Abstract: Failed back surgery syndrome (FBSS) is a term used to define an unsatisfactory outcome of a patient who underwent spinal surgery, irrespective of type or intervention area, with persistent pain in the lumbosacral region with or without it radiating to the leg. The possible reasons and risk factors that would lead to FBSS can be found in distinct phases: in problems already present in the patient before a surgical approach, such as spinal instability, during surgery (for example, from a mistake by the surgeon), or in the postintervention phase in relation to infections or biomechanical alterations. This article reviews the current literature on FBSS and tries to give a new hypothesis to understand the reasons for this clinical problem. The dysfunction of the diaphragm muscle is a component that is not taken into account when trying to understand the reasons for this syndrome, as there is no existing literature on the subject. The diaphragm is involved in chronic lower back and sacroiliac pain and plays an important role in the management of pain perception.
Abstract: The treatment of failed back surgery syndrome (FBSS) can be equally challenging to surgeons, pain specialists, and primary care providers alike. The onset of FBSS occurs when surgery fails to treat the patient’s lumbar spinal pain. Minimizing the likelihood of FBSS is dependent on determining a clear etiology of the patient’s pain, recognizing those who are at high risk, and exhausting conservative measures before deciding to go into a revision surgery. The workup of FBSS includes a thorough history and physical examination, diagnostic imaging, and procedures. After determining the cause of FBSS, a multidisciplinary approach is preferred. This includes pharmacologic management of pain, physical therapy, and behavioral modifica- tion and may include therapeutic procedures such as injections, radiofrequency ablation, lysis of adhesions, spinal cord stimulation, and even reoperations.
Methods: The investigators studied 13 sequential patients of both sexes, between 18 and 70 years old, with persistent chronic pain (more than six months) in the lumbar region and in the lower limbs related to failed back surgery syndrome (FBSS). Pain was classified as neuropathic and non-neuropathic regarding the topography (lumbar and lower limb), based on the DN4 (Douleur Neuropathique 4) questionnaire. The patients received the ozone gas in the lumbar epidural space via spinal-sacral endoscopy. Clinical evaluation was performed before, imme- diately after (24 hours), and 1, 3, and 6 months after intervention with visual analog scale and Oswestry Disability Index (ODI).
Failed Back Surgery Syndrome (FBSS) is a relatively common condition causing chronic low back and/or leg pain persisting or recurring after one or more lumbar surgeries, associated with functional disability, low levels of Quality of Life [1, 2], and high rate of loss of product- ivity, with a significant economic impact [3, 4]. It has been estimated that affects 0.61% of general population, with an annual incidence of 0.033% . It has been re- ported that 30% of patients having lumbar spinal surgery will develop FBSS . Low levels of Health-Related Quality-of-Life (HRQoL) have been reported for patients with severe chronic pain . A systematic review reports that HRQoL in patients with FBSS is lower than in pa- tients with other chronic conditions such as neuropathic pain disorder (e.g. diabetic polyneuropathy) and other conditions like stroke or heart failure . The impact of FBSS and its management on individuals ’ health and its economic cost to society are considerable . In patients who experience persistent pain after conventional med- ical management, Spinal Cord Stimulation (SCS) might be recommended . More recently, specific recommen- dations for appropriate SCS implantation have been published . In 2008 the National Institute for Health and Care Excellence (NICE) recommended the use of SCS for the treatment of neuropathic pain, including those caused by FBSS, and underlined the need of obser- vational research able to generate robust evidence about the durability of benefits of SCS in the real world con- text . Among the studies conducted in this area in the past years [10–14], the PRECISE study is the first real- world study showing the value for money of SCS in pa- tients with FBSS refractory to conventional medical management. In particular, the cost-utility acceptability curve obtained from the analyses of the data suggests that under the assumption that decision makers ’ willing- ness to pay per Quality-Adjusted-Life-Years (QALYs) is € 60,000, SCS implantation is cost-effective in 80 and 85% of cases, according to the NHS ’ s and societal point of views, respectively.
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All procedures were performed in the operating room under general anaesthesia. General anaesthesia was induced with propofol (2 mg/kg), fentanyl (2 μg/kg), midazolam (0.05 mg/kg), and atracurium (0.5 mg/kg). Anaesthesia was maintained by isoflurane inhalation (1–2%) and fentanyl 1 μg/kg/hour was used as intraoperative analgesia. Heart rate, systolic, diastolic, mean arterial blood pressure (MAP) and oxygen saturation were non- invasively monitored throughout the surgery. Ventilation was controlled and minute ventilation was adjusted to maintain end tidal CO 2 at 35 ± 5 mmHg. Intraoperative neuromuscular block was produced with atracurium. At the end of surgery, atropine sulphate 0.02 mg/kg and neostigmine 0.04 mg/kg were administered intravenously for reversal of muscle relaxation and the trachea was extubated. Following extubation, patients were maintained on supplemental O 2 until awake in the recovery room. Bradycardia and hypotension were defined as heart rate < 60 beat/min, and MAP < 65 mmHg and treated with atropine or ephedrine 5 mg IV, respectively.
The data from our nationwide online survey of 1842 lumbar surgery patients revealed new information about the preva- lence and sociodemographic characteristics of FBSS. We found that residual abnormal sensations such as numbness, coldness, or paresthesia in the lower extremities and dull ache in the low back were highly associated with patient satisfaction and QOL following low back surgery. Also, these residual symptoms were significantly correlated with the development of FBSS. Our findings indicate that FBSS may be reduced by emphasizing the delivery of precise pre- surgical prognostic information, based on comprehensive epidemiologic data, to patients and by conducting clinical procedures, preparations, and follow-up assessments with a strong focus on patient satisfaction.
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complied and provided data at the first posttherapy follow-up. By this measure, 33% (10/30) of per-protocol subjects responded to PEMF therapy. When categorized by surgical history, a much higher proportion of subjects whose most- recent back surgery was discectomy were responders (60%, 6/10 subjects), compared to subjects who had undergone decompression (laminectomy/ foraminotomy; 21%, 3/14) or fusion (17%, 1/6) without discectomy (Table 3). Further, 40% of subjects in the discectomy subpopulation (4/10) reported $50% improvement in back and/or leg pain scores. No difference was noted in the response rates of subjects who were on opioids at study entry versus those not on opioids, nor in subjects with predominant axial low-back pain versus predominant radicular leg pain at study entry. In terms of subject age, per-protocol subjects older than 50 years of age were more frequently responders (42%, 8/19), relative to the entire per-protocol population. The mean decreases in back and leg PI scores were 44% ± 28% and 55% ± 27%, respec- tively, for responders in the per-protocol group (Table 3). A similar mean decrease in back and leg PI was reported for per-protocol group responders in the discectomy subpopu- lation (44% ± 29% and 54% ± 30%, respectively) (Table 3). In terms of timing of response, most responders showed a substantial early response, and all responders demonstrated the response in PI within the first 3 weeks of treatment (Figure 2).
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Spinal cord stimulation (SCS) has been used as a therapy for chronic pain for over 40 years. 5 The Food and Drug Administration in the United States has approved SCS for chronic pain of the trunk and limbs. The most common indica- tions for SCS include complex regional pain syndrome (CRPS), failed back surgery syndrome (FBSS), and intractable angina pectoris. 6 Over the past 20 years the number of spinal cord stimulators implanted has greatly increased; from 1997 to 2006 there was a 159% increase in spinal cord stimulator implants in the Medicare population alone. 7 Studies have demonstrated symptomatic improvement in patients with SCS. The PROCESS trial demonstrated the health-related quality of life increased in patients with FBSS who had spinal cord stimulators. 8 CRPS patients who undergo spinal cord stimulator implant in addition to physical therapy have signi ﬁ - cantly less pain than patients enrolled in physical therapy alone. 9 However, the evidence comparing the effect of SCS on opioid and pain medication reduction in chronic pain patients has not been well established. We conducted a systematic review and meta-analysis to synthesize the evi- dence about the effect of SCS on opioid and pain medication consumption.
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Significant differences were calculated by dividing the cohort into diagnosis-related subgroups, pain intensity sub- groups, and patients with migrational background versus natives. A significant high prevalence of sleep deprivation was found in patients with failed back surgery syndrome, and patients with migrational background, while only low sig- nificance was calculated for patients with intervertebral disc disease. Patients with failed back surgery syndrome usually have a long patient career of chronification. This, as well as psychological factors could trigger the sleep deprivation. A migrational background may also be associated with higher social and psychological distress (social isolation, lower income, language, or adaptation problems), resulting in a higher prevalence of sleep deprivation. Among the group of intervertebral disc disease, there was no significant difference between the cervical and lumbar disc disease subgroup. No significant relationship to sleep deprivation was found for patients with spinal stenosis.
Method/Design: Patients will be recruited in approximately 30 centers across Canada, Europe, and the United States. Eligible patients with low back pain exceeding leg pain and an average Numeric Pain Rating Scale score ≥ 5 for low back pain will be randomized 1:1 to spinal cord stimulation plus optimal medical management or to optimal medical management alone. The investigators will tailor individual optimal medical management treatment plans to their patients. Excluded from study treatments are intrathecal drug delivery, peripheral nerve stimulation, back surgery related to the original back pain complaint, and experimental therapies. Patients randomized to the spinal cord stimulation group will undergo trial stimulation, and if they achieve adequate low back pain relief a neurostimulation system using the Specify® 5-6-5 multi-column lead (Medtronic Inc., Minneapolis, MN, USA) will be implanted to capture low back pain preferentially in these patients. Outcome assessment will occur at baseline (pre-randomization) and at 1, 3, 6, 9, 12, 18, and 24 months post randomization. After the 6-month visit, patients can change treatment to that received by the other randomized group. The primary outcome is the proportion of patients with ≥ 50% reduction in low back pain at the 6-month visit. Additional outcomes include changes in low back and leg pain, functional disability, health-related quality of life, return to work, healthcare utilization including medication usage, and patient satisfaction. Data on adverse events will be collected. The primary analysis will follow the intention-to-treat principle. Healthcare use data will be used to assess costs and long-term cost-effectiveness. Discussion: Recruitment began in January 2013 and will continue until 2016.
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Objective: Failed back surgery syndrome is characterized by the presence of intractable pain and varying degrees of functional incapacity after lumbar spine surgery. Because the mechanisms that cause pain are variable, treatment of this syndrome is quite difficult, and one of the most common methods that is used for treatment nowadays is epidural injection. This research evaluates the analgesic efficacy of addition of oral gabapentin treatment to epidural corticosteroid application in patients with failed back surgery syndromes.
Methods/design: The TRIAL-STIM Study is a superiority, parallel-group, three-centre, randomised controlled trial in patients with chronic neuropathic pain with a nested qualitative study and economic evaluation. The study will take place in three UK centres: South Tees Hospitals NHS Foundation Trust (The James Cook University Hospital); Basildon and Thurrock University Hospitals NHS Foundation Trust; and Leeds Teaching Hospitals NHS Trust. A total of 100 adults undergoing SCS implantation for the treatment of neuropathy will be included. Subjects will be recruited from the outpatient clinics of the three participating sites and randomised to undergo a screening trial prior to SCS implant or an implantation-only strategy in a 1:1 ratio. Allocation will be stratified by centre and minimised on patient age ( ≥ 65 or < 65 years), gender, presence of failed back surgery syndrome (or not) and use of high frequency (HF10 ™ ) (or not). The primary outcome measure is the numerical rating scale (NRS) at 6 months compared between the screening trial and implantation strategy and the implantation-only strategy. Secondary outcome measures will include diagnostic accuracy, the proportion of patients achieving at least 50% and 30% pain relief at 6 months as measured on the NRS, health-related quality-of-life (EQ-5D), function (Oswestry Disability Index) , patient satisfaction (Patients ’ Global Impression of Change) and complication rates. A nested qualitative study will be carried out in parallel for a total of 30 of the patients recruited in each centre (10 at each centre) to explore their views of the screening trial, implantation and overall use of the SCS device. The economic evaluation will take the form of a cost – utility analysis.
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The success following the revision surgery depends on the proper preoperative evaluation,precise diagnosis, pain free interval,number of previous surgeries, age, sex and the experience of the operating surgeon. The overall success rate was 60%. The patients with the instability had good outcome than the other group patients which is comparable to other studies. Patients with PFI > 6 months have good outcome than with patients < than 6 months which is statistically significant. Younger patients had better outcome which may be due to good post op rehabilitation. Outcome of the patients treated with fusion and without fusion had similar results this is because the short term follow up.
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Exclusion criteria are: has been or is being treated with spinal cord stimulation, subcutaneous nerve stimulation, peripheral nerve stimulation or an implantable intrathecal drug delivery system; leg pain score >30 mm assessed by VAS at screening visit; evidence of an active disruptive psychiatric disorder that is significant enough to impact the perception of pain, compliance to intervention and/or ability to evaluate treatment outcome, as determined by the investigator; pain condition unrelated to FBSS that is severe enough to overshadow the FBSS pain in the opin- ion of the investigator; evidence of a spinal instability or anatomic compression that requires further surgery; spinal fusion at more than three vertebral levels; currently en- rolled in or plans to enroll in any concurrent drug and/or device study that may confound the results of this study; allergic or has shown hypersensitivity to any materials of the device system which come in contact with the body; history of coagulation disorder or lupus erythematosus; in- volved in current litigation regarding back pain.
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Aetiologies related to facet joints involved in the pathogenesis of low back pain (LBP) occur in 15 – 37% of patients after surgery [9, 10], .and injury to the facet joint has been reported to cause a series of postoperative complications [6, 11]. Meanwhile, tears in the posterior annulus is an important trigger for discogenic LBP and LDH, which are two principal causes of FBSS [1, 12, 13]. The facet cartilage plays a key role in protecting the pos- terior annulus during torsion, and the capsule of the facet joint plays a similar role during flexion [14, 15]. Given that facetectomy does not directly cause injury to the articular surface and the capsule, variation in the stress distribution may result in secondary damage and increase the incidence of annulus tears [1, 12]. Further- more, rich innervation is a typical histological feature of the facet capsule, and any increase in the mobility of the
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syndrome when various combinations of the existing thera- peutic strategies prove ineffective. Opioids and their major adjuvants usually produce positive results in the treatment of chronic pain, especially when other therapeutic approaches fail. There is an increasing demand for alternative therapeutic strategies by patients and clinicians when available therapies are marginally effective, or not well tolerated. In this con- text, the authors assessed the effectiveness of an alternative approach for chronic refractory pain associated with FBSS, using cannabinoids as a multimodal treatment approach to neuropathic pain. The plant Cannabis sativa L. has been used for centuries, both for recreational and medicinal purposes. Only in recent times, studies about exogenous cannabinoids have been performed to evaluate their therapeutic value and to investigate the role of endogenous cannabinoids (endocannabinoids) in physiology and pathophysiology of many neurologic and neuropsychiatric diseases. 16–18 Several
Abbreviations: CMM, conventional medical management; CRPS, complex regional pain syndrome; DRG, dorsal root ganglion; FBSS, failed back surgery syndrome; HF, high frequency; ITT, intention-to-treat; min, minimum; max, maimum; OA, osteoarthritis; ODI, Oswestry disability index; PC, pain clinic; PT, physical therapy; PVD, peripheral vascular disease; QOL, quality of life; RCT, randomized controlled trial; RF, radio frequency; SCS, spinal cord stimulation; UC, usual care; VAS, visual analog scale; WC, workers compensation; LBP, low back pain.
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While the use of bulking agents at our institution was associated with a good early response, as expected durability was limited, and often required a second injection. In these women, due to medical comorbidities, patient choice, or multiple failed prior operative procedures, bulking agents were the best therapeutic option, and overall there was acceptable clinical efficacy. Given the current funding challenges in Canadian healthcare, this study provides important evidence supporting the role of bulking agents for selected patients with recurrent stress urinary
We made an analytic cross-sectional study conducted between June and Decem- ber 2016 in rheumatology hospital unit of National Hospital University Hubert Koutoukou Maga of Cotonou. Eighty-two (82) patients with mechanical low back pain were recruited exhaustively for 12 months. The prevalence of MS was defined using the criteria of the International Diabetes Federation 2005: waist > 94 cm in men or >80 cm in women, associated with at least two of following factors:
groups. All those findings of diminished ovarian reserve could not be supported by pre and postoperative serum FSH and E2 levels. Then, Saliholu et al.,  supported that excision of endometrioma led to a significant decrease in AMH levels (p<0.001) but nonsignificant change in FSH levels and his explanation for this finding was that FSH is not relevant to ovarian reserve and the clinical outcomes of fertility but Ercan et al.  failed to show the negative effect of surgery on the ovarian reserve and stated that if surgery is carried out by an experienced physician with recognition of the cleavage of the cyst capsule and proper excision of the endometrioma, it is a safe approach and some studies have evaluated the effect of laparoscopic stripping of endometrioma on follicle-stimulating hormone and estradiol, other serum markers of ovarian reserve; these studies reported the ovarian- reserve markers were unaffected by laparoscopic surgery .