A presentation to sumerizes causes and management of the Failed Back Syndrome

1. THE FAILED BACK
SYNDROME
PROF.WALID MAANI
JORDAN UNIVERSITY HOSPITAL

2. DEFINITION
Any condition where there is failure to
improve satisfactorily following back
surgery

3. 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

4. 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)

5. CLASSIFICATION OF FAILURE
 No improvement immediately after surgery
with outright failure to improve mono- or
polyradiculopathy
1) Wrong pre-operative diagnosis
2) Technical error

6. 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

7. 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

8. 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)

9. 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

10. CLASSIFICATION OF FAILURE
 Temporary relief but recurrence of pain
2) Mid-term (within weeks to months)
 Recurrent disc prolapse
 Battered root
 Arachnoiditis
 Patient expectations

11. 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

12. 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.

13. 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 arachnoiditis
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.

14. 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

15. 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. .

16. 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 1968
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.

17. TYPES
 SYNOVIAL CYSTS  GANGLION CYSTS
(those having a synovial (those lacking lining
lining membrane) membrane)

18. 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

19. 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.

20. 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

21. 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

22. IMAGING
PRE OPERATIVE TI WEEKS POST OP T1 8

23. IMAGING
SYNOVIAL CYST
PRE OPERATIVE TI WEEKS POST OP T1 8

24. IMAGING
SYNOVIAL CYST
PRE OPERATIVE T2 WEEKS POST OP T2 8

25. IMAGING
HYPERTOPHIED LIGAMENT
DECOMPRESSED CANAL
STENOSED LATERAL RECESS
SYNOVIAL CYST
HYPERTOPHIED JOINT
PRE OPERATIVE T2 WEEKS POST OP T2 8

27. FRAGMENT
COMMUNICATION
BETWEEN JOINT
AND CYST
INFECTED FLUID

28. 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)