Failed Back Surgery Syndrome

Posted by e-Medical PPT Friday, December 16, 2011
Pain TypesNOCICEPTIVE PAIN
results from ongoing activation of mechanical, thermal, or chemical nociceptors
typically opioid-responsive
eg. pain related to mechanical instability

NEUROPATHIC PAIN
spontaneous or evoked pain that occurs in the absence of ongoing tissue damage
typically opioid-resistant***
eg. pain secondary to nerve root injury

Failed Back Surgery Syndrome
FBSS is a term applied to a heterogeneous group of individuals who share only one characteristic - continued back and/or extremity pain following one or more spinal operations
15% of patients will experience persistent or recurrent symptoms
Spectrum of abnormalities ranging from purely organic to purely psychological, but in most cases consists of a physiological abnormality complicated by psychological factors
FBSS is perhaps the prototypical example of chronic pain as a biopsychosocial disorder

Failed Back Patient Profile
Pain and suffering often disproportionate to any identifiable disease process
Depression
Physical deconditioning
Inappropriate use of physician-prescribed medications
Superstitious beliefs about bodily functions
Failure to work or perform expected physical and cognitive activities
No active medical problems that can be remediated with the expectation of relief of pain

Post-operative Causes of Back Pain
Deconditioning       
Trauma           
Muscle spasm        
Wrong level fused
Myofascial pain       
Insufficient levels fused
Spinal instability       
Pseudomeningocele
Diskogenic pain       
Graft donor site pain
Facet arthropathy       
Psychosocial factors
Infection
Pseudarthrosis
Loose hardware
Arachnoiditis...

Management
Therapeutic Heat
Increases muscle temperature, decrease spindle sensitivity, increases blood flow
Pain relief, increase in tissue extensibility, reduction of muscle spasm
Superficial heat
 Greatest effect 0.5cm from skin
Deep heat
 Ultrasound diathermy
  Heat up to 5cm deep to skin
  Treatment of deep soft tissues
Hydrotherapy
 Buoyancy minimizes stress to joints

Cold Therapy
Affects muscle spindle and may modulate neurotransmitters
Provides longer pain relief than heat
Ice and gel packs, vapocoolant sprays, cold baths
Particularly useful for trigger points,
Treatment of choice for acute injuries

TENS
Electrical energy transmitted from skin surface
Rationale based on “Gate Theory” of pain
Most effective at high-frequency, low-intensity
“Acupuncture TENS” – high-intensity, low-frequency
Questionable benefit for chronic back pain

Therapeutic Exercise and Massage
Essential for restoration of function
“Hurt” vs. “Harm”
Stretching exercises
Strengthening exercises
Aerobic exercises
Therapeutic massage

Anticonvulsant Agents (AEDS)
Similarities in pathophysiology of neuropathic pain and epilepsy
All AEDS ultimately act on ion channels
Efficacy of AEDS most clearly established for neuropathic conditions characterized by episodic lancinating pain
Most clinical studies have focused on DPN and PHN
Use of AEDS in patients with FBSS is nearly entirely empiric.

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