Failed Back Syndrome

THE FAILED BACK SYNDROME

PROF.WALID MAANI

JORDAN UNIVERSITY HOSPITAL

DEFINITION

Any condition where there is failure to improve satisfactorily following back

surgery

Vert Mooney in 1988

We in the industrialized societies have a significant burden. We must explain why the problem of chronic back disability in third world countries is virtually unknown. Have we the sophisticated, scientific physicians created our own monster, the failed back syndrome?

Mooney V. (1988): The failed back. Int Disabil Stud 10:32-36

CLASSIFICATION OF FAILURE

No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy

Temporary relief but recurrence of pain Early recurrence of symptoms (within weeks) Mid-term (within weeks to months) Longer-term failures (within months to years)

CLASSIFICATION OF FAILURE

No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy

1) Wrong pre-operative diagnosis

2) Technical error

CLASSIFICATION OF FAILURE

No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy1) Wrong pre-operative diagnosis

1) Tumor2) Infection3) Metabolic Disease4) Psychosocial5) Discogenic pain (IDD,IDR)6) Decompression done too late for disc

sequestration

CLASSIFICATION OF FAILURE

No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy2) Technical error

1) Missed level or levels

2) Failure to perform adequate decompression1) Missed fragment including foraminal disc

2) Failure to recognize canal stenosis

3) Conjoined nerve root

CLASSIFICATION OF FAILURE

Temporary relief but recurrence of pain1) Early recurrence of symptoms (within weeks)

2) Mid-term (within weeks to months)

3) Longer-term failures (within months to years)

CLASSIFICATION OF FAILURE

Temporary relief but recurrence of pain1) Early recurrence of symptoms (within weeks)

1) Infection

2) Meningeal cyst

3) Juxtafacet cyst1) Synovial cyst

2) Ganglion cyst

CLASSIFICATION OF FAILURE

Temporary relief but recurrence of pain2) Mid-term (within weeks to months)

Recurrent disc prolapse Battered root Arachnoiditis Patient expectations

Battered root syndrome

The permanent radiculopathy caused by surgical trauma was first called the battered root problem by Bertrand in 1975. It is the reappearance of radicular pain after the relief of sciatica by operation. The pain is constant, burning, increased by motion or Valsalva. At that time rhizotomy was suggested as the treatment. Since it is considered now as a type of peripheral neuropathy, the treatment shifted to spinal cord stimulation (SCS).

Bertrand G. The battered root problem Orthop Clin North Am. 1975 Jan;6(1):305-10

Arachnoiditis

Arachnoiditis is a disease of the spine which results in the clumping or sticking of nerve roots together inside the spinal fluid. The nerves adhere together therefore the technical name of the condition is "adhesive arachnoiditis".

Arachnoiditis occurs intradurally whereas peridural fibrosis occurs extradurally in the epidural space.

Clumping of roots

Arachnoiditis

The most common causes of arachnoiditis are meningitis, spine surgery and trauma.  

A cause for which there are a few case reports in the literature are epidural steroid injections . Epidural analgesia not cause.

The incidence of arachnoiditis after spine surgery in patients undergoing re-operation for pain ranges from 3.5% to 16%

Ribeiro C, Reis FC Findings and outcome of revision lumbar disc surgery J Spinal Disord 1999 Aug;12(4):287-92 and

Lumbar arachnoiditis Acta Med Port 1998 Jan;11(1):59-65.

Operative photograph of adhesive arachnoiditis

CLASSIFICATION OF FAILURE

Temporary relief but recurrence of pain3) Longer-term failures (within months to years)

1) Recurrent stenosis or development of lateral stenosis from disc space collapse

2) Instability

Disc space collapse

A number of relapses are due to disc space collapse. Although the disc height is often decreased in the preoperative patient with a herniated nucleus pulposus, it is an exceedingly common occurrence following surgical discectomy.

Disc space narrowing is very important in terms of decreasing the size of the neural foramina and altering facet loading and function.

The entire process predisposes to the development of hypertrophic changes of the articular processes.

Hanley EN, Shapiro DE. The development of low-back pain after excision of a lumbar disc. J Bone Joint Surg 1989;71A:719-721

Schneck CD. The anatomy of lumbar spondylosis. Clin Orthop 1985;193:20-37. .

JUXTAFACIT (JFC) CYSTS

Term originated by Kao et al in 1974

First reported by von Gruker in 1880 during autopsy

First diagnosed clinically in 1968

CYSTS ADJACENT TO THE FACET

JOINT, OR ARISINGFROM THE

LIGAMENTUM FLAVUM

Kao C.C., Winkler S.S., Turner J.H: Synovial Cyst of Spinal Facet. J Neurosurg 41:372-6,1974.Kao C.C., Uihlein A., Bickelr W.H: Lumbar Intraspinal Extradural Ganglion Cyst. J Neurosurg 29:168-72,1968.

TYPES

SYNOVIAL CYSTS (those having a synovial

lining membrane)

GANGLION CYSTS (those lacking lining

membrane)

ETIOLOGY

Unknown Possibilities

Synovial fluid extrusion from the joint Latent growth of a developmental rest Myxoid degeneration and cyst formation in

collagenous connective tissue Increased motion plays a role in some cases

INCIDENCE

Rare (2 in 1000 CT Spine) Frequency of diagnosis is rising due to:

Frequent use of MRI Clinical awareness

Mercader J. Gomez J.M., Cardinal C.: Intraspinal Synovial Cysts: Diagnosis by CT. Follow up and spontaneous remission. Neuroradiology 27:346-8, 1985.

CLINICAL PRESENTATION

May be asymptomatic Average age 60 More in females In patients with severe spondylosis, facet joint

degeneration and spondylolisthesis. L4/5 is the commonest level May be bilateral Radicular pain is the commonest symptom

CLINICAL PRESENTATION

May contribute to canal stenosis and produce intermittent claudication

May present as a quada equina lesion Symptoms are more intermittent than with

firm compressing lesions like HID A sudden increase in symptoms may indicate

hemorrhage in the cyst

IMAGING

PRE OPERATIVE TI 8 WEEKS POST OP T1

IMAGING

PRE OPERATIVE TI 8 WEEKS POST OP T1

SYNOVIAL CYST

IMAGING

PRE OPERATIVE T2 8 WEEKS POST OP T2

SYNOVIAL CYST

IMAGING

PRE OPERATIVE T2 8 WEEKS POST OP T2

HYPERTOPHIED LIGAMENT

STENOSED LATERAL RECESS

HYPERTOPHIED JOINT

DECOMPRESSED CANAL

SYNOVIAL CYST

FRAGMENT

COMMUNICATION BETWEEN JOINT AND CYST

INFECTED FLUID

DIFFRENTIAL DIAGNOSIS

Differentiating JFC from other masses rely on appearance and location: Neurofibroma (may not be calcified) Free fragment of HID ( not cystic, anterolateral) Epidural or nerve root metastases ( not cystic) Arachnoid cyst ( not associated with joint) Perineural cysts (Tarlov) ( usually on sacral

roots)