Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
FBSS - The Missing Link
- Dennis James Capolongo (24 October 2003)
-
More pathophysiology, less exhortation
- Lina Talbot (27 October 2003)
-
Letter to editor
- John H. K. Fitton (27 October 2003)
-
A Careful Touch
- Jonathan P Driver-Jowitt (4 November 2003)
-
Failed back surgery syndrome does not have to be failed pain relief.
- A.R. Cooper (4 November 2003)
-
Preventing failed back surgery syndrome
- Hauns Weisl (10 November 2003)
-
Success is Possible!
- Gabrielle Czaja, MPT (5 December 2003)
-
Re: Failed Back Surgery - All of the responses
- Andy Goldberg (1 August 2004)
-
Any new pain relief possibilities in past 4 years?
- Sandra L. Schrank (16 April 2007)
-
FBSS - two comments
- Richard Bartley (20 April 2007)
|
|
|||
|
Dennis James Capolongo, Director The End-Depo-Now Campaign 20852-1423
Send response to journal:
|
It should be mentioned that the cause for most failed back surgeries remains unknown. Yet, this does not negate the fact that most surgeons who perform back surgeries are now starting to recognize a better record of success when injectable steroid compounds are left out of the operation equation... yes, you heard me straight,... when injectable steroids are administered into the surgery site just before suturing, the risks are increased that the patient will suffer from neurological complications. Here in the States, we are gathering statistical data to support this assertion. Back surgery candidates who have NEVER had steroid epidural injections, sympathetic nerve-block injections, (or whatever you wish to call them), either prior, during or post surgically, tend to have a far better recovery, with lower levels of post surgery pain than those who have had them! The administration of post surgical steroidal infusions have proven to be far superior than injectable steroid compounds, (which are far different in their chemical composition than intravenous steroids) when literally poured into the incision site before they close you up! These steroids have no place in the spinal operating room. Just ask the manufacturers. Kindest regards
Competing interests: None declared |
|||
|
|
|||
|
Lina Talbot, General medicine, registrar, retired Torquay, Devon, TQ1 3TB
Send response to journal:
|
Making the diagnosis of failed back surgery syndrome, (or better perhaps, postdiscotomy syndrome), alerts the physician to possibilities that are more likely to be present in the operated spine (1). There is substantial evidence available for the role of epidural and arachnoid fibrosis in the pathogenesis of the symptoms of pain & disability. (2) That this does not always lead to such symptoms is not the same as saying that it never does. Despite the variation in symptoms and aetiologies between patients, they are usually encouraged to follow very much the same form of rehabilitative programme. The danger of this essentially “suck it and see” approach is demonstrated by the well-known attrition rate of these programmes. There is little evidence available relating to conservative treatment of pain & functional impairment in failed back surgery syndrome. The study cited by Verbeek looks at rehabilitation for non-selected patients following first-time discectomy, rather than at patients with failed back surgery syndrome. (3) The evidence relating to physiotherapy for chronic back pain using rigorous outcome measurements suggests limited success. (4) 1. Anderson VC, Israel Z. Failed Back Surgery Syndrome. Current Review of Pain 2000; 4:105–111. 2. Ross JS, Roberson JT, Frederickson RC, et al.: Association between peridural scar and recurrent radicular pain after lumber discectomy: magnetic resonance evaluation. Neurosurgery 1996; 38:855–861. 3. Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M. Rehabilitation following first-time lumbar disc surgery: a systematic review within the framework of the Cochrane Collaboration. Spine 2003;28:209-18. 4. McQuay H. Relief of chronic non-malignant pain. 1999; The Oxford Pain Internet Site: http://www.jr2.ox.ac.uk/bandolier/booth/painpag/index.html Competing interests: None declared |
|||
|
|
|||
|
John H. K. Fitton, GP Principal Dryland surgery, Kettering NN16 8JZ
Send response to journal:
|
Congratulations to Dr Talbot for the article 'Failed Back Syndrome'. It is the first I have read in thirty years which describes the condition of one of my patients who was once dismissed as mad by one of the specialists involved in his care. As a back sufferer who in his thirties once lay in agony for five weeks feeling that a disc was just rotting away [subsequent MRI reported it to be 'degenerate', whatever that means] I think it is disgraceful that some doctors still talk about the management of 'low back pain' as though it is a diagnosis. Do we talk about the management of 'low abdominal pain'? Of course not! In my professional lifetime the understanding and management of diseases of the stomach and the cervix have been transformed but our knowledge of low back disease does not seem to have progressed much at all. Competing interests: I have a 'degenerate' disc |
|||
|
|
|||
|
Jonathan P Driver-Jowitt, Consultant Orthopaedic surgeon Claremont Hospital, Main Road Claremont 7700, Cape Town, South Africa.
Send response to journal:
|
The adverse sequelae of discectomy may be related to technique. The following seem to lessen the incidence, and yet are often not practiced: 1. Meticulous preservation of the inter/supraspinous ligament. 2. No or minimal resection of bone. 3. Careful and sound reattachment of the supraspinous ligament to the spinous processes 4. Meticulous preservation of the ligamentum flavum, which should be detached from the laminar extremes, and later closed over the dura as a window following the discectomy. This is the only structure designed to clothe the epidural tissues. If it is removed then a continuum of scar from dura to para-vertebral muscle is inevitable - as muscle is subsequently recruited, so the dura will be repeatedly pulled. 5. The epidural fat must be handled like the precious matter which it is. It offers the dura its freedom to move. Too often it is bruised, or sucked away. 6. Only the surgeon should retract the nerve root. 7. To attempt discectomy without magnification is not acceptable 8. The wound, including the disc space, should be copiously lavaged throughout, but especially before closure. This removes tissue which will necrotise, like disc fragments, pieces of sub-cutaneous fat, muscle (which should not have been damaged, and should not be there), but most important cotton and other fibres originating from swabs, shown to be highly inflammogenic. 9. An appropriate spinal table, for example a "butt board", such as that made by Codman. This will reduce para-vertebral vein bleeding to the negligable. 10. Never use diathermy. 11. Never use "absorbable", would-be haemostatic, sponge. Rather leave any ooze - it will always stop Competing interests: None declared |
|||
|
|
|||
|
A.R. Cooper, Consultant in Anaesthesia & Pain Relief Pain Relief Clinic, Causeway Hospital, Coleraine, N. Ireland, BT52 1JS
Send response to journal:
|
I would agree that the term failed back surgery syndrome (FBSS) is unhelpful for both patient and practitioners, as it can mean different things to each group. FBSS is usually accepted as referring to the persistence of radicular pain, frequenty experienced in the legs, after surgery intended to relieve such pain. The incidence is variable being reported as 10% to 50% of surgeries for prolapsed intervertebral disc. The aetiologies varies but the single most common factor is related to the entrapment and eventual encasement of the nerve roots in fibrous tissue. This results in nerve ischemia, neuritis and radicular pain. Certainly any treatment must primarily address the relief of pain, which is not generally well managed in these patients. Specialists in interventional pain relief procedures specifically attempt to address the cause of this disabling pain, by use of modern invasive techniques. Imaging modalities such as CT and MRI can assist in demonstrating the presence of scar tissue and perineural fibrosis, but functional assessment techniques such as spinal endoscopy, caudal and transforaminal epiduroplasty, allow the targeting of pain generators within the epidural space and simultaneous treatment. It has been demonstrated that the standard epidural injection techniques employed in the vast majority of pain clinics are ineffective in reaching these areas in FBSS. Injected drugs from a standard epidural technique remain in the unaffected posterior epidural space and not reach the site of pain generation in the antero-lateral epidural space. This is in contrast to the more specific and effective techniques involving the passage of a special reinforced (Racz) catheter into the anterio-lateral epidural space, whereby adhesiolysis of scars can be achieved, and subsequent freeing up of the nerves. A variety of methods used to achieve this for effective relief of radicular pain, whether it is in the lumbar or cervical spine. Recently with the improvement in fibreoptics it is possible for a direct examination of the epidural space to be made using very fine endoscopes, and subsequent adhesiolysis to be carried out. In more difficult cases where these techniques are either not possible or ineffective, then neuromodulation procedures are available, involving either spinal cord stimulation from an implanted electrical pulse generator, or an intrathecal drug delivery system whereby drugs are delivered directly into the central nervous system. More recently developments in neuromodulation methods such as non neurodestructive pulsed radiofrequency procedures to the central nervous system which offer an alternative to the more invasive procedures are being increasingly used for pain relief in FBSS. I would agree that there is a need for a multimodal approach, both in terms of drugs, the disciplines involved, and the particular techniques used. However effective pain relief is dependant on targeting the primary cause of the pathology, which then can then best ensure that subsequent mulitdisciplinary rehabilitation programmes can best be used. Improvements in the provision of multidisciplinary rehabilitation programmes should mirror that in interventional pain relief provision. They should compliment each other for the benefit of this difficult pain population which is so often neglected because of lack of specialist provision. It is possible to improve the outcome of such patients if an interventional approach is used from the outset. Competing interests: None declared |
|||
|
|
|||
|
Hauns Weisl, Retired Orthopaedic Surgeon 10 Greenlawns, Cardiff CF23 6AW
Send response to journal:
|
Dear Sir However much one sympathises with Dr Talbot’s problem, this is no justification for publishing Talbot’s and Verbeek’s article denigrating the diagnostic label of “failed back surgery syndrome”; it is a good diagnostic label and it clearly describes the patient’s condition. I would like to say something about avoiding this condition. As Talbot states the diagnosis of prolapsed intervertebral disc is clinical and must demonstrate nerve compression. – lumbar discectomy is not indicated for any other condition. The patient’s assessment should if possible include a review of the general practitioner’s notes to exclude other causes of backache/sciatica, including psychogenic factors and personal injury claims. Under this heading one would have expected Talbot and Verbeek to refer to the work of Waddell and Schober. Prior to operating on cases which might lead to “failed back surgery syndrome” there should be careful examination including chest expansion (to exclude ankylosing spondylitis) and examining lumbar movement, straight leg raising and carrying out the Schober test in two out of the three positions of standing, sitting and lying supine. The straight leg raising should be repeated in Scott’s test and in the manner practised by physicians (who carry out the straight leg raising by flexing the hip and then straightening the knee). By carrying out the examination meticulously and looking for inconsistent findings, one would hope to reduce the number of “failed back surgery syndrome” cases. Competing interests: None declared |
|||
|
|
|||
|
Gabrielle Czaja, MPT, Owner/Clinician physiotherapy private practice Washington Health & Healing, Inc. Washington DC USA 20037
Send response to journal:
|
Thank you for articulating so well the dilemma encountered by many patients, and the clinicians who try to help them. As a physiotherapist and certified teacher of the Alexander Technique (better known in the UK than here in the US) I treat people who want to avoid surgery as well as those whose surgical outcomes are unsuccessful. It is my experience that for the person with back pain of any kind, but expecially those pre- and post- surgery, study of the Alexander Technique should be a primary intervention, regardless of outcome with previous physiotherapy. The Alexander Technique is a safe, non- aggressive, well established intervention for restoring normal biomechanics of the spine through true neuromuscular re-education, not simply "posture training". The principles of the technique are based on the cognitive use of the inhibitory function of the nervous system, so beautifully outlined in Sir Charles Sherrington's 1932 Noble Prize lecture, "Inhibition as a Coordinative Factor". As the individual's kinesthetic awareness and spine coordination improves, the faster and better chance the local environment (tissue, neurovascular structures) can heal. Many post surgical patients are initially prevented, appropriately, from participating in traditional physiotherapy exercises to allow structures at the disc level to heal. Alexander Technique lessons can be commenced almost immediately since the individual only needs to be semi-supine, seated in a chair, standing or walking, normal activities of daily living. This intervention can ensure the best possible success for any person with any level of back dysfunction. Competing interests: None declared |
|||
|
|
|||
|
Andy Goldberg, Orthopaedic Specialist Registrar London, HA7
Send response to journal:
|
Dear Sir, I think this section is very useful although highlights the incredible fragmentation of medical knowledge in this complex area. I have had three operations during the last year following a failed micro-discectomy. Having studied the literature, I feel that in general our knowledge and the research in this area is incomplete and inadequate. Dr Talbot states that there is substantial evidence available for the role of epidural and arachnoid fibrosis in the pathogenesis of the symptoms of pain & disability. It would be helpful if Dr Talbot could recite details of the "numerous studies" as my search of the literature has really only showed conflicting and incomplete evidence. I note that Dr Talbot recites just one reference and think it is important to point out that the quoted study by Ross and Roberson, was in fact sponsored by the manufacturers of ADCON-L, a commercially available gel used in back surgery to prevent such adhesions. I think that Jonathan Driver-Jowitts response is excellent, albeit a little complex for generalists, but what he is pointing out is of vital importance. Namely that just because two patients undergo a discectomy does not mean that they have necessarily had the same surgical care and attention to detail. Surgeons indeed differ hugely in surgical technique and this is one of the reasons that studies in this area are potentially flawed and it is not easy to compare patients simply by diagnosis or operation. I note Gabrielle Czajas comments on the use of physiotherapy and rehabilitation in distinct contrast to Dr Talbots comments on the same. In the same vain as Jonathan's comments on surgical perfection, I have personally noted enormous differences between the skills and abilities of different physiotherapists and alternative therapists. In my own case, I was very much of risk of falling into the “failed back surgery” category with vague neurological symptoms and general apathy. It was suggested to me that I was describing symptoms of instability although an interventional MRI scan in various degrees of flexion and extension revealed no gross instability. I searched the literature in desperation and in the end, agreed to undergo a spinal fusion procedure on the basis that micro-instability was responsible for my vague symptoms. It was told to me that stable scar tissue is better than unstable scar tissue. I am only a few months post surgery but already I am starting to feel better and regain my confidence and at last am beginning to feel positive about a future. I have recently taken up a series of exercises using special Pilates equipment and am encouraged by the results. My message is clear. I think there are a number of misconceptions regarding "failed back surgery syndrome". Three issues are key: 1) Get the right diagnosis in the first place. 2) If surgery is necessary, the surgeon must be meticulous and care about small things as described by Jonathan Driver-Jowitt. 3) Rehab must be early and by an expert in whom you trust and have confidence. I do not think these three ideals are met in the vast majority of patients and this to me is the sad reason why so many patients feel caught in a web of confusion. Competing interests: None declared |
|||
|
|
|||
|
Sandra L. Schrank, microbiologist Quest Diagnostics 80102
Send response to journal:
|
Lina Talbot, We were very interested in your "Failed back surgery syndrome" article. You mentioned that you knew about the condition first hand and had experienced different proceedures and physiotherapy and occupational therapy. The purpose of this response is to ask if you have found any new successful pain relief possibilities in the past 4 years, other than heavy pain medications. We would be most interested. Thank you. Competing interests: None declared |
|||
|
|
|||
|
Richard Bartley, Physiotherapist Abergele, Wales
Send response to journal:
|
1. A R Cooper describes specialist investigations and treatment that are generally inaccessible for most British patients with FBSS. I would be very interested to know whether other European and North American countries routinely provide such sophisticated services. 2. I would agree with the concern expressed over the quality of physiotherapy services for patients with FBSS and back pain in general. I think this reflects guru-led physiotherapy practices that dominated the profession in the 1980's and 1990's, which thankfully now seem to be waning. Competing interests: I run a back pain triage clinic |
|||