failed back syndrome
DESCRIPTION
A presentation to sumerizes causes and management of the Failed Back SyndromeTRANSCRIPT
THE FAILED BACK SYNDROME
PROF.WALID MAANI
JORDAN UNIVERSITY HOSPITAL
DEFINITION
Any condition where there is failure to improve satisfactorily following back
surgery
Vert Mooney in 1988
We in the industrialized societies have a significant burden. We must explain why the problem of chronic back disability in third world countries is virtually unknown. Have we the sophisticated, scientific physicians created our own monster, the failed back syndrome?
Mooney V. (1988): The failed back. Int Disabil Stud 10:32-36
CLASSIFICATION OF FAILURE
No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy
Temporary relief but recurrence of pain Early recurrence of symptoms (within weeks) Mid-term (within weeks to months) Longer-term failures (within months to years)
CLASSIFICATION OF FAILURE
No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy
1) Wrong pre-operative diagnosis
2) Technical error
CLASSIFICATION OF FAILURE
No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy1) Wrong pre-operative diagnosis
1) Tumor2) Infection3) Metabolic Disease4) Psychosocial5) Discogenic pain (IDD,IDR)6) Decompression done too late for disc
sequestration
CLASSIFICATION OF FAILURE
No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy2) Technical error
1) Missed level or levels
2) Failure to perform adequate decompression1) Missed fragment including foraminal disc
2) Failure to recognize canal stenosis
3) Conjoined nerve root
CLASSIFICATION OF FAILURE
Temporary relief but recurrence of pain1) Early recurrence of symptoms (within weeks)
2) Mid-term (within weeks to months)
3) Longer-term failures (within months to years)
CLASSIFICATION OF FAILURE
Temporary relief but recurrence of pain1) Early recurrence of symptoms (within weeks)
1) Infection
2) Meningeal cyst
3) Juxtafacet cyst1) Synovial cyst
2) Ganglion cyst
CLASSIFICATION OF FAILURE
Temporary relief but recurrence of pain2) Mid-term (within weeks to months)
Recurrent disc prolapse Battered root Arachnoiditis Patient expectations
Battered root syndrome
The permanent radiculopathy caused by surgical trauma was first called the battered root problem by Bertrand in 1975. It is the reappearance of radicular pain after the relief of sciatica by operation. The pain is constant, burning, increased by motion or Valsalva. At that time rhizotomy was suggested as the treatment. Since it is considered now as a type of peripheral neuropathy, the treatment shifted to spinal cord stimulation (SCS).
Bertrand G. The battered root problem Orthop Clin North Am. 1975 Jan;6(1):305-10
Arachnoiditis
Arachnoiditis is a disease of the spine which results in the clumping or sticking of nerve roots together inside the spinal fluid. The nerves adhere together therefore the technical name of the condition is "adhesive arachnoiditis".
Arachnoiditis occurs intradurally whereas peridural fibrosis occurs extradurally in the epidural space.
Clumping of roots
Arachnoiditis
The most common causes of arachnoiditis are meningitis, spine surgery and trauma.
A cause for which there are a few case reports in the literature are epidural steroid injections . Epidural analgesia not cause.
The incidence of arachnoiditis after spine surgery in patients undergoing re-operation for pain ranges from 3.5% to 16%
Ribeiro C, Reis FC Findings and outcome of revision lumbar disc surgery J Spinal Disord 1999 Aug;12(4):287-92 and
Lumbar arachnoiditis Acta Med Port 1998 Jan;11(1):59-65.
Operative photograph of adhesive arachnoiditis
CLASSIFICATION OF FAILURE
Temporary relief but recurrence of pain3) Longer-term failures (within months to years)
1) Recurrent stenosis or development of lateral stenosis from disc space collapse
2) Instability
Disc space collapse
A number of relapses are due to disc space collapse. Although the disc height is often decreased in the preoperative patient with a herniated nucleus pulposus, it is an exceedingly common occurrence following surgical discectomy.
Disc space narrowing is very important in terms of decreasing the size of the neural foramina and altering facet loading and function.
The entire process predisposes to the development of hypertrophic changes of the articular processes.
Hanley EN, Shapiro DE. The development of low-back pain after excision of a lumbar disc. J Bone Joint Surg 1989;71A:719-721
Schneck CD. The anatomy of lumbar spondylosis. Clin Orthop 1985;193:20-37. .
JUXTAFACIT (JFC) CYSTS
Term originated by Kao et al in 1974
First reported by von Gruker in 1880 during autopsy
First diagnosed clinically in 1968
CYSTS ADJACENT TO THE FACET
JOINT, OR ARISINGFROM THE
LIGAMENTUM FLAVUM
Kao C.C., Winkler S.S., Turner J.H: Synovial Cyst of Spinal Facet. J Neurosurg 41:372-6,1974.Kao C.C., Uihlein A., Bickelr W.H: Lumbar Intraspinal Extradural Ganglion Cyst. J Neurosurg 29:168-72,1968.
TYPES
SYNOVIAL CYSTS (those having a synovial
lining membrane)
GANGLION CYSTS (those lacking lining
membrane)
ETIOLOGY
Unknown Possibilities
Synovial fluid extrusion from the joint Latent growth of a developmental rest Myxoid degeneration and cyst formation in
collagenous connective tissue Increased motion plays a role in some cases
INCIDENCE
Rare (2 in 1000 CT Spine) Frequency of diagnosis is rising due to:
Frequent use of MRI Clinical awareness
Mercader J. Gomez J.M., Cardinal C.: Intraspinal Synovial Cysts: Diagnosis by CT. Follow up and spontaneous remission. Neuroradiology 27:346-8, 1985.
CLINICAL PRESENTATION
May be asymptomatic Average age 60 More in females In patients with severe spondylosis, facet joint
degeneration and spondylolisthesis. L4/5 is the commonest level May be bilateral Radicular pain is the commonest symptom
CLINICAL PRESENTATION
May contribute to canal stenosis and produce intermittent claudication
May present as a quada equina lesion Symptoms are more intermittent than with
firm compressing lesions like HID A sudden increase in symptoms may indicate
hemorrhage in the cyst
IMAGING
PRE OPERATIVE TI 8 WEEKS POST OP T1
IMAGING
PRE OPERATIVE TI 8 WEEKS POST OP T1
SYNOVIAL CYST
IMAGING
PRE OPERATIVE T2 8 WEEKS POST OP T2
SYNOVIAL CYST
IMAGING
PRE OPERATIVE T2 8 WEEKS POST OP T2
HYPERTOPHIED LIGAMENT
STENOSED LATERAL RECESS
HYPERTOPHIED JOINT
DECOMPRESSED CANAL
SYNOVIAL CYST
FRAGMENT
COMMUNICATION BETWEEN JOINT AND CYST
INFECTED FLUID
DIFFRENTIAL DIAGNOSIS
Differentiating JFC from other masses rely on appearance and location: Neurofibroma (may not be calcified) Free fragment of HID ( not cystic, anterolateral) Epidural or nerve root metastases ( not cystic) Arachnoid cyst ( not associated with joint) Perineural cysts (Tarlov) ( usually on sacral
roots)