A 35 years female was referred to pain clinic for her persistent pain in the back following spine surgery for almost 6 years. She got implants of screw and plates to fix her spine. Her leg pain was relieved but back pain was still persisting. Over few months pain started to become very severe and started affecting her daily life. She was treated with physiotherapy, epidural injections, exercise program, Chiropractice, and was also suggested re-do spine surgery. But as MRI was fine with no evidence of nerve compression, and the implants were looking properly placed, surgery decision was not accepted by patients. after seeing multiple hospitals and consultants she visited our clinic.

It was one of the most challenging case where no obvious pathology was visualised. We have observed in past that many patients were having muscle issues post surgery and therefor we posted her for Psoas muscle and Quadratus Lumborum muscle injection, but she did not responded to it. 

After thorough re-examination we were unable to pin point the structure causing the pain. I remembered reading one article where the cause of pain was soft tissue overlying implant. So I decided to inject directly over the pedicular screw at painful site. I did it under C-arm (Fluoroscopic guidance). Patient had instant relief and is still painfree. 

The lesson learnt is that we should sometime think out of the box to diagnose and treat patients. Sometimes such unusual cases can be treated with unconventional treatments.

Everyone suffers from back pain at some point of their life. Many suffer from chronic back pain. Dr Kailash Kothari and all pain specialist doctors at Pain clinic of India are forefront of creating awareness about prevention and non surgical treatment of back pain. We welcome Organisations, societies and various clubs to organise such awareness meets for their members. Our team will come and conduct awareness lecture, free screening/checkups and will provide help for needy patients.We believe in creating a healthy and fit society. 

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Failed back surgery syndrome can be managed. True or False? Take the quiz to learn more.

Q1. how many different types of spine surgery you know?

1. One

2. Two

3. Three

4. Four

Answer: Four

There are mainly three types of back surgeries: Laminectomy, Discectomy, Spinal Fusion and minimally invasive Endoscopic spine surgery:

Laminectomy: Such surgery is performed when there is compression of one or more nerve roots due to bony growths from a lamina of vertebrae. The growth makes the spinal column narrow, resulting in compression of nerve root/roots. In this type of surgery, a small part of lamina bone is removed.

Discectomy: Such surgery is performed when there is compression of one or more nerve roots due to herniation of a vertebral disc. In Discectomy, a part of disc compressing the nerve is removed.

Spinal Fusion: Such surgery is performed when there are irreversible arthritic changes, or instability of the spine, between two or more vertebrae. Spinal Fusion is generally used to correct the problems related to small bones of the spine causing stenosis and spinal canal stenosis.

Q2. Back surgery completely cures back pain.

1. True

2. False

Answer: False

Back surgery may not cure back pain 100%. In fact, in many cases, back pain may come back after surgery. This is called "Failed Back surgery syndrome" (FBSS ). It is estimated that the incidence of FBSS is around 25-40%. In other cases, even if back pain is cured, the patient may complain of leg pain. However, the leg pain may wane after a few weeks. This purely depends on patient to patient and the severity of the spine condition.

Q3. What are the most severe risks of back surgery?

1. Blood clots in legs and lungs

2. Heart attack and stroke

3. Nerve damage lead to paralysis, weakness, sexual dysfunction, loss of bladder or bowel control.

4. All the above

Answer: All the above

Every surgery has some degree of risk. In case of back surgery, there may be a number of risks depending on the type of surgery. The most severe of these are the risks of blood clots in the legs and lungs, heart attack, stroke and nerve damage.

Q4. Failed back surgery syndrome can be managed.

1. True

2. False

Answer: True

Failed back surgery indicates recurrence of patients same back pain and leg pain or occurrence of new pain in back or leg which was not there before the surgery. In most cases the reason inadequate clearance of nerve compression, damage to the spinal structure like nerves or scar tissue formation. In cases of inadequate surgery patient might require re-do spine surgery. If there is damage to the structure it need further surgical or pain management treatment. However, in may cases, one can get over the pain by doing regular stretching exercises after the surgery. Nevertheless, if scar tissue has affected the nerve roots, there is little that exercise alone can do. You need to perform specialised treatment called Racz procedure of scar adhesiolysis via a Racz catheter insertion under fluoroscopic guidance at pain clinics.

If you need exercises as well to take pain relieving medicines for around a year, you must consult pain clinic for long term pain relief. In cases where pain do not respond to these therapies, you may need spinal cord stimulation implantation treatment. Also consult your doctor at pain clinic regarding means of combating the pain.

Q5. What symptoms of nerve compression are RED FLAG and needs urgent back?

1. Back pain

2. Sexual dysfunction

3. Loss of bladder or bowel control.

4. Pain or numbness going down the arms or legs.

Answer: Loss of bladder or bowel control.

If you have Loss of bladder or bowel control its a RED FLAG sign. This means there is severe compression and this needs immediate surgery to remove the compression. The endoscopic surgery is one of the most rewarding and curative at Spine and pain clinics. Early surgery within 2 days improves the outcome. As the time is prolonged the chances of permanent damage is increased.

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Confusions: Sciatica is often misunderstood as lower back pain due to the similarity in their symptoms.

Familiarization: Sciatica is a pain caused by the sciatic nerve whose function is to carry neurological messages from the brain to the spinal cord. The pain usually radiates between buttocks to the toes. This pain is not only caused by the sciatic nerve but also caused by the joints, muscles and the discs.

Differentiation:

Lower back pain is usually a dull aching pain at the belt line /hip part occurring on one side whereas sciatica is a sharp shooting pain.

Causes:

Lower back pain can manifest due to pain from joint muscle and disc caused due to sudden movement, bad postures, menstrual cycles, stress and sickness. Catalysts of spasms could be a minor incident of sneezing, coughing or even putting on a sock. In hindsight, sciatica can be an acute outbreak easy to pinpoint unlike lower back pain, sciatic pain causes numbness along the whole foot and should not be overlooked and if continual pain exists then one should consult a physician.

Tenure:

Lower back pain if unresolved and is agonizing till after 6 weeks, should be consulted to a physician.

Conclusion:

Sciatica and lower back pain can be efficiently managed if timely counsel is taken.