Management Failed back syndrome

1 management

1.1 opioids
1.2 patient selection
1.3 total disc replacement
1.4 electrical stimulation

management

failed syndrome (fbs) well-recognized complication of surgery of lumbar spine. can result in chronic pain , disability, disastrous emotional , financial consequences patient. many patients have traditionally been classified spinal cripples , consigned life of long-term narcotic treatment little chance of recovery. despite extensive work in recent years, fbs remains challenging , costly disorder.

opioids

a study of chronic pain patients university of wisconsin found methadone known use in treatment of opioid dependence, methadone provides effective analgesia. patients experience inadequate pain relief or intolerable side effects other opioids or suffer neuropathic pain may benefit transition methadone analgesic agent. adverse effects, particularly respiratory depression , death, make fundamental knowledge of methadone s pharmacological properties essential provider considering methadone analgesic therapy patient chronic pain.

patient selection

patients have sciatic pain (pain in back, radiating down buttock leg) , clear clinical findings of identifiable radicular nerve loss caused herniated disc have better post operative course have low pain. if specific disc herniation causing pressure on nerve root cannot identified, results of surgery disappointing. patients involved in worker s compensation, tort litigation or other compensation systems tend fare more poorly after surgery. surgery spinal stenosis has outcome, if surgery done in extensive manner, , done within first year or of appearance of symptoms.

oaklander , north define failed syndrome chronic pain patient after 1 or more surgical procedure spine. delineated these characteristics of relation between patient , surgeon:

in absence of financial source disability or worker s compensation, other psychological features may limit ability of patient recover surgery. patients unfortunate, , fall category of chronic pain despite desire recover , best efforts of physicians involved in care. less invasive forms of surgery not uniformly successful; approximately 30,000-40,000 laminectomy patients obtain either no relief of symptomatology or recurrence of symptoms. less invasive form of spinal surgery, percutaneous disc surgery, has reported revision rates high 65%. no surprise, therefore, fbss significant medical concern merits further research , attention medical , surgical communities.

total disc replacement

lumbar total disc replacement designed alternative lumbar arthodesis (fusion). procedure met great excitement , heightened expectations both in united states , europe. in late 2004, first lumbar total disc replacement received approval u.s. food , drug administration (fda). more experience existed in europe. since then, initial excitement has given way skepticism , concern. various failure rates , strategies revision of total disc replacement have been reported.

the role of artificial or total disc replacement in treatment of spinal disorders remains ill-defined , unclear. evaluation of new technique difficult or impossible because physician experience may minimal or lacking. patient expectations may distorted. has been difficult establish clear cut indications artificial disc replacement. may not replacement procedure or alternative fusion, since recent studies have shown 100% of fusion patients had 1 or more contraindications disc replacement. role of disc replacement must come new indications not defined in today s literature or relaxation of current contraindications.

a study regan found result of replacement same @ l4-5 , l5-s1 charite disc. however, prodisc ii had more favorable results @ l4-5 compared l5-s1.

a younger age predictive of better outcome in several studies. in others has been found negative predictor or of no predictive value. older patients may have more complications.

prior spinal surgery has mixed effects on disc replacement. has been reported negative in several studies. has been reported have no effect in other studies. many studies inconclusive. existing evidence not allow drawing definite conclusions status of disc replacement @ present.

electrical stimulation

many failed patients impaired chronic pain in , legs. many of these treated form of electrical stimulation. can either transcutaneous electrical nerve stimulation device placed on skin on or nerve stimulator implanted electrical probes directly touch spinal cord. also, chronic pain patients utilize fentanyl or narcotic patches. these patients severely impaired , unrealistic conclude application of neurostimulation reduce impairment. example, doubtful neurostimulation improve patient enough return competitive employment. neurostimulation palliative. tens units work blocking neurotransmission described pain theory of melzack , wall. success rates implanted neurostimulation has been reported 25% 55%. success defined relative decrease in pain.