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1
Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
drsandeep123@gmail.com...
FBSS
• Failed back surgery syndrome
Numbers of spine surgery increasing
!
Surgical results not always successful
3
Failed Back Surgery Syndrome
FBSS is a term applied to a heterogeneous group of
individuals who share only one character...
Failed back surgery syndrome
• Definition: the results of re-operation did not differ
significantly from those of initial ...
Failed back surgery syndrome
• No improvement
• Getting worse
• Recurrence after a period of pain relief
!
• Wrong diagnos...
6
Failed Back Patient Profile
Pain and suffering often disproportionate to any
identifiable disease process
Depression
Phy...
7
The “Ds” of FBSS
Disuse
Deconditioning
Drug misuse
Dependence
Depression
Disability
8
9% – 28% of the
population suffers from
moderate to severe chronic
non-cancer pain
American Pain Society
(2002); Chronic...
9
Pain Types
NOCICEPTIVE PAIN
results from ongoing activation of mechanical, thermal, or chemical nociceptors
typically op...
10
Neuropathic Pain
Pain in absence of ongoing tissue damage
Pain in an area of sensory loss
Paroxysmal or spontaneous pai...
11
Biopsychosocial Model of Pain
Pain Behavior
Suffering
Pain
Nociception
12
Failed Back Surgery Syndrome

Surgical Complications
Disk space infection
Iatrogenic instability
Nerve root injury
Reta...
13
CLASSIFICATION OF FAILURE
■ No improvement immediately after surgery
with outright failure to improve mono- or
polyradi...
14
■ No improvement immediately after surgery
with outright failure to improve mono- or
polyradiculopathy
1) Wrong pre-ope...
15
CLASSIFICATION OF FAILURE
■ No improvement immediately after surgery
with outright failure to improve mono- or
polyradi...
16
Failed Back Surgery Syndrome

Physician Decision Making
Poor patient selection
Poor patient selection
Poor patient sele...
Problems of re-operation
• Poor landmarks of anatomy
• Wrong level
• Neural injury
• Blood loss
• Longer op time
• Difficu...
F.B.S.S.
History taking
Neuro. exam
Image study
Psychosocial evaluation
Specific diagnosis
Mechanical causes Non-mechanica...
19
Most common cause of failed
back syndrome is poor
judgment on the part of the
physician. Surgery prescribed
as a last r...
20
CLASSIFICATION OF FAILURE
!
■ Temporary relief but recurrence of pain
1) Early recurrence of symptoms (within weeks)
1)...
21
JUXTAFACET (JFC) CYSTS :
■ Term originated by Kao
et al in 1974
■ First reported by von
Gruker in 1880 during
autopsy
■...
22
TYPES
■ SYNOVIAL CYSTS
(those having a synovial
lining membrane)
■ GANGLION CYSTS
(those lacking lining
membrane)
23
ETIOLOGY
Unknown
Possibilities
Synovial fluid extrusion from the joint
Latent growth of a developmental rest
Myxoid deg...
24
IMAGING
PRE OPERATIVE TI
8 WEEKS POST OP T1
SYNOVIAL CYST
SYNOVIAL CYST
25
IMAGING
PRE OPERATIVE T2 8 WEEKS POST OP T2
HYPERTOPHIED LIGAMENT
STENOSED LATERAL RECESS
HYPERTOPHIED JOINT
DECOMPRESS...
26
CLASSIFICATION OF FAILURE
!
■ Temporary relief but recurrence of pain
2) Mid-term (within weeks to months)
■ Recurrent ...
27
Battered root syndrome
The permanent radiculopathy caused by surgical trauma
was first called the battered root problem...
28
Arachnoiditis
Arachnoiditis is a disease of the spine which
results in the clumping or sticking of nerve roots
together...
29
Arachnoiditis
The most common causes of arachnoiditis are meningitis, spine 

surgery and trauma.
A cause for which the...
30
CLASSIFICATION OF FAILURE
!
■ Temporary relief but recurrence of pain
3) Longer-term failures (within months to years)
...
31
Disc space collapse
A number of relapses are due to disc space collapse.
Although the disc height is often decreased in...
32
Evaluation of the Patient with FBSS
Detailed pain history including prior treatments and
MOST IMPORTANTLY the outcome o...
33
Pain History
Where is it located?
Does the pain radiate?
When did it start and under what circumstances?
What is the qu...
34
Pain History
Effect of pain on sleep
Medications taken for pain
Health professionals consulted
Patient’s beliefs concer...
35
Treatment History
What therapies have been tried and what were the
outcomes?
Physical therapy
Injections
▪ Epidural ste...
36
Imaging Studies
Static plain radiographs
Spinal alignment
Flexion/extension views
Instability
Computed tomography (CT)
...
37
38
Post-operative Causes of Back Pain
Deconditioning Trauma
Muscle spasm Wrong level fused
Myofascial pain Insufficient le...
39
Post-operative Causes of Leg Pain
Retained disk fragment Arachnoiditis
Recurrent HNP Synovial cyst
Far lateral disk Roo...
40
Goals of Chronic Pain Management in Patients
with FBSS
Functional improvement
Functional improvement
Functional improve...
41
Common Features of Multidisciplinary Pain
Management
Physical therapy and rehabilitation
Medication management
Patient ...
42
Multidisciplinary Pain Clinic Personnel
Physicians
Neurosurgeon
Orthopedic surgeon
Anesthesiologist
Neurologist
Physiat...
43
44
Electrophysiological Studies
EMG is likely of greater utility in FBSS than
in primary low back pain and sciatica
!
Grea...
45
Diagnostic Blockade
Rationale is straightforward
In practice, it is much more
complicated
Specificity may be low
Single...
46
Facet Block
Blockade of the innervation of the facet joint will relieve
pain in some patients with facet disease
47
Facet Block
Rarely useful in patient with
FBSS
Transitional facet disease
above a fused level
!
Anatomy obliterated and...
48
Selective Nerve Root Block
Must be done accurately to provide any useful
information
!
One root at a time
!
Small volum...
49
Anticonvulsant Agents (AEDS)
Similarities in pathophysiology of neuropathic pain and
epilepsy
!
All AEDS ultimately act...
50
Antidepressant Analgesics

Relieves all components of neuropathic pain
!
Clear separation of analgesic and
antidepressa...
51
Corticosteroids
Useful in the short term for treatment of radicular pain
!
Limited role in the long-term treatment of F...
Adjacent instability( Case )
• Well-defined spondylolisthesis
• Dynamic instability with Slippage > 4 mm
Angle change > 10...
Risk factors --- not clearly defined
• Implant rigidity
• Bone grafting technique
• Gender
• Age
• Decompression beyond fu...
Procedures
• Decompression
– Through adjacent virgin site to stenosis
– Medial facetectomy
• Extension of PLF with autogra...
Best treatment is prevention
• Preservation of segmental stability during
decompression
• Avoidance of violating adjacent ...
Results of multiple operated back is still favorable
Right diagnosis
Right patient
Right surgery
Right surgeon
57
This presentation is for doctors in general.!
. Some graphics and jpeg files are taken from
Google Image  to heighten th...
58
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Approach to Failed back surgery syndrome (FBSS ) Agrasen hospital gondia vidarbha dr sandeep c agrawal www.drsandeepagrawal.com www.agrasenortho.com

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Failed Back and Neck Surgery Syndromes happen when a surgery to correct pain completely fails to alleviate the pain and in some cases makes the pain worse.

There are many reasons why a surgery could fail to provide results, both related to the patient and the surgeon.

How is it that a patient could cause a surgery to fail. A great example of this would be that a patient has undergone a spinal fusion to correct spinal instability in the lower back. The surgeon has advised the patient that smoking cigarettes which could severely reduce the healing chances and effect the fusion process. The patient ignores the doctor and continues to smoke and the fusion doesn’t heal. This is an example of the patient being at fault.

In what ways could a surgeon be at fault? There are many times that there is fault before the surgery is even performed. If there is an inaccurate diagnoses the surgery will be performed in the wrong area, and possibly the wrong surgery will be done. It is important to seek a second opinion of a specialist before proceeding with surgery of any kind. If two heads can agree on what and where the problem is, it is likely that there will be an accurate diagnosis.

One of the most common reasons for Failed Back and Neck Surgery Syndrome is that the surgeon is just not experienced enough in the technique being performed and he/she doesn’t perform it properly. This is why it is important to ask the right questions to the surgeon before moving forward with the surgery. How long have you been performing back surgeries? How long have you been performing this specific surgical procedure? and how many times a year do you perform this surgery.

Back and neck surgeries are procedures meant to be a permanent fix for a specific problem and correcting failed back or neck surgery is difficult.
Human spine is a complex structure that provides both mobility (so to bend and twist) and stability (so to remain upright). The normal curvature of spine has an “s”- like curve when looked at from the side. This curvature allows even distribution of weight and with stand stress.

Published in: Science
  • The spine is composed of 33 bones, called vertebrae, divided into five sections: the cervical, thoracic, and lumbarspine sections, and the sacrum and coccyx bones. The cervical section of the spine is made up of the top seven vertebrae in the spine, C1 to C7, and is connected to the base of the skull. The top two vertebrae are also know as the atlas and axis, which form the joint for connecting the skull to the spine. The cervical section is responsible for mobility and normal functioning of the neck, as well as protection of the spinal cord, arteries and nerves that travel from the brain to the body. The thoracic section of the spine is located at chest level, between the cervical and lumbar vertebrae. The vertebrae in this section are labeled T1 to T12 and serve as attachments for the rib cage. The lumbar section is located between the thoracic vertebrae and the sacrum. The five lumbar vertebrae, labeled L1 to L5, are the main weight-bearing section of the spinal column. The sacrum is the section located at the base of the spine. It does not have discs separating the vertebrae, because its five levels, S1 to S5, are fused together. The pelvis is connected to the spinal column at the sacrumsection. The coccyx is at the very base of the spinal column and is made of four vertebrae that are fused together.
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Approach to Failed back surgery syndrome (FBSS ) Agrasen hospital gondia vidarbha dr sandeep c agrawal www.drsandeepagrawal.com www.agrasenortho.com

  1. 1. 1 Dr.Sandeep Agrawal Consultant Orthopedic Surgeon MS,DNB Agrasen Hospital Gondia Maharashtra India drsandeep123@gmail.com www.drsandeepagrawal.com www,agrasenortho.com Failed Back Surgery Syndrome(FBSS) SYNOVIAL CYST
  2. 2. FBSS • Failed back surgery syndrome Numbers of spine surgery increasing ! Surgical results not always successful
  3. 3. 3 Failed Back Surgery Syndrome FBSS is a term applied to a heterogeneous group of individuals who share only one characteristic - continued back and/or extremity pain following one or more spinal operations 15% of patients will experience persistent or recurrent symptoms Spectrum of abnormalities ranging from purely organic to purely psychological, but in most cases consists of a physiological abnormality complicated by psychological factors FBSS is perhaps the prototypical example of chronic pain as a biopsychosocial disorder
  4. 4. Failed back surgery syndrome • Definition: the results of re-operation did not differ significantly from those of initial surgery ! • Etiology: – Recurrent disc herniation – Segmental instability – Spinal stenosis – Infection
  5. 5. Failed back surgery syndrome • No improvement • Getting worse • Recurrence after a period of pain relief ! • Wrong diagnosis • Inadequate treatment – Wrong level or side – Inadequate decompression or stabilization
  6. 6. 6 Failed Back Patient Profile Pain and suffering often disproportionate to any identifiable disease process Depression Physical deconditioning Inappropriate use of physician-prescribed medications Superstitious beliefs about bodily functions Failure to work or perform expected physical and cognitive activities No active medical problems that can be remediated with the expectation of relief of pain
  7. 7. 7 The “Ds” of FBSS Disuse Deconditioning Drug misuse Dependence Depression Disability
  8. 8. 8 9% – 28% of the population suffers from moderate to severe chronic non-cancer pain American Pain Society (2002); Chronic pain in America: roadblocks to relief Chronic Pain – Scope of the Problem
  9. 9. 9 Pain Types NOCICEPTIVE PAIN results from ongoing activation of mechanical, thermal, or chemical nociceptors typically opioid-responsive eg. pain related to mechanical instability ! NEUROPATHIC PAIN spontaneous or evoked pain that occurs in the absence of ongoing tissue damage typically opioid-resistant*** eg. pain secondary to nerve root injury
  10. 10. 10 Neuropathic Pain Pain in absence of ongoing tissue damage Pain in an area of sensory loss Paroxysmal or spontaneous pain Characteristics of pain: burning, pulsing, stabbing Allodynia, hyperalgesia, or dysesthesias Delay in onset following injury Presence of major neurological deficit Poor response to opioids
  11. 11. 11 Biopsychosocial Model of Pain Pain Behavior Suffering Pain Nociception
  12. 12. 12 Failed Back Surgery Syndrome
 Surgical Complications Disk space infection Iatrogenic instability Nerve root injury Retained disk fragment Recurrent disk herniation Inadequate decompression Complications of fusion and instrumentation Adhesive arachnoiditis
  13. 13. 13 CLASSIFICATION OF FAILURE ■ No improvement immediately after surgery with outright failure to improve mono- or polyradiculopathy 1) Wrong pre-operative diagnosis 2) Technical error
  14. 14. 14 ■ 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
  15. 15. 15 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
  16. 16. 16 Failed Back Surgery Syndrome
 Physician Decision Making Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection Poor patient selection
  17. 17. Problems of re-operation • Poor landmarks of anatomy • Wrong level • Neural injury • Blood loss • Longer op time • Difficulty in instrumentation • Inadequate bone graft
  18. 18. F.B.S.S. History taking Neuro. exam Image study Psychosocial evaluation Specific diagnosis Mechanical causes Non-mechanical causes Appropriate surgery Medical tx Rehabilitation Psycho. tx
  19. 19. 19 Most common cause of failed back syndrome is poor judgment on the part of the physician. Surgery prescribed as a last resort, with a hope and a prayer that it might alleviate the pain.
  20. 20. 20 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
  21. 21. 21 JUXTAFACET (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 ARISING FROM 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.
  22. 22. 22 TYPES ■ SYNOVIAL CYSTS (those having a synovial lining membrane) ■ GANGLION CYSTS (those lacking lining membrane)
  23. 23. 23 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
  24. 24. 24 IMAGING PRE OPERATIVE TI 8 WEEKS POST OP T1 SYNOVIAL CYST SYNOVIAL CYST
  25. 25. 25 IMAGING PRE OPERATIVE T2 8 WEEKS POST OP T2 HYPERTOPHIED LIGAMENT STENOSED LATERAL RECESS HYPERTOPHIED JOINT DECOMPRESSED CANAL SYNOVIAL CYST
  26. 26. 26 CLASSIFICATION OF FAILURE ! ■ Temporary relief but recurrence of pain 2) Mid-term (within weeks to months) ■ Recurrent disc prolapse ■ Battered root ■ Arachnoiditis ■ Patient expectations
  27. 27. 27 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
  28. 28. 28 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.
  29. 29. 29 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. 

  30. 30. 30 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
  31. 31. 31 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. .
  32. 32. 32 Evaluation of the Patient with FBSS Detailed pain history including prior treatments and MOST IMPORTANTLY the outcome of each ! Obtain appropriate imaging studies (including those on which surgical decisions were based) ! Attempt to establish the underlying cause of the pain; however……….
  33. 33. 33 Pain History Where is it located? Does the pain radiate? When did it start and under what circumstances? What is the quality of the pain? What is the severity of the pain (VAS scores) What factors make it worse? What factors make it better? Are there associated symptoms?
  34. 34. 34 Pain History Effect of pain on sleep Medications taken for pain Health professionals consulted Patient’s beliefs concerning the cause of pain Expectations of outcome of treatment Family expectations Pain reduction required for “reasonable activities
  35. 35. 35 Treatment History What therapies have been tried and what were the outcomes? Physical therapy Injections ▪ Epidural steroids, nerve root blocks, facet blocks, etc Medication history What drugs? Dose? How long? Effect?
  36. 36. 36 Imaging Studies Static plain radiographs Spinal alignment Flexion/extension views Instability Computed tomography (CT) Bony surgical defects Hardware placement Fusion mass Magnetic resonance imaging (MRI) Soft tissue and neural structures Radionuclide imaging Technetium99 bone scan Indium111 WBC scan
  37. 37. 37
  38. 38. 38 Post-operative Causes of Back Pain Deconditioning Trauma Muscle spasm Wrong level fused Myofascial pain Insufficient levels fused Spinal instability Pseudomeningocele Diskogenic pain Graft donor site pain Facet arthropathy Psychosocial factors Infection Pseudarthrosis Loose hardware Arachnoiditis
  39. 39. 39 Post-operative Causes of Leg Pain Retained disk fragment Arachnoiditis Recurrent HNP Synovial cyst Far lateral disk Root sleeve meningocele Lateral recess stenosis Loose hardware Inadequate decompression Facet fracture Wrong level decompressed Psychosocial factors Nerve root injury Retained foreign body Epidural fibrosis
  40. 40. 40 Goals of Chronic Pain Management in Patients with FBSS Functional improvement Functional improvement Functional improvement!!! Improvement in physical activities and exercise tolerance Reduction in narcotic use Reduction in healthcare consumption Return to work Pain reduction
  41. 41. 41 Common Features of Multidisciplinary Pain Management Physical therapy and rehabilitation Medication management Patient education about pain and body function Psychological treatments Coping skills training Vocational assessment Therapies targeted toward improving the likelihood of return to work Surgical interventions for selected patients
  42. 42. 42 Multidisciplinary Pain Clinic Personnel Physicians Neurosurgeon Orthopedic surgeon Anesthesiologist Neurologist Physiatrist Internal medicine Psychiatrist Addictionologist Nurses Psychologists Physical Therapist Occupational Therapist Vocational counselor Social worker Dietician Recreational staff Administrative support staff
  43. 43. 43
  44. 44. 44 Electrophysiological Studies EMG is likely of greater utility in FBSS than in primary low back pain and sciatica ! Greatest use is for establishing the presence of a peripheral neuropathy ! May be helpful for defining a feigned neurological deficit ! Rarely using in decision-making regarding treatment
  45. 45. 45 Diagnostic Blockade Rationale is straightforward In practice, it is much more complicated Specificity may be low Single blocks (positive or negative) have a high error rate Placebo controls provide the most accurate information Multiple blocks using different agents BLOCKS ARE ADJUNCTS AND SHOULD NEVER BE SUBSTITUTED FOR SOUND CLINICAL JUDGEMENT !
  46. 46. 46 Facet Block Blockade of the innervation of the facet joint will relieve pain in some patients with facet disease
  47. 47. 47 Facet Block Rarely useful in patient with FBSS Transitional facet disease above a fused level ! Anatomy obliterated and accurate block not possible ! Blockade of pseudarthrosis may sometimes be useful
  48. 48. 48 Selective Nerve Root Block Must be done accurately to provide any useful information ! One root at a time ! Small volume of local anesthetic without steroids ! Confirm the presence of an adequate block ! Confirm findings on repetitive blocks
  49. 49. 49 Anticonvulsant Agents (AEDS) Similarities in pathophysiology of neuropathic pain and epilepsy ! All AEDS ultimately act on ion channels ! Efficacy of AEDS most clearly established for neuropathic conditions characterized by episodic lancinating pain ! Most clinical studies have focused on DPN and PHN ! Use of AEDS in patients with FBSS is nearly entirely empiric
  50. 50. 50 Antidepressant Analgesics
 Relieves all components of neuropathic pain ! Clear separation of analgesic and antidepressant effects ! Although other agents (eg anti-epileptics)) may be regarded as 1st line therapy over antidepressants, there is no good evidence for this practice ! More selective agents are either less effective or not useful (serotonergic, noradrenergic)
  51. 51. 51 Corticosteroids Useful in the short term for treatment of radicular pain ! Limited role in the long-term treatment of FBSS ! Epidural or transforaminal steroids for selected patients Cochrane Review (Nelemans, et al., 2002) Most trials included patients with radicular pain No significant difference in pain relief after 6 weeks or 6 months between ESI and placebo
  52. 52. Adjacent instability( Case ) • Well-defined spondylolisthesis • Dynamic instability with Slippage > 4 mm Angle change > 10° on flexion and extension views
  53. 53. Risk factors --- not clearly defined • Implant rigidity • Bone grafting technique • Gender • Age • Decompression beyond fused level • Posterior complex ! • Biomechanical factors
  54. 54. Procedures • Decompression – Through adjacent virgin site to stenosis – Medial facetectomy • Extension of PLF with autograft • Instrumentation – Old screws ! new screws with larger diameter – TPS through virgin pedicles of adjacent segment
  55. 55. Best treatment is prevention • Preservation of segmental stability during decompression • Avoidance of violating adjacent joint during instrumentation • As short fusion as possible • Preservation of intact posterior complex
  56. 56. Results of multiple operated back is still favorable Right diagnosis Right patient Right surgery Right surgeon
  57. 57. 57 This presentation is for doctors in general.! . Some graphics and jpeg files are taken from Google Image  to heighten the specific points in this presentation. ! • If there is any objection/or copyright violation, please inform drsandeep123@gmail.com for prompt deletion. ! • It is intended for use only by the doctors of orthopaedic surgery.! . Views expressed in this presentation are personal. • .For any confusion please contact the sole author for clarification. ! • Every body is allowed to copy or download and use the material best suited to him. !
  58. 58. 58

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