The Roles of the Hip, Spine, Sacroiliac Joint, and Other Structures in Patients with Persistent Pain after Back Surgery

https://doi.org/10.1053/j.semss.2007.11.003Get rights and content

Failed back surgery implies that the outcome of spine surgery did not meet the expectations of the patient and surgeon. The structural cause of failed back surgery syndrome can be identified in 90% of patients. The outcome of treatment is best when treatment is specific for the cause of pain. The most common spinal causes include pain from a disc at the index or adjacent level, pain from a facet or sacroiliac joint, and neuropathic pain. Common extraspinal causes include primary hip disorders and greater trochanteric bursitis. Treatment options include rehabilitation, spinal injections and interventions, medications, and salvage surgery and should be based on the medical evidence and the cause of pain.

Section snippets

Discogenic Pain

There is consistent evidence from several retrospective studies that one cause of FBSS is pain that arises from within a disc itself, usually referred to as discogenic pain.1, 2, 3 Discogenic pain has been identified as the predominant problem in about 21% of patients with FBSS. It can occur at the level of the index surgery, at one or more adjacent segments, or occasionally within the levels of a previous solid posterolateral fusion.8, 9 In addition, recurrent or residual disc herniation (HNP)

Facet Joint Pain

The facet joints are a cause of pain in 15 to 30% of patients with chronic LBP.22, 23 The prevalence of facet joint pain in patients with FBSS is estimated to be 3 to 16%.2, 25 Moshirfar and co-workers and Shah and co-workers described a 33 and 24% incidence, respectively, of facet joint violation in patients undergoing lumbar fusion with pedicle screw fixation.26, 27 Neither study reported the clinical status of the patients. There has been increased interest in the role of facet joints since

Sacroiliac Joint Pain

There is sufficient and consistent evidence that shows that the sacroiliac joint (SIJ) can be a cause of pain in up to 15 to 30% of patients with chronic LBP.39, 40 The prevalence of SIJ pain is at least 2 to 3% in patients with FBSS and may be higher in patients who have had fusion, especially fusion to the sacrum.2, 41 The SIJ can be injured during graft harvesting, which usually causes early-onset pain.42 The joint appears susceptible to stress transfer after fusion to the sacrum, in which

The Hip Joint and Related Structures

Disorders of the hip can mimic and/or coexist with lumbar spine disorders. The prevalence of hip pain lasting longer than 1 month in persons aged 65 to 74 years is 19%, so it is not surprising that in older patients disorders of the hip (most often osteoarthritis) and spine (particularly spinal stenosis) may coexist.48 To complicate matters, there is overlap between their respective symptoms and signs.7 In the patient with FBSS, hip pathology may have been present before back surgery and not

Spinal Stenosis and LBP

The classic symptoms of spinal stenosis are leg pain with walking (neurogenic claudication) or standing. However, we believe there are patients with spinal stenosis that present with axial low back pain. Their characteristic pattern is LBP with standing or walking and complete or near complete relief of pain sitting, quite the opposite of discogenic pain, but similar to facet joint pain. They usually experience at least temporary relief of pain after epidural steroid injection, not the case

Neuropathic Pain

Neuropathic pain is pain that arises from injury or physiological dysfunction of the peripheral or central nervous system (CNS). There are several clinical mechanisms that might lead to neuropathic pain in patients with FBSS. There may be structural nerve injury due to prolonged compression of a nerve by spinal stenosis or disc herniation. In either case, pain continues despite technically successful surgical removal of the disc herniation or relief of the stenosis. Nerve damage due to neural

Peripheral Nerve Entrapments

Peripheral nerve trauma and entrapment can mimic radiculopathy (“pseudoradiculopathy”).53 In the patient with FBSS, the most likely relevant problems are lateral femoral cutaneous nerve entrapment or injury (meralgia paresthetica), which presents with pain in the lateral or anterolateral thigh; peroneal nerve entrapment; and sciatic nerve entrapment. With entrapments, pain will be in the distribution of the peripheral nerve involved, not in a true lumbar dermatome. There may be a positive

References (53)

  • S. Cohen et al.

    Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary?A pilot study

    Br J Anaesth

    (2005)
  • J. Campbell et al.

    Mechanisms of neuropathic pain

    Neuron

    (2006)
  • A. Waguespack et al.

    Etiology of long-term failures of lumbar spine surgery

    Pain Med

    (2002)
  • C.W. Slipman et al.

    Etiologies of failed back surgery syndrome

    Pain Med

    (2002)
  • C.V. Burton et al.

    Causes of failure of surgery on the lumbar spine

    Clin Orthop

    (1981)
  • R. Guyer et al.

    Failed back surgery syndrome: diagnostic evaluation

    J Am Acad Orthop Surg

    (2006)
  • E.W. Fritsch et al.

    The failed back surgery syndromeReasons, intraoperative findings, and long-term results: a report of 182 operative treatments

    Spine

    (1996)
  • M.D. Brown et al.

    Differential diagnosis of hip disease versus spine disease

    Clin Orthop Related Res

    (2004)
  • W. Barrick et al.

    Anterior fusion improves discogenic pain at levels of posterolateral fusion

    Spine

    (2000)
  • C.R. Weatherly et al.

    Discogenic pain persisting despite solid posterior fusion

    J Bone Joint Surg Br

    (1986)
  • M. Coppes et al.

    Innervation of “painful” lumbar discs

    Spine

    (1997)
  • P. Park et al.

    Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature

    Spine

    (2004)
  • A.S. Hilibrand et al.

    Adjacent segment degeneration and adjacent segment the consequences of spinal fusion?

    Spine J

    (2004)
  • A. Schwarzer et al.

    The prevalence and clinical features of internal disc disruption in patients with chronic low back pain

    Spine

    (1995)
  • R. Derby et al.

    The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes

    Spine

    (1999)
  • F.T. Wetzel et al.

    The treatment of lumbar spinal pain syndromes diagnosed by discographyLumbar Arthrodesis

    Spine

    (1994)
  • Cited by (5)

    • Myofascial force transmission in sacroiliac joint dysfunction increases anterior translation of humeral head in contralateral glenohumeral joint

      2014, Polish Annals of Medicine
      Citation Excerpt :

      Sacroiliac joint is one of the common cause for low back and pelvic girdle pain.1–3 Evidence suggests that the sacroiliac joint dysfunction (SJD) as the primary source of low back pain in 22.5% of patients,4,5 and one of the potential causes of failed back surgery syndrome among patients with previous spine surgery.6 SJD refers to any altered or impaired functioning of the somatic framework of sacroiliac joint and its related components such as arthrodial, myofascial, ligamentous, given that the articular surfaces are variable in anatomical position from side to side in an individual.7

    • Using the SAFE principles when evaluating electrical stimulation therapies for the pain of failed back surgery syndrome

      2011, Neuromodulation
      Citation Excerpt :

      Neuromodulation therapies must be compared directly with other procedures including spinal surgery. As stated, surgery for low back pain or low back pain with concomitant leg pain, while potentially curative, is associated with a high degree of failure (13) and complications (39) and leads to a significant number of re-operations for the same problem or new problems (14,15,19–23). Because we consider surgery as a potential treatment for the pain of FBSS, it is our opinion that the decision to perform a primary or repeat spinal surgery for pain should be evaluated and compared with other pain therapies and placed within a single continuum of pain care based on logical evaluative principles.

    View full text