Intractable Chronic Pain in Patient with Post-laminectomy Syndrome (Failed Back Surgery)
The patient is a 51-year-old male who presents for evaluation of low back and left leg pain secondary to lumbosacral neuritis and failed back surgery syndrome. He had a lumbar laminectomy performed 4-years ago for stenosis.
He works full time as a college professor but cannot tolerate sitting or standing for more than 20-minutes. His job is being affected and he has developed insomnia and mild depression secondary to pain. He reports 7/10 sharp and shooting pain. Pain radiates from his lower back down the left leg into the foot.
On exam, he is hunched at the waist and ambulates with an antalgic gait using a cane. He has paraspinous tenderness and slight weakness in the legs.
OxyContin®, Lyrica®, and Cymbalta® in optimal dosing did not provide sufficient pain relief. Since surgery, he has undergone interlaminar epidural steroid injections, without relief, as well as SI joint and lumbar facet injections. Aquatic and physical therapy were also tried to no avail.
A series of 3 transforaminal injections brought the pain down to 5/10.
MRI (not available) revealed scar tissue around the L5 nerve root, multilevel degenerative disc disease, and mild to moderate foraminal stenosis at several levels.
Post-laminectomy (Failed Back Surgery) Syndrome (FBSS).
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After psychological screening, the patient underwent a Spinal Cord Stimulator (SCS) trial to control back and leg pain. A single percutaneous lead at T7-T8 provided excellent coverage of his back and leg pain.
Figure 1. Fluoroscopic views of lead position within the epidural space (SCS trial)
Post-laminectomy Syndrome (PLS) or Failed Back Surgery Syndrome (FBSS) is a nonspecific term describing persistent lower back or leg pain after surgery. Common structural causes include foraminal stenosis, painful disc, pseudarthrosis, neuropathic pain, recurrent disc herniation, or sacroiliac joint pain.
Up to 40% of the patients undergoing spine surgery may develop FBSS and an unknown proportion of these patients undergo spine re-operations. (1-3) The current treatment of patients with FBBS ranges from additional conservative therapies, such as physical rehabilitation therapy and systemic analgesics, to more frequently invasive interventions, such as epidural steroid injections, ablative surgery, re-operations, and spinal cord stimulation. Spinal cord stimulation seems to be an effective alternative to spine re-operation. (4, 5) A recent randomized control study favors spinal cord stimulation as an early interventional pain modality because it improves not only back or leg pain but also reduces health care costs. (6)
1. North RB, Kidd DH, Zahurak M, James CS, Long DM. Spinal cord stimulation for chronic, intractable pain: experience over two decades. Neurosurgery. 1993 Mar;32(3):384-94; discussion 394-5.
2. Javid MJ, Hadar EJ. Long-term follow-up review of patients who underwent laminectomy for lumbar stenosis: a prospective study. J Neurosurg. 1998 Jul;89(1):1-7.
3. North RB, Ewend MG, Lawton MT, Kidd DH, Piantadosi S. Failed back surgery syndrome: 5-year follow-up after spinal cord stimulator implantation. Neurosurgery. 1991 May;28(5):692-9.
4. North RB, Kidd DH, Piantadosi S. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a prospective, randomized study design. Acta Neurochir Suppl. 1995;64:106-8.
5. Bell GK, Kidd D, North RB. Cost-effectiveness analysis of spinal cord stimulation in treatment of failed back surgery syndrome. J Pain Symptom Manage. 1997 May;13(5):286-95.
6. North RB, Kidd D, Shipley J, Taylor RS. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery. 2007 Aug;61(2):361-8; discussion 368-9.
The patient returned to the clinic for suture removal and noted his pain was now a 2/10 and stated, "I am having such wonderful pain relief in my low back and I have noticed that my gait is better because I am not walking hunched over."
On his 1-month follow up, visit he reported his back pain continues to improve. His surgical incisions are well-healed and he has been able to reduce narcotic usage by more than 40%. His pain continues to remain at 2/10 and he has not had any trouble programming or charging his SCS unit.
Almost 1-year following implantation of the SCS system, the patient reports the unit covers the majority of his pain. He continues to enjoy significant pain relief without narcotics. Below is an excerpt from the letter he sent me:
"….At the risk of sounding overly dramatic, I thought that any substantial physical part of my life was effectively over before this procedure. I could scarcely move without pain and any real range of motion was almost non-existent because of the pain that it caused. Now I look forward to the days and years ahead with great enthusiasm…."
Doctor Kapural and Ms. Ferreira present a classic case of neuropathic leg pain from FBSS. Epidural scarring is often blamed for neuritic pain postoperatively.
Dorsal column stimulation provides an excellent means to treat patients with neuropathic pain that is unresponsive to medical, injection, and ablative therapies. Axial back pain can also be treated, but typically with varied success.
As mentioned, psychological screening is an important component of the workup for spinal cord stimulation. It is required by many insurance carriers and Medicare can retroactively deny payment if screening was not performed.
Most physicians trial patients for 3 to 5 days. A 12-day trial is atypical. Patients can tell within a few days how well they will respond; but again, insurance carriers typically require a minimum trial period of 72-hours.
Like most interventional and surgical treatments, following the proper indications can help ensure successful patient outcomes such as this.
Reasons for prolonged SCS trials are few. Mainly, a 10- to 15-day trial is conducted to be able to better assess the patient's functional capacity and improvement. We found that very few patients would be able to conduct all of the tasks they used to do around the house, with family, and socially within a 3-day trial. Therefore, a prolonged trial will allow them to clearly judge how much they improved in function and not just to assess improvement in pain scores.
In addition, it may be that some of the initial placebo responses can be eliminated by prolonged trialing. At this time, this is a pure speculation, but we noticed that a few of our patients will state that they initially thought that SCS was "working" for them and then, as the days go by, they were not satisfied with overall improvements in pain and function.