Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review.

The introduction of the term Persistent Spinal Pain Syndrome (PSPS-T1/2), replacing the older term Failed Back Surgery Syndrome (FBSS), has significantly influenced our approach to diagnosing and treating post-surgical spinal pain. This comprehensive review discusses this change and its effects on patient care. Various diagnostic methods are employed to elucidate the underlying causes of back pain, and this information is critical in guiding treatment decisions. The management of PSPS-T1/2 involves both causative treatments, which directly address the root cause of pain, and symptomatic treatments, which focus on managing the symptoms of pain and improving overall function. The importance of a multidisciplinary and holistic approach is emphasized in the treatment of PSPS-T1/2. This approach is patient-centered and treatment plans are customized to individual patient needs and circumstances. The review concludes with a reflection on the impact of the new PSPS nomenclature on the perception and management of post-surgical spinal pain.

Efficacy of Spinal Cord Stimulation for Failed Back Surgery Syndrome in Elderly Patients: A Retrospective Study.

Objectives: Failed back surgery syndrome (FBSS) refers to a condition where symptoms such as low back pain, leg pain, and numbness persist or recur after lumbar surgery; it has been reported to occur in 10%-40% of patients who have undergone lumbar surgery. Spinal cord stimulation (SCS) has been reported useful for low back and leg pain due to FBSS. In this study, we studied the efficacy and safety of SCS for FBSS in older adults. Methods: Among FBSS patients who underwent an SCS trial between November 2017 and December 2020, those with at least 50% pain reduction during the trial phase who requested spinal cord stimulator implantation underwent implantation of a stimulator under local anesthesia. The patients were divided into two groups: patients aged <75 years (<75-year-old group) and patients aged ≥75 years (≥75-year-old group). The male/female ratio, symptom duration, operative duration, visual analog scale (VAS) scores before and after one year of surgery, responder rate (RR), complications one year after surgery, and stimulator removal rate were analyzed. Results: There were 27 cases in the <75-year-old group and 46 in the ≥75-year-old group, with no significant differences in male/female ratio, duration of pain, or operative time between the two groups. VAS scores for low back pain, leg pain, and overall pain one year after surgery were improved significantly from respective preoperative scores in both groups (P < 0.001). There were no significant differences in low back pain VAS, leg pain VAS, overall pain VAS, RR, complications one year after surgery, or stimulator removal rate between the two groups. Conclusion: SCS reduced pain effectively in both <75-year-old and ≥75-year-old groups with no differences in complications. Therefore, spinal cord stimulator implantation was considered a viable option for FBSS treatment in older adults because it can be performed under local anesthesia and is associated with a low incidence of complications.

Teleexercise for geriatric patients with failed back surgery syndrome.

Introduction: Failed back surgery syndrome (FBSS) is defined as back pain which either persists after attempted surgical intervention or originates after a spine surgery. There is a high risk of perioperative morbidity and a high likelihood of extensive revision surgery in geriatric patients with FBSS or post-laminectomy foraminal stenosis. Methods: There is a need for less invasive methodologies for the treatment of FBSS, such as patient-tailored exercise training, with attention to the cost and special needs of the geriatric patients with FBSS. This commentary will provide some background regarding teleexercise (utilizing an internet-based platform for the provision of exercise-related care) for FBSS and will propose three exercises which are easy to administer over online-based platforms and can be the subject of future investigation. Results: Given the documented benefits of regular rehabilitative exercises for patients with FBSS, the high cost of face-to-face services, and the need for infection mitigation in the wake of the COVID-19 Pandemic, teleexercise may be a practical and cost-beneficial method of exercise delivery, especially for geriatric patients with limitations in mobility and access to care. It should be noted that, prescription of these exercises should be done after face-to-face evaluation by the physician and careful evaluation for any "red flag" symptoms. Conclusion: In this commentary, we will suggest three practical exercise training methodologies and discuss the benefits of teleexercise for geriatric patients with FBSS. Future research should aim to assess the efficacy of these exercises, especially when administered through telehealth platforms.

Altered central pain processing assessed by quantitative sensory testing in patients with failed back surgery syndrome.

OBJECTIVE: To investigate the presence of altered central pain processing in patients with failed back surgery syndrome (FBSS) using quantitative sensory testing (QST). METHODS: This study included 34 patients with FBSS, 102 patients post-lumbar surgery without low back pain (LBP), and 102 healthy subjects. All subjects underwent both pressure pain threshold (PPT) and conditioned pain modulation (CPM) in both local and remote pain-free areas, as well as temporal summation (TS) in a remote pain-free area. All patient subjects were assessed using the Pain Catastrophizing Scale (PCS), Beck Anxiety Inventory (BAI), Beck Depression Index (BDI), Numeric rating pain scale (NRS) and Oswestry Disability Index (ODI). RESULTS: Compared with both control groups, FBSS patients showed a reduction in both PPT and CPM in both tested areas, along with increased TS in a pain-free area (P < 0.05). Furthermore, the patients with FBSS had a significantly higher prevalence of anxiety, depression and pain catastrophizing thoughts than the patient controls (P < 0.05). In the FBSS patients, there was a significant correlation between LBP at rest and both CPM and TS in the pain-free areas, and QST measurements were also associated with the ODI, PCS and BAI (P < 0.05). CONCLUSION: These findings support the existence of augmented central pain processing in patients with FBSS, which may be caused by dysfunction of endogenous pain facilitation and inhibition. This central amplification of pain may contribute to both LBP intensity and disability in FBSS patients. Therefore, treatment efforts should take into account functional alterations in the central nervous system of FBSS patients.

Combining Psychophysical and EEG Biomarkers for Improved Observation of Altered Nociceptive Processing in Failed Back Surgery Syndrome.

Diagnosis and stratification of chronic pain patients is difficult due to a lack of sensitive biomarkers for altered nociceptive and pain processing. Recent developments enabled to preferentially stimulate epidermal nerve fibers and simultaneously quantify the psychophysical detection probability and neurophysiological EEG responses. In this work, we study whether using one or a combination of both outcome measures could aid in the observation of altered nociceptive processing in chronic pain. A set of features was extracted from data from a total of 66 measurements on 16 failed back surgery syndrome patients and 17 healthy controls. We assessed how well each feature discriminates both groups. Subsequently, we used a random forest classifier to study whether psychophysical features, EEG features or a combination can improve the classification accuracy. It was found that a classification accuracy of 0.77 can be achieved with psychophysical features, while a classification accuracy of 0.65 was achieved using only EEG features.Clinical Relevance-This study shows which combined features of nociceptive detection behavior and evoked EEG responses are most sensitive and specific to altered nociception in failed back surgery syndrome.

[Failed back surgery syndrome: the role of central sensitization and treatment approaches]. / Sindrom neudachnoi operatsii na pozvonochnike: rol' tsentral'noi sensitizatsii i podkhody k lecheniyu.

OBJECTIVE: To study a role of central sensitization (CS) in patients with Failed Back Surgery Syndrome (FBSS) after decompression of the lumbar and/or sacral roots. MATERIAL AND METHODS: The study included three groups of patients: 1) early FBSS (e-FBSS, n=23), pain after surgery decreased, but continued to significantly bother the patient, or recurred in the first 6 months after surgery; 2) middle FBSS (m-FBSS, n=42), pain after surgery completely stopped, but recurred within 6-12 months; 3) late FBSS (l-FBSS, n=31), if pain relapse occurred more than 12 months later. Neurological status assessment, study of muscle trigger zones (MTZ), postoperative scar trigger zones (TZS), pain assessment according to the Visual Analogue Scale (VAS), CS assessment according to the Russian version of the Central Sensitization Inventory (CSI) were performed. Treatment included the following stages: stage 1 (non-steroidal anti-inflammatory drug (NSAID) meloxicam 15 mg 7 days); stage 2 (aminophenylbutyric acid hydrochloride (APAH) 250 mg 3 times a day 14 days); stage 3 (fluvoxamine 50 mg daily 8 weeks); stage 4 (MTZ and TZS treatment, fitness program). In addition to the previously described 96 patients, 15 patients (4 men and 11 women, aged 36-47 years) with FBSS and widespread pain, corresponding to the criteria for fibromyalgia ACTTION-APS Pain Taxonomy, who took only milnacipran 25-50 mg daily for two months (WSP-FBSS group), were studied. RESULTS: At baseline, CSI and VAS are as follows: CSI=72.2±6.5; VAS=58.5±8.8 in the e-FBSS group; CSI=49.2±9.0; VAS=39.5±5.3 in the m-FBSS group; CSI=18.1±5.9; VAS=18.1±5.4 in the l-FBSS group. All patients have active MTZ and TZS. The differences between MTZ and TZS subgroups were in the reproduction of pain - the appearance of pain characteristic of the patient during stimulation (pressure) of the MTZ or TZS. In the e-FBSS group, there is the low efficacy of NSAIDs, the moderate efficacy of APAH, the high efficacy of fluvoxamine. In the m-FBSS group, the moderate efficacy of NSAIDs and APAH and the high efficacy of fluvoxamine are observed. In the l-FBSS group, there is the high efficacy of NSAIDs. In the WSP-FBSS group, VAS and CSI are 58.8±9.2 mm and 75.1±8.04, respectively, before treatment, 15.51±5.1 mm (p=0.00032) and 25.6±8.2 (p=0.0002), respectively, after 2 months of treatment. CONCLUSIONS: In patients with FBSS, MTZ and TZS should be treated taking into account CS. The study shows the efficacy of APAH, fluvoxamine and milnacipran in the presence of CS.

[Minimally invasive implantation technique of a system for spinal cord stimulation]. / Minimal-invasive Implantationstechnik eines Systems zur epiduralen Rückenmarkstimulation.

OBJECTIVE: Spinal cord stimulation (SCS) targets structures of the dorsal column and dorsal horn of the spinal cord with electrical impulses, thereby, modulating pain perception. For chronic pain patients, e.g., in failed back surgery syndrome (FBSS), the aim is to achieve pain relief and enable patients to improve their quality of life. INDICATIONS: Failed back surgery syndrome, complex regional pain syndrome (CRPS) type I and II, therapy-refractory ischemic pain, neuropathic pain syndromes (e.g., phantom limb pain). CONTRAINDICATIONS: Identification of degenerative alterations as the cause of pain; untreated mental illness. SURGICAL TECHNIQUE: A two-stage implantation technique is performed. Initially, after percutaneous implantation of epidural leads a trial period with stimulation by an external pulse generator is evaluated. Following verification of pain relief, a subcutaneous internal pulse generator is implanted. FOLLOW-UP: Early mobilization and adjustment of stimulation parameters. RESULTS: In all, 19 consecutive patients with FBSS were treated by high frequency SCS (HF-SCS) and included in a prospective prognostic study. In 18 patients, an internal pulse generator (IPG) for HF-SCS was permanently implanted. Therapy success was assessed using the Oswestry Disability Index (ODI), visual analogue pain scale (VAS) and painDetect questionnaire. Neuropathic pain of the legs versus the back (median values: VAS leg 71 mm, VAS back 69 mm) was dominant in the patients at a preoperative mean ODI of 63%. With HF-SCS therapy, a pronounced pain reduction was seen and persisted in the follow-up after 6 months (VAS leg 18 mm, VAS back 24 mm). The ODI showed an improvement to a mean of 24% after 6 months.

Persistent Spinal Pain Syndrome: A Proposal for Failed Back Surgery Syndrome and ICD-11.

OBJECTIVE: For many medical professionals dealing with patients with persistent pain following spine surgery, the term Failed back surgery syndrome (FBSS) as a diagnostic label is inadequate, misleading, and potentially troublesome. It misrepresents causation. Alternative terms have been suggested, but none has replaced FBSS. The International Association for the Study of Pain (IASP) published a revised classification of chronic pain, as part of the new International Classification of Diseases (ICD-11), which has been accepted by the World Health Organization (WHO). This includes the term Chronic pain after spinal surgery (CPSS), which is suggested as a replacement for FBSS. METHODS: This article provides arguments and rationale for a replacement definition. In order to propose a broadly applicable yet more precise and clinically informative term, an international group of experts was established. RESULTS: 14 candidate replacement terms were considered and ranked. The application of agreed criteria reduced this to a shortlist of four. A preferred option-Persistent spinal pain syndrome-was selected by a structured workshop and Delphi process. We provide rationale for using Persistent spinal pain syndrome and a schema for its incorporation into ICD-11. We propose the adoption of this term would strengthen the new ICD-11 classification. CONCLUSIONS: This project is important to those in the fields of pain management, spine surgery, and neuromodulation, as well as patients labeled with FBSS. Through a shift in perspective, it could facilitate the application of the new ICD-11 classification and allow clearer discussion among medical professionals, industry, funding organizations, academia, and the legal profession.

Effects of Spinal Cord Stimulation on Heart Rate Variability in Patients With Failed Back Surgery Syndrome: Comparison Between a 2-lead ECG and a Wearable Device.

OBJECTIVES: Heart rate variability recordings have the potential to examine the role of the autonomic nervous system. Several wearable devices are nowadays readily available. Up until now, no studies explored whether a wearable device is able to reliably measure a treatment response in chronic pain patients. Therefore, the aim of this study is to evaluate the reliability of a Polar V800 (Polar Electro Oy, Finland) wearable device to accurately measure RR intervals in patients with failed back surgery syndrome (FBSS) during spinal cord stimulation (SCS), as compared with an eMotion 2-lead ECG recording. MATERIALS AND METHODS: Twenty-two patients diagnosed with FBSS and treated with SCS participated in this study. HRV was measured with a 2-lead ECG registration tool and a Polar V800 during on and off state of SCS. Intraclass correlation coefficients, correlations, limits of agreement, Cronbach's α, and effect sizes were calculated. RESULTS: Analysis based on the recordings from the ECG and wearable device revealed the same HRV parameters (except for the time-frequency domain) to capture the treatment response of SCS. Parameters that are relevant for measuring the SCS treatment response have strong correlations (r ≥ .82), good ICC values (ICC ≥0.82), acceptable consistency (α ≥ .9), and limited bias. CONCLUSIONS: Similar pre- to posttreatment changes were revealed between a wearable device and 2-lead ECG with reliable HRV estimates for parameters that are able to capture the treatment changes. This suggests that a wearable heart rate monitor might be a reliable wearable tool for the detection of pre- to post treatment changes of SCS, in patients with FBSS.

The dimensions of "failed back surgery syndrome": what is behind a label?

BACKGROUND: The term failed back surgery syndrome (FBSS) has been criticized for being too unspecific and several studies have shown that a variety of conditions may underlie this label. The aims of the present study were to describe the specific symptoms and to investigate the primary and secondary underlying causes of FBSS in a contemporary series of patients who had lumbar spinal surgery before. METHODS: We used a multilevel approach along three different axes defining symptomatic, morphological, and functional pathology dimensions. RESULTS: Within the study period of 3 years, a total of 145 patients (74 f, 71 m, mean age 51a, range 32-82a) with the external diagnosis of FBSS were included. Disk surgery up to 4 times and surgery for spinal stenosis up to 3 times were the commonest index operations. Most often, the patients complained of low back pain (n = 126), pseudoradicular pain (n = 54), and neuropathic pain (n = 44). Imaging revealed osteochondrosis (n = 61), spondylarthrosis (n = 48), and spinal misalignment (n = 32) as the most frequent morphological changes. The majority of patients were assigned at least to two different symptomatic subcategories and morphological subcategories, respectively. According to these findings, one or more functional pathologies were assigned in 131/145 patients that subsequently enabled a specific treatment strategy. CONCLUSIONS: FBSS has become rather a vague and imprecisely used generic term. We suggest that it should be avoided in the future both with regard to its partially stigmatizing connotation and its inherent hindering to provide individualized medicine.

Comparison of conventional, burst and high-frequency spinal cord stimulation on pain relief in refractory failed back surgery syndrome patients: study protocol for a prospective randomized double-blinded cross-over trial (MULTIWAVE study).

BACKGROUND: While the evolution of technology provides new opportunities to manage chronic refractory pain using different waveform modalities of spinal cord stimulation in failed back surgery syndrome (FBSS), there is no randomized controlled trial available to compare the efficacy of these different stimulations waveforms to date. MULTIWAVE is a prospective, randomized, double-blinded, crossover trial study designed to compare the clinical efficacy of tonic conventional stimulation (TCS), burst stimulation (BURST) and high-frequency stimulation (HF) in FBSS patients over a 15-month period in SCS implanted patients. METHODS/DESIGN: Twenty-eight patients will be recruited in the Poitiers University Hospital, in Niort and La Rochelle Hospitals in France. Eligible patients with post-operative low back and leg pain with an average visual analog scale (VAS) score ≥ 5 for low back pain are implanted and randomly assigned to one of the six arms (in a 1:1:1:1:1:1 ratio), where they receive a 3-month combination of TCS, BURST and HF including one treatment modality per month and varying the order of the modality received within the six possible combinations. Patients receiving intrathecal drug delivery, peripheral nerve stimulation and back resurgery related to the original back pain complaint and experimental therapies are excluded from this study. Patients included in the spinal cord stimulation group undergo trial stimulation, and they all receive a TCS treatment for 2 months, as the gold standard modality. Thereafter, patients are randomly assigned to one of the six arms for the total duration of 3-month crossover period. Then, patients choose their preferred stimulation modality (TCS, BURST, or HF) for the follow-up period of 12 months. Outcome assessments are performed at baseline (first implant), before randomization (2 months after baseline) and at 1, 2, 3, 6, 9 and 15 months post-randomization. Our primary outcome is the average global VAS of pain over 5-day pain diary period between baseline and after each period of stimulation. Additional outcomes include changes in leg and back pain intensity, functional disability, quality of life, psychological state, paraesthesia intensity perception, patient satisfaction and the number of adverse events. DISCUSSION: Recruitment began in February 2017 and will continue through 2019. TRIAL REGISTRATION: Clinicaltrials.gov NCT03014583 . Registered on 9 January 2017.

First Report of Extraspinal Lead Migration Along a Thoracic Spinal Nerve After Spinal Cord Stimulation.

BACKGROUND: Spinal cord stimulation for failed back surgery syndrome and chronic pain is a well-established treatment regimen today. Lead migration is the most common complication; mainly epidural caudal more than cranial electrode migration from the primary position is described repeatedly throughout the literature. CASE DESCRIPTION: A 60-year-old male patient with failed back surgery syndrome was eligible for spinal cord stimulation. Surgery had been performed 4 weeks before readmission with proper lead positioning of both electrodes in the midline of the epidural space. The electrode fixation mechanism at L2/3 had to be revised and was replaced with multiple ligature fixations due to the patient's slim build. He presented to our outpatient clinic with thoracic right-sided pain matching T5 with signs of overstimulation of the paravertebral muscles. X-ray imaging revealed cranial migration of 1 lead to T4 and a right-sided extraspinal migration of the other lead along a spinal nerve in T5 exiting the neuroforamen and following beneath the corresponding rib dorsally. Revision surgery was performed using a thoracic paddle electrode. CONCLUSIONS: Lead migration remains a challenge in spinal cord stimulation regardless of the fixation method. Rare unusual migration patterns in addition to simple caudal or cranial migration might pose a challenge for revision surgery and thus might reduce overall treatment efficacy.

Fantastic Four: Age, Spinal Cord Stimulator Waveform, Pain Localization and History of Spine Surgery Influence the Odds of Successful Spinal Cord Stimulator Trial.

BACKGROUND: There is a dearth in our understanding of the factors that are predictive of successful spinal cord stimulator (SCS) trials and eventual conversion to permanent implants. Knowledge of these factors is important for appropriate patient selection and treatment optimization. OBJECTIVES: Although previous studies have explored factors predictive of trial success, few have examined the role of waveform in trial outcomes. This study sought to establish the relationship of neuraxial waveform and related measures to trial outcomes. STUDY DESIGN: This study used a retrospective chart review design. METHODS: Data were retrospectively collected on 174 patients undergoing SCS trials upon institutional review board approval of the study protocol. Indications for SCS were: complex regional pain syndrome, failed back surgery syndrome with radicular symptoms, peripheral neuropathy, and axial low back pain. Descriptive statistics and logistic regression analyses were used to assess the association of demographic and clinical variables with SCS trial outcomes. RESULTS: The study population comprised 56% women, had a median age of 55 (interquartile range [IQR], 44-64), and 32 of 174 (18%) patients failed SCS trials. Individuals with successful trials (>= 50% pain relief) were significantly younger and had a median age of 54 years (IQR, 42-60) compared to those who failed SCS trials (median age 66 years; IQR, 50-76; P = .005). Adjusting for age, gender, number of leads, pain category, and diagnoses: surgical history (odds ratio [OR] = 4.4; 95% confidence interval [CI], 1.3-15.8) and paresthesia-based tonic-stimulation (OR = 10.3; 95% CI, 1.7-62.0), but not burst or high frequency, were significantly associated with successful trials. Of note, the number of leads (whether dual or single), pain duration, characteristics, and category (nociceptive vs neuropathic) were not significant factors. An interaction between surgical spine history and lower extremity pain was significantly associated with a positive trial (P = .005). LIMITATIONS: This study was limited by its retrospective nature and focus on a patient population at a single major academic medical center. CONCLUSIONS: Paresthesia-based tonic stimulation, age, and surgical history have significant effects on SCS trials. Prospective and randomized controlled studies may provide deeper insights regarding impact on costs and overall outcomes.IRB Approval #: 2018P002216. KEY WORDS: Pain duration, pain location, spinal cord stimulator trial, stimulator waveform, surgical history.

High-Dose Spinal Cord Stimulation for Treatment of Chronic Low Back Pain and Leg Pain in Patients With FBSS, 12-Month Results: A Prospective Pilot Study.

OBJECTIVES: To investigate the long-term effect of high-dose spinal cord stimulation (HD-SCS) in patients with chronic refractory low back and leg pain due to failed back surgery syndrome (FBSS). STUDY DESIGN: Prospective case series; pilot study. MATERIALS AND METHODS: Patients with chronic low back and leg pain (CBLP) due to failed back surgery syndrome (FBSS) were screened for SCS according to the Dutch Neuromodulation Society guidelines. Patients with a pain score of >50 (on a visual analogue scale from 0 to 100) for both low back and leg pain, were selected for participation in this study. During intraoperative screening one or two electrodes were implanted to ensure adequate paresthesia coverage of the back and leg pain area. During the 14 days trial period patients received two programs: a conventional or low-dose (LD) program with 30 Hz; 390 µsec and a high-dose (HD) program with 420 Hz, 400 µsec. They all started with LD-SCS and changed to HD-SCS after three days. If patients reported more than 50% pain relief with either program a rechargeable neurostimulator was implanted for permanent SCS. The scores for low back pain and leg pain were recorded separately. Other therapy related outcomes that were collected are pain medication use, Quebec back pain disability scale (QBPDS), patient satisfaction, employment status, stimulation settings, and adverse events. We present the 6- and 12-months results. Results are presented as mean ± SD. RESULTS: Thirteen patients, nine females and four males (mean age: 49.7 ± 8.1 years), were included between July 2015 and March 2016. Eleven patients responded to SCS during the trial period and were implanted with a neurostimulator. Most patients preferred HD-SCS over LD-SCS and the overall use of HD-SCS increased over time. At 6 to 12 months follow-up, two patients discontinued the study. In one patient low back pain returned despite optimal stimulation settings. The second patient was neither satisfied with LD nor HD and had the system explanted. VAS Leg pain at baseline was 71.2 ± 33.8 and reduced to 25.7 ± 24.0 at 6 months and 23.4 ± 32.0 at 12 months. VAS Back pain at baseline was 66.7 ± 33.2 and reduced to 36.8 ± 41.6 at 6 months and 26.1 ± 33.2 at 12 months. Pain medication was significantly reduced and QBPDS improved from 59.2 ± 12.2 at baseline to 44.1 ± 13.7 at 12 months. Five patients returned to work and overall patient satisfaction at the end of the study was high. CONCLUSION: This pilot study shows promising results of offering HD-SCS in addition to LD-SCS for treatment of chronic back and leg pain in patients with failed back surgery syndrome.

Percutaneous Endoscopic Lumbar Foraminotomy for Foraminal Stenosis with Postlaminectomy Syndrome in Geriatric Patients.

INTRODUCTION: Postlaminectomy syndrome (PLS) or failed back surgery syndrome is a condition characterized by persistent pain following a back surgery. Degenerative processes may result in foraminal stenosis development over time, even after a successful surgery. Percutaneous endoscopic lumbar foraminotomy (PELF) offers a minimally invasive means of treating foraminal stenosis after a back surgery. The objective of this study was to evaluate the outcomes of PELF for foraminal stenosis with PLS in geriatric patients. METHODS: Two-year follow-up data were collected from 21 consecutive patients aged 65 years or older (mean age, 72.4 years) who underwent PELF for foraminal stenosis with PLS. Transforaminal endoscopic foraminal decompression was performed under local anesthesia. Outcomes were assessed using visual analog scale pain score, Oswestry Disability Index, and modified Macnab criteria. RESULTS: Mean visual analog scale for leg pain improved from 8.48 at baseline to 3.33 at 6 weeks, 2.10 at 1 year, and 2.19 at 2 years after PELF (P < 0.01). Mean Oswestry Disability Index improved from 67.29 at baseline to 30.69 at 6 weeks, 22.50 at 1 year, and 20.81 at 2 years after PELF (P < 0.01). Based on the modified Macnab criteria, excellent or good results were obtained in 81.0% of patients and symptomatic improvements were obtained in 95.2% of patients. CONCLUSIONS: The transforaminal endoscopic approach can provide a better access angle to achieve a sophisticated foraminal decompression with less facet and dural injury. Therefore, PELF under local anesthesia can be useful for PLS or postoperative foraminal stenosis in elderly patients.

Discontinuation of Chronic Opiate Therapy After Successful Spinal Cord Stimulation Is Highly Dependent Upon the Daily Opioid Dose.

OBJECTIVES: The aim of this study was to determine if any of the factors recorded on a standard clinical history of a patient considered for spinal cord stimulation (SCS) would be associated with reduction or cessation of opioids following implantation. DESIGN: Retrospective, single academic center. METHODS: Patients included in the chart analysis underwent implantation of percutaneous SCS devices from 1999 to 2015 with follow-up until the end of September 2018. Patients who achieved at least an average of 50% pain reduction were included for analysis of daily opioid intake. Patients were then divided into 4 groups that included no opioid use, stable opioid daily dose, weaned opioid dose, and complete cessation of opioids. Statistical methods were used to analyze for associations between opioid intake after SCS insertion and usual elements of a clinical history, including adjuvant medications, numeric pain rating, past medical history, psychiatric illness, substance abuse, employment, and smoking history. RESULTS: In a group of 261 patients who had undergone implantation, 214 met the criteria for analysis and had a median age of 50 years, with majority having the diagnoses of failed back surgery syndrome and complex regional pain syndrome. The only factor that was associated with complete cessation of opioid use was a median dose of 30 mg of morphine per day (P < 0.01) and was observed in 15% of subjects who used opioids preoperatively. CONCLUSION: The elimination of opioid dependence following initiation of SCS therapy is highly dependent on the daily dose.

Dextrose injections for failed back surgery syndrome: a consecutive case series.

PURPOSE: Patients with chronic low back pain, who do not respond to conservative treatment methods, generally undergo surgical revision operations, and sometimes an undesirable condition called failed back surgery syndrome (FBSS) may be inevitable. Hereby, dextrose is one of the regenerative methods that has gained popularity in the treatment of many musculoskeletal problems, and we aimed to present and evaluate the outcomes of 5% dextrose for the treatment of FBSS. METHODS: It has been designed as a consecutive case series. A total of 79 patients with FBSS, who had minimum 6 months of symptoms and did not respond to 3 months of conservative methods between May 2014 and March 2016, participated in the study. Prolotherapy injections were applied in posterior and lateral approaches. Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) were used for the pre- and post-treatment evaluations. Patient satisfaction was assessed with using a 5-point Likert scale by phone contacting. RESULTS: There was statistically significant difference between repeated VAS and ODI measurements. CONCLUSIONS: These results may be the first step giving a lead to an undiscovered field. This treatment method should be kept in mind for FBSS patients before giving a decision of revision surgery. These slides can be retrieved under Electronic Supplementary Material.

Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Consensus Statement on Definition and Outlines for Patient Assessment.

Failed back surgery syndrome (FBSS) is a controversial term for identifying patients affected by new, recurrent, or persistent pain in the low back and/or legs following spinal surgery. The lack of a comprehensive standardized care pathway compromises the appropriate management of FBSS patients, which is associated with a heavy financial burden. An international panel of spine surgeons, neurosurgeons, and pain specialists with a particular interest in FBSS established the chronic back and leg pain (CBLP) network with the aim of addressing the challenges and barriers in the clinical management of FBSS patients by building a common transdisciplinary vision. Based on literature reviews, additional input from clinical expertise of multiple professional disciplines, and consensus among its members, the network attempted to provide recommendations on the management of patients with FBSS utilizing a multidisciplinary team (MDT) approach. The presentation of this work has been divided in two separate parts to enhance its clarity. This first paper, in favour of selecting appropriate validated tools to improve the FBSS patient assessment, focuses on FBSS taxonomy and its clinical implications for evaluation. Concise recommendations for assessment, treatment, and outcome evaluation using a MDT approach would be an important resource for specialists and nonspecialist clinicians who manage patients with FBSS, to improve decision-making, reduce variation in practice, and optimize treatment outcomes in this difficult-to-treat population.