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Although the term involves controversy, failed back surgery syndrome (FBSS) is defined as lumbar pain with or without radicular symptom that persists or appears after one or several surgical interventions. FBSS is not necessarily the consequence of a failed surgical procedure but rather a mismatch between the outcome and the patient’s and surgeon’s presurgical expectations. Specific reasons for pain, including infection, pseudomeningocele, and/or hematoma, should be ruled out before establishing FBSS as a diagnosis. The incidence of FBSS ranges between 10% and 40%. Moreover, low back pain lifetime prevalence is estimated to range between 60% and 85%, with an estimated global incidence of 9.4%. Therefore, low back pain represents a critical health problem and entails significant social, financial, and psychological consequences for the patients. Preoperative patient-related conditions such as anxiety, hypochondriasis, and cognitive impairment may negatively influence surgical outcomes. Similarly, poor patient selection and inadequate surgical planning are well known predisposing factors for the development of this syndrome. Insufficient decompression of the lateral recess or the neural foramen is the most common cause of failed surgical technique leading to FBSS, accounting for 25% to 29% of the cases. Postoperative issues may also contribute and include recurrent disc herniations (in up to 15% of the patients), epidural fibrosis (20%–36%), and postsurgical instability. Diagnosis of this condition must include a careful matching of the clinical presentation with the suspected anatomical anomaly, as well as a psychosocial assessment that includes behavioral elements such as anxiety disorder and secondary gain. Treating patients with chronic pain persisting after spine surgery is extremely challenging and requires multidisciplinary medical approaches. Currently, there are no high-level studies supporting specific management strategies for FBSS. However, after excluding clear indications for decompression or restoration of physiological spine balance, treatment of FBSS should begin with conservative management (including cognitive behavioral therapies), followed by minimally invasive procedures, and finally surgical interventions. Surgical treatment for FBSS is controversial and is sometimes associated with worsening of the clinical symptoms. Studies report that no more than 30% of the patients have a successful outcome after a second surgery and that the percentage of patients experiencing resolution of their symptoms diminishes with each subsequent surgical procedure. Therefore, surgical treatment for FBSS is reserved for patients with clear anatomical or pathological cause for their pain, typically after failure of nonsurgical treatment. We present a case of a 63-year-old male presenting with chronic pain and radicular symptoms after multiple spine surgeries and diagnosis concerning for FBSS.
Chief complaint: lower limb pain
History of present illness: This is a 63-year-old male with a history of multiple lumbar surgeries, including instrumented fusion and three revision laminectomies. The patient presented with persistent bilateral lower extremity pain, with the pain markedly worse in his left leg. His pain has been constant for many years with a recent worsening. His last surgery was 1 year prior and latest imaging showed solid fusion of his lumbar construct. Additionally, a lumbosacral magnetic resonance imaging (MRI) was performed, demonstrating findings compatible with arachnoiditis ( Fig. 21.1 ).
Medications: oxycodone, fentanyl patch
Allergies: no known drug allergies
Past medical and surgical history: chronic pain, previous L2-sacrum fusion and decompression with three revisions and last surgery was complicated by cerebrospinal fluid leakage
Family history: none
Social history: smoker
Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; sensation diminished in his lower left limb with an L4, L5 distribution.
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Preoperative | ||||
Additional tests requested |
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Surgical approach selected |
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T9-10 thoracic laminectomy and insertion of spinal cord stimulator lead for trial |
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Revision L5-S1 fusion with lateral MIS L5-S1 ALIF (XALIF), prone L5-S1 MIS revision fusion |
Goal of surgery | Spinal canal decompression, solid fusion | Pain management | Stabilization, lordosis correction, L5-S1 fusion | Restore intervertebral height, indirect decompression of L5-S1 foramina, achieve solid arthrodesis at L5-S1 with improvement of lordosis to improve spinal-pelvic parameters |
Perioperative | ||||
Positioning |
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Prone on Montreal mattress |
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Surgical equipment |
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Fluoroscopy |
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Medications | Tranexamic acid | None | None | Gabapentin, Celebrex, steroids, bupivacaine liposome injection suspension with bupivacaine 1:1, Toradol |
Anatomical considerations | Thecal sac, middle sacral arteries, sympathetic plexus | Thecal sac, lamina |
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Common iliac vessels and branches, peritoneum, ureter, sympathetic plexus |
Complications feared with approach chosen | Pseudoarthrosis, vascular complications | Epidural fibrosis |
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CSF leak |
Intraoperative | ||||
Anesthesia | General | General | General | General |
Exposure |
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T9-10 |
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Levels decompressed |
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T9-10 |
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L5-S1 |
Levels fused |
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None |
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L5-S1 |
Surgical narrative |
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Position prone, paramedian needle to localize operative level, midline incision, bilateral muscle dissection, placement of McCulloch retractor, check x-ray to confirm T9-10 level, microscope brought in, laminectomy with high-speed drill, remainder of lamina removed with flavectomy once bone thinned, paddle tunneller and placement of spinal cord stimulator, tunnel out separate incision and connected to further lead that is tunneled percutaneously to the skin, closure in layers |
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Stage 1 (lateral XALIF): right lateral decubitus with left side up on radiolucent table with bed rail mounted retractor holders placed rostral on ipsilateral side and caudal on contralateral side, spine needles and fluoroscopy to localize and guide Wiltse approach to S1 screw heads, inject 5 mL of bupivacaine mixture into tracts prior to opening, incision and monopolar cautery to identify S1 tulip heads, remove set screw, pack off incisions, check cross table AP and mark midline with proper Ferguson angle, true lateral imaging to identify anterior/posterior boundaries of disc space and lordotic angle, extend line anteriorly to midline and split difference with AP mark and ASIS, approach surgeon performs retroperitoneal opening and access to disc space, set retractor blades, confirm disc level and medial-lateral positioning with fluoroscopy, ALIF with sequential distraction/dilation of disc space, achieve 20 degree hyperlordotic implant with proper interference fit, keep trial in place for 5 minutes to ensure no IOM changes from baseline, place implant with extrasmall BMP and cellular allograft, place anterior plate/screws with appropriate size to avoid collision with posterior transpedicular instrumentation, close anterior incision with closure of abdominal wall fascia, staple posterior incision closed. Stage 2 (revision posterior instrumentation): transfer patient prone on Jackson table, right PSIS pin placement with frame, cone beam CT for navigation, reopen incision with navigation guidance to remove L5 set screws, cobalt drill to cut rods proximal to L5 screw head, remove rods and L5-S1 screws, replace with 1 mm larger screws under navigation, retap at S1 with under navigation with powered undersized tap to breach anterior cortical wall to facilitate bicortical fixation, replace roads and screws, final cone beam CT to evaluate hardware, inject remainder of bupivacaine solution into paraspinal muscles, no drain |
Complication avoidance | Multistaged approach, examine fusion construct, upsize screws if needed, vascular surgery to help with approach, ensure nice punctate bleeding in bone bed before rasping, BMP to help fusion | Spinal cord stimulator trial | Two stage approach, remove implant posteriorly to allow more lordosis anteriorly, anatomical retroperitoneal approach to L5-S1 disc space, dissect with bipolar cautery near disc space, place hyperlordotic ALIF cage | Identify S1 tulips first, retroperitoneal approach, restore lordosis with hyper lordotic implant, keep trial in for 5 minutes to ensure no IOM changes, surgical navigation, bicortical S1 pedicle screws, postinstrumentation cone beam CT |
Postoperative | ||||
Admission | Floor | Floor | Floor | Floor/step down unit |
Postoperative complications feared | Vascular injury, ileus, FI complications, infections, dural tear | Malposition of stimulator, epidural hematoma |
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Ileus, L5 nerve root traction injury, ischemic leg, sympathetic plexus injury |
Anticipated length of stay | 3 days | 2–3 days | 3 days | 2–4 days |
Follow-up testing | L-spine x-rays 1 month, 3 months, 6 months, 1 year, 2 years after surgery | Trial stimulation | L-spine x-ray after drain removal | Upright AP/lateral lumbar x-rays |
Bracing | TLSO for 12 weeks | None | None | Soft lumbo-sacral orthotic |
Follow-up visits | 2 weeks, 1 month, 3 months, 6 months, 1 year, 2 years after surgery | 1–2 days for implantation of generator if trial stimulation successful | 3 months, 6 months, 12 months after surgery | 2 weeks after surgery with nurse visit, 6 and 12 weeks with x-rays, 9 months with lumbar CT and 36 in AP and lateral upright x-rays |
Recurrent disc herniation
Hardware malfunction/malposition
Nerve root compression/foraminal stenosis
Epidural abscess/hematoma
Malingering/psychological disorders
Failed back syndrome
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