Treatment Options for Failed Back Surgery Syndrome Patients With Refractory Chronic Pain: An Evidence Based Approach

Frailty is not an independent risk factor for worse clinical outcomes in lumbar spinal surgery: a prospective cohort study

PURPOSE

Recently, many studies revealed that frailty affects unfavorably on postoperative outcomes in lumbar spinal diseases. This study aimed to investigate the relationship between frailty and clinical outcomes while identifying risk factors associated with worse clinical outcomes following lumbar spinal surgery.

METHODS

From March 2019 to February 2021, we prospectively enrolled eligible patients with degenerative lumbar spinal diseases requiring surgery. Frailty was assessed preoperatively. To identify the impact of frailty on lumbar spinal diseases, clinical outcomes, which were measured with patient-reported outcomes (PROs) and postoperative complications, were compared according to the frailty. PROs were assessed preoperatively and one year postoperatively. In addition, risk factors for preoperative and postoperative worse clinical outcomes were investigated.

RESULTS

PROs were constantly lower in the frail group than in the non-frail group before and after surgery, and the change of PROs between before and after surgery and postoperative complications were not different between the groups. In addition, frailty was a persistent risk factor for postoperative worse clinical outcome before and after surgery in lumbar spinal surgery.

CONCLUSION

Frailty persistently affects the clinical outcome negatively before and after surgery in lumbar spinal surgery. However, as the change of the clinical outcome is not different between the frail group and the non-frail group, it is difficult to interpret whether the frail patients are vulnerable to the surgery. In conclusion, frailty is not an independent risk factor for worse clinical outcome in lumbar spinal surgery.

6. Persistent spinal pain syndrome type 2

INTRODUCTION

Persistent Spinal Pain Syndrome (PSPS) refers to chronic axial pain and/or extremity pain. Two subtypes have been defined: PSPS-type 1 is chronic pain without previous spinal surgery and PSPS-type 2 is chronic pain, persisting after spine surgery, and is formerly known as Failed Back Surgery Syndrome (FBSS) or post-laminectomy syndrome. The etiology of PSPS-type 2 can be gleaned using elements from the patient history, physical examination, and additional medical imaging. Origins of persistent pain following spinal surgery may be categorized into an inappropriate procedure (eg a lumbar fusion at an incorrect level or for sacroiliac joint [SIJ] pain); technical failure (eg operation at non-affected levels, retained disk fragment, pseudoarthrosis), biomechanical sequelae of surgery (eg adjacent segment disease or SIJ pain after a fusion to the sacrum, muscle wasting, spinal instability); and complications (eg battered root syndrome, excessive epidural fibrosis, and arachnoiditis), or undetermined.

METHODS

The literature on the diagnosis and treatment of PSPS-type 2 was retrieved and summarized.

RESULTS

There is low-quality evidence for the efficacy of conservative treatments including exercise, rehabilitation, manipulation, and behavioral therapy, and very limited evidence for the pharmacological treatment of PSPS-type 2. Interventional treatments such as pulsed radiofrequency (PRF) of the dorsal root ganglia, epidural adhesiolysis, and spinal endoscopy (epiduroscopy) might be beneficial in patients with PSPS-type 2. Spinal cord stimulation (SCS) has been shown to be an effective treatment for chronic, intractable neuropathic limb pain, and possibly well-selected candidates with axial pain.

CONCLUSIONS

The diagnosis of PSPS-type 2 is based on patient history, clinical examination, and medical imaging. Low-quality evidence exists for conservative interventions. Pulsed radiofrequency, adhesiolysis and SCS have a higher level of evidence with a high safety margin and should be considered as interventional treatment options when conservative treatment fails.

Clinical Patient-Relevant Outcome Domains for Persistent Spinal Pain Syndrome-A Scoping Review and Expert Panels

Large variation exists in the monitoring of clinical outcome domains in patients with persistent spinal pain syndrome (PSPS). Furthermore, it is unclear which outcome domains are important from the PSPS patient's perspective. The study objectives were to identify patient-relevant outcome domains for PSPS and to establish a PSPS outcomes framework. PubMed, CINAHL, Cochrane, and EMBASE were searched to identify studies reporting views or preferences of PSPS patients on outcome domains. The Arksey and O'Malley framework was followed to identify outcome domains. An expert panel rated the domains based on the importance for PSPS patients they have treated. A framework of relevant outcome domains was established using the selected outcome domains by the expert panel. No studies were found for PSPS type 1. Five studies with 77 PSPS type 2 patients were included for further analysis. Fourteen outcome domains were identified. An expert panel, including 27 clinical experts, reached consensus on the domains pain, daily activities, perspective of life, social participation, mobility, mood, self-reliance, and sleep. Eleven domains were included in the PSPS type 2 outcomes framework. This framework is illustrative of a more holistic perspective and should be used to improve the evaluation of care for PSPS type 2 patients. Further research is needed on the prioritization of relevant outcome domains.

Catheter Tip-Associated Mass With Continuous Infusion of Sufentanil for Persistent Spinal Pain Syndrome Type 2: A Case Report Including Histopathologic Examination and Review of the Associated Basic and Clinical Research

OBJECTIVES

Intrathecal opioids delivered by implanted pumps are used to treat malignant or nonmalignant chronic pain. In this study, we 1) review a case in which intrathecal infusions of sufentanil along with other adjuvants were used and after an extended period led to an intrathecal mass and 2) compared and contrasted the potential mechanisms for these phenomena.

MATERIALS AND METHODS

A woman aged 66 years with a history of scoliosis and multiple spine surgeries was treated with an implantable drug delivery system for treating persistent pain after laminectomy. The patient received intrathecal medication comprising sufentanil, bupivacaine, and clonidine.

RESULTS

Intrathecal therapy over approximately ten years served to reduce pain and improve function over the treatment period. After the extended treatment interval, the patient developed an intrathecal mass that was associated with impairment. The mass was surgically removed. Systematic histopathology revealed the space-occupying mass to largely comprise fibroblasts and some inflammatory cells embedded in a collagen mass located proximally to the catheter tip.

CONCLUSIONS

To our knowledge, this is the first published case report of sufentanil causing this complication. The science and mechanism of intrathecal catheter tip-associated mass formation and associated clinical research correlates are reviewed in detail, and explanations for this phenomenon are proposed based on histochemical analysis of the patient's pathology findings.

Strong Association of Depression and Anxiety With the Presence of Back Pain While Impact of Spinal Imaging Findings is Limited: Analysis of an MRI Cohort Study

Development of back pain is multifactorial, and it is not well understood which factors are the main drivers of the disease. We therefore applied a machine-learning approach to an existing large cohort study data set and sought to identify and rank the most important contributors to the presence of back pain amongst the documented parameters of the cohort. Data from 399 participants in the KORA-MRI (Cooperative health research in the region Augsburg-magnetic resonance imaging) (Cooperative Health Research in the Region Augsburg) study was analyzed. The data set included MRI images of the whole body, including the spine, metabolic, sociodemographic, anthropometric, and cardiovascular data. The presence of back pain was one of the documented items in this data set. Applying a machine-learning approach to this preexisting data set, we sought to identify the variables that were most strongly associated with back pain. Mediation analysis was performed to evaluate the underlying mechanisms of the identified associations. We found that depression and anxiety were the 2 most selected predictors for back pain in our model. Additionally, body mass index, spinal canal width and disc generation, medium and heavy physical work as well as cardiovascular factors were among the top 10 most selected predictors. Using mediation analysis, we found that the effects of anxiety and depression on the presence of back pain were mainly direct effects that were not mediated by spinal imaging. In summary, we found that psychological factors were the most important predictors of back pain in our cohort. This supports the notion that back pain should be treated in a personalized multidimensional framework. PERSPECTIVE: This article presents a wholistic approach to the problem of back pain. We found that depression and anxiety were the top predictors of back pain in our cohort. This strengthens the case for a multidimensional treatment approach to back pain, possibly with a special emphasis on psychological factors.

Effect of spinal cord stimulation on quality of life and opioid consumption in patients with failed back surgery syndrome

BACKGROUND

Failed back surgery syndrome (FBSS) is a constellation of conditions occurring after spine surgeries, characterized by the presence of persistent or recurring low back pain that has a significant impact on patients' quality of life. Neuromodulation in the form of Spinal Cord Stimulation (SCS) is considered an indispensable treatment modality in the management of certain chronic pain conditions and it is showing good results for improvement in pain scores and functional capacity of the FBSS patients.

OBJECTIVES

To assess the change in pain scores, quality of life, and opioid medication intake as an outcome of neuromodulation procedures performed on patients diagnosed with failed back surgery syndrome, and to detect the post-procedure complications.

METHODS

A prospective observational study was conducted at two university hospitals in Egypt and the U.S.A. during the period from September 2019 to August 2021 for patients who underwent spinal cord stimulation procedures for FBSS with follow-up period of at least 1 year. Patients who are 18 years old or older diagnosed with FBSS for more than 6 months and treated with spinal cord stimulation with successful trials during this time frame were included in the study.

RESULTS

Thirty-four patients were included in this study who had successful SCS trials and underwent permanent implantation of SCS devices with post-procedure follow-up period of 12 months. Patients showed a median pain numerical rating scale (NRS) of 7/10 at baseline with a median NRS of 4/10 through the follow-up period. Basic mobility and daily activity scores assessed by activity measure of post-acute care (AM-PAC) showed significant improvement from the mean of 16.87 ± 2.74 at baseline to a mean of 19.97 ± 2.93 through follow-up. In addition, there was a reduction in opioid medication usage. Post-procedure complications was of low percentage with the most detected were battery dysfunction in 7 patients and pocket pain in 6 patients. Reoperation was needed in 13 patients with 4 needed just revision and 9 patients required a complete removal of the device.

CONCLUSION

Spinal cord stimulation is an effective modality of treatment for cases of failed back surgery syndrome with a statistically significant reduction in pain scores and a significant improvement in quality of life. Also, it achieves a recognizable reduction in opioid analgesic medications, with a reliable safety profile as detected with the recorded post-procedure complications. However, randomized controlled trials with more patients and long-term follow-up are highly recommended.

Failed back surgery syndrome successfully ameliorated with Chiropractic Biophysics® structural rehabilitation improving pain, disability as well as sagittal and coronal balance: a Chiropractic Biophysics® case report with a 6 year follow-up

[Purpose] To present the case of the amelioration of chronic pain and disability in a patient suffering from failed back surgery syndrome. [Participant and Methods] A 27-year-old male with chronic low back pain was treated with a Coflex® intra-spinous instrument, however, it was removed shortly after due to poor outcome including worsening pain and disability. Radiographic assessment revealed significant posterior translation of the thorax complicated by significant loss of the normal lumbar lordosis and a left lateral translated thoracic cage posture. Chiropractic Biophysics® technique was applied over a 5.5-month period leading to structural spine improvements as well as improved pain, Oswestry disability index (ODI) and quality of life (QOL). [Results] There was a 21 mm reduction in posterior thoracic translation, a 6.2° improvement in lumbar lordosis and a 16 mm reduction in lateral thoracic translation corresponding with improved ODI and QOL scores. A 6 year follow-up showed successful outcome despite some degenerative changes in the spine at the prior surgical level. [Conclusion] This case adds to the growing literature showing the efficacy of non-surgical spinal rehabilitative methods in improving outcomes in patients with spinal deformity and associated disabilities. This case also demonstrates necessity of the continued criterion standard of spinal radiography for biomechanical assessment.

Factors Predicting Clinically Relevant Pain Relief After Spinal Cord Stimulation for Patients With Chronic Low Back and/or Leg Pain: A Systematic Review With Meta-Analysis and Meta-Regression

RATIONALE

To optimize results with spinal cord stimulation (SCS) for chronic low back pain (CLBP) and/or leg pain, including persistent spinal pain syndrome (PSPS), careful patient selection based on proved predictive factors is essential. Unfortunately, the necessary selection process required to optimize outcomes of SCS remains challenging.

OBJECTIVE

This review aimed to evaluate predictive factors of clinically relevant pain relief after SCS for patients with CLBP and/or radicular leg pain, including PSPS.

MATERIALS AND METHODS

In August 2023, PubMed, Cinahl, Cochrane, and EMBASE were searched to identify studies published between January 2010 and August 2023. Studies reporting the percentage of patients with ≥50% pain relief after SCS in patients with CLBP and leg pain, including PSPS at 12 or 24 months, were included. Meta-analysis was conducted to pool results for back, leg, and general pain relief. Predictive factors for pain relief after 12 months were examined using univariable and multivariable meta-regression.

RESULTS

A total of 27 studies (2220 patients) were included for further analysis. The mean percentages of patients with substantial pain relief were 68% for leg pain, 63% for back pain, and 73% for general pain at 12 months follow-up, and 63% for leg pain, 59% for back pain, and 71% for general pain at 24 months follow-up assessment. The implantation method and baseline Oswestry Disability Index made the multivariable meta-regression model for ≥50% back pain relief. Sex and pain duration made the final model for ≥50% leg pain relief. Variable stimulation and implantation method made the final model for general pain relief.

CONCLUSIONS

This review supports SCS as an effective pain-relieving treatment for CLBP and/or leg pain, and models were developed to predict substantial back and leg pain relief. To provide high-grade evidence for predictive factors, SCS studies of high quality are needed in which standardized factors predictive of SCS success, based on in-patient improvements, are monitored and reported.

Inhibition of miR-96-5p alleviates intervertebral disc degeneration by regulating the peroxisome proliferator-activated receptor γ/nuclear factor-kappaB pathway

BACKGROUND

Intervertebral disc degeneration (IDD) is the main pathogenesis of low back pain. MicroRNAs (miRNAs) have been found to exert regulatory function in IDD. This study aimed to investigate the effect and potential mechanism of miR-96-5p in IDD.

METHODS

In vitro cell model of IDD was established by treating human nucleus pulposus cells (HNPCs) with interleukin-1β (IL-1β). The level of peroxisome proliferator-activated receptor γ (PPARγ) was examined in the IDD cell model by Western blot and quantification real-time reverse transcription-polymerase chain reaction (qRT-PCR). The expression level of miR-96-5p was detected by RT-qPCR. Effects of PPARγ or/and PPARγ agonist on inflammatory factors, extracellular matrix (ECM), apoptosis, and nuclear factor-kappaB (NF-κB) nuclear translocation were examined through enzyme-linked immunosorbent assay (ELISA), Western blot, flow cytometry assay, and immunofluorescence staining. The Starbase database and dual luciferase reporter assay were used to predict and validate the targeting relationship between miR-96-5p and PPARγ, and rescue assay was performed to gain insight into the role of miR-96-5p on IDD through PPARγ/NF-κB signaling.

RESULTS

PPARγ expression reduced with concentration and time under IL-1β stimulation, while miR-96-5p expression showed the reverse trend (P < 0.05). Upregulation or/and activation of PPARγ inhibited IL-1β-induced the increase in inflammatory factor levels, apoptosis, degradation of the ECM, and the nuclear translocation of NF-κB (P < 0.05). MiR-96-5p was highly expressed but PPARγ was lowly expressed in IDD, while knockdown of PPARγ partially reversed remission of IDD induced by miR-96-5p downregulation (P < 0.05). MiR-96-5p promoted NF-κB entry into the nucleus but PPARγ inhibited this process.

CONCLUSION

Inhibition of miR-96-5p suppressed IDD progression by regulating the PPARγ/NF-κB pathway. MiR-96-5p may be a promising target for IDD treatment clinically.

Inhibition of Neurogenic Inflammatory Pathways Associated with the Reduction in Discogenic Back Pain

STUDY DESIGN

Retrospective cohort study.

PURPOSE

This study aimed to determine whether the initiation of anti-calcitonin gene-related peptide (CGRP inhibitor) medication therapy for migraines was also associated with improvements in back/neck pain, mobility, and function in a patient population with comorbid degenerative spinal disease and migraine.

OVERVIEW OF LITERATURE

CGRP upregulates pro-inflammatory cytokines such as tumor necrosis factor-α, interleukin-6, brain-derived neurotrophic factor, and nerve growth factor in spinal spondylotic disease, which results in disc degeneration and sensitization of nociceptive neurons. Although CGRP inhibitors can quell neurogenic inflammation in migraines, their off-site efficacy as a therapeutic target for discogenic back/neck pain conditions remains unknown.

METHODS

All adult patients diagnosed with spinal spondylosis and migraine treated with CGRP inhibitors at a single academic institution between 2017 and 2020 were retrospectively identified. Patient demographic and medical data, follow-up duration, migraine severity and frequency, spinal pain, functional status, and mobility before and after the administration of CGRP inhibitors were collected. Paired univariate analysis was conducted to determine significant changes in spinal pain, headache severity, and headache frequency before and after the administration of CGRP inhibitors. The correlation between changes in the spinal pain score and functional or mobility improvement was assessed with Spearman's rho.

RESULTS

In total, 56 patients were included. The mean follow-up time after the administration of CGRP inhibitors was 123 days for spinal pain visits and 129 days for migraine visits. Back/neck pain decreased significantly (p <0.001) from 6.30 to 4.36 after starting CGRP inhibitor therapy for migraine control. As recorded in the spine follow-up notes, 25% of patients experienced a functional improvement in the activities of daily living, and 17.5% experienced mobility improvement while taking CGRP inhibitors. Change in back/ neck pain moderately correlated (ρ=-0.430) with functional improvement but was not correlated with mobility improvement (ρ=-0.052).

CONCLUSIONS

Patients taking CGRP inhibitors for chronic migraines with comorbid degenerative spinal conditions experienced significant off-target reduction of back/neck pain.

Novel Pulsed Ultrahigh-frequency Spinal Cord Stimulation Inhibits Mechanical Hypersensitivity and Brain Neuronal Activity in Rats after Nerve Injury

BACKGROUND

Spinal cord stimulation (SCS) is an important pain treatment modality. This study hypothesized that a novel pulsed ultrahigh-frequency spinal cord stimulation (pUHF-SCS) could safely and effectively inhibit spared nerve injury-induced neuropathic pain in rats.

METHODS

Epidural pUHF-SCS (± 3V, 2-Hz pulses comprising 500-kHz biphasic sinewaves) was implanted at the thoracic vertebrae (T9 to T11). Local field brain potentials after hind paw stimulation were recorded. Analgesia was evaluated by von Frey-evoked allodynia and acetone-induced cold allodynia.

RESULTS

The mechanical withdrawal threshold of the injured paw was 0.91 ± 0.28 g lower than that of the sham surgery (24.9 ± 1.2 g). Applying 5-, 10-, or 20-min pUHF-SCS five times every 2 days significantly increased the paw withdrawal threshold to 13.3 ± 6.5, 18.5 ± 3.6, and 21.0 ± 2.8 g at 5 h post-SCS, respectively (P = 0.0002, < 0.0001, and < 0.0001; n = 6 per group) and to 6.1 ± 2.5, 8.2 ± 2.7, and 14.3 ± 5.9 g on the second day, respectively (P = 0.123, 0.013, and < 0.0001). Acetone-induced paw response numbers decreased from pre-SCS (41 ± 12) to 24 ± 12 and 28 ± 10 (P = 0.006 and 0.027; n = 9) at 1 and 5 h after three rounds of 20-min pUHF-SCS, respectively. The areas under the curve from the C component of the evoked potentials at the left primary somatosensory and anterior cingulate cortices were significantly decreased from pre-SCS (101.3 ± 58.3 and 86.9 ± 25.5, respectively) to 39.7 ± 40.3 and 36.3 ± 20.7 (P = 0.021, and 0.003; n = 5) at 60 min post-SCS, respectively. The intensity thresholds for pUHF-SCS to induce brain and sciatic nerve activations were much higher than the therapeutic intensities and thresholds of conventional low-frequency SCS.

CONCLUSIONS

Pulsed ultrahigh-frequency spinal cord stimulation inhibited neuropathic pain-related behavior and paw stimulation evoked brain activation through mechanisms distinct from low-frequency SCS.

EDITOR’S PERSPECTIVE

Short-Term Health Care Costs of High-Frequency Spinal Cord Stimulation for the Treatment of Postsurgical Persistent Spinal Pain Syndrome

OBJECTIVE

High-frequency spinal cord stimulation (HF-SCS) is a treatment option for postsurgical persistent spinal pain syndrome (type 2 PSPS). We aimed to determine the health care costs associated with this therapy in a nationwide cohort.

MATERIALS AND METHODS

IBM Marketscan® Research Databases were used to identify patients who underwent HF-SCS implantation from 2016 to 2019. Inclusion criteria included prior spine surgery or diagnoses of PSPS or postlaminectomy pain syndrome any time within the two years before implantation. Inpatient and outpatient service costs, medication costs, and out-of-pocket costs were collected six months before implantation (baseline) and one, three, and six months after implantation. The six-month explant rate was calculated. Costs were compared between baseline and six months after implant via Wilcoxon sign rank test.

RESULTS

In total, 332 patients were included. At baseline, patients incurred median total costs of $15,393 (Q1: $9,266, Q3: $26,216), whereas the postimplant median total costs excluding device acquisition were $727 (Q1: $309, Q3: $1,765) at one month, $2,840 (Q1: $1,170, Q3: $6,026) at three months, and $6,380 (Q1: $2,805, Q3: $12,637) at six months. The average total cost was reduced from $21,410 (SD $21,230) from baseline to $14,312 (SD $25,687) at six months after implant for an average reduction of $7,237 (95% CI = $3212-$10,777, p < 0.001). The median device acquisition costs were $42,937 (Q1: $30,102, Q3: $65,880). The explant rate within six months was 3.4% (8/234).

CONCLUSIONS

HF-SCS for PSPS was associated with significant decreases in total health care costs and offsets acquisition costs within 2.4 years. With the rising incidence of PSPS, it will be critical to use clinically effective and cost-efficient therapies for treatment.

Microstructural Changes in the Spinothalamic Tract of CPSS Patients: Preliminary Results from a Single-Center Diffusion-Weighted Magnetic Resonance Imaging Study

INTRODUCTION

Chronic pain after spinal surgery (CPSS), formerly known as failed back surgery syndrome, encompasses a variety of highly incapacitating chronic pain syndromes emerging after spinal surgery. The intractability of CPSS makes objective parameters that could aid classification and treatment essential. In this study, we investigated the use of cerebral diffusion-weighted magnetic resonance imaging.

METHODS

Cerebral 3T diffusion-weighted (DW-) MRI data from adult CPSS patients were assessed and compared with those of healthy controls matched by age and gender. Only imaging data without relevant artefacts or significant pathologies were included. Apparent diffusion coefficient (ADC) maps were calculated from the b0 and b1000 values using nonlinear regression. After skull stripping and affine registration of all imaging data, ADC values for fifteen anatomical regions were calculated and analyzed with independent samples T-tests.

RESULTS

A total of 32 subjects were included (sixteen CPSS patients and sixteen controls). The mean ADC value of the spinothalamic tract was found to be significantly higher in CPSS patients compared with in healthy controls (p = 0.013). The other anatomical regions did not show statistically different ADC values between the two groups.

CONCLUSION

Our results suggest that patients suffering from CPSS are subject to microstructural changes, predominantly within the cerebral spinothalamic tract. Additional research could possibly lead to imaging biomarkers derived from ADC values in CPSS patients.

Chronic pain after spine surgery: Insights into pathogenesis, new treatment, and preventive therapy

Chronic pain after spine surgery (CPSS) is often characterized by intractable low back pain and/or radiating leg pain, and has been reported in 8-40% of patients that received lumbar spine surgery. We conducted a literature search of PubMed, MEDLINE/OVID with a focus on studies about the etiology and treatments of CPSS and low back pain. Our aim was to provide a narrative review that would help us better understand the pathogenesis and current treatment options for CPSS. This knowledge will aid in the development of optimal strategies for managing postoperative pain symptoms and potentially curing the underlying etiologies. Firstly, we reviewed recent advances in the mechanistic study of CPSS, illustrated both structural (e.g., fibrosis and scaring) and non-structural factors (e.g., inflammation, neuronal sensitization, glial activation, psychological factor) causing CPSS, and highlighted those having not been given sufficient attention as the etiology of CPSS. Secondly, we summarized clinical evidence and therapeutic perspectives of CPSS. We also presented new insights about the treatments and etiology of CPSS, in order to raise awareness of medical staff in the identification and management of this complex painful disease. Finally, we discussed potential new targets for clinical interventions of CPSS and future perspectives of mechanistic and translational research. CPSS patients often have a mixed etiology. By reviewing recent findings, the authors advocate that clinicians shall comprehensively evaluate each case to formulate a patient-specific and multi-modal pain treatment, and importantly, consider an early intraoperative intervention that may decrease the risk or even prevent the onset of CPSS.

Translational potential statement

CPSS remains difficult to treat. This review broadens our understanding of clinical therapies and underlying mechanisms of CPSS, and provides new insights which will aid in the development of novel mechanism-based therapies for not only managing the established pain symptoms but also preventing the development of CPSS.

Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review

The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain.

Spinal Cord Stimulation for Failed Back Surgery Syndrome: to Trial or Not to Trial?

Spinal cord stimulation (SCS) is a recommended therapy to treat failed back surgery syndrome (FBSS). A trial period is practiced to enhance patient selection. However, its fundamental evidence is limited, especially concerning long-term benefit and therapy safety. We compared the long-term (5.3 ± 4.0 years) clinical outcome and therapy safety of a trialed and nontrialed implantation strategy, including multidimensional variables and pain intensity fluctuations over time. A multicenter cohort analysis was performed in 2 comparable groups of FBSS patients. Regarding eligibility, patients had to be treated with SCS for at least 3 months. While the Trial group comprised patients who underwent an SCS implantation after a successful trial, the No-Trial group encompassed patients who underwent complete implantation within 1 session. The primary outcome measures were pain intensity scores and complications. The Trial and No-Trial groups consisted of 194 and 376 patients (N = 570), respectively. A statistically but not clinically significant difference in pain intensity (P = .003; effect = 0.506 (.172-.839)) was found in favor of the Trial group. No interaction between a time dependency effect and pain intensity was noted. Whereas trialed SCS patients were more likely to cease opioid usage (P = .003; OR = .509 (.326-.792)), patients in the No-Trial group endured fewer infections (P = .006; proportion difference = .43 (.007-.083)). Although the clinical relevance of our findings should be proven in future studies, this long-term real-world data study indicates that patient-centered assessments on whether an SCS trial should be performed have to be investigated. According to the current ambiguous evidence, SCS trials should be considered on a case-by-case basis. PERSPECTIVE: The currently available comparative evidence, together with our results, remains ambiguous on which SCS implantation strategy might be deemed superior. An SCS trial should be considered on a case-by-case basis, for which further investigation of its clinical utility in certain patient populations or character traits is warranted.

Physical functioning following spinal cord stimulation: a systematic review and meta-analysis

BACKGROUND

Spinal cord stimulation (SCS) has emerged as an important treatment for chronic pain disorders. While there is evidence supporting improvement in pain intensity with SCS therapy, efforts to synthesize the evidence on physical functioning are lacking.

OBJECTIVE

The primary objective of this meta-analysis was to assess long-term physical function following 12 months of SCS for chronic back pain.

EVIDENCE REVIEW

PubMed, EMBASE, Scopus, and CENTRAL databases were searched for original peer-reviewed publications investigating physical function following SCS. The primary outcome was physical function at 12 months following SCS therapy for chronic back pain compared with baseline. A random effects model with an inverse variable method was used. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to determine the certainty of evidence.

FINDINGS

A total of 518 studies were screened, of which 36 were included. Twenty-two studies were pooled in the meta-analysis. There was a significant reduction in Oswestry Disability Index (ODI) scores at all time frames up to 24 months following implantation. Pooled results revealed significant improvement in ODI scores at 12 months with a mean difference of -17.00% (95% CI -23.07 to -10.94, p<0.001). There was a very low certainty of evidence in this finding as per the GRADE framework. There was no significant difference in subgroup analyses based on study design (randomised controlled trials (RCTs) vs non-RCTs), study funding, or stimulation type.

CONCLUSION

This meta-analysis highlights significant improvements in physical function after SCS therapy. However, this finding was limited by a very low GRADE certainty of evidence and high heterogeneity.

Spinal epidural fibrosis following hemostatic agent employment

OBJECTIVE

Failed Back Surgery Syndrome (FBSS) refers to a subset of patients who have new or persistent pain after spinal surgery for back or leg pain. Epidural fibrosis (EF) is a common cause of FBSS. Many agents aiming to prevent EF have been tested. However, hemostatic agents are readily available at hospitals, easy to reach and frequently used. For these reasons, oxidized regenerated cellulose, polysaccharide hemostat, hemostatic thrombin-gelatin matrix and chitosan linear polymer were evaluated for their effects on epidural fibrosis on rats after laminectomy.

METHODS

40 Sprague-Dawley rats were randomly divided into 5 equal groups including the control group where only the laminectomy was performed. The other 4 groups received hemostatic agents after laminectomy. The rats were euthanized 45 days later and were assessed by a blinded observer to grade the fibrosis level.

RESULTS

The study revealed that oxidized regenerated cellulose, polysaccharide hemostat and hemostatic thrombin-gelatin matrix lowered the epidural fibrosis grade which was statistically significant (p < 0.001). Although chitosan linear polymer created fibrosis similar to the control group it was not proven to be statistically significant (p = 0.8999). However, when compared with other hemostatic agents it resulted in a higher fibrosis grade (p < 0.001).

CONCLUSION

The results obtained from this experimental study revealed that Pahacel, Sealfoam and Surgiflo, were effective in reducing epidural fibrosis after laminectomy in rats.

Teleexercise for geriatric patients with failed back surgery syndrome

Introduction

Failed back surgery syndrome (FBSS) is defined as back pain which either persists after attempted surgical intervention or originates after a spine surgery. There is a high risk of perioperative morbidity and a high likelihood of extensive revision surgery in geriatric patients with FBSS or post-laminectomy foraminal stenosis.

Methods

There is a need for less invasive methodologies for the treatment of FBSS, such as patient-tailored exercise training, with attention to the cost and special needs of the geriatric patients with FBSS. This commentary will provide some background regarding teleexercise (utilizing an internet-based platform for the provision of exercise-related care) for FBSS and will propose three exercises which are easy to administer over online-based platforms and can be the subject of future investigation.

Results

Given the documented benefits of regular rehabilitative exercises for patients with FBSS, the high cost of face-to-face services, and the need for infection mitigation in the wake of the COVID-19 Pandemic, teleexercise may be a practical and cost-beneficial method of exercise delivery, especially for geriatric patients with limitations in mobility and access to care. It should be noted that, prescription of these exercises should be done after face-to-face evaluation by the physician and careful evaluation for any “red flag” symptoms.

Conclusion

In this commentary, we will suggest three practical exercise training methodologies and discuss the benefits of teleexercise for geriatric patients with FBSS. Future research should aim to assess the efficacy of these exercises, especially when administered through telehealth platforms.

Effect of Body Mass Index on Paddle Lead Spinal Cord Stimulator Safety Implantation for Chronic Pain Management

OBJECTIVE

Spinal cord stimulators (SCS) represent an effective treatment for patients with chronic pain issues. This study examines extremely obese patients (body mass index [BMI] ≥40) as appropriate surgical candidates for paddle lead SCS trial via partial thoracic laminectomy and whether obesity impacts implantation safety.

METHODS

A retrospective review of patients treated with partial thoracic laminectomy and paddle lead SCS trial between October 1, 2016 and September 30, 2019 was performed. The primary outcome was implantation safety (complication rate within minimum of 90 days) in patients with extreme obesity (BMI ≥40) compared with patients with BMI <40 and secondary outcome was effectiveness (successful trial leading to final implantation). Seventy-three patients underwent SCS trial.

RESULTS

Four (5.48%) patients developed complications with only 1 patient in the BMI ≥40 cohort (not statistically significant). Overall trial success rate was 82.2% (60/73) with statistically significant higher success rates among patients with a BMI ≥40 (93.3% vs. 74.4%, P = 0.0183).

CONCLUSIONS

We conclude that paddle lead SCS trial in extremely obese patients is reasonable to offer with the expectation of similar safety concerns as those for patients with a lower BMI.

Paraspinal muscles atrophy on both sides and at multiple levels after unilateral lumbar partial discectomy

To identify the changes in cross-sectional areas (CSAs) and fatty infiltration of both sides of the paravertebral muscles and their associations with prognostic factors in patients who underwent unilateral lumbar discectomy. We retrospectively reviewed 27 patients who underwent magnetic resonance imaging before and after 1- or 2-level lumbar discectomy. The CSAs and functional cross-sectional areas of the paraspinal muscles were bilaterally measured from L1 to L2 to L5 to S1 based on T2-weighted axial images. These parameters were compared pre-and postoperatively. CSAs and functional cross-sectional areas decreased also in non-operative, non-surgical levels, not only in operated levels after discectomy. In the correlation analysis, the CSA of psoas major muscle at L1 to L2 was significantly decreased in patients with lower preoperative lordosis (r = 0.598, P = .040). The postoperative CSA of psoas major muscle at L4 to L5 was lower in those with the higher Pfirrmann grade (r = -0.590, P = .002); however, the CSA of quadratus lumborum muscle at L1 to L2 showed the opposite result (r = 0.526, P = .036). Similar results were also observed in the partial correlation adjusted for age and postoperative duration. Patients who underwent discectomy experienced overall paraspinal muscle atrophy in the lumbar region, including surgical and non-surgical sites. Such atrophic changes emphasized the need for core strengthening and lumbar rehabilitation from the early period after partial discectomy.

The analgesic effect of lumbar sympathetic ganglion block in patients with failed back surgery syndrome

Background

Persistent or recurrent lumbosacral pain is a common symptom after spinal surgery. Several interventions have been introduced for failed back surgery syndrome; however, their clinical efficacy, safety, and cost-effectiveness are insufficient. Sympathetic ganglion block has been selected for pain associated with the sympathetic nervous system. In this study, we compared pain and quality of life in patients with failed back surgery syndrome who responded and did not respond to lumbar sympathetic ganglion block.

Methods

We included 84 patients diagnosed with failed back surgery syndrome who had lumbosacral pain and underwent lumbar sympathetic ganglion block between January 2020 and April 2021. The patients' data were retrospectively analyzed; clinical outcomes were assessed before (T0), 1 week after (T1), and 4 weeks after (T4) lumbar sympathetic ganglion block. Based on the pain difference from T0 to T1, we categorized patients into two groups: patients with ≥ 50% pain reduction (responder group) and patients with < 50% pain reduction (non-responder group). Demographic, clinical, surgical, and fluoroscopic data were evaluated and compared. The primary outcome was pain scores and the EuroQol-5D score from T0 to T4.

Results

Among the 84 patients analyzed, 41 (48.8%) experienced ≥ 50% pain reduction at 1 week after lumbar sympathetic ganglion block. Lumbar sympathetic ganglion block significantly improved pain at T1 and T4 compared to T0 in both groups. Lumbar sympathetic ganglion block improved the EuroQol-5D score at T1 compared to T0 in the responder group. The responder group had a significant decrease in pain at T1 from T0 and T4 from T0 and a significant decrease in the EuroQol-5D score at T1 from T0 compared with the non-responder group. Coldness of the leg over time did not differ between the groups. No serious adverse events occurred in either of the groups.

Conclusion

Lumbar sympathetic ganglion block may improve pain at 1 and 4 weeks in patients with failed back surgery syndrome. Patients with ≥ 50% pain reduction at 1 week showed simultaneous improvement in quality of life and pain reduction at 4 weeks.

Clinical trial registration

https://cris.nih.go.kr/cris/index/index.do, identifier KCT0007236.

Efficacy of Spinal Cord Stimulation for Failed Back Surgery Syndrome in Elderly Patients: A Retrospective Study

Objectives

Failed back surgery syndrome (FBSS) refers to a condition where symptoms such as low back pain, leg pain, and numbness persist or recur after lumbar surgery; it has been reported to occur in 10%-40% of patients who have undergone lumbar surgery. Spinal cord stimulation (SCS) has been reported useful for low back and leg pain due to FBSS. In this study, we studied the efficacy and safety of SCS for FBSS in older adults.

Methods

Among FBSS patients who underwent an SCS trial between November 2017 and December 2020, those with at least 50% pain reduction during the trial phase who requested spinal cord stimulator implantation underwent implantation of a stimulator under local anesthesia. The patients were divided into two groups: patients aged <75 years (<75-year-old group) and patients aged ≥75 years (≥75-year-old group). The male/female ratio, symptom duration, operative duration, visual analog scale (VAS) scores before and after one year of surgery, responder rate (RR), complications one year after surgery, and stimulator removal rate were analyzed.

Results

There were 27 cases in the <75-year-old group and 46 in the ≥75-year-old group, with no significant differences in male/female ratio, duration of pain, or operative time between the two groups. VAS scores for low back pain, leg pain, and overall pain one year after surgery were improved significantly from respective preoperative scores in both groups (P < 0.001). There were no significant differences in low back pain VAS, leg pain VAS, overall pain VAS, RR, complications one year after surgery, or stimulator removal rate between the two groups.

Conclusion

SCS reduced pain effectively in both <75-year-old and ≥75-year-old groups with no differences in complications. Therefore, spinal cord stimulator implantation was considered a viable option for FBSS treatment in older adults because it can be performed under local anesthesia and is associated with a low incidence of complications.

The Association Between Bodily Functions and Cognitive/Emotional Factors in Patients With Chronic Pain Treated With Neuromodulation: A Systematic Review and Meta-Analyses

OBJECTIVES

To date, pain relief in general continues to be the most prominent outcome measurement in daily routine care and clinical research. Nevertheless, the awareness of a shift toward more functional outcomes and/or emotional and cognitive outcomes has been raised. The interplay between bodily functions (such as pain intensity) and emotional or cognitive factors, however, has not yet been fully elucidated. The aim of this study was to systematically review the evidence for associations between bodily functions and cognitive and emotional factors in patients with chronic pain who are treated with neuromodulation.

MATERIALS AND METHODS

Four data bases were consulted for this systematic literature review: PubMed, Web of Science, Scopus, and Embase. The Downs and Black Checklist (modified) was used to assess the risk of bias. The study protocol was prospectively registered at the International prospective register of systematic reviews (PROSPERO, CRD42021226803). If two or more studies reported correlation coefficients for a specific association, a meta-analysis based on correlation coefficients was performed for that specific association.

RESULTS

The initial data base search identified a total of 1432 studies, of which 19 studies were eventually included in the systematic review. Evidence was found for two associations: 1) a positive correlation between pain intensity and anxiety (r = 0.42; 95% CI, 0.34 to 0.50) and 2) a positive correlation between pain intensity and depression (r = 0.32; 95% CI, 0.10 to 0.51). The association between pain intensity and catastrophizing was not statistically significant (r = 0.23; 95% CI, -0.36 to 0.69).

CONCLUSIONS

On the basis of the associations between pain intensity and anxiety/depression, a biopsychosocial approach might be the most suitable in clinical practice to properly address all aspects of the International Classification of Functioning, Disability, and Health framework in patients who are treated with neuromodulation.

The post spinal surgery syndrome: A review

Post spinal surgery syndrome(PSSS) has always been considered only for the pain it causes. However, many other neurological deficits do happen after lower back surgery. The aim of this review is to look into the various other neurological deficits that could happen after a spinal surgery. Using the keywords, foot drop, cauda equina syndrome, epidural hematoma, nerve and dural injury in spine surgery, the literature was searched. Out of the 189 articles obtained, the most important were analyzed. The problems associated with spine surgery have been published in the literature but are much more than the failed back surgery syndrome and cause more discomfort to the patients. To bring about a more sustained and collective awareness and understanding of these complications following spinal surgery, we encompassed all these complications under the heading of PSSS.

Spinal Cord Stimulation Meets Them All: An Effective Treatment for Different Pain Conditions. Our Experience and Literature Review

IntroductionSpinal Cord Stimulation (SCS) is an emerging minimally invasive technique which uses neuromodulation to manage different forms of intractable pain. SCS is a well-established option for the treatment of various pain conditions, and nowadays, indications are ever increasing.Materials and MethodsIn this study, we present our case series of 49 patients who underwent SCS at our Institution for the treatment of pain from different etiologies, and discuss our 10-year experience in SCS. For the purpose of this study, we also performed a systematic review of current indications and new perspectives in SCS.ResultsAmong our case series, patients were differentiated into two groups upon prior spinal surgery: patients who had undergone prior spinal surgery for back pain were defined as the "FBSS (failed back surgery syndrome) group," instead patient suffering from different types of pain but who had never undergone surgery were defined as the "naive group." As regards clinical response to SCS, 20 patients out of 36 (55.56%) were classified as responders in the FBSS group; in the "naïve" group, 10 patients out of 13 (76.92%) were classified as responders. Among the "not responders" group, several patients suffered from infections.Of the recent literature about SCS, 2124 records were screened and 37 studies were finally included in the qualitative synthesis for our systematic review.DiscussionIn case of FBSS, surgical revision is often associated with a high morbidity and corresponding low rates of success. Unfortunately, patients affected by chronic pain often become refractory to conservative treatments. Spinal Cord Stimulation (SCS) is nowadays considered as an effective therapy for several chronic and neuropathic pain conditions, such as failed back surgery syndrome. As regards the economic impact of SCS, implantation of an SCS system results in short-term costs increase, but the annual cumulative costs decrease during the following years after implantation, when compared to the costs of conventional management. Beyond the application for the treatment of FBSS, SCS has also been used for the treatment of other types of chronic non-oncological pain such as neuropathic pain and chronic back pain ineligible for surgical intervention. This evidence paved the way to establishing the potential role of SCS also for the treatment of oncological pain. However, the effectiveness and relative safety of SCS for cancer-related pain has not yet been adequately established.ConclusionsSpinal Cord Stimulation is a well-established treatment option in for FBSS. Beyond that, SCS has also been used for the treatment of "naive" patients, suffering from other types of chronic, both oncological and non-oncological, medical-refractory pain such as neuropathic pain and chronic back pain ineligible for surgical intervention.

Non-Invasive Treatments for Failed Back Surgery Syndrome: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS).

METHODS

Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups.

RESULTS

The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS.

CONCLUSIONS

Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.

Incidence and risk factors of spinal cord stimulation for persistent or recurrent pain after lumbar spine surgery: a population-based study

PURPOSE

This study aims to elucidate the incidence of and independent risk factors for spinal cord stimulator implantations for patients who underwent lumbar spine surgery.

METHODS

The PERFormance, Effectiveness, and Cost of Treatment (PERFECT) episodes database, which was established for selected diseases and procedures in Finland, includes all patients who underwent lumbar spine surgery for degenerative spine conditions or spinal cord stimulation (SCS) in Finland from 1986 to 2018. The data on age, sex, hospital diagnoses, surgical procedures, and causes of death were imported from the Finnish national registers into the PERFECT database.

RESULTS

Between 1986 and 2018, 157,824 patients had their first lumbar spine procedure and for 1769 (1.1%) of them, a subsequent SCS procedure was observed during the follow-up. The cumulative incidence of SCS for persistent or recurrent pain after lumbar disk herniation, spinal stenosis, degenerative disk disease, and spondylolysis and spondylolisthesis surgery at 15 years was 1.2%, 1.0%, 2.7%, and 2.6% respectively. At 15 years, the cumulative incidence of SCS for persistent or recurrent pain after lumbar spine surgery after five or more lumbar spinal operations was 11.9%.

CONCLUSION

Repeated surgery was the most prominent significant risk factor for SCS for persistent or recurrent pain after lumbar spine surgery. The risk of SCS for persistent or recurrent pain after lumbar spine surgery increases significantly along with the number of lumbar spine procedures. When considering repeated lumbar spine surgery, careful evaluation of treatment options should take place to ensure good patient outcomes.

Efficacy of Peripheral Nerve Field Stimulation for the Management of Chronic Low Back Pain and Persistent Spinal Pain Syndrome: A Narrative Review

OBJECTIVES

Various approaches have been developed with a view to treating the back pain component in patients with chronic low back pain (CLBP) and persistent spinal pain syndrome (PSPS). Emerging evidence shows that peripheral nerve field stimulation (PNFS) may be an efficacious therapeutic modality against axial low back pain. Hence, the aim of the review was to evaluate the analgesic efficacy and safety of PNFS, when used alone or as an adjunct to spinal cord stimulation (SCS), for managing CLBP and PSPS.

MATERIALS AND METHODS

A comprehensive search for clinical studies on PNFS and PNFS + SCS used for the management of CLBP and/or PSPS was performed using PubMed, EMBASE, MEDLINE via Proquest, and Web of Science.

RESULTS

A total of 15 studies were included, of which four were randomized controlled trials (RCTs), nine were observational studies, and two were case series. For patients receiving PNFS, a significant decrease in back pain intensity and analgesic consumption, together with a significant improvement in physical functioning, was observed upon implant of the permanent system. Meanwhile, the addition of PNFS to SCS in refractory cases was associated with a significant reduction in back and leg pain, respectively.

CONCLUSIONS

This review suggests that PNFS, when used alone or in combination with SCS, appears to be effective in managing back pain. However, high-quality evidence that supports the long-term analgesic efficacy and safety is still lacking. Hence, RCTs with a larger patient population and of a longer follow-up duration are warranted.

The current role and future directions of imaging in failed back surgery syndrome patients: an educational review

BACKGROUND

Failed back surgery syndrome (FBSS) is an umbrella term referring to painful sensations experienced by patients after spinal surgery, mostly of neuropathic nature. Adequate treatment of FBSS is challenging, as its etiology is believed to be multifactorial and still not fully clarified. Accurate identification of the source of pain is difficult but pivotal to establish the most appropriate treatment strategy. Although the clinical utility of imaging in FBSS patients is still contentious, objective parameters are highly warranted to map different phenotypes of FBSS and tailor each subsequent therapy.

MAIN BODY

Since technological developments have weakened the applicability of prior research, this educational review outlined the recent evidence (i.e., from January 2005 onwards) after a systematic literature search. The state of the art on multiple imaging modalities in FBSS patients was reviewed. Future directions related to functional MRI and the development of imaging biomarkers have also been discussed.

CONCLUSION

Besides the fact that more imaging studies correlated with symptomatology in the postoperative setting are warranted, the current educational review outlined that contrast-enhanced MRI and MR neurography have been suggested as valuable imaging protocols to assess alterations in the spine of FBSS patients. The use of imaging biomarkers to study correlations between imaging features and symptomatology might hold future potential; however, more research is required before any promising hypotheses can be drawn.

Is There a Difference in Fear-Avoidance, Beliefs, Anxiety and Depression Between Post-Surgery and Non-Surgical Persistent Spinal Pain Syndrome Patients?

Introduction

Patients with post-surgery persistent spinal pain syndrome (PSPS) or non-surgical PSPS might be affected by sustained fear-avoidance beliefs (FAB), anxiety and depression. In this scenario, this study aimed to describe those aspects in patients with post-surgery PSPS and non-surgical PSPS.

Methods

This study included patients with PSPS, and non-surgical PSPS, over 18 years, with quarterly evaluations at the Chronic Pain Clinic. After evaluation, demographic and clinical characteristics were obtained. The Beck Depression Inventory-II, Beck Anxiety Inventory, Douleur neuropathique 4 questions, Visual Analog Pain Scale, and Fear-Avoidance Beliefs Questionnaire-Brazilian Version (FABQ-Brazil) were used to evaluate psychological aspects.

Results

Forty-six patients were included, 23 patients with post-surgery PSPS and 23 with non-surgical PSPS. Both groups had high scores in the physical and work domains of the FABQ, high rates of absenteeism and most patients in these groups had moderate-to-severe neuropathic pain and some degree of anxiety and/or depression. The groups showed no statistically significant difference (p > 0.05) when comparing all questionnaires.

Discussion

This is one of the first studies to evaluate FAB and other associated psychological factors, such as anxiety and depression, in patients with post-surgery PSPS in a follow-up several years after surgery and compare with patients diagnosed with non-surgical PSPS. In this study, most patients in both groups had high scores in the FABQ domains, not having statistically relevant difference between groups.

Conclusion

Even though there was no statistically relevant difference between the PSPS patient with or without surgical history in terms of the assessed outcome measures, the described scores for fear-avoidance beliefs, pain, anxiety and depression were high, showing an interference in the daily life activities of those patients.

Effectiveness of plasma rich in growth factors in the management of chronic spinal pain: a case series of 32 patients

Background: This prospective, case-series study aimed to assess the clinical effectiveness of plasma rich in growth factors (PRGF) in patients with chronic low back pain (LBP) and to identify the features of the responsive patients. Materials & methods: PRGF was injected into the intervertebral disc, epidural space and/or facet and sacroiliac joints of 32 patients with chronic LBP. The efficacy of the treatment was assessed by algo-functional scores after 3 and 6 months. Results: Overall, the patients did not ameliorate after PRGF treatment, although eight patients showed an algo-functional improvement. They were mainly males treated at two sites who were younger, less sedentary and with fewer musculoskeletal co-morbidities than the nonresponders. Conclusion: PRGF is a potential treatment in a specific subpopulation of difficult-to-treat patients affected by chronic LBP.

Professional Status of Persistent Spinal Pain Syndrome Patients after Spinal Surgery (PSPS-T2): What Really Matters? A Prospective Study Introducing the Concept of "Adapted Professional Activity" Inferred from Clinical, Psychological and Social Influence

Persistent Spinal Pain Syndrome Type 2 (PSPS-T2) represents a main cause of work disruption. Beyond its societal consequences, occupational inactivity is responsible for a major decrease in physical/mental health in individuals but remains poorly analyzed. We designed a study to prospectively examine Professional Status (PS) evolution and its association with key bio-psychological markers. Data from 151 consecutively included working-age PSPS-T2 patients were analyzed to determine the proportion of professional inactivity and the relationships between PS and Social Gradient of Health (SGH), Numeric Pain Rating Scale (NPRS), EuroQol 5-Dimensional 5-Level (EQ-5D-5L), Oswestry Disability Index (ODI), Hospital Anxiety and Depression Scale (HADS), and Fear-Avoidance Belief Questionnaire work subscale (FABQ-W). Despite optimized medical management, 73.5% of PSPS-T2 patients remained inactive after 1 year of follow-up/p = 0.18. Inactive patients presented a low SGH/p = 0.002, higher NPRS/p = 0.048, lower EQ-5D-5L/p < 0.001, higher ODI/p = 0.018, higher HADS-D/p = 0.019 and higher FABQ-W/p < 0.001. No significant mediation effect of FABQ-W on SGH consequences regarding PS was observed in our structural model/p = 0.057. The link between unemployment and bio-psycho-social pain dimensions appears bidirectional and justifies intense collaboration with social workers. Optimizing therapeutical sequencing towards personalized professional plans implies restoring "Adapted Physical Function" as an initial goal, and tailoring an "Adapted Professional Activity", matching with patient expectations and capabilities, as a final objective.

Efficacy of DiscoGel in Treatment of Degenerative Disc Disease: A Prospective 1-Year Observation of 67 Patients

Patients with degenerative disc disease may suffer from chronic lumbar discogenic (DP) or radicular leg (RLP) pain. Minimally invasive DiscoGel therapy involves the percutaneous injection of an ethanol gel into the degenerated disk's nucleus pulposus. This paper compares the 1-year outcome of such treatment in DP and RLP patients. We operated on 67 patients (49 men and 18 women) aged 20-68 years (mean age 46 ± 11 years) with DP (n = 45) and RLP (n = 22), of at least 6-8 weeks duration, with no adverse effects. We evaluated the treatment outcome with Core Outcome Measures Index (COMI) and Visual Analog Scale (VAS). A year after the ethanol gel injection, in the DP cohort, COMI and VAS dropped by 66% (6.40 vs. 2.20) and 53% (6.33 vs. 2.97), respectively. For the RLP patients, the corresponding values dropped 48% (7.05 vs. 3.68) and 54% (6.77 vs. 3.13). There were no differences between the cohorts in COMI and VAS at the follow-up end. Six months into the study, 74% of DP and 81% of RLP patients did not use any analgesics. Ethanol gel therapy can be effective for many patients. Moreover, its potential failure does not exclude surgical treatment options.

High-frequency spinal cord stimulation in failed back surgery syndrome patients with predominant low back pain-single-center experience

Treatment of patients with failed back surgery syndrome (FBSS) with predominant low back pain (LBP) remains challenging. High-frequency spinal cord stimulation (HF10 SCS) is believed to achieve significant pain reduction. We aimed to evaluate the real-life efficacy of HF-10 SCS in a tertiary spine center. A prospective observational study of all patients with FBSS and predominant LBP who underwent HF-10 SCS surgery was performed between 2016 and 2018. Patients > 18 years with Visual Analogue Scale (VAS) scores of ≥ 5 for LBP and pain duration > 6 months under stable medication were implanted percutaneous under general anesthesia and a trial phase of 7-14 days was accomplished. Primary end point was a successful trial defined as ≥ 50% VAS score reduction for LBP. Thirty-four of 39 (85%) subjects had a successful trial. Fifty-three percent were female and the mean age was 69 years. Median follow-up lasted for 10 months. Devices were removed after a median of 10 months in 5 cases. Remaining 29 patients stated significant VAS score reduction for LBP from 8.1 to 2.9 and VAS for leg pain from 4.9 to 2.2. Twenty-four percent of all patients were able to discontinue their opioids. Eight of 9 patients (89%) with signs of adjacent disc disease and 7 of 10 (70%) patients with hardware failure were successfully implanted with significant VAS reduction for LBP. HF-10 SCS achieves significant pain reduction in most patients with FBSS and predominant LBP. It might be an efficient alternative to revision surgery.

The effectiveness of spatially cross-linked polymer in the postoperative epidural fibrosis prevention: an experimental study

Introduction. Epidural fibrosis is an urgent problem in modern spinal surgery and orthopedics. The formation of connective tissue in the epidural space after performing surgical interventions on the spinal column inevitably leads to adhesion of the latter to the dura mater and compression of neural structures, followed by the formation of clinical and neurological symptoms. The  search for literary sources in domestic and foreign scientific databases has demonstrated the presence of several works studying the effectiveness of barrier methods for preventing the development of epidural fibrosis. It should be noted that the results of these studies are ambiguous and largely contradictory.

The purpose was to study the effectiveness of using a spatially cross-linked polymer in the postoperative lumbar epidural fibrosis prevention in an experiment.

Materials and methods. The study included 26 male Wistar rats (average body weight 338.5±9.07 g), which were divided into two groups: Group I (control, n = 12): animals underwent laminectomy at the level of vertebral bodies LVII – SI  without application of spatially crosslinked polymer; Group II (experimental, n = 14): animals underwent laminectomy at the level of vertebral bodies LVII – SI  followed by application of a spatially cross-linked polymer to the dura mater. The morphological and instrumental parameters were studied.

Results. Significant differences were noted in the severity of epidural fibrosis (χ2 = 14.846, p = 0.003), the number of newly formed vessels (F = 14.371, p<0.001), the number of fibroblasts (F = 11.158, p<0.001), as well as in the severity of vertebral stenosis channe l according to multislice computed tomography (χ2 = 17.207, p=0.002) between the control and experimental groups of animals.

Conclusion. Application of a spatially cross-linked polymer to the dura mater is an effective way to prevent the development of postoperative epidural fibrosis.

Electrochemical Skin Conductance Alterations during Spinal Cord Stimulation: An Experimental Study

Despite the well-known clinical effects of spinal cord stimulation (SCS), the mechanisms of action have not yet been fully unraveled. The primary aim of this study was to measure whether electrochemical skin conductance, as a measure of peripheral sympathetic autonomic function, is altered by SCS. A second aim was to compare skin conductance levels of patients with failed back surgery syndrome (FBSS) with age- and sex-matched healthy controls. Twenty-three patients with FBSS treated with SCS participated in this study. Sudomotor function was measured with the Sudoscan^TM instrument on the hands and feet during SCS on and off states. Difference scores in skin conductance between patients and age- and sex-matched healthy controls were calculated. Normal sudomotor function at the painful lower limb was revealed for 61% of the patients when SCS was activated. Skin conductance levels were not altered between on and off states of SCS. Differences in scores between patients and healthy controls were significantly different from zero. This study showed that SCS does not influencing the sympathetic nervous system in patients with FBSS, as measured by skin conductance levels. Moreover, it suggested that there is no normalization of the functioning of the sympathetic nervous system, despite the effectiveness of SCS to reduce pain intensity.

Effects of adhesion barrier gel on functional outcomes of patients with lumbar disc herniation surgery; A systematic review and meta-analysis of clinical trials

Failed Back Surgery Syndrome (FBSS) is persistent pain and disability following lumbar laminectomy which is associated with decreased quality of life and disability and has been reported in up to 40% of the patients undergoing lumbar laminectomy. Several approaches have been introduced to reduce the rate of the FBSS. Among these, applying anti-adhesive barrier gels have been studied with interest with controversial results. The aim of the current study was to determine the effects of anti-adhesive barrier gels on functional outcome and recurrence of patients undergoing lumbar disc surgery. We searched databases including EMBASE, PUBMED, Web of Science, Scopus, Cochrane Library, and scholar databases until November 2019. To assess the heterogeneity across included studies was used Cochran's Q and I-square (I²) statistics. Standardized mean difference (SMD) and 95% CI between were used to estimate pooled effect sizes. Out of 4507, 10 clinical trials found to be appropriate for current meta-analysis. The pooled results of included clinical trials indicated that adhesion barrier gel significantly decreased leg pain (LP) (SMD = −0.31; 95% CI, −0.60, −0.03; P = 0.032; I²: 59.2%) among patients with lumbar disc herniation surgery. Back pain (BP) (SMD = −0.03; 95% CI, −0.23, 0.16; P = 0.734; I²: 40.2%), and Oswestry disability index (ODI) (SMD = −0.11; 95% CI, −0.27, 0.05; P = 0.178; I²: 0.0%), were not significantly affected following adhesion barrier gel application. Application of adhesion barrier gel in single level lumbar disc surgery is associated with deceased leg pain. However, its application does not affect the low back pain, disability and gate. Further, larger randomized clinical trials are required.

A Closer Look into the Association between the Sacroiliac Joint and Low Back Pain

INTRODUCTION

Low back pain is the most common type of global disability and annually costs the United States over two billion dollars. Opioids have been used to reduce low back pain, although current evidence concerning efficacy is lacking. Sacroiliac joint dysfunction (SIJD) is estimated to be a primary pain source of low back pain in between 10 and 25% of affected patients. The primary objective of this study was to evaluate the rate of SIJD identified through osteopathic techniques in a convenience sample of patients seeking low back pain treatment. The secondary objective was to assess prevalence of low back pain and SIJD among different age groups, and genders.

METHODS

Retrospective chart reviews were completed the adult patients who had received osteopathic manipulative treatment for low back pain at Family Health and Wellness Center in Essexville, MI from January 2018 through June 2019. The prevalence of patients with SIJD was identified during reviews of osteopathic procedural documentation for patients seeking low back pain treatment. Data regarding patients’ age, sex, and treatment modalities were also extracted. Descriptive statistics consisting of frequencies and percentages were calculated.

RESULTS

A total of 84 patient records were reviewed. A total of 51 (60.7%) patients seeking low back pain treatment were diagnosed with SIJD identified by osteopathic providers. This included patients with both lumbar and sacral diagnoses simultaneously. SIJD alone accounted for 26 (31%) of patients seeking treatment. Female patients were more likely to have SIJD involvement than males. Forty one (48.8%) treated patients were between 45-64 years old. Muscle Energy Technique was documented to be the most used for 68 (81%) patients. In addition, techniques tended to move from direct to indirect for older patients.

DISCUSSION

Our study demonstrated that SIJD appeared to contribute to low back pain in 51 (60.7%) of low back pain cases identified using osteopathic techniques. This is much greater than the previously reported percentages of 10 to 25%. One possible confounding influence included varied resident screening and reporting of sacral dysfunction. Since multiple areas of the body can be treated at one time, our current procedure notes did not allow for distinguishing between which types of modalities were used on each region or capture residents’ preferred treatments.

CONCLUSIONS

Although further studies are needed, our results suggest that knowledge of SIJD’s impact on low back pain could lead to improved patient outcomes such as decreased medical costs and opioid use.

Factors Predicting the Success of Adhesiolysis Using a Steerable Catheter in Lumbar Failed Back Surgery Syndrome: A Retrospective Study

Failed back surgery syndrome (FBSS) is a commonly encountered disease after lumbar surgery. There are many cases where it is difficult to choose a treatment because no specific cause can be found. Nevertheless, according to recent reports, adhesiolysis has shown reasonable evidence. However, considering its poor cost-effectiveness, adhesiolysis cannot be used as the first line of treatment. FBSS patients often suffer from chronic pain; accordingly, they become frustrated when this treatment produces a poor response. Therefore, before the procedure, the target group must be selected carefully. We sought to identify the pre-procedure factors predicting the effect of adhesiolysis in FBSS. A total of 150 patients were evaluated and analyzed retrospectively. Of these 150 patients, 69 were classified as responders three months after the procedure (46%). The outer diameter of the catheter during the procedure and grade of foraminal stenosis were correlated with the procedure effect. In conclusion, of the 2.1 mm diameter of the catheter, 1.7 mm of it was used during the procedure, and the milder the foraminal stenosis, the greater the pain reduction effect was three months after the procedure.

The dimensions of "failed back surgery syndrome": what is behind a label?

BACKGROUND

The term failed back surgery syndrome (FBSS) has been criticized for being too unspecific and several studies have shown that a variety of conditions may underlie this label. The aims of the present study were to describe the specific symptoms and to investigate the primary and secondary underlying causes of FBSS in a contemporary series of patients who had lumbar spinal surgery before.

METHODS

We used a multilevel approach along three different axes defining symptomatic, morphological, and functional pathology dimensions.

RESULTS

Within the study period of 3 years, a total of 145 patients (74 f, 71 m, mean age 51a, range 32-82a) with the external diagnosis of FBSS were included. Disk surgery up to 4 times and surgery for spinal stenosis up to 3 times were the commonest index operations. Most often, the patients complained of low back pain (n = 126), pseudoradicular pain (n = 54), and neuropathic pain (n = 44). Imaging revealed osteochondrosis (n = 61), spondylarthrosis (n = 48), and spinal misalignment (n = 32) as the most frequent morphological changes. The majority of patients were assigned at least to two different symptomatic subcategories and morphological subcategories, respectively. According to these findings, one or more functional pathologies were assigned in 131/145 patients that subsequently enabled a specific treatment strategy.

CONCLUSIONS

FBSS has become rather a vague and imprecisely used generic term. We suggest that it should be avoided in the future both with regard to its partially stigmatizing connotation and its inherent hindering to provide individualized medicine.

Effectiveness of Epiduroscopy for Patients with Failed Back Surgery Syndrome: A Systematic Review and Meta-analysis

INTRODUCTION

Low-back or leg pain in patients suffering from failed back surgery syndrome (FBSS) is often severe, having a major impact on functionality and quality of life. Despite conservative and surgical treatments, pain can be persistent. An alternative treatment option is epiduroscopy, a minimally invasive procedure based on mechanical adhesiolysis of epidural fibrosis. As epidural fibrosis is speculated to be a major contributor in the pathophysiologic process of FBSS, this review evaluates the effectiveness of epiduroscopy in FBSS patients.

METHODS AND MATERIALS

A systematic literature search was performed in PubMed, Embase, and Cochrane databases. Critical appraisal was performed using validated tools. Meta-analysis was performed using generic inverse variance analysis.

RESULTS

From the 286 identified articles, nine studies were included. The visual analogue scale (VAS) average was 7.6 at baseline, 4.5 at 6, and 4.3 at 12 months. The Oswestry Disability Index (ODI) average was 61.7% at baseline, 42.8% at 6, and 46.9% at 12 months. An average of 49% of patients experienced significant pain relief at 6 and 37% at 12 months. Meta-analysis showed a pooled VAS mean difference of 3.4 (2.6 to 4.1; 95% confidence interval [CI]) and 2.8 (1.6 to 4.0; 95% CI) and pooled ODI mean difference of 19.4% (12.5 to 26.4%; 95% CI) and 19.8% (13.8 to 25.9%; 95% CI) at 6 and 12 months, respectively.

CONCLUSION

Current literature demonstrates a clinically relevant reduction in pain and disability scores at 6 to 12 months after mechanical adhesiolysis in FBSS patients. The quality of evidence is moderate, and the level of recommendation is weak. Practitioners should consider the benefits of epiduroscopy after weighing the risks for individual patients with FBSS.

Analysis of Subdural Injection During Lumbar Interlaminar Epidural Injection in Failed Back Surgery Syndrome

Persistent or recurrent back and leg pain following spinal surgery, known as failed back surgery syndrome (FBSS), significantly limits daily life activities. A lumbar epidural injection can reduce adhesions, inflammation, and nerve compression, although the epidural space can be distorted due to dura mater and epidural tissues changes after spinal surgery. This study analyzed subdural injection during lumbar epidural injection in FBSS patients. We retrospectively analyzed data from 155 patients who received a lumbar interlaminar epidural injection to manage FBSS. We grouped the patients based on the injected contrast medium appearance in the subdural (group S) or epidural spaces (group E) in fluoroscopic contrast images. Demographic, clinical, surgical and fluoroscopic data were recorded and evaluated, as were the pain scores before and after injection. There were 59 patients (38.1%) in the subdural group. Injection distance from the surgery level differed between the groups. Risk of subdural injection at level 1 distance from the surgery level had an odds ratio of 0.374, and at level ≥2, it was 0.172, when compared to level 0. Subdural incidence differed with the distance from surgical site. Physicians should strive to reduce subdural incidence when the injection is planned at surgery site in FBSS.

Long-Term Multicolumn-Lead Spinal Cord Stimulation Efficacy in Patients with Failed Back Surgery Syndrome: A Six-Year Prospective Follow-up Study

OBJECTIVE

The use of multicolumn-lead spinal cord stimulation (SCS) to control back pain (BP) and leg pain (LP) in patients with failed back surgery syndrome (FBSS) in the short term and mid-term has been well documented. Our study investigated whether SCS remained efficient after 72 months.

METHODS

In an observational, single-center study, we assessed SCS efficacy in 62 patients with FBSS patients. BP, LP, and magnitude of daily activity limitation (DAL) were graded using a 0-10 visual analog scale (VAS) preoperatively and at 2, 6, 12, 24, 36, and 72 months after SCS implantation. Sleep quality, use of medications, and complications were also recorded.

RESULTS

Of the 62 patients, 15 with complete follow-up data available were still using their SCS device at 72 months (SCS+). For these patients, the VAS scores for BP, LP, and DAL had changed from a median of 9 (interquartile range [IQR], 8.5-10), 7 (IQR, 6-8), and 8 (IQR, 8-9) preoperatively to a median of 4 (IQR, 3-4.5), 3 (IQR, 1.5-3.5), and 3 (IQR, 2-4) at 72 months. Their quality of sleep and analgesic medication consumption had also improved. In a subset of patients no longer using the SCS device after 72 months (SCS-), the VAS scores for BP, LP, and DAL, quality of sleep, and medication consumption were comparable to those for the SCS+ group. The SCS- group was less satisfied with the technique and were less professionally active than were the SCS+ group.

CONCLUSIONS

The SCS device provides sustained beneficial effects on BP, LP, DAL, sleep, and medication consumption in patients with FBSS still using it at 72 months postoperatively. Further studies are needed to identify the factors of adherence to the technique and the chances of success compared with the natural evolution of FBSS.

A Systematic Review of Economic Evaluations Reporting the Cost-Effectiveness of Spinal Cord Stimulation

OBJECTIVES

Spinal cord stimulation (SCS) is a recognized treatment for chronic pain. This systematic review aims to assess economic evaluations of SCS for the management of all chronic pain conditions, summarize key findings, and assess the quality of studies to inform healthcare resource allocation decisions and future research.

METHODS

Economic evaluations were identified by searching general medical and economic databases complemented with screening of reference lists of identified studies. No restrictions on language or treatment comparators were applied. Relevant data were extracted. The quality of included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

Fourteen studies met the inclusion criteria and were judged to be of acceptable quality. Economic evaluations assessed SCS for the management of refractory angina pectoris, failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), diabetic peripheral neuropathy (DPN), and peripheral arterial disease. Model-based studies typically applied a 2-stage model, i.e. decision tree followed by Markov model. Time horizon varied from 1 year to lifetime. Cost-effectiveness ranged widely from dominant (SCS cost-saving and more effective) to incremental cost-effectiveness ratio of >£100,000 per quality-adjusted life-year. Cost-effectiveness appeared to depend on the time horizon, choice of comparator, and indication. Ten of the studies indicated SCS as cost-saving or cost-effective compared with the alternative strategies.

CONCLUSION

The results consistently suggest that SCS is cost-effective when considering a long-term time horizon, particularly for the management of FBSS and CRPS. Further studies are needed to assess the cost-effectiveness of SCS for ischemic pain and DPN.

Burst Spinal Cord Stimulation: A Clinical Review

Objective

Clinical review on outcomes using burst spinal cord stimulation (SCS) in the treatment of chronic, intractable pain.

Design

Narrative clinical literature review conducted utilizing a priori search terms including key words for burst spinal cord stimulation. Synthesis and reporting of data from publications including an overview of comparative SCS outcomes.

Results

Burst SCS demonstrated greater pain relief over tonic stimulation in multiple studies, which included blinded, sham-controlled, randomized trials. Additionally, burst stimulation impacts multiple dimensions of pain, including somatic pain as well as emotional and psychological elements. Patient preference is weighted toward burst over tonic due to increased pain relief, a lack of paresthesias, and impression of change in condition.

Conclusion

Burst SCS has been shown to be both statistically and clinically superior to tonic stimulation and may provide additional benefits through different mechanisms of action. Further high-quality controlled studies are warranted to not only elucidate the basic mechanisms of burst SCS but also address how this unique stimulation signature/pattern may more adequately handle the multiple affective dimensions of pain in varying patient populations.

Effectiveness of and Factors Associated with Balloon Adhesiolysis in Patients with Lumbar Post-Laminectomy Syndrome: A Retrospective Study

Post-laminectomy syndrome (PLS) is characterized by chronic pain and complex pathological entity after back surgery. An epidural adhesiolysis is considered an effective treatment option for lumbar PLS. In this study, we retrospectively analyzed the outcome and evaluated the predictive factors of combined epidural adhesiolysis and balloon decompression using inflatable balloon catheters in lumbar PLS cases. One hundred and forty-seven subjects were retrospectively assessed and analyzed. The percentages of patients who exhibited treatment response were 32.0%, 24.5%, and 22.4% of the study population at 1, 3, and 6 months, respectively. In multivariate logistic regression analysis, the pain duration was independently associated with the treatment response six months after combined epidural adhesiolysis and balloon decompression (odds ratio = 0.985, 95% confidence interval = 0.971-0.999; p = 0.038). In addition, the receiver operating characteristic curve analysis showed that the area under the curve of pain duration after lumbar surgery was 0.680 (95% confidence interval = 0.597-0.754, p = 0.002), with an optimal cut-off value of ≤14 months, sensitivity of 51.5%, and specificity of 81.4% Our results suggest that an early intervention using combined epidural adhesiolysis and balloon decompression in lumbar PLS patients may be associated with a favorable outcome, even though it has limited effectiveness.