Failed Back Syndrome
By William L. Lippert, M.D., Colorado Springs LIVING WELL Magazine
Many patients have undergone spinal surgery for relief of pain in the back or legs, often associated with numbness or weakness. Spine surgery has two primary objectives: to either decompress the nerves or spinal cord so they are no longer assaulted or pinched, or to stabilize a painful joint or joints. Most patients do well with surgery and realize a significant reduction in their pain. Some patients, however, either fail to achieve pain relief, or have pain return in time after surgery. Chronic back or leg pain after spinal surgery is referred to as failed back syndrome or post laminectomy syndrome.
Back pain is much harder to treat than leg pain and may not respond to conservative pain management or surgery. There are many structures in the spine that generate pain that do not lend themselves to conventional therapy. It may be that axial pain has a much bigger set of pain generators and not at all limited to only pinching of nerves or stability. In any event, some well-intended and well-performed surgeries may not accomplish the desired goals despite excellent repair of the spine.
For patients who do respond to their surgery, some unfortunately will have either a return of similar pain or different new pain months to years later. Often times the problem evolves from an alteration in the forces on the spine driven from the initial spine pathology as well as changes incurred by the necessary surgical experience. Surgical fusion in particular can transfer forces that once were spread over several spinal segments to one or two segments adjacent to the fusion creating a “transitional syndrome” with subsequent potential for deterioration at that level. This area of deterioration may result in spinal stenosis, a narrowing of the spinal canal. Fibrosis and scarring after surgery can also assault adjacent nerves. Stenosis and nerve assault may give rise to resurgence of pain.
When pain persists or returns after surgery, the patient is intensely evaluated and usually will undergo conservative therapy. This could include medical management, physical therapy, and interventional pain care – e.g., injections for the spine. There may be surgical pathology identified by MRI or CT scan and if conservative care fails, more aggressive treatment might be considered. This is where the “right” decision about subsequent treatment becomes more controversial.
Until the last decade, open reoperation for failed backs with surgically amenable pathology was, in general, the gold standard for care. After years of scientific studies, the optimal care for failed backs is less clear. When long-term data are reviewed, conservative care deserves consideration. So what other option do we have? What we would like is a reversible, less invasive method to reduce pain without major surgery and without medications. That method may be spinal cord stimulation.
Spinal cord stimulation involves using electrical energy to diminish pain signals reaching the brain. Leads can be placed in the spine (spinal cord stimulation) or near peripheral nerves (peripheral nerve stimulation). Stimulation is a two-step process beginning with the first step called the “trial.” The trial requires no surgery but is a percutaneous procedure that places the soft electrical leads in position through a small needle. Once the leads are in position, the area of pain complaint is “stimulated” creating a tingling sensation. The trial lasts for three to seven days and the leads are then removed. The patient evaluates how significantly the pain was reduced during the trial. If quality of life was clearly improved the patient is scheduled for the second step of the process-implantation. Implantation is an outpatient surgical procedure that takes a little over an hour to place the leads and pain “pacemaker” under the skin. The pacemaker can be recharged and controlled entirely by placing a special device over the skin.
Stimulation is a very effective means of controlling pain with spinal pathology that resists more conservative therapies. Avoidance of higher risk surgical procedures is an obvious advantage. While stimulation is not for everyone, it offers an attractive alternative for those seeking a more conservative means to control their pain.
William L. Lippert, M.D., is board certified in pain management and anesthesiology. He may be reached at 719-380-7246.