yogabook / pathology / failed back surgery sondrome fbss, postnukleotomie-syndrom
Contents
Definition
FBSS describes persistent or newly occurring pain after back surgery, for example after disc surgery (prolapse), tumour surgery, spinal canal stenosis surgery, arthrodesis surgery, as defined by the International Association for the Study of Pain:
„lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location“.
The operations are usually performed on CLBP patients. It makes sense to classify the complaints as:
- persistent (inadequate treatment, errors or side effects of treatment)
- Recurrent (after a symptom-free interval due to scarring or relapse)
- New onset (complications, iatrogenic changes)
The causes can be varied, from misdiagnosis and subsequent incorrect treatment to inadequate decompression and scarring to iatrogenic nerve damage. Insufficient resection or slippage of nucleus material is also possible. Tissue severed during surgery reduces the stability of the spine and can therefore cause problems; this also applies to laminectomies (resection of the vertebral arch with the processus spinosus). One pathomechanism here is load displacement onto neighbouring structures. Aseptic inflammation is also possible, as is pseudoarthrosis (e.g. incorrect arthrodesis). If pain radiates into the leg, the cause is usually nerve compression due to intervertebral discs or in the spinal canal (spinal canal stenosis) or epidural fibrosis. Localised lumbar back pain, on the other hand, is more likely to be due to facet joint disorders (facet syndrome), ISG problems or myofascial causes. Attention must be paid to red flags, such as those indicating cauda equina syndrome or malignancy.
The pain is nociceptor pain (discogenic or facet-related due to instabilities), neuropathic pain (epidural scarring, fibrosis, affection of nerve roots) or mixed. The spectrum of symptoms generally relates to the operated area of the back and the spinal nerves distal to the extremity. After the operation, scar tissue can form around nerve roots and cause pain. Nerves can be accidentally injured during surgery. With adjacent segment disease, surgery increases the stress on neighbouring vertebral segments, which can lead to pain of a type or location previously unknown. Furthermore, germs may have penetrated during the operation and cause an infection. Problems with implants or arthrodesis are also possible.
It is known that the likelihood of chronic pain increases with every intervention in the spine. Arthrodesis (lumbar fusion) leads to FBSS in 30% to 46% of cases, microdiscectomies in 19% to 25% of cases.
Several groups of predisposing factors have been identified:
- Pre-operative factors: those rooted in the patient, their dispositions and their suffering. These include anxiety, depression, psychological comorbidities, obesity, smoking, psychologically stressful factors, stenosis, fibrosis, and disc hernias. Among these factors, psychosocial factors are the most significant. Previous spinal surgery is also a significant predisposing factor, and pain relief is often not achieved.
- intraoperative factors such as surgery on the wrong segment, surgery on a segment where the pain affects several segments (multi-segment procedures are difficult to operate on); failure to recognise lumbarisation of sacral vertebrae or sacralisation of lumbar vertebrae. This also includes misidentification of the cause of the pain. It also includes inadequate surgical technique or incorrect execution
- Post-operative factors, differentiate here between avoidable and unavoidable: causative factors include spinal canal stenosis, spinal instability, epidural fibrosis or disturbances of the neighbouring segments
Epidemiology
FBSS occurs in 30% of cases of intervertebral disc surgery.
Cause
see above
Predisposing
- Previous WS-OPs
- Psychological dispositions
Diagnosis
- MRT
- Nerve conductivity
Symptoms
- Symptoms persisting postoperatively despite surgery or new symptoms occurring according to type or localisation, which are local or can usually be described as ischialgiform with or without corresponding paraesthesia.
- Possibly mobility restrictions, limited use of strength due to pain, etc.
- possibly sleep disorders
- Possibly a tendency to depression
Therapy
- PT/KGG
- NSAIDs if necessary
- Epidural injections if necessary
- Movement therapy: Strengthening of the relevant muscles (regional and those in the kinetic chains); stretching and tone reduction where necessary; improvement of coordination and proprioception where necessary
- Specific pain interventions of various kinds, such as spinal cord stimulation (SCS), transcutaneous electrical nerve stimulation (TENS)
- Interdisciplinary approach if necessary