Failed back syndrome or post-laminectomy syndrome is a condition characterized by chronic pain after surgery. Many factors may contribute to the onset or development of FBS, including residual or recurrent spinal cord, persistent post-operative pressure on the spinal nerve, joint mobility changes, joint hypermobility with instability, scarring (fibrosis), depression, anxiety, sleep deprivation. , spinal muscle decondition and even infection Propionibacterium acnes . A person may be prone to developing FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral vascular (vascular) vessels.
Common symptoms associated with FBS include diffuse, dull and sore pain involving the back or legs. Abnormal sensitivities may include a sharp, piercing, piercing stab in the extremities. The term "post-laminectomy syndrome" is used by some doctors to show the same conditions as a failed back syndrome.
Post-laminectomy syndrome treatment includes physical therapy, special low-level chiropractic care, micro electric neuromuscular stimulator, minor nerve block, transcutaneous electrical nerve stimulation (TENS), behavioral medication, nonsteroidal anti-inflammatory drugs (NSAIDs), membrane stabilizers, antidepressants, stimulation spinal cord, and intrathecal morphine pump. The use of epidural steroid injections may be helpful in some cases. Use of targeted anatomy from potent anti-TNF anti-inflammatory therapies is being investigated.
The number of spinal surgeries varies around the world. The United States and the Netherlands report the highest number of spine surgeries, while Britain and Sweden report the fewest. More recently, there is a call for more aggressive surgical treatment in Europe. The success rate of spine surgery varies for various reasons.
Video Failed back syndrome
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Patients who have undergone one or more surgeries on the lumbar spine, and continue to experience and report subsequent pain can be divided into two groups. The first group are those who have never indicated the operation, or the operation performed is never possible to achieve the desired result; and those who indicated surgery, but technically did not achieve the desired results. It has been observed that patients who have a dominant pain presentation in a radicular pattern will have better outcomes than those with a dominant back pain complaint.
The second group includes patients who have incomplete or inadequate surgery. Lumbar spine stenosis is negligible, especially when associated with disc bulges or herniation. Disk removal, while not addressing the presence of stenosis, can lead to disappointing results. Sometimes operating at the wrong level occurs, as does failure to recognize extruded or alienated disk fragments. Inadequate or improper surgical exposure may cause other problems in not reaching the underlying pathology. Hakelius reported a 3% serious incidence of nerve root damage.
In 1992, Turner et al. published a survey of 74 journal articles that reported results after decompression for spinal stenosis. Good to excellent results reported an average of 64% of patients. However, there are various results reported. There are better results in patients who have degenerative spondylolistesis. A similarly designed study by Mardjekto et al. found that spinal arthrodesis together (fusion) had a greater success rate. Herron and Trippi evaluated 24 patients, all with degenerative spondylolistesis treated with laminectomy alone. At follow-up varied between 18 and 71 months after surgery, 20 of 24 patients reported good results. Epstein reported in 290 patients treated for a 25-year period. Excellent results are obtained in 69% and good results in 13%. These optimistic reports do not correlate with a "back to competitive job" level, which is largely bleak in most of the spine surgery series.
Studies by Cohen show that up to 25% of all low back pain is sacroiliac joints in origin and that the diagnosis of sacroiliac joint disease is often overlooked by physicians. Studies by Ha, et al., Demonstrated that the incidence of SI joint degeneration in post-lumbar fusion operations was 75% at 5 years postoperatively, based on imaging. Studies by DePalma and Liliang, et al., Demonstrated that 40-61% of post-lumbar symptomatic fusion patients for SI joint dysfunction are based on diagnostic blocks.
In the last two decades there has been a dramatic increase in fusion operations in the US: in 2001 more than 122,000 lumbar fusions were made, a 22% increase from 1990 in fusion per 100,000 population, rising to 250,000 in 2003 and 500,000 in 2006. In 2003, the national bill for hardware for fusion alone is estimated to have jumped to $ 2.5 billion per year. For patients with advanced pain after surgery that is not due to the above complications or conditions, the interventional pain doctor talks about the need to identify the "pain producer" ie the anatomical structure responsible for the patient's pain. To be effective, the surgeon should operate on the correct anatomical structure, but it is often impossible to determine the source of the pain. The reason for this is that many patients with chronic pain often have disc bulges at multiple levels of the spine and physical examination and imaging studies can not determine the source of the pain. In addition, the fusion of the spine itself, especially if more than one spinal level is operated, may result in "adjacent segment degeneration". This is thought to be the case because the unified segment may cause increased torque strength and stress transmitted to intervertebral discs located above and below the fused vertebra. This pathology is one of the reasons behind the development of artificial discs as a possible alternative to fusion operations. But fusion surgeons argue that spine fusion is more time-tested, and artificial discs contain metal hardware that is unlikely to survive during biological matter without breaking down and leaving metal fragments in the spinal canal. It represents different thoughts. (See the discussion on replacing the infra disk.)
Another highly relevant consideration is the growing recognition of the importance of "chemical radiculitis" in the formation of back pain. The main focus of surgery is to remove the "pressure" or reduce the mechanical compression of the nerve element: either the spinal cord, or the nerve roots. But it is increasingly recognized that back pain, not solely due to compression, may actually be entirely caused by chemical inflammation of the nerve roots. It has been known for several decades that disk herniation causes major inflammation in related nerve roots. In the last five years, more and more evidence has pointed to specific inflammatory mediators of this pain. This inflammatory molecule, called tumor necrosis factor-alpha (TNF), is released not only by a herniated or prominent disc, but also in cases of disc rupture (annular tear), by facet joints, and in spinal stenosis. In addition to causing pain and inflammation, TNF can also contribute to disc degeneration. If the cause of the pain is not compression, but TNF-mediated inflammation, then this might explain why surgery may not relieve the pain, and possibly even worsen it, produce FBSS.
Smoking
Recent studies have shown that regular smokers will fail all spine surgery, if the purpose of the surgery is to decrease pain and disturbance. Many surgeons consider smoking as an absolute contraindication to spine surgery. Nicotine seems to disrupt bone metabolism through induced calcitonin resistance and decreased osteoblastic function. It can also limit the diameter of small blood vessels leading to increased scar formation.
There is a link between smoking, back pain and chronic pain syndrome of all types.
In a report of 426 spine surgical patients in Denmark, smoking was shown to have a negative effect on overall patient fusion and satisfaction, but there was no measurable influence on functional outcomes.
There is hypothetical assumption validation that postoperative smoking cessation helps reverse the effects of smoking on outcomes after spinal fusion. If the patient stops smoking in the postoperative period, there is a positive impact on success.
Smoking regularly in adolescence is associated with waist pain in young adults. Smoking for years shows a link between the girls.
A recent study shows that cigarette smoking is bad for serum hydrocodone levels. The prescribing doctor should be aware that in some smokers, serum hydrocodone levels may not be detected.
In a study from Denmark that reviewed many reports in the literature, it was concluded that smoking should be regarded as a weak risk indicator and not the cause of lower back pain. In many epidemiological studies, the link between smoking and back pain has been reported, but variations in approach and results make this literature difficult to reconcile. In a large-scale study of 3482 patients undergoing lumbar spine surgery from the National Spine Network, comorbid (1) smoking, (2) compensation, (3) self-reported poor overall health and (4) pre-existing psychological factors is predictive in the risk of high failure. Follow-up is done at 3 months and one year after surgery. Preoperative depression disorder tends not to work well.
Smoking has been shown to increase the incidence of postoperative infections as well as decrease the level of fusion. One study showed 90% of postoperative infections occurred in smokers, as well as myonecrosis (muscle damage) around the wound.
Maps Failed back syndrome
Pathology
Before the onset of CT scans, the pathology of failed back syndrome is difficult to understand. Computerized tomography in conjunction with metrizamide myelography in the late 1960s and 1970s enabled a direct observation of the mechanisms involved in postoperative failure. Six different pathological conditions were identified:
- Recurring or fixed herniation
- Spinal stenosis
- Postoperative infection
- Fibrosis post epidural surgery
- Adhesive Arachnoiditis
- Nerve Injury
Repeated or persistent disk herniation
Deleting disks at one level may cause disc herniation at different levels at a later time. Even the most complete surgical excision of the disk still leaves 30-40% of the disk, which can not be disposed of safely. This retained disc may return sometime after surgery. Almost every major structure in the stomach and posterior retroperitoneal space has been injured, at some point, by removing the disc using posterior laminectomy/discectomy surgical procedures. The most prominent is the laceration of the left internal iliac vein, located near the anterior portion of the disc. In some studies, recurrent pain in the same radicular pattern or different patterns can be as high as 50% after disc operation. Many observers have noted that the most common cause of back syndrome failure is due to recurrent herniation at the same rate that was initially operated. Rapid appointment in a second operation can be curative. Clinical features of recurrent disc herniation usually involve significant pain-free intervals. However, physical findings may be lacking, and a good history is needed. The duration for the appearance of new symptoms can be short or long. Diagnostic signs such as straight limb test may be negative even if real pathology is present. The presence of a positive myelogram may represent a new herniation, but can also be an indication of a post-operative scarring situation just mimicking a new disk. Newer MRI imaging techniques have clarified this dilemma. Conversely, repetitive disks can be difficult to detect with scarring. Myelography is not sufficient to fully evaluate the patient for recurrent disk disease, and CT scan or MRI is required. Network density measurements can help.
Although laminectomy complications for herniation can be significant, a recent series of studies involving thousands of patients published under the supervision of Dartmouth Medical School concluded in four years of follow-up that those undergoing surgery for lumbar herniation achieved greater improvement. than patients who are not surgically operating in all primary and secondary outcomes except for employment status.
Spinal stenosis
Spinal stenosis can be a late complication after laminectomy for disc herniation or when surgery is performed for a major pathological condition of spinal stenosis. In the Maine Study, among patients with lumbar spine stenosis who completed follow-up of 8 to 10 years, lower back pain, dominant symptom improvement, and satisfaction with current circumstances were similar in patients initially underwent surgery or non-surgery. However, pain relief legs and functional status associated with larger backs continue to support those who initially receive surgical treatment.
A large study of spinal stenosis from Finland found a prognostic factor for postoperative work ability was the ability to work before surgery, under 50 years of age, and no previous back surgery. Long-term outcomes (mean follow-up time of 12.4 years) were excellent in 68% of patients (59% women and 73% of men). Furthermore, in longitudinal follow-up, the results increased between 1985 and 1991. No specific complications were manifested during this long-term follow-up. Patients with total or subtotal blocks in preoperative mielography achieved the best results. Furthermore, patients with stenosis block improved their outcome significantly in longitudinal follow-up. Postoperative stenosis seen in computed tomography (CT) scans was observed in 65% of 90 patients, and it was severe in 23 patients (25%). However, successful or unsuccessful surgical decompression is not correlated with patients' subjective disability, walking capacity or pain severity. Previous back surgery has a strong deterioration effect on operating outcomes. This effect is particularly evident in patients with total blocks in preoperative myelography. The outcome of the patient's surgery with previous back surgery is similar to that of a patient without previous back surgery when the time interval between the last two operations is more than 18 months.
MRI findings post-operative stenosis may be of limited value compared with symptoms experienced by the patient. The patient's perception of improvement has a much stronger correlation with long-term surgical results than the structural findings seen in postoperative magnetic resonance imaging. Degenerative findings have a greater effect on patients' walking capacity than stenosis findings
Postoperative radiological stenosis is very common in patients undergoing surgery for lumbar spine stenosis, but this does not correlate with clinical outcomes. Doctors should be cautious when reconciling clinical symptoms and signs with postoperative computed tomography findings in patients who are operated for lumbar spine stenosis.
A study from Georgetown University reported on one hundred patients who had undergone decompression surgery for lumbar stenosis between 1980 and 1985. Four patients with postfusion stenosis were included. A 5-year follow-up period was achieved in 88 patients. The median age was 67 years, and 80% were over 60 years old. There is a high incidence of concurrent medical diseases, but the major disability is lumbar stenosis with neurological involvement. Initially there was a high incidence of success, but the recurrence of neurological involvement and persistence of lower back pain led to an increase in the number of failures. Up to 5 years, this number has reached 27% of the total population available, indicating that the failure rate could reach 50% in the expected life expectancy of most patients. Of the 26 failures, 16 are secondary to renewed neurological involvement, occurring in new stenosis levels in the eight and recurrence of stenosis at the operating level in eight. The re-surgery was successful in 12 of these 16 patients, but two required a third operation. The incidence of spondylolisthesis at 5 years was higher in surgical failure (12 out of 26 patients) than in surgical success (16 of 64). Spondylolisthetic stenosis tends to recur within a few years after decompression. Due to age and related illness, fusion may be difficult to achieve within this group.
Postoperative infection
A small percentage of lumbar surgery patients will develop postoperative infections. In many cases, this is a bad complication and does not bode well for final or future workplace improvement. Reports from the surgical literature indicate infection rates anywhere from 0% to almost 12%. Incidence of infection tends to increase as the complexity of the procedure and the time of surgery increase. The use of metal implants (instrumentation) tends to increase the risk of infection. Factors associated with increased infection include diabetes mellitus, obesity, malnutrition, smoking, previous infections, rheumatoid arthritis, and immunodeficiency. Previous wound infections should be considered contraindicated for further spine surgery, as the likelihood of increasing such patients with more minor surgery. Prophylactic antimicrobial (antibiotic administration during or after surgery before infection begins) reduces surgical site infection rates on lumbar spine surgery, but many variations exist regarding its use. In a Japanese study, utilizing the Centers for Disease Control recommendations for prophylactic antibiotics, an overall rate of 0.7% infection was noted, with a single-dose antibiotic group having an infection rate of 0.4% and a 0.8% antibiotic antibiotic rate. Previous authors have used prophylactic antibiotics for 5 to 7 days postoperatively. Under the Centers for Disease Control and Prevention guidelines, their antibiotic prophylaxis is converted into a day of operation only. It was concluded there was no statistical difference in rates of infection between two different antibiotic protocols. Under the CDC guidelines, single-dose prophylactic antibiotics prove efficacious for prevention of infection in lumbar spine surgery.
Epidural postoperative fibrosis
A scarring epidural after laminectomy for disk excision is a common feature when re-operating for recurrent sciatica or radiculopathy. When scarring is associated with recurrent disc/herniation and/or spinal stenosis, this is relatively common, occurring in more than 60% of cases. For a time, theorized that placing a fat graft over a dural could prevent postoperative scarring. However, the initial enthusiasm has been reduced in recent years. In broad laminectomies involving 2 or more vertebrae, postoperative scarring is the norm. This is most commonly seen around the nerve roots of L5 and S1.
Arachnoiditis adhesive
Fibrous scar tissue can also be a complication in subarachnoid space. It's very difficult to detect and evaluate. Prior to the development of magnetic resonance imaging, the only way to ensure arachnoiditis is to open the dura. On the day of CT scan and Pantopaque and later, Metrizamide myelography, the presence of arachnoiditis may be speculated based on radiographic findings. Frequently, myelography before the introduction of Metrizamide is the cause of arachnoiditis. This can also be caused by long-term pressure caused by severe herniation or spinal stenosis. The presence of epidural scarring and arachnoiditis in the same patient may be quite common. Arachnoiditis is a broad term that suggests meninges inflammation and subarachnoid space. Various causes exist, including infection, inflammation, and neoplastic processes. Causes of infection include bacterial agents, viruses, fungi, and parasites. Noninfectious inflammatory processes include surgery, intrathecal bleeding, and intrathecal intravenous agents (such as myelographic contrast media, anesthesia (eg chloroprocaine), and steroids (eg Depo-Medrol, Kenalog). Lately iatrogenic arachnoiditis has been associated with the wrong Epidural Steroid Injection therapy when inadvertently given intrathecally. Preservatives and suspension agents are found in all steroid injections, which are not indicated for US epidural administration. Food & amp; Drug Administration due to reports of severe side effects including arachnoiditis, paralysis and death, has now been directly linked to the onset of disease after the early stages of chemical meningitis. Neoplasia includes hematogenous spread of systemic tumors, such as breast and lung carcinoma, melanoma, and non-Hodgkin's lymphoma. Neoplasia also includes direct seeding of cerebrospinal fluid (CSF) from primary central nervous system (CNS) tumors such as glioblastoma multiforme, medulloblastoma, ependymoma, and choroid plexus carcinoma. Actually, the most common cause of arachnoiditis in non-infectious failing or cancerous back syndrome. This is because non-specific scars are secondary to the underlying operations or pathology.
Nerve injury
Laseration of the nerve roots, or damage from cautery or traction can cause chronic pain, but this can be difficult to determine. Chronic compression of the nerve roots by persistent agents such as disc, bone (osteophyte) or scar tissue can also permanently damage the nerve roots. Epidural scarring caused by early pathology or occurring after surgery can also cause nerve damage. In one study of back patients who failed, the presence of pathology was recorded to be in the same location as the rate of surgery performed in 57% of cases. The remaining cases develop pathology at different levels, or on the opposite side, but on the same level as the surgery is performed. In theory, all back patients who fail have some kind of nerve injury or damage that leads to the persistence of symptoms after a sensible healing time.
Diagnosis
Management
Failed back syndrome (FBS) is a recognized complication of surgery of the lumbar spine. It can cause chronic pain and disability, often with poor emotional and financial consequences for the patient. Many patients have traditionally been classified as "paralyzed spine" and left to long-term narcotic drug treatment with little chance of recovery. Despite extensive work in recent years, FBS remains a challenging and costly intrusion.
Opioid
A study of patients with chronic pain from the University of Wisconsin found that methadone is best known for its use in the treatment of opioid dependence, but methadone also provides effective analgesia. Patients who experience inadequate pain or side effects that can not be tolerated with other opioids or who suffer from neuropathic pain may benefit from the transition to methadone as its analgesic agent. Side effects, particularly respiratory depression and death, make fundamental knowledge about the pharmacological properties of methadone important for the provider considering methadone as an analgesic therapy for patients with chronic pain.
Patient choice
Patients with sciatic pain (back pain, radiation to the buttocks) and clear clinical findings of identifiable identifiable neuronal loss caused by disc herniation will have better postoperative travel than those with only back pain under. If certain disc herniations that cause pressure on the nerve roots can not be identified, the results of operations may be disappointing. Patients involved in workers compensation, litigation lawsuits or other compensation systems tend to fare worse after surgery. Surgery for spinal stenosis usually has good results, if surgery is done extensively, and is performed within the first year or so of the appearance of symptoms.
Oaklander and North define Back Failure Syndrome as a patient with chronic pain after one or more surgical procedures to the spine. They illustrate the characteristics of the relationship between the patient and the surgeon:
- Patients make increasing demands on the surgeon to relieve pain. The surgeon may feel strongly responsible for administering the drug when the surgery has not reached the desired goal.
- The patient becomes increasingly angry because of failure and may become aware of the law.
- There is an increase in narcotic painkillers that can be habitual or addictive.
- In the face of costly conservative treatments that are likely to fail, surgeons are persuaded to try further operations, although this is also a possibility of failure.
- The likelihood of returning to a profitable job decreases with increasing disability length.
- Financial incentives to remain disabled can be considered as greater than incentives to recover.
In the absence of financial resources for worker disability or compensation, other psychological features may limit the patient's ability to recover from surgery. Some patients are unfortunate, and fall into the category of "chronic pain" despite their desire to recover and the best efforts of the doctors involved in their care. Even less invasive forms of operation do not work uniformly; about 30,000-40,000 laminectomy patients do not get symptoms of symptomatology or symptomatic relapse. Another form of less invasive spinal surgical surgery, percutaneous disc surgery, has reported a revision rate as high as 65%. Therefore, it is not surprising that FBSS is a significant medical problem that requires further research and attention by the medical and surgical community.
Total disk replacement
Total lumbar replacement was originally designed to be an alternative to lumbar arthodesis (fusion). This procedure was met with tremendous excitement and high expectations both in the United States and Europe. In late 2004, the first total lumbar replacement received approval from the US Food and Drug Administration (FDA). More experience exists in Europe. Since then, early excitement has given way to skepticism and worry. Various failure rates and strategies for revision of total disk replacement have been reported.
The role of artificial or total disk replacement in the treatment of spinal disorders remains unclear and unclear. Evaluation of new techniques is difficult or impossible because the doctor's experience may be minimal or less. Patient expectations may be distorted. It is difficult to set clear cutting indications for artificial disk replacement. This may not be a replacement or alternative procedure for fusion, as recent research has shown that 100% of fusion patients have one or more contraindications for disk replacement. The role of replacing the discus must come from a new indication that is not defined in the current literature or contraindicated relaxation at this time.
A study by Regan found the same replacement results on L4-5 and L5-S1 with CHARITE disks. However, ProDisc II has a better result on L4-5 compared to L5-S1.
Younger age is a better outcome predictor in some studies. In others it has been found to be a negative predictor or no predictive value. Older patients may have more complications.
Previous spinal surgery has a mixed effect on disc replacement. It has been reported negatively in several studies. It has been reported to have no effect on other studies. Much research can not be concluded. The available evidence does not allow for a definite conclusion about the current status of the disk replacement.
Electrical stimulation
Many back patients who fail are significantly impaired by chronic pain in the back and legs. Many of these will be treated with some form of electrical stimulation. It may be a transcutaneous electric nerve stimulation device placed in the skin over the back or a back implanted nerve stimulator with an electrical probe that directly touches the spinal cord. Also, some chronic pain patients use fentanyl or narcotic patches. These patients generally experience severe and unrealistic disorders to conclude that the application of neurostimulation will reduce the disorder. For example, it is doubtful whether neurostimulation will improve patients enough to return to competitive jobs. Neurostimulation is palliative. The TENS unit works by blocking the neurotransmission as described by Melzack and Wall pain theory. The success rate for neurostimulation implantation has been reported 25% to 55%. Success is defined as relative pain relief.
Prognosis
Under the rules endorsed by Title II and XVI of the United States Social Security Act radical radiculopathy, arachnoiditis and spinal stenosis are recognized as a condition of deactivation under List 1.04 A (radiculopathy), 1.04 B (arachnoiditis) and 1.04 C (stenosis spine).
Back to work
In an innovative Canadian study, Waddell et al. report on the value of the re-operation and the return to work in the case of workers compensation. They concluded that workers undergoing spinal surgery take longer to get back to their jobs. After two spinal surgeries are done, some if anyone ever returns to get any work done. After two spine surgeries, most people in the workers comp system will not be made better with more surgery. Most will get worse after the third operation.
Episodes of back pain associated with work injuries in workers' compensation arrangements are usually short-lived. About 10% of the episodes will not be simple, and will degenerate into chronic and crippling back pain conditions, even if surgery is not performed.
It has been hypothesized that job dissatisfaction and individual perception of physical demands are associated with increased recovery time or increased risk of no recovery at all. Individual social and psychological work factors, as well as employer-employer relationships also tend to be associated with time and rate of recovery.
A Finnish study of re-employment in patients with surgically treated spinal stenosis found that: (1) no patients had retired before surgery returned to work thereafter. (2) Variables that predict postoperative ability to work for women are: to be healthy to work at the time of operation, age & lt; 50 years at surgery, and duration of symptoms of lumbar spine stenosis & lt; 2 years. (3) For men, these variables are: to be eligible to work during surgery, age & lt; 50 years at the time of surgery, no previous surgery, and the extent to which the surgical procedure is equal to or less than one laminectomy. The working capacity of women and men is not different after lumbar spinal stenosis surgery. If the goal is to maximize work capacity, then, when lumbar spine stenosis surgery is indicated, it should be done without delay. In patients with lumbar spine stenosis who & gt; Aged 50 years and sick leave, unrealistic to expect that they will return to work. Therefore, after extensive surgical procedures, re-education of patients for lighter work may increase the likelihood of these patients returning to work.
In a related Finnish study, a total of 439 patients who were operated for lumbar spine stenosis during the period 1974-1987 were reexamined and evaluated for work and functional capacity about 4 years after decompression surgery. Ability to work before or after surgery and history of no previous re-operation is a predictive variable of good results. Prior to the operation of 86 patients working, 223 patients sick leave, and 130 patients have retired. After surgery, 52 patients were employed and 70 unemployed patients returned to work. No retired patient returns to work. Ability to work before surgery, under 50 years of age at the time of surgery and absence of previous surgery predicts postoperative ability to work.
A report from Belgium noted that patients reportedly returned to work on average 12 to 16 weeks after surgery for lumbar herniation. However, there are studies that provide confidence in the value of previous stimulation to return to work and the performance of normal activities after discectomy is limited. On further assessment, it was found that no patient changed jobs due to back or leg pain. The quicker the recommendations are made to get back to work and perform normal activities, the more likely it is for the patient to comply. Patients with continuous back condition have a low priority to return to work. The probability of returning to work decreases with increasing work time. This is especially true in Belgium, where 20% of individuals do not resume work after surgery for spinal lumbar herniation.
In Belgium, medical advisers from disease funds have a legally important role in the assessment of work capacity and medical rehabilitation measures for employees whose fitness work is threatened or reduced for health reasons. The steps are set out in the laws of sickness and invalidity. They are in accordance with the principle of preventing long-term disability. It is clear from the author's experience that these measures are not consistently adapted to medical practice. Most medical advisers focus purely on the evaluation of physical damage, leaving little or no time for rehabilitation efforts. In many other countries, the evaluation of work capacity is performed by a social security doctor with comparable duties.
In a comprehensive series of studies conducted by the University of Washington School of Medicine, it was determined that the results of lumbar fusion performed on wounded workers were worse than those reported in most published cases. They found that 68% of lumbar fusion patients were still unable to return to work two years after surgery. This is in stark contrast to the 68% postoperative satisfaction report in many series. In a follow-up study it was found that the use of intervertebral fusion devices increased rapidly after its introduction in 1996. Increased use of these metals was associated with a greater risk of complications without increasing the rate of disability or reoperation.
Research
Identification of tumor necrosis factor-alpha (TNF) as a major cause of spinal inflammatory pain now suggests an entirely new approach to patients selected with FBSS. Specific and powerful TNF inhibitors became available in the US in 1998, and were shown to be potentially effective for treating sciatica in an experimental model beginning in 2001. The targeted anatomy administration of one of the anti-TNF agents, etanercept, patented treatment methods, has been suggested in published pilot studies to be effective for treating selected patients with chronic disc-related pain and FBSS. The scientific basis for pain relief in these patients is supported by many of the current review articles. In the future new imaging methods can enable the identification of non-invasive sites of nerve inflammation, thus allowing more accurate localization of the "pain-producing" responsible for the production of symptoms. This treatment is still experimental.
If chronic pain in FBSS has chemical components that produce inflammatory pain, then before additional surgery it may make sense to use an anti-inflammatory approach. Often this is first tried with non-steroidal anti-inflammatory drugs, but the long-term use of non-steroidal anti-inflammatory drugs (NSAIDS) for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicities; and NSAIDs have limited value to intervene in the TNF mediation process. A commonly used alternative is the injection of cortisone into the spine adjacent to a suspected pain generator, a technique known as "epidural steroid injection". Although this technique began more than a decade ago for FBSS, the efficacy of epidural steroid injections is now generally considered limited to short-term pain relief in certain patients only. In addition, epidural steroid injections, in certain settings, can lead to serious complications. Fortunately now there is a new method emerging that directly targets TNF. This TNF targeted method is a very promising new approach for patients with severe chronic spinal pain, such as those with FBSS. Additional approaches, such as rehabilitation, physical therapy, anti-depressant, and, in particular, graduation training programs, can all be a useful addition to the anti-inflammatory approach. In addition, more invasive modalities, such as spinal cord stimulation, may offer help for certain patients with FBSS, but this modality, although often referred to as "minimally invasive", requires additional surgery, and has its own complications.
Worldwide perspectives
A report from Spain notes that the investigation and development of new techniques for spinal surgery are not free from conflict of interest. The influence of financial strength in the development of new technology and its immediate application to spinal surgery, shows the relationship between published results and industry support. Authors who have developed and defended fusion techniques have also published new articles that praise new spine technology. The author calls the spine surgery "American Stock and Exchange" and "spine surgery bubbles". The scientific literature shows no clear evidence in the cost-benefit study of most spinal surgical interventions cultured compared to conservative care. It has not been proven that fusion and disk replacement operations are a better choice than conservative treatment. Need to point out that there is currently "a relationship between industry and back pain, and there is also a back pain industry". Nonetheless, the "spine surgery market" is growing because patients are demanding solutions to their back problems. A wave of scientific evidence seems to counter spinal fusion in degenerative disc disease, discogenic pain, and specific back pain. After decades of progress in this field, the results of spinal fusion are mediocre. New epidemiological studies show that "spinal fusion should be accepted as an unproven or experimental method for the treatment of back pain". The surgical literature on spinal fusion published in the last 20 years determined that instrumentation appeared to slightly increase the rate of fusion and instrumentation that did not improve clinical outcomes in general. We still need randomized studies to compare surgical results with a natural history of the disease, placebo effect, or conservative treatment. The European guidelines for the management of chronic lumbar pain show "strong evidence" which suggests that complicated and demanding spinal surgery where different instrumentation is used, is no more effective than simple, safe and less costly fusion posterolateral fusion without instrumentation. More recently, the literature published in this field sent a message to use "minimally invasive techniques"; - neglect of transpedicular fusion. Surgery in general, and the use of metal fixation should be discarded in most cases.
In Sweden, the national registry of lumbar spine surgery was reported in 2000 that 15% of patients with spinal stenosis surgery undergo concurrent fusion. Despite the traditional conservative approach to spine surgery in Sweden, there are calls from the country to a more aggressive approach to lumbar procedures in recent years.
Cherkin et al., Evaluating surgical attitudes around the world. There are twice the number of surgeons per capita in the United States compared to the UK. The numbers are similar to Swedish. Despite having very few spinal surgeons, the Dutch proved quite aggressive in surgery. Sweden, despite having a large number of conservative surgeons and resulting in relatively few operations. Most operations are conducted in the United States. In the UK, more than a third of patients do not insist on waiting more than a year to see a spinal surgeon. In Wales, more than half waited for more than three months to consult. Lower reference levels in the UK were found to prevent surgery in general. Service fees and easy access to care are thought to encourage spinal surgery in the United States, while salaried positions and conservative philosophy lead to fewer operations in the UK. There are more spine surgeons in Sweden than in the United States. However, it was speculated that Swedish surgeons limited to compensation 40-48 hours a week can lead to conservative philosophy. It should be noted that there is a call for a more aggressive approach to lumbar surgery in both the UK and Sweden in recent years.
References
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