THE FAILED BACKSYNDROME PROF.WALID MAANIJORDAN UNIVERSITY HOSPITAL
DEFINITIONAny 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 polyradiculopathy 1) Wrong pre-operative diagnosis 1) Tumor 2) Infection 3) Metabolic Disease 4) Psychosocial 5) 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 polyradiculopathy 2) Technical error 1) Missed level or levels 2) Failure to perform adequate decompression 1) Missed fragment including foraminal disc 2) Failure to recognize canal stenosis 3) Conjoined nerve root
CLASSIFICATION OF FAILURE Temporary relief but recurrence of pain 1) 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 pain 1) Early recurrence of symptoms (within weeks) 1) Infection 2) Meningeal cyst 3) Juxtafacet cyst 1) Synovial cyst 2) Ganglion cyst
CLASSIFICATION OF FAILURE Temporary relief but recurrence of pain 2) 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 Clumping of roots 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.
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% Operative photograph of adhesive arachnoiditisRibeiro C, Reis FC Findings and outcome of revision lumbar disc surgery J Spinal Disord 1999 Aug;12(4):287-92 andLumbar arachnoiditis Acta Med Port 1998 Jan;11(1):59-65.
CLASSIFICATION OF FAILURE Temporary relief but recurrence of pain 3) 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:719-721Schneck CD. The anatomy of lumbar spondylosis. Clin Orthop 1985;193:20-37. .
JUXTAFACIT (JFC) CYSTS CYSTS ADJACENT Term originated by Kao TO THE FACET et al in 1974 JOINT, OR ARISING First reported by von Gruker in 1880 during FROM THE autopsy LIGAMENTUM FLAVUM First diagnosed clinically in 1968Kao C.C., Winkler S.S., Turner J.H: Synovial Cyst of Spinal Facet. JNeurosurg 41:372-6,1974.Kao C.C., Uihlein A., Bickelr W.H: Lumbar Intraspinal ExtraduralGanglion Cyst. J Neurosurg 29:168-72,1968.
TYPES SYNOVIAL CYSTS GANGLION CYSTS (those having a synovial (those lacking lining lining membrane) 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 awarenessMercader 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 SYNOVIAL CYST PRE OPERATIVE TI WEEKS POST OP T1 8
IMAGING SYNOVIAL CYST PRE OPERATIVE T2 WEEKS POST OP T2 8
IMAGINGHYPERTOPHIED LIGAMENT DECOMPRESSED CANAL STENOSED LATERAL RECESS SYNOVIAL CYSTHYPERTOPHIED JOINT PRE OPERATIVE T2 WEEKS POST OP T2 8
FRAGMENT COMMUNICATION BETWEEN JOINT AND CYSTINFECTED 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)