Postsurgical Radicular and Neuropathic Pain

Patient History

The patient is a 42-year-old man on Workers' Compensation with a severely herniated and degenerated lumbar disc and left leg pain.

Examination

The physical examination revealed numbness and dysesthesias in the right L5 distribution. The patient's strength was normal.

Prior Treatment

The patient underwent a decompression and fusion with mini-open TLIF on the left and percutaneous screw placement on the right. The surgery relieved his left leg pain but post-operatively, he experienced new right leg pain. He described the pain as radicular and electric in nature.

He was put on several medications including gabapentin and Lyrica^®. The patient also underwent epidural injections and blocks. Medication and injection therapies provided minimal relief. He then underwent explantation of the right-sided instrumentation, but pain persisted.

Images

The myelogram (Figure 1) was obtained post-explantation of the right-sided instrumentation. The medialized screw trajectory is clearly seen. The right L5 nerve root is obscured by epidural fibrosis, while the left root is clearly visible.

Figure 1. Myelogram. Image courtesy of Jason M. Highsmith, MD, and SpineUniverse.com.

Diagnosis

Post-operative radicular and neuropathic pain.

Selected Treatment

Since his pain was radicular and neuropathic in nature, and he had failed other interventional treatments, he was deemed a candidate for a spinal cord stimulator trial.

Outcome

On the last day of his 3-day spinal cord stimulation trial, he declared, "When the stimulator is on, it is as though the pain is not there." The patient then underwent permanent implantation of the spinal cord stimulator. At his 2-week visit, he said he wanted to be off all pain medications. A short time later, he returned to work full-time without restrictions.

Case Discussion

Gerard Malanga, MD

Physiatrist

New Jersey Sports Medicine, LLC
New Jersey Regenerative Institute

Although Spinal Cord Stimulation (SCS) has been available for the last two decades, tremendous advances during recent years are significant. Newer technologies used in stimulator wires and battery systems make SCS attractive to chronic pain patients, such as those with persistent low back pain with or without radicular pain.

In addition, there is increased scientific evidence to support the efficacy of SCS. In particular, North et al demonstrated SCS superiority to repeat spinal surgery. Patients first undergo a trial, as in this case, after appropriate selection and psychological screening. The trial allows the patient to experience the type of relief and sensation they will experience before permanent implantation.

There is no alteration of anatomy with either the trial or permanent stimulator, which allows addition future treatment if necessary. Most interventional pain practitioners require at least a 50% reduction in pain to deem the trial successful. When successful, permanent implantation is scheduled.

Doctor Highsmith's case represents an optimal outcome from SCS: pain resolution, the patient is off all medications, AND can return to work!

Reference:
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.