Rapport : Douleurs lombaires postopératoiresOptimal 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
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:
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inappropriate or premature selection of patients for surgery;
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persistence of pain due to irreversible neural injury;
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inadequate surgery;
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new damage to the nerves or spine;
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extensive fusion;
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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.
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