of controlled FBSS studies in the literature. Controlled trials in FBSS using so-called conservative therapies (e.g. specific oral medications, physical therapy techniques, behavioral modifications) are scarce. Among those available trials, the definition of “conservative” therapy varies considerably both in the number of modalities used and the total duration of treatment. Trials examining these interventions often mix FBSS patients with populations with chronic low back pain (CLBP), regardless of etiology. The implication is that many of these studies are not specifically designed or powered for the FBSS patient, making it difficult to derive any conclusions or treatment recommendations. In contrast, well-controlled FBSS studies using invasive procedures, such as spinal cord stimulation (SCS), epidural injections or adhesiolysis are more prevalent in the literature.

We are unaware of a published comprehensive review of the optimal management (which includes pharmacologic therapy, rehabilitative options and behavioral therapy) of FBSS. The aim of this paper is therefore to provide a contemporary evidence-based review of the various conservative treatment options for the FBSS patient, as well as to provide a brief overview of patient assessment and work-up. For the purposes of this review, we define optimal management as any therapy that is not invasive in nature (i.e. blocks, epidurals, SCS, or any molecular entity or energy current directly targeting the spinal column and/or spinal nerves) to include pharmacologic therapy, rehabilitative options and behavioral therapy.

Section snippets

Materials and methods

We conducted a literature search using PubMed (through March 2013). We focused on studies published over the last 20 years. Only English language articles were included. Search terms included “failed back surgery syndrome”, “FBSS”, “failed back syndrome”, and “post-laminectomy syndrome”. We included the following study designs in our review: randomized controlled trials (RCTs), prospective cohort studies, and case series (retrospective and prospective). Case reports were excluded. Bibliographies

Etiologic factors

Managing the FBSS patient involves the identification of any one, or combination, of several etiologies (Fig. 1). Multiple factors which may contribute to the onset or development of FBSS include, but are not limited to:

  • inappropriate or premature selection of patients for surgery;

  • persistence of pain due to irreversible neural injury;

  • inadequate surgery;

  • new damage to the nerves or spine;

  • extensive fusion;

  • infections or arachnoiditis from procedures, such as discography, administration of epidural

Discussion

The optimal management of the FBSS patient remains challenging. This is illustrated by the absence of clinical guidelines for the management of FBSS. In this study we aimed to overview the evidence for conservative therapy and considered three broad interventions groupings – pharmacotherapy, physical therapy and rehabilitation and psychological interventions.

There were several issues with regards to pharmacological trials in FBSS. Most commonly the studies groups were heterogeneous and

Conclusion

Optimal medical, rehabilitative and behavioral management of patients with failed back surgery syndrome includes a multi-modal, interdisciplinary approach (Fig. 2) emphasizing behavioral approaches, such as CBT, a specific rehabilitation process to include lumbar stabilization, neural flossing and activity modification and should focus on pharmaceutical options with a poly-analgesic approach consisting of agents specifically chosen for their effects on pain or other co-existing pathologies,

Disclosure of interest

Dr. Desai is a consultant for Medtronic, Inc and Kimberly-Clark Medical.

Dr. Rigoard is a consultant for Medtronic Inc and received honoraria for medical training from St Jude Medical, research grants from Medtronic Inc & St Jude Medical.

Prof. Taylor is a consultant for Medtronic Inc.

All other authors reported no conflict of interest for this study.

Acknowledgements

We would like to thank the N3Lab for his technical help, and the direction of research department of Poitiers University Hospital, represented by Mrs. Guyon and Mr. De Bideran for their support.

References (42)

  • M.W. Morningstar et al.

    Manipulation under anesthesia for patients with failed back surgery: retrospective report of 3 cases with 1-year follow-up

    J Chiropr Med

    (2012)
  • D.M. Doleys et al.

    Multidimensional outcomes analysis of intrathecal, oral opioid, and behavioral-functional restoration therapy for failed back surgery syndrome: a retrospective study with 4 years’ follow-up

    Neuromodulation Technol Neural Interface

    (2006)
  • E. Sparkes et al.

    A systematic literature review of psychological characteristics as determinants of outcome for spinal cord stimulation therapy

    Pain

    (2010)
  • K. Saravanakumar

    Bonica's Management of Pain

    (2010)
  • P. Tharmanathan et al.

    Diagnosis and treatment of failed back surgery syndrome in the UK: mapping of practice using a cross-sectional survey

    Br J Pain

    (2012)
  • L. Talbot

    Failed back surgery syndrome

    BMJ

    (2003)
  • K. Kumar et al.

    Spinal cord stimulation in treatment of chronic benign pain: challenges in treatment planning and present status, a 22-year experience

    Neurosurgery

    (2006)
  • K. Kumar et al.

    The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation

    Neurosurgery

    (2008)
  • P. Ganty et al.

    Failed back surgery syndrome: a suggested algorithm of care

    Br J Pain

    (2012)
  • E.A. Shipton

    Low back pain and the post-laminectomy pain syndrome

    South Afr Med J Suid-Afr Tydskr Vir Geneeskd

    (1989)
  • A. Hussain et al.

    Interventional pain management for failed back surgery syndrome

    Pain Pract

    (2014)
  • Cited by (26)

    • The incidence of failed back surgery syndrome varies between clinical setting and procedure type

      2022, Journal of Clinical Neuroscience
      Citation Excerpt :

      Intraoperative factors included poor technique, surgical complications, incorrect level of surgery, and inability to achieve the aim of surgery. In addition, excessive fusion or inadequate decompression during surgery can be a contributing factor [22]. Postoperative factors include progression of disease, epidural fibrosis or arachnoiditis, new instability, and myofascial pain syndrome.

    • The Predictive Value of Transcutaneous Electrical Nerve Stimulation for Patient Selection in Peripheral Nerve Field Stimulation for Chronic Low Back Pain: A Prospective Study

      2021, Neuromodulation
      Citation Excerpt :

      Back pain following spinal surgery shows more likely a shift to a neuropathic pain component (10). This condition is challenging and remains difficult to treat as various etiologies and pain characteristics negatively impact function, behavior, and psychosocial well-being (11–15). For treatment success, multimodal treatment plays a crucial role (16).

    • Immediate post-discectomy percutaneous facet nerve continuous and nerve root pulsed radiofrequency and intraluminal injection of steroid with hyaluronidase improved outcome of surgery for lumbar disk herniation

      2017, Egyptian Journal of Anaesthesia
      Citation Excerpt :

      There are rehabilitative interventions and behavioral protocols that demonstrate promise. Pathways based on medication management remain difficult to clearly define [8]. A population-based study in Finland found that about 14% of all primary lumbar discectomies required additional surgical interventions; however, Wallis implant is probably incapable of reducing the incidence of recurrent herniations [9].

    • Failed back surgery syndrome: What's in a name? A proposal to replace "FBSS" by "POPS"...

      2015, Neurochirurgie
      Citation Excerpt :

      This approach has remained unsuccessful to date secondary to the difficulty in wholesale categorization of patients and the lack of a true algorithmic approach. However, this type of pathophysiological segmentation might be used to predict the quality and possibly the magnitude of response to the various treatments proposed (classical response to opioids in mechanical pain, efficacy of neurostimulation in predominantly neuropathic pain, for example), although these features have not been formally defined due to the lack of a clearly defined rationale [30]. This concept of pathophysiological mechanisms must also be completed by the spatial dimension concerning the topographic distribution of the pain, as it would appear that chronic persistent radicular pain can be fairly frequently assimilated to neuropathic pain, while the problem of the pain mechanism becomes much more complex when trying to interpret thoracolumbar pain, where biomechanical and neuropathic mechanisms appear to be much more interrelated and difficult to isolate.

    View all citing articles on Scopus
    View full text