Post Surgical Back Pain – Causes, Symptoms, Treatment

Post Surgical Back Pain /Failed back surgery syndrome (FBSS) is a complex set of post-surgical pain symptoms encountered after a patient has had surgery on the lumbar spine for disc-related abnormal pathology. The patient may feel present with recurrent pain and persistent pain, with or without radiculopathy, following spinal surgery. Pain may appear after surgery and persist despite the intervention for up to 3 months or more, with chronic pain.[rx] There are other name of this condition definitions for the same disorder such as postlumbar surgery syndrome, postlaminectomy syndrome, failed back syndrome, and postoperative persistent syndrome.[rx,rx]

Failed back surgery syndrome or “failed back syndrome” refers to persistent pain after spinal surgery about 3 months later. It man have a number of serious problems that may including iatrogenic vigorous effects in the spine or incision area such as the development of scar tissue, nerve damage, or weakening of physical structures and posture. A disability may increase and the demand for medication may also increase. This opinion piece will discuss broadly the background and scale of failed back surgery syndrome. There will be a description of the medical and psychological factors that have been reported as causes of poor outcomes from spinal surgery.

Types of Post Surgical Back Pain

Below are the types of back and neck pain people with failed back surgery syndrome may experience. In these cases, some patients have one or more types.

• Chronic pain – It may be sustained significant pain that lasts for more than 12 weeks. Chronic pain is the opposite of acute pain, which is short-term pain that may be severe. Acute pain is expected during spine surgery recovery, but the pain should fade as the spine heals.
• Nociceptive pain – It is a Localized pain that may be dull or sharp. This is the type of pain patients may experience immediately after surgery (eg, the heightened pain felt around the incision site). When most people think of pain, nociceptive pain is what comes to mind.
• Neuropathic pain (neuropathy) – The pain arises due to nerve-related pain is caused by damage to the nerves or spinal cord compression in the root of the nerve. Unlike nociceptive pain, which can be traced to a single site or area, neuropathic pain often shoots and moves, affecting large areas of your body and buttock. Examples of this type of pain include numbness, burning, tingling, weakness, and other abnormal sensations (called paresthesia).
• Radicular pain (radiculopathy) – A subset of nerve pain abnormality (neuropathy) is called radiculopathy, or a group of radicular pain. The characteristic of radicular pain radiate from one area to another (eg, upper back or lumber reason to the low back down the buttocks, legs, and feet, such as sciatica).

Causes of Post Surgical Back Pain

Pain in the leg likely indicates and feel nerve compression from the condition of stenosis, epidural fibrosis, or disc herniation, and it may be more while low back pain is more common in facet joint arthropathy, sacroiliac joint issues, or myofascial etiologies. Failed back surgery syndrome is a condition with a complex etiology and many factors that predispose patients towards chronic pain. These predictive factors generally divide into preoperative (patient) factors, intraoperative factors, and postoperative factors.[rx][rx][rx][rx]

• Preoperative Causes – It is previous and after causes of the patient associated with failed back surgery syndrome include anxiety, depression, or other psychiatric comorbidities, obesity, smoking, the presence of litigation or worker’s compensation claims, and physical or radiologic findings such as stenosis, fibrosis, and disc herniation.[rx][rx]
• Psychosocial causes – It is the second most psychological causes that have been shown to have the strongest association with the development of FBSS.[rx] Additionally, the choice of an inappropriate surgical candidate, or theory and technique, or surgical approach correlates with a higher risk of developing FBSS.[rx] Patients who have undergone multiple prior back surgeries have the highest chance of developing FBSS and a lower chance of achieving successful pain resolution with surgery than surgeons have done.[rx]
• Intraoperative causes – It is the sense for developing failed back surgery syndrome to include operating at either the wrong way surgery vertebral level or operating at a single level while the origin of pain spans several levels, thus providing insufficient pain relief.[rx][rx]
• The wrong vertebral – The Vertebralcoloumn level may pertain to factors such as lumbarization, sacralization, or even more important when the etiology gets attributed to a non-attributable pathological condition. These factors represent the symptoms in clearly identifying a locus in patients with multi-segment changes. Improper technique or unconsciousness during surgery may also lead to failure of the back syndrome to relieve pain or the onset of new pain.[rx]
• Fusion surgery considerations – The surgery to fixed the two adjuvant vertebrae such as failure to fuse and/or implant abnormality failure, or a transfer lesion to another level after a spine fusion, when the next level degenerates more pain and becomes a pain generator.
• Lumbar decompression back surgery considerations – It is such a condition as recurrent spinal canal stenosis,  or disc herniation, PLID, inadequate decompression of a nerve root, preoperative nerve damage or postoperative that does not heal after decompressive surgery, or nerve damage that occurs during the surgery)
• Scar tissue considerations – It causes after surgery in such as forming epidural fibrosis, which refers to a formation of scar tissue around the nerve root and spinal column
• Postoperative rehabilitation – Due to adequate consciousness of continued pain from a secondary pain generator.
• Post-Surgery Pain – It is the most dangerous indication of failed back surgery symptoms that happened in past a certain point certain causes of the pain from surgery should begin to remember while the effects of the surgery reducing pain should take hold. If you continue to have the same level of pain or struggle with even more pain, despite 6 weeks of recovery, it’s likely that something went wrong either during or after the procedure of back failed surgery. Your doctor may be advised to stay in touch with a pain management professional or your doctor and with your doctor and to schedule regular checkups to be sure including imaging if you’re left with a significant amount of pain and abnormality about 3 months or more after surgery.
• Nerve Pain – All pain is “nerve pain”, but certain forms of pain due to nerve root compression specifically point towards pinched nerves, recurring disc herniation, failed spinal fusion, or the formation of scar tissue around the surgical site putting pressure on a specific nerve or nerve root all of which are possible symptoms of a failed back symptoms surgery. Each major nerve exhibits and causes different symptoms, but common issues include severe leg pain, the paresthesia to long walk or sitting, running down the side of the leg, lower back pain getting worse, etc.
• Spasms & Joint Lockage – Another bad sign pointing towards failure or the possibility of another issue is joint lockage and muscle spasms. Muscle spasms and cramps are not too uncommon immediately after surgery, but they shouldn’t occur after recovery. If you struggle to bend your leg or get sudden spasms and cramps preventing you from walking, then you must immediately consult a professional.
• Severe Weakness – Nerves are responsible for sending signals into the body from the brain, and lumbar disc herniation often leaves people with limb paresis (partial paralysis or immobility in the limbs). Surgery to correct disc herniation quite often relieves patients of these symptoms and gives them back more control over their limbs. While it isn’t guaranteed that any given patient makes a full recovery, continued muscle weakness – or increased muscle weakness, and partial paralysis – may be a sign of FBSS.

The most non-surgical causes include

• Herniated nucleus propulsors (HNP) at a non-surgical site
• Facet arthrosis
• Spinal Stenosis
• Spondylolysis with or without Spondylolisthesis
• Referred to pain.
• myofascial pain
• segment instability
• Epidural hematoma,
• Recurrent HNP at the operative site,
• Infection such as diskitis,
• Osteomyelitis or arachnoiditis,
• Epidural scar
• Meningocele or CSF fistula.

Symptoms of Post Surgical Back Pain

• Persistent or recurrent pain – in the back/neck or limbs despite surgery or treatment thought likely to relieve pain.
• Chronic radicular pain – that has recurred or persists in the same distribution despite anatomically satisfactory previous spinal surgery. (Leveque)^[rx]
• Lumbar (cervical) pain – of unknown origin either persisting despite the surgical intervention or appearing after surgical intervention for spinal (origin) pain originally in the same topographical distribution.^[rx]
• Chronic back and leg pain – that persists or recurs despite the application of the back surgery clinical pathway.
• Radicular symptoms – in the failed back patient may be due to a multitude of reasons including herniated disc, postoperative adhesions, a thickened ligamentum flavum, spondylolisthesis with or without an associated par defect, osteophyte formation from facet arthropathy, or other degenerative changes that may lead to central or transforaminal stenosis.
• Original symptoms return – When the symptoms surgery intended to correct come back, it may indicate failed back surgery.
• New problems arise – Spine surgery may have fixed original symptoms, but new pain (pain in a different part of the spine or a different type of pain) warrants a discussion with your doctor.
• Reduced mobility – It takes time to recover from spine surgery and that process can affect your endurance, flexibility, and movement. However, reduced mobility or limitations in movement that is different from expected or develops after the recovery period should be discussed with your doctor. An example is a limited range of motion in your neck or low back.
• Headaches develop – If they weren’t part of your medical history before your surgery, the headache may signal a nerve problem after a cervical spine (neck) procedure.

The symptoms that may indicate life-threatening conditions; include, but are not limited to: saddle anesthesia or bowel/bladder incontinence, indicative of cauda equina syndrome; fever, chills, or weight loss indicating infection; and signs of malignancy.[rx][rx] Patients should also have an evaluation for anxiety, depression, and other psychiatric conditions due to their high comorbidity with FBSS.[rx]

Diagnosis of Post Surgical Back Pain

Treatment of Post Surgical Back Pain

Non-Pharmacological Treatment for failed back  surgery syndrome

• Physical therapy – Physical therapy can help the patient optimize gait and posture and can improve muscle strength and physical function.[rx,rx] Other conservative measures that may help postoperative back pain involve psychotherapy measures including stress reduction and cognitive behavioral therapy to body and mind fit.[rx] Finally, noninvasive procedures or systems including acupuncture and scrambler therapy can be used to minimize the pain associated with FBSS.[rx,rx] These conservative measures should be done in conjunction with medication management to optimize pain relief.
• Transcutaneous electrical nerve stimulation – may provide an alternative/complement to medication in patients with FBSS. Its effectiveness in chronic low back pain is, however, still have controversial [rx, rx]. Other nonpharmacological complementary therapies, such as acupuncture, manual therapy, functional restoration, and cognitive behavioral therapy, may also be utilized, although the level and supporting team most of these therapies in the management of chronic back pain is moderate at best [rx, rx].
• High-frequency spinal cord stimulation – This technique has been shown to be of particular value in patients with FBSS with a predominant lower back pain component.^[rx]A frequency of about 5000–10,000 Hz is used. A major advantage is that patients do not have to rely on the perception of paraesthesia, itching in the affected area. There are no efficacy, cost-effectiveness, or safety data from a randomized controlled trial or comparison with conventional SCS in relation to the long-term use of this technology.
• Dorsal root ganglion stimulation – A specially designed lead is placed around the dorsal root ganglion, via the epidural space, and this produces pleasant paraesthesia in a dermatome or part of it. The major advantages seem to be that there is no change in perception of paraesthesia with posture, and it is possible to target dermatomes that would otherwise be difficult to target with conventional SCS (foot, groin, etc.) without overspill of paraesthesia into other dermatomes. There are minimal long-term data regarding efficacy, safety, and cost-effectiveness.^[,rx]
• Peripheral nerve field stimulation – Specially designed leads have been approved for this use, especially for treating the neuropathic back pain component of FBSS. The use of this technique, in combination with conventional SCS or alone, has been published with impressive results in case series.^[rx] However, cost-effectiveness and long-term efficacy are not established.
• Radiofrequency ablation – RFA of nerves are often used to provide sustained relief that a diagnostic block or therapeutic injection cannot provide. Successfully targeting the intended nerve is achieved, maximizing the size of the lesion. This can be done by performing multiple RFA in different locations, increasing the temperature and time of the ablation, using bipolar RF or cooled RF.[rx,rx]
• Neuromodulation – Spinal cord stimulation (SCS) is a treatment modality that has shown tremendous potential in the management of FBSS. The advent of SCS came just 2 years after Melzak and Wall’s 1965 groundbreaking paper on Gate Theory with Shealy and Mortimer’s case study on the complete elimination of pain in a 70-year-old male with metastatic bronchogenic carcinoma by means of electrical stimulation of the dorsal columns.[rx,rx]
• Chiropractic – The results of several studies showed significant improvement for patients with failed back surgery who were managed with chiropractic care

Medications

Oral pharmacological treatment of FBSS is multimodal and increasingly controversial.

• Anticonvulsant drugs – have gained popularity for neuropathic pain, with gabapentin (Neurontin) and pregabalin (Lyrica) being the most commonly used preparations. Gabapentin has been shown to be superior to naproxen in alleviating back and leg pain after spinal surgery [^rx]. Pregabalin plays a role in the prevention of pain before and after surgery, with its effect apparently increasing with time [^rx].
• Antidepressants – (amitriptyline and duloxetine) [rx]. Two-drug combinations for the treatment of neuropathic pain in adults have been shown to improve analgesic efficacy [rx].
• Chemical neuromodulation – by continuous intrathecal drug delivery (IDD) based on morphine or ziconotide administration may be considered for patients preferentially with neuropathic pain who have responded to strong oral opioids in the presence of severe adverse events [rx–rx]
• Epidural injections – Epidural steroid injections (ESIs) are the most commonly performed procedure in pain clinics around the world.[rx] These can be administered primarily by three approaches: transforaminal, interlaminar, or caudally, and are indicated for symptoms of radiculopathy.
• Intrathecal drug delivery – Similar to a spinal cord stimulator, spinal drug delivery (or intrathecal drug delivery) involves implanting a small pump in the stomach and running a catheter to the spine to deliver pain medication. It is used for people with chronic back pain who need large doses of narcotics to deal with the pain. Compared to oral medication, this “pain pump” requires a smaller dose of narcotics because the medication goes directly to the area of pain.
• Long-term Oxycodone – Naloxone is given to counteract the long-term effects of narcotic use. In one case study, Spanish research Dr. Borja Mugabure Bujedo recorded that a combination of  Oxycodone – naloxone can be a good alternative for the management of Failed Back Surgery Syndrome when other interventional or pharmacologic strategies have failed in a case report in the journal Anesthesiology and pain medicine. In this case report, higher doses than those recommended as a maximum daily ceiling (80/40 mg) were used in one selected patient with severe pain.[rx]
• Platelet Rich Plasma Therapy in combination with Prolotherapy – Some doctors may recommend the use of Platelet Rich Plasma to help patients with failed back surgery syndrome. Platelet Rich Plasma is an injection of your concentrated blood platelets into the area of pain. The concentrated blood platelets bring healing and regenerating growth factors to the areas possibly damaged or affected by surgery. Recent research says that
• Platelet-rich plasma (PRP) represents an additional approach – as it has shown some promise in bone regeneration, and should be explored for its potential role in limiting spinal fusion surgery failures.[rx]

Why Does Failed Back Syndrome Happen?

One of the most common situations in which we see failed back syndrome is after spinal fusion surgery. The spine is not immediately, fully fused after spinal fusion; rather, surgeons have created an environment that encourages fusion, through the use of a tissue graft between two (or more) vertebrae.

For the vertebrae to fully fuse, the spine must be stabilized and immobilized to a degree. If the environment for growing new bone tissue is not quite right, the spinal fusion may prove ineffective. This is one of the main causes of the failed back syndrome.

Another common scenario happens after a discectomy or laminectomy to relieve symptoms of a herniated disc when the patient has degenerative disc disease (DDD). The surgery may have been performed flawlessly, but DDD can affect multiple locations in the spinal column.

Sometimes patients have one disc herniation repaired only to find that another herniation has occurred after recovery from the surgery, or a more minor existing herniation was being masked by stronger symptoms, which the surgery addressed.

The risk of failed back syndrome rises with each surgery. According to a 2018 review in Asian Spine Journal, about half of initial surgeries are successful. That percentage, however, drops to 30 percent, then 15 percent, then 5 percent after the second, third, and fourth surgeries.

Aside from the choice of surgery, the number of surgeries, and the presence of other spinal conditions, the risk of the failed back syndrome can be increased by a number of factors after surgery. In the short-term, some of these include:

• Infection
• Nerve injury
• Hematoma formation

In later stages, changes to the spinal column can affect the way a patient moves, which can cause further spinal problems after time.

What exercises help reduce Failed Back Syndrome pain?

There are 4 exercises your spine specialist may recommend helping you reduce failed back pain nerve pain caused by degenerative disc disease: pelvic tilt, knee to chest, lower trunk rotations, and all fours opposite arm and leg extensions. Each low-impact exercise is demonstrated in narrated videos and written instructions are provided to help you fine-tune your sciatica home exercise program.

Pelvic Tilt

Purpose: To strengthen the lower abdominal muscles and stretch the low back.

How to perform a pelvic tilt

• Lie on your back.
• Exhale and tighten your abdominal muscles while pushing your belly button toward the floor and flatten your lower back.
• Hold the position for 5 seconds.
• Repeat the pelvic tilt 10 times holding the position for 5 seconds each time.

How can I tell if I’m doing the pelvic tilt right?

• Place your pinky finger on your hip bone and thumb on your lowest rib (same side of your body).
• As you tighten your abdominal muscles, the amount of space between your pinky finger and thumb should get smaller.

Pelvic tilts can help strengthen the lower abdominal muscles and stretch the low back. Photo Source: 123RF.com.

Knee to Chest

Purpose: To help reduce nerve compression in your low back, which may help alleviate lower back pain.

• Lie on your back.
• Starting with either your left or right knee and use your hands to gently pull the bent knee toward your chest.
• Hold for 10 seconds.
• Repeat the movement with the opposite knee.
• Perform the movement 3 to 5 times holding the position for 10 seconds each time.
• Next, use your hands to gently pull both knees toward your chest.
• Hold for 10 seconds.
• Repeat the movement with both knees 3 to 5 times holding the position for 10 seconds each time.

Lower Trunk Rotations

Purpose: To increase your spine’s mobility and flexibility.

• Lie on your back with both knees bent upright and both feet flat on the floor (called the hook lying position).
• While holding both knees together, rotate your knees to one side and hold for 3 to 5 seconds. You will feel a gentle stretching sensation on the opposite side of your lower back and hip area.
• Next, contact your abdominal muscles and rotate both knees to the opposite side and hold for 3 to 5 seconds.
• Repeat up to 10 times on each side.

All Fours Opposite Arm and Leg Extensions

Purpose: To strengthen your abdominal muscles, low back, and stabilize those areas.

• Begin by positioning yourself on all fours.
• Contract your abdominal muscles to help keep your back flat and straight.
• Raise one leg upward behind you and straighten in outward.
• Hold for 3 to 5 seconds.
• Repeat the movement on your opposite side.

When you can perform this exercise 10 times with tolerable pain, you can add arm movement with each leg extension:

• Extend the arm (opposite side from the leg) upward and outward in front of your body.
• Hold for 3 to 5 seconds.
• Repeat on the opposite side.
• Perform this exercise up to 10 times.

How can these exercises work to reduce sciatic pain?

The abdominal and spinal muscles are essential components of the spine’s support system, which—anatomically, can be likened to your internal spinal brace. These 4 low-impact exercises, when performed correctly and under your spine specialist’s guidance, can help strengthen your spine and increase its flexibility and range of motion. While you cannot halt the effects of degenerative disc disease (eg, cause of bulging or herniated disc), exercise can help fortify the spine’s structural components that may reduce pain and speed healing.

Furthermore, exercise causes your body to release endorphins—hormones that interact with pain receptors in the brain that can reduce the perception of pain.

References

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