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Failed Back Surgery Syndrome
Recurrent herniated disc and
symptomatic hypertrophic scar can produce similar low back symptoms
and radiculopathy. Gradually increasing symptoms beginning a
year or more after discectomy are considered more likely a result
of scar radiculopathy, while a more abrupt onset at any interval
after surgery is more likely due to recurrent herniated disc.
Failed back surgery syndrome
is seen in 10-40 percent of patients who undergo back surgery.
It is characterized by intractable pain and varying degrees of
functional incapacitation occurring after spine surgery.
Epidural adhesions may occur
with no previous treatment of low back pain or sciatica in some
patients. Primary formation of epidural adhesions in the epidural
space could explain why treatments sometimes fail and why surgery
should be avoided in patients whose CT or myelograms are negative
for nerve root compression.
The clinical features of lumbosacral
spinal fibrosis are polymorphic. Lumbar pain and sciatica that
become worse, even with minimal physical activities (seen in
60 percent of patients) are the main complaints. Nocturnal cramps
and distal paresthesia are common. Twenty-five percent of patients
have low back pain without radiculopathy. Ten percent show cauda
equina syndrome with sphincter dysfunction and saddle hypesthesia.
Lasegue's sign is positive in only 20 percent of the cases, but
the absence of knee and ankle reflexes is frequent.
Case Presentation of a Postsurgical
Failed Back
Complaint: A 43-year-old, white,
single male was seen for the chief complaints of low back and
right leg pain causing antalgic posture with occasional pain
into the left leg as well. The patient had back surgery in 1990
for a laminectomy, and a spinal fusion in 1991. He noted that
his back pain returned immediately following the surgeries. He
had been seen at many clinics without any improvement.
Examination: Examination of the
low back at this time revealed marked restriction of range-of-motion,
flexion at 40 degrees, extension at five degrees, right and left
lateral flexion at 10 degrees, and rotation at 20 degrees, all
of which were accompanied by pain. Straight leg raising was bilaterally
painful at 50 degrees, creating leg pains. The muscle power of
the lower extremities was grade five of five bilaterally. The
right ankle reflex was absent, while the remaining deep reflexes
of the lower extremities were +2 bilaterally. No sensory changes
were noted on pinwheel examination. The circulation was good.
Radiographic examination revealed
the following: An extensive interlaminar fusion at the L4-S1
levels. Lateral projection revealed advanced degeneration of
L4-L5 and L5-S1 disc spaces with the posterior fusion in place.
My impressions of this case were
as follows:
A. Spinal fusion, interlaminar,
at L4-L5 and the sacrum, with advanced degenerative disc disease
at the L4-L5 and L5-S1 levels.
B. Possibility of postsurgical
stenosis a L4-L5 and L5-S1.
C. Lumbosacral paraspinal myofascitis.
The lumbar spine was treated
by goading of acupressure points B22 through B49 (gluteus), followed
by a specific adjustment (L3-L4), that is with the fusion of
L4 to the sacrum; all of the flexion, extension, and lateral
bending motions have been transferred to L3-L4 level. I feel
that maintaining complete range-of-motion with minimal stress
can help to alleviate and prevent future degenerative changes
at L3-L4 level. This will be the level of motion of this patient's
spine for the rest of his life. In addition to this, we utilized
tetanizing current (interferential), with moist heat to the paravertebral
muscles of the lumbar spine and pelvis. The treatment of postsurgical
backs can be extremely difficult, especially when sciatic pains
are present.
This patient is still under my
care and is seen bimonthly. He still has occasional soreness
in his left gluteal region, but maintains that he can tolerate
this.
According to Calodney,1 the diagnosis
and treatment of persistent pain in the previously operated low
back patient is an increasingly common and complex problem. Over
300,000 laminectomies are performed in the United States each
year, and as many as 10-40 percent of patients continue to experience
symptoms over the long run.
Accurate diagnosis is mandatory
for initiation of successful treatment. According to a study
by Burton et al.,2 the most common lesions accounting for surgical
failure are recurrent or persistent disc herniation, arachnoiditis,
epidural fibrosis, along with unidentified myofascial pain syndromes.
In summary, I have contacted
the neurosurgeons and orthopedic surgeons in the area and encouraged
their referral to the chiropractor's office instead of the usual
physical therapist. The chiropractor can treat the joints of
the spine above and below the fusion to prevent degenerative
changes. We can also do soft tissue work to alleviate myofascial
problems.
Surgeons understand that the
failed back surgery syndrome is an iatrogenic disease. The best
solution is prevention of unnecessary surgery.
- References
- 1.Calodney A: Failed Back Surgery
Syndrome.
- 2.Burton AK: Prediction of the
clinical source of low back trouble using multivariable modules.
Spine, 16:7-14, 1991.
- Randy V. Curtis, DC Longview,
Texas
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