Pain After Spine Surgery

Are you still feeling pain after spine surgery? Sometimes the pain may increase or change its character after spine surgery. Upto 50% of patients may have this problem after different kinds of spine surgery. It is called failed back surgery syndrome or post-laminectomy syndrome or simply failed back syndrome. There are only a few pain management clinics in India to manage these serious patients. Spinal cord stimulation may be the only treatment option at times.

What is the failed back surgical syndrome or failed back syndrome?

Persistence of pain after spine surgery or appearance of new pain and disability after back surgery is known as failed back surgery syndrome (FBSS). The same condition is also known as a failed back syndrome. This condition is most commonly seen after laminectomy surgery of the spine and thus it is also known as a post-laminectomy syndrome.

Why is it called failed back surgery syndrome? Is it an operational failure?

FBSS is not a good name for the condition. Even after a perfect operation, pain may persist or appear new. Pain is a complex symptom that may not correlate with structural damage. That is why reasons for pain should be investigated and treated, and surgery should not be blamed and called a  failure of surgery.

What are the common types of back surgery that lead to FBSS?

The most common surgery that leads to FBSS is laminectomy for spinal canal stenosis. Operations for a slipped disc such as discectomy, stabilization operations line fixation with plate and screw are the other common back surgeries that may lead to FBSS.

Why does FBSS happen? What are the causes or reasons behind it?

There are many reasons and not a single reason and that is why the condition is known as a syndrome and not a disease. The reasons are as follows:

1. The most common reason is the mismatch between the structural source of pain and the target of surgery. The structure creating pain may appear normal in X-ray, CT scan, or MRI images and at the same time, the abnormal degenerated structures seen in these images may remain asymptomatic. The surgeon may therefore operate on the abnormal pathologic structure and perform a perfect operation, but the structure that generates pain remains the same. Thus, the persistence of the same pain can occur.
2. Another reason may be that after surgery dense fibrosis generates that entangles the nerves and creates a new type of pain. Fibrosis may also cause the narrowing down of the spinal canal and produce pressure on the spinal cord. This pressure on the spinal cord may damage the nerves of the spinal cord or the nerve roots.
3. Few other factors that may be responsible for FBSS are infection, pseudoarthrosis, load redistribution after surgery, etc. All these may finally lead to FBSS.

What are the treatments of pain after spine surgery or FBSS?

Since FBSS has many reasons, the treatment depends on the cause. Multiple treatment options are therefore available. Conservative management or management without surgery or intervention is most preferred by the patients and is of the first choice. This conservative management consists of reassurance of the patients, medicines such as analgesics, gabapentin, or pregabalin, antidepressants such as amitriptyline, and duloxetine must be tried first and combined. If the symptoms are not well controlled, interventional procedures should be considered. Repeat operations are avoided and with more operations are carried out, the chances of success are reduced.

What are the interventional  procedures for FBSS?

There are few interventional procedures for the treatment of pain in FBSS. The frequently done interventional procedures are epidural adhesiolysis with epidural steroid injection and spinal cord stimulation implantation. 

What is Epidural Adhesiolysis?

Epidural adhesiolysis and epidural steroid injection together is the most common procedure for this. The epidural space is distended by local anesthetic and saline injection into the epidural space. Then steroid in injected. The steroid helps to reduce nerve root inflammation that is associated with nerve root compression. Sometimes Racz catheter, a special epidural catheter loaded with a guidewire and a stylet is used to break the epidural adhesion. This procedure is also called caudal neuroplasty of Racz adhesiolysis. Gabor Racz is a great pain physician and he invented this catheter and the procedure.

What is Spinal Cord Stimulation?

The other way to treat FBSS is by stimulating the spinal cord. It’s like a cardiac pacemaker and is therefore called a spinal pacemaker. Here a battery is implanted under the skin which generates a mild electrical current at specific parameters. This current is delivered at epidural space through a special array of electrodes inside an epidural catheter which is known as spinal cord stimulator lead. Depending on the number of electrodes inside the lead can be bipolar, quadripolar, octopolar leads. The lead in the epidural area electrodes is implanted through a special type of epidural needle and attached with the power generator or battery.

The electrical current at a specific frequency stimulates A-beta fibers and stimulation of A-beta fibers close the gate for pain carrying A-delta and C type nerves This is a small operation done under local anesthesia to create a subcutaneous pocket to implant the power generator. Very recently spinal cord stimulators are available without an implantable power generator where electrodes are stimulated with an external energy source.

Video for Spinal Cord Stimulation lead implant

Look at this video of how leads of the spinal cord are implanted

 

Conclusion

Spinal cord stimulation is the best form of treatment in failed back surgery syndrome and the most commonly done procedure. This is a non-surgical interventional procedure that can give a new life to the patient who had one or multiple spine surgeries. The only disadvantage of this procedure is the cost involved, the implantable system is very costly, and the total cost of treatment in India is about 15-20 lakh INR.