Disability Pension Did Not Reduce Opioid Use Among Patients With Failed Back Surgery Syndrome Who Were Trialed and Implanted for Spinal Cord Stimulation.

BACKGROUND: Spinal cord stimulation (SCS) is an effective treatment for failed back surgery syndrome (FBSS). In patients with FBSS, opioids have often been initiated, even before SCS is trialed. OBJECTIVE: We studied the effect of retirement on opioid use in patients with chronic pain after failed back surgery. STUDY DESIGN: A retrospective study design. SETTING: The study was conducted at Kuopio University Hospital. METHODS: The study group consisted of all 230 patients with SCS trialed or implanted for FBSS at Kuopio University Hospital Neurosurgery from January 1, 1996 through December 31, 2014. All purchases of prescribed opioids and their daily defined doses, as well as data on working ability, were obtained from the Social Insurance Institution. Patients were divided into 3 groups: SCS trial only, SCS implanted permanently, and SCS implanted but later explanted. We analyzed the differences in opioid use among these groups 2 years before and 2 years after the start of their disability pension (DP). RESULTS: During the follow-up period, a total of 60 patients received a DP. One year before DP, the majority of patients used opioids (n = 43, 72%), and throughout the one-year follow-up after retirement, the number of users increased slightly (n = 46, 77%). In the permanently implanted SCS group, the number of strong opioid users decreased after retirement. Most patients used a moderate dose (0.1-10.5 morphine milligram equivalent/d). Retirement appeared to interrupt dose escalation in all groups, but doses increased further as the follow-up continued. LIMITATIONS: No structured questionnaires were used in this study. Also, many underlying factors contributing to chronic pain were missing. CONCLUSIONS: DP did not reduce the use of opioids in patients with FBSS. Opioid doses were lower and dose escalation less steep with continuous SCS therapy.

Gabapentinoids Associated With Lower Explantation Rate in 203 Patients With Spinal Cord Stimulation for Failed Back Surgery Syndrome.

BACKGROUND: Spinal cord stimulation (SCS) is an effective treatment in failed back surgery syndrome (FBSS). The effect of neuropathic pain medication use on SCS outcome is poorly understood. OBJECTIVE: To study the effect of gabapentinoid use on SCS outcome measured by trial success, explantation rate and opioid dose reduction during a 2-yr follow-up. METHODS: The study cohort included 203 consecutive FBSS patients who underwent SCS in a single tertiary center during January 1997 to March 2014. Purchase data of gabapentinoids, opioids, tricyclic antidepressants, serotonin and noradrenaline reuptake inhibitors, and benzodiazepines during January 1995 to March 2016 were retrieved from national registries. RESULTS: In multivariate Cox regression analysis, patients using gabapentinoids had significantly fewer explantations during the 2-yr follow-up (hazard ratio [HR] 0.2, 95% CI 0.04-0.81, P = .03). In contrast, patients with opioid use of >40 morphine milligram equivalent before implantation had significantly more explantations (HR 6.7, 95% CI 2.5-18, P < .01). In bivariate logistic regression analysis adjusted for patient specific factors, year of SCS implantation, use of neuropathic pain medication, opioids, and benzodiazepines, patients using gabapentinoids significantly more often discontinued opioids or reduced their dose by more than 50% during the 2-yr follow-up (odds ratio 5.7, 95% CI 1.4-23, P = .015). CONCLUSION: The use of gabapentinoids was associated with a significantly lower spinal cord stimulator explantation rate and a higher chance of opioid discontinuation or >50% dose reduction. This indicates that patients with SCS could benefit from concomitant use of gabapentinoids. Prospective randomized trials are warranted to verify this hypothesis.

[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.

Celecoxib-Loaded Electrospun Fibrous Antiadhesion Membranes Reduce COX-2/PGE2 Induced Inflammation and Epidural Fibrosis in a Rat Failed Back Surgery Syndrome Model.

To date, failed back surgery syndrome (FBSS) remains a therapy-refractory clinical condition after spinal surgery. The antiadhesion membrane is applied to prevent FBSS by isolating fibrosis; however, the inflammation stimulated by the foreign body and surgical trauma needs to be further resolved simultaneously. Therefore, we developed new electrospun polycaprolactone (PCL) fibrous membranes loaded with celecoxib (CEL) to prevent fibrosis and inflammation associated with FBSS. The CEL-loaded PCL fibers were randomly distributed, and the drug was released over two weeks. Fluorescence micrographs revealed that the fibroblasts proliferated less on the PCL-CEL fibrous membranes than in the PCL group and the blank control. In the rat laminectomy model after 4 weeks, magnetic resonance imaging of epidural fibrosis was least in the PCL-CEL group. Expression of COX-2 and PGE2 was lower in the PCL-CEL group. It concluded that the CEL-loaded PCL membrane could reduce fibrosis and inflammation in a rat model of FBSS via COX-2/PGE2 signaling pathways.

Metformin attenuates post-epidural fibrosis by inhibiting the TGF-ß1/Smad3 and HMGB1/TLR4 signaling pathways.

Excessive post-epidural fibrosis is a common cause of recurrent back pain after spinal surgery. Though various treatment methods have been conducted, the safe and effective drug for alleviating post-epidural fibrosis remains largely unknown. Metformin, a medicine used in the treatment of type 2 diabetes, has been noted to relieve fibrosis in various organs. In the present study, we aimed to explore the roles and mechanisms of metformin in scar formation in a mouse model of laminectomy. Post-epidural fibrosis developed in a mouse model of laminectomy by spinous process and the T12-L2 vertebral plate with a rongeur. With the administration of metformin, post-epidural fibrosis was reduced, accompanied with decreased collagen and fibronectin in the scar tissues. Mechanistically, metformin decreased fibronectin and collagen deposition in fibroblast cells, and this effect was dependent on the HMGB1/TLR4 and TGF-ß1/Smad3 signalling pathways. In addition, metformin influenced the metabolomics of the fibroblast cells. Taken together, our study suggests that metformin may be a potential option to mitigate epidural fibrosis after laminectomy.

High-Dose Spinal Cord Stimulation Reduces Long-Term Pain Medication Use in Patients With Failed Back Surgery Syndrome Who Obtained at Least 50% Pain Intensity and Medication Reduction During a Trial Period: A Registry-Based Cohort Study.

OBJECTIVES: High-dose spinal cord stimulation (HD-SCS) revealed positive results for obtaining pain relief in patients with failed back surgery syndrome (FBSS). However, it is less clear whether HD-SCS also is able to reduce pain medication use. The aim of this registry-based cohort study is to explore the impact of HD-SCS on pain medication use in FBSS patients. MATERIALS AND METHODS: Data from the Discover registry was used in which the effectiveness of HD-SCS was explored in neurostimulation-naïve FBSS patients as well as in rescue patients. All neurostimulation-naïve FBSS patients positively responded to a four-week SCS trial period in which at least 50% pain relief and 50% medication reduction were obtained. Medication use was measured with the Medication Quantification Scale III (MQS) in 259 patients at baseline and at 1, 3, and 12 months of HD-SCS. Additionally, defined daily doses (DDD) and morphine milligram equivalents (MME) were calculated as well. RESULTS: One hundred thirty patients reached the visit at 12 months. In neurostimulation-naïve patients, a statistically significant decrease in MQS (χ2 = 62.92, p < 0.001), DDD (χ2 = 11.47, p = 0.009), and MME (χ2 = 21.55, p < 0.001) was found. In rescue patients, no statistically significant improvements were found. In both patient groups, statistically significant reductions in the proportion of patients on high-risk MME doses ≥90 were found over time. At the intraindividual level, positive correlations were found between MSQ scores and pain intensity for back (r = 0.56, r = 0.31, p < 0.001) and leg pain (r = 0.61, r = 0.22, p < 0.001) in neurostimulation-naïve and rescue patients, respectively. CONCLUSIONS: Registry data on HD-SCS in FBSS patients revealed a statistically significant and sustained decrease in pain medication use, not only on opioids, but also on anti-neuropathic agents in neurostimulation-naïve patients, who positively responded to an SCS trial period with at least 50% pain relief and 50% pain medication decrease, but not in rescue patients.

Higher Preimplantation Opioid Doses Associated With Long-Term Spinal Cord Stimulation Failure in 211 Patients With Failed Back Surgery Syndrome.

OBJECTIVE: Spinal cord stimulation (SCS) is an effective treatment in failed back surgery syndrome (FBSS). We studied the effect of preimplantation opioid use on SCS outcome and the effect of SCS on opioid use during a two-year follow-up period. MATERIALS AND METHODS: The study cohort included 211 consecutive FBSS patients who underwent an SCS trial from January 1997 to March 2014. Participants were divided into groups, which were as follows: 1) SCS trial only (n = 47), 2) successful SCS (implanted and in use throughout the two-year follow-up period, n = 131), and 3) unsuccessful SCS (implanted but later explanted or revised due to inadequate pain relief, n = 29). Patients who underwent explantation for other reasons (n = 4) were excluded. Opioid purchase data from January 1995 to March 2016 were retrieved from national registries. RESULTS: Higher preimplantation opioid doses associated with unsuccessful SCS (ROC: AUC = 0.66, p = 0.009), with 35 morphine milligram equivalents (MME)/day as the optimal cutoff value. All opioids were discontinued in 23% of patients with successful SCS, but in none of the patients with unsuccessful SCS (p = 0.004). Strong opioids were discontinued in 39% of patients with successful SCS, but in none of the patients with unsuccessful SCS (p = 0.04). Mean opioid dose escalated from 18 ± 4 MME/day to 36 ± 6 MME/day with successful SCS and from 22 ± 8 MME/day to 82 ± 21 MME/day with unsuccessful SCS (p < 0.001). CONCLUSIONS: Higher preimplantation opioid doses were associated with SCS failure, suggesting the need for opioid tapering before implantation. With continuous SCS therapy and no explantation or revision due to inadequate pain relief, 39% of FBSS patients discontinued strong opioids, and 23% discontinued all opioids. This indicates that SCS should be considered before detrimental dose escalation.

Does ultrasound-guided facet joint injection reduce pain and improve mobility in patients with failed back surgery syndrome?

OBJECTIVES: This study aims to evaluate whether ultrasound (US)-guided facet joint injection reduces pain and improves mobility in patients with failed back surgery syndrome (FBSS). PATIENTS AND METHODS: This retrospective study included 27 patients (8 males, 19 females; mean age 43.6±11.5 years; range, 31 to 54 years) who underwent US-guided facet injections for FBSS between January 2017 and January 2019. Patients' medial records were assessed. Pain rating scores were evaluated with the Numeric Rating Scale (NRS). Functional status was assessed with Oswestry Disability Index (ODI) version 2.0. Lumbar flexion degree was noted. After injection (lidocaine-betamethasone mixture), patients were reevaluated at first and sixth months. The study data were analyzed with Wilcoxon signed-rank test. RESULTS: Successful facet joint injections were achieved without any complications in all patients. The median duration of time after surgery was 7.8±1.3 months. Mean duration of pain was 6.7±5.7 months. There was a significant decrease in NRS values between baseline and sixth month comparison (7.0 at baseline and 6.0 at sixth month, p=0.006). Baseline-first month and first-sixth months comparisons were not significant (p=0.165 and p=0.106, respectively). For ODI, no significant change was observed between baseline-first month, first-sixth months, and baseline-sixth month comparisons (p=0.109, p=0.857, and p=0.095, respectively). For lumbar flexion, all comparisons resulted in significant increase (50.0° for baseline, 60.0° at first month, and 70.0° at sixth month; p<0.001 for baseline-first month comparison, p<0.001 for baseline-sixth month comparison, and p<0.001 for first-sixth months comparison). CONCLUSION: Our results show that pain is reduced and mobility is improved with US-guided facet joint injections in patients with FBSS.

Randomized clinical trial comparing buprenorphine/naloxone and methadone for the treatment of patients with failed back surgery syndrome and opioid addiction.

Opioid analgesic consumption has led to an unprecedented epidemic of overdose death and opioid addiction in the US history. The treatment of chronic pain in patients with opioid addiction who receive prescriptions for opioid medications presents a clinical dilemma. Continuing opioid medication could result in hyperalgesia rendering opioids ineffective and results in iatrogenic therapeutic damage as evidenced by the worsening of addiction. Discontinuing opioid medications could result in severe pain and cravings that often leads the patient to the illicit market. This study compared methadone and buprenorphine/naloxone in patients with failed back surgery syndrome and opioid addiction. Nineteen participants were randomly assigned to methadone or buprenorphine/naloxone and were followed for 6 months. In an intent-to-treat analysis analgesia, craving, functioning, drug use, depression, and treatment retention were assessed monthly. It was planned to enroll 66 patients with failed back surgery syndrome and opioid addiction; however, enrollment was closed early due to suspected abuse of medications. Patients in both treatment conditions exhibited significantly improved 24-hour pain severity with up to 20% reduction of pain severity at the last follow-up (p < .05). However, patients receiving methadone reported significantly reduced current pain severity, whereas patients receiving buprenorphine/naloxone did not. Patients reported significantly improved functioning, fewer cravings, less opioid use, and depression (p < .05) across the treatment conditions. When given a choice between methadone and buprenorphine/naloxone, buprenorphine/naloxone is recommended due to its superior safety profile. Treatment with either needs to be monitored closely.

Continuous Intravenous Lidocaine as an Effective Pain Adjunct for Opioid-Induced Bowel Dysfunction: A Case Report.

This case study describes a patient with suspected opioid-induced bowel dysfunction who had improved pain control when treated with intravenous (IV) lidocaine. An 80-year-old man with failed back surgery syndrome managed with an intrathecal (IT) pump presented with protracted abdominal pain. The acute pain service initiated a lidocaine infusion at 1 mg·min, and the patient reported significant pain relief. The patient experienced refractory abdominal pain with 3 attempts to wean the lidocaine infusion. Eventually, a successful transitional regimen was achieved with methylnaltrexone and transdermal lidocaine patches. Lidocaine infusions may be an effective and underutilized multimodal adjunct for nonsurgical pain conditions.

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.

[A retrospective investigation of the efficiency of transforaminal anterior epidural steroid injections in patients with low back pain and the effects of interventional pain therapy on quality of life]. / Bel agrili hastalarda transforaminal anterior epidural steroid enjeksiyonunun etkinliginin ve girisimsel tedavinin yasam kalitesine etkisinin retrospektif arastirilmasi.

OBJECTIVES: The aim of this retrospective study was to evaluate the efficacy of transforaminal anterior epidural steroid and local anesthetic injections (TAESE) and the effects on quality of life in patients with low back pain. METHODS: The study patients (n=191) were divided into 3 groups: disc herniation (DH), failed back surgery (FBS), and spinal stenosis (SS). A visual analog scale (VAS) and verbal pain scale (VPS) were used to assess patient pain. Scores were measured before treatment (VAS 0), in the first month of application (VAS 1), 3 months (VAS 3), and 6 months (VAS 6). Patient quality of life was examined using the 36-Item Short Form Health Survey (SF-36). RESULTS: In all 3 groups, there was a statistically significant reduction in pain compared with the VAS 0 score at 1, 3, and 6 months (p<0.001). The reduction in VAS/VPS was greatest in the DH group, followed by the FBS and SS groups, respectively. All of the parameters of the SF-36 measurement were lower in the SS patients compared with the DH patients. The quality of life score was lowest in the SS patients, though the physical health and social functioning scores were lowest in the FBS group. CONCLUSION: TAESE is effective and can be safely performed in patients who have low back pain due to DH, FBS, or SS. The quality of life result was less successful in SS patients, particularly in the parameter of physical role limitations.

Extended-release gabapentin for failed back surgery syndrome: results from a randomized double-blind cross-over study.

Persistent pain after lumbar surgery (failed back surgery syndrome [FBSS]) remains a leading indication for chronic analgesia. However, no analgesics have proven efficacious for this condition. Although trials have evaluated gabapentinoids for chronic low back pain, none of these trials focused solely on FBSS. This randomized, double-blind cross-over trial evaluated the efficacy of gabapentin (1800 mg/day) for FBSS. Eligible patients had a diagnosis of FBBS, an average daily pain score of at least 4 of 10, a neuropathic pain component (indicated by the PainDetect), and reported at least half of their pain radiating in their lower extremity. Participants were randomized to 2, 7-week study periods separated by a 10-day washout. The primary outcome measure was a 0 to 10 numeric rating scale (NRS) of average pain. Secondary measures included the McGill Pain Questionnaire and Patient Global Impression of Change. The treatment effect was analyzed using a mixed effect analysis of covariance with fixed effects for treatment, period, and baseline 7-day mean NRS pain score and a random effect for the participant. The outcome of the model was the mean 7-day NRS score for the last 7 days of each treatment period. Thirty-two participants were randomized and included in the primary analysis; 25 completed both study periods. No difference was detected between treatments on any outcome measure, including the primary (least square mean difference in NRS: -0.01 confidence interval: [-0.22 to 0.20]). Given the escalating rate of complex lumbar surgery, future research to develop novel therapies for this prevalent syndrome is needed.

Narcotic Addiction in Failed Back Surgery Syndrome.

Back pain is a common health problem that reduces the quality of life for human beings worldwide. Several treatment modalities have been reported as effective for pain relief. Generally, patients often undergo surgical interventions as pain becomes intractable, after conservative treatment. With advances in surgical techniques, those choosing spinal surgery as an option have increased over time, and instrumentation is more popular than it was years ago. However, some patients still have back pain after spinal operations. The number of patients classified as having failed back surgery syndrome (FBSS) has increased over time as has the requirement for patients receiving long-term analgesics. Because pain relief is regarded as a human right, narcotics were prescribed more frequently than before. Narcotic addiction in patients with FBSS has become an important issue. Here, we review the prevalence of FBSS, the mechanism of narcotic addiction, and their correlations. Additionally, several potentially effective strategies for the prevention and treatment of narcotic addiction in FBSS patients are evaluated and discussed.

Efficacy, Effectiveness, Safety, and Cost-effectiveness of Epidural Adhesiolysis for Treating Failed Back Surgery Syndrome. A Systematic Review.

BACKGROUND: Failed back surgery syndrome (FBSS) has a profound impact on patients' quality of life and represents a major clinical challenge and a significant economic burden for society. Adhesiolysis is used as a treatment to eliminate perineural/epidural adhesions in patients with chronic pain attributed to FBSS. OBJECTIVE: To evaluate the efficacy, effectiveness, safety, and cost-effectiveness of epidural adhesiolysis compared with other procedures for treating FBSS. METHOD: A systematic review was conducted. The electronic databases Medline/PreMedline, EMBASE, Cochrane Library Plus, Centre for Reviews and Dissemination databases, SCOPUS, Science Citation Index, and PEDRO were consulted through April 2017. Predefined criteria were used to determine inclusion of the studies and to assess their methodological quality. RESULTS: Ten reports were included. No randomized controlled trials (RCTs) on efficacy or cost-effectiveness were found. Three reports (corresponding to two RCTs, N = 212) suggested that adhesiolysis was effective, especially for pain and disability. However, both studies presented serious methodological flaws. In addition to RCTs, seven observational studies with high risk of bias reported data on effectiveness and safety. Fifty-eight adverse events were reported among 130 patients undergoing endoscopic adhesiolysis, and 19 among the 110 undergoing percutaneous adhesiolysis. CONCLUSIONS: The evidence on the efficacy and cost-effectiveness of adhesiolysis for treating FBSS is nonexistent, whereas evidence on its effectiveness and safety is insufficient. Incorporating data from observational studies did not improve the quality of the evidence on effectiveness.

Comparison of 3 Approaches to Percutaneous Epidural Adhesiolysis and Neuroplasty in Post Lumbar Surgery Syndrome.

BACKGROUND: Percutaneous epidural adhesiolysis and neuroplasty (PEAN) has been proven to be safe and effective in treating different spine pathologies, in particular post lumbar surgery syndrome (PLSS). OBJECTIVES: The purpose of this study was to compare the efficacy and complication rates of the 3 different PEAN anatomical approaches (caudal, S1 foraminal, and L5-S1 transforaminal) used to treat PLSS. STUDY DESIGN: This study used a case control, blind study. SETTING: The research took place at the pain clinic and interventional pain practice room at Asyut University Hospital, Assiut, Egypt. METHODS: Sixty consecutive PLSS patients were recruited and randomized into 3 groups (caudal, S1 foraminal, and L5-S1 transforaminal) before receiving adhesiolysis and neuroplasty. All patients underwent nerve conduction studies and magnetic resonance imaging (MRI). Pain severity levels were assessed and measured using the Oswestry Disability Questionnaire (OSW) and the Visual Analog Scale (VAS). Patient satisfaction was evaluated using a Likert scale. The first assessment was performed prior to the procedure to determine the patients' baseline levels of pain severity. Follow-up assessments were performed 1-, 3-, and 6-months after the procedure. RESULTS: Results of the group pairwise analysis indicated that, relative to baseline, there were significant decreases in pain relief scores (VAS and OWS) and functional assessment expressed by patients' satisfaction across all time intervals and in all 3 groups (P < 0.01). Conversely, a between group analysis revealed that VAS, OWS, and patient satisfaction scores were comparable across the 3 groups at all time intervals (P > 0.05). There were no differences in rates of complications between the 3 different groups. LIMITATIONS: Our study was limited by the low number of patients and the short duration (6 months) of follow-up. CONCLUSION: The 3 anatomical approaches (caudal, S1 foraminal, and L5-S1 transforaminal) result in the same outcome with regard to pain relief and complication rate. KEY WORDS: Post lumber surgery syndrome, post laminectomy back pain, percutaneous adhesiolysis, Racz catheter, percutaneous neuroplasty.

Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation.

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be used to treat back and leg pain in FBSS patients. This paper presents a detailed protocol for using spinal cord stimulation with surgical leads in FBSS patients. In our department, with the patient under general anesthesia, we place the lead in the epidural space by means of a small laminectomy at the 10th thoracic level. Placement of the lead is followed by a 1 month trial period with an externalized lead. If pain relief is greater than 50% at the end of this 1 month stimulation trial (required by Belgian reimbursement criteria), an internal pulse generator is then placed under the skin and connected to the lead in a second surgical procedure. We have demonstrated that using this technique in rigorously selected FBSS patients can significantly improve back pain, leg pain, patient activity, and quality of life for a sustained period of time.

A Randomized, Multicenter, Double-Blind, Parallel Pilot Study Assessing the Effect of Mechanical Adhesiolysis vs Adhesiolysis with Corticosteroid and Hyaluronidase Administration into the Epidural Space During Epiduroscopy.

OBJECTIVE: Epiduroscopy is a proven method of diagnosis and treatment for chronic radicular pain after spinal surgery, which is known as failed back surgery syndrome (FBSS). The aim of the study was to compare the efficacy of drugs (the enzyme hyaluronidase and corticosteroid DEPO-Medrol) administrated into the epidural space during epiduroscopy, performed within the ventral and ventro-lateral epidural space with a focus on releasing foraminal adhesions. METHODS: Forty-eight patients with diagnosed FBBS were randomized into two groups before epiduroscopy. Group A received the standard treatment-mechanical lysis of fibrotic tissue in the epidural space. Group B received hyaluronidase and corticosteroid methylprednisolone acetate during the procedure. Subjects were followed for six and 12 months via scheduled double-blinded examinations by pain physicians. Leg and back pain intensity was assessed by an 11-point numerical rating scale, and patients' functional disability was assessed by the Oswestry Disability Index (ODI). RESULTS: Study subjects showed a significant decrease in ODI score in both groups (P < 0.05). Significantly lower pain scores for leg pain (P < 0.05) and back pain (P < 0.05) were also recorded after the six-month follow-up. However, the one-year follow-up showed a return to the baseline ODI values of most monitored pain scores in both groups (P > 0.05). Improvement was only noted on the NRS for back pain at one-year follow-up (P < 0.05). CONCLUSIONS: A significant improvement of leg and back pain was found in both groups after six months. ODI was significantly improved only in group B in both the six- and 12-month intervals. Back pain at one-year follow-up was only improved in group B.

Segmental Spinal Myoclonus Complicating Lumbar Transforaminal Epidural Steroid Injection.

OBJECTIVE: Lumbar transforaminal epidural steroid injection is commonly used for treating lumbar radicular pain. We report a case of segmental spinal myoclonus that developed during lumbar transforaminal epidural injection with local anesthetic and steroid. CASE REPORT: A 58-year-old woman with failed back surgery syndrome presented with low back and right L3 and L4 radicular pain. As she had responded well previously to diagnostic selective nerve root injection with local anesthetic at the right L3 and L4 levels, lumbar transforaminal epidural steroid injection at the same levels was scheduled. During injection of ropivacaine and triamcinolone at the right L3-4 intervertebral foramen, she complained of back pain and immediately developed involuntary contraction of her right hip. The procedure was terminated. No new neurological deficit was detected when she was examined 15 minutes after the procedure. There were no abnormalities from blood tests and magnetic resonance imaging of the lower thoracic and lumbar spine. A neurologist subsequently made the clinical diagnosis of segmental spinal myoclonus. The myoclonus improved over 1 month and eventually resolved completely. CONCLUSIONS: Segmental spinal myoclonus is a rare complication after lumbar transforaminal epidural steroid and local anesthetic injection. Pain physicians should be aware of this potential complication.

Failed back surgery syndrome: a new strategy by the epidural injection of MESNA.

PURPOSE: Evaluate the efficacy and safety of MESNA (sodium 2-mercaptoethanesulfonate) injection into the epidural space in the FBSS. METHODS: We designed a prospective phase II longitudinal study. Six consecutive patients were enrolled. Patients underwent one peridural injection per week for 3 weeks. NRS and ODI were investigated before and 48 h after injections, and at 1 week, 1 month and 2 months after the last procedures. Opioids intake is investigated before procedures and 1 week, 1 month and 3 months after the last procedures. Lumbosacral MRI is performed before the first procedure, at the end and 3 months after the last procedures. RESULTS: From baseline, at 3 months, NRS in standing, sitting and lying position improved, respectively, of 34.29, 30.56 and 26.47%; ODI improved of 20.3%; the average decrease in morphine intake was 20.54%. No difference in MR images was found. Conclusions Our preliminary results suggest that MESNA might be an efficacy alternative to common practice.