Neurochirurgie
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Low back surgery, including as many type of spine procedures as the multitude of failed back surgery syndrome (FBSS) etiologies, is not always the answer for patients with chronic low back pain. Paradoxically, although a patient is considered to present FBSS because he has already undergone spinal surgery, any new symptom in the back or deterioration of back pain must not be immediately attributed to FBSS, but could be related to another cause independently of the initial mechanical problem. The aim of this paper is to extensively review the potential back pain generators in FBSS patients and to discuss their respective roles and interactions in back pain pathophysiology. ⋯ Clinical investigations of the low back pain component in FBSS patients should be based on meticulous dissection of all potential triggers that could be a source of the nociceptive pain characteristics and possibly amenable to further aetiological treatment. Clinicians should therefore refine pain management strategies to ensure that the chronic nature of the pain becomes the guiding principle for multidisciplinary assessment.
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Failed back surgery syndrome (FBSS) results from a cascade of medical and surgical events that lead to or leave the patient with chronic back and radicular pain. This concept is extremely difficult to understand, both for the patient and for the therapist. The difficulty is related to the connotations of failure and blame directly associated with this term. The perception of the medical situation varies enormously according to the background and medical education of the clinician who manages this type of patient. Eight health system experts (2 pain physicians, 1 orthopaedic spine surgeon, 1 neuro spine surgeon, 1 functional neurosurgeon, 1 physiatrist, 1 psychologist and one health-economic expert) were asked to define and share their specialist point of view concerning the management of postoperative back and radicular pain. Ideally, it could be proposed that the patient would derive optimal benefit from systematic confrontation of these various points of view in order to propose the best treatment option at a given point in time to achieve the best possible care pathway. ⋯ The initial pejorative connotation of FBSS suggesting failure or blame must now be replaced to direct the patient and therapists towards a temporal concept focusing on the future rather than the past. In addition to the redefinition of an optimised care pathway, a consensus based on consultation would allow redefinition and renaming of this syndrome in order to ensure a more positive approach centered on the patient.
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Persisting pain after spine surgery remains a challenge for the patient and the pain physician. The etiology depends on age, pathology and the interval between the first and the revision surgery. In young patients who underwent initially to discectomy, the etiology of failed back surgery syndrome (FBSS) is commonly a recurrence of herniation whereas in the elderly population, who has previously undergone a spinal fusion, persisting pain might be due to secondary sagittal unbalance associated, as a consequence, to adjacent disc disease or pseudarthrosis. ⋯ Dealing with FBSS patients is far from simple but it corresponds to daily practice for spine surgeons. Clinical and radiological assessments should include a full diagnostic work-up focusing on sagittal balance. Surgical treatment and re-operation might be an option if a consistent source of pain is detected.
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Review Meta Analysis
Optimal medical, rehabilitation and behavioral management in the setting of failed back surgery syndrome.
Failed back surgery syndrome (FBSS) constitutes a constellation of symptoms grouped together and attributed to prior surgical intervention. Clinicians often poorly understand the heterogeneity of this condition combined with the etiological factors responsible for its development. Therefore, it would follow that an algorithmic treatment approach to patients diagnosed with this syndrome might pose challenges. The clinical work-up of the patient involves history, examination and appropriate diagnostic imaging as well as behavioral assessment. ⋯ Overall, the literature provides very limited guidance on the comprehensive management of patients suffering from FBSS. There are rehabilitative interventions and behavioral protocols that demonstrate promise. Pathways based on medication management remain difficult to clearly define.