Pain After Spine Surgery

07 February 2011

Spine surgery may not alleviate all pain associated with the conditon causing symptoms. After spine surgery, a patient may find themselves still suffering from back pain. To decide the proper treatment plan, many steps need to be taken.

An office visit at a pain specialist for pain after back surgery should include obtaining a history, performing a physical exam, and doing additional studies. The patient may also be asked if they have recently seen the spine surgeon that did their back surgery.  Once this information is gathered and a diagnosis is made, then a treatment plan can be created and executed.  While treating back pain after spine surgery, the process in finding the best answer to this question usually involves these steps:

History

A thorough history about recurring back pain and symptoms should be obtained.  How did the symptoms return? Was there a fall or some type of accident that brought the symptoms on? Are the symptoms the same as before? If there is no inciting event, and the symptoms are of similar nature prior to the back surgery, then more than likely there is not new pathology with the spine.  This, of course, is not always the case, so further information is always needed.  The pain physician may also inquire about any radiating “tingling” or “numbness” sensation down the lower extremities.  Is there weakness? Does the pain feel “burning”? Serious symptoms could include bowel or bladder incontinence and/or new weakness.

Physical

A physical exam will need to be conducted to assess if there are any new neurological symptoms.  Prior to the exam, a pain physician should acquire a baseline exam from old medical records as well as in the new consult visit.  Did the patient have a foot drop before the surgery or is it new?  There should be a focus on abnormal reflexes, sensory deficits, and loss of strength.  If there are any of these findings, then the patient might have new pathology of the spinal cord and/or its nerve roots, which is also known as myelopathy. An exam performed on the patient’s spine joints or facet joints will be conducted to see if this reproduces the patient’s symptoms.

Additional Studies

Imaging, such as an MRI, CT scan with a myelogram, or simple flexion/extension x-rays can be helpful in assessing for new pathology.  An option is to perform minimally invasive; x-ray guided diagnostic blocks to the medial branch nerves.  The medial branch nerves innervate the joints of the spine called the facet joints.  These joints can often be a source of pain above and below an area of the spine that has been fused from a back surgery.  If the patient gets relief from these nerve blocks, then it can be determined that pain emanates from these facet joints.  The patient may also undergo a nerve conduction study or EMG to assess if the there might be pathology originating from the spinal cord or its nerve roots versus the peripheral nerves. 

Diagnosis

If the patient has new pathology and findings, then the appropriate diagnosis can be made.  It could be a new herniated disc, muscle spasm, or compression of the spine, called a vertebral compression fracture. It could be an enlargement of the main ligament in the back of the spine leading to a narrowing of the spinal canal, which is is called spinal canal stenosis.  It might be faulty surgical hardware, although this is less common.   If the patient has no new pathology, then the diagnosis of post laminectomy pain syndrome is usually made.  This is simply pain that persists after spine surgery.

Treatment

As a general rule, most pain physicians will have the patient re-evaluated by the spine surgeon who did the initial surgery.  Special care should be taken to explain to the patient that this does not necessarily mean that they will have to have another back operation. It is an important step in the diagnostic and treatment plan process.  If the patient has significant new pathology and is at risk for permanent spinal cord injury, then a second surgery may be needed.  If the patient has a diagnosis that is non-surgical, then many different treatment options can be explored.  A good spine surgeon and pain specialist will work in concert together, along with the goals and desires of the patient, to determine if a re-operation is best.

Conservative treatment measures such as physical therapy and medications that include non-steroidal anti-inflammatory drugs (NSAIDS), muscle-relaxants, and pain medications may suffice.  Chiropractic care and acupuncture are options.  Treatment to fix vertebral body fractures can be done by placing cement in the bones through a procedure called vertebroplasty.  Facet joint pain can be alleviated by cauterizing the nerves to the joints utilizing a procedure called radiofrequency ablation.

Minimally invasive procedures can be highly successful in treating this type of pain.  Contrary to popular belief, some patients still receive periodic epidural steroid injections after their back surgery to treat recurring “sciatica” or radiating leg pain.  The thinking behind this is that although the disc may be stabilized or a majority of it removed, there may still be some inflammation of the nerve(s) from the spine.  This may be from direct mechanical compression, adhesions (scar tissue), or inflammatory agents released from the disc.  The steroid from the epidural may help alleviate this inflammation and, in essence, “calm” the nerve.  Another highly successful procedure that can be done is a procedure that that was created by Professor Dr. Gabor Racz, called an epidural lysis of adhesions or the Racz procedure.  It is also minimally invasive and involves the chemical and mechanical breakdown of the scar tissue that can result from back surgery.  This procedure typically works best when done within a year of the surgery.

Lastly, if all conservative and minimally invasive avenues are exhausted and the patient’s pain still persists, a spinal cord stimulator (SCS) may be recommended.  Post laminectomy pain syndrome is the number one reason why this procedure is done in the United States.  One the benefits of this procedure is the fact that patients will get to try it out (called an SCS trial) to see if it works for you before any kind of surgical intervention.   An SCS trial is very similar to an epidural, but instead of medications being placed through the needles, a small flexible lead is placed through the needle and steered with x-ray guidance to the right location.  The device is then tested and there is an exchange of the painful transmissions for a mild massaging sensation in the patient’s area(s) of pain.  The needles are then removed and the small leads are taped to the skin.  The patient tries the device for 3-5 days, and if the patient has more than 50% reduction in their normal pain symptoms, they are a candidate to have the permanent device placed. Unlike many other surgeries, SCS has a “try it before you buy it” option.  If the patient is convinced that this device will help them, the device is permanently implanted like a pacemaker and is sometimes called a “pacemaker for pain.”

Pain after spine surgery can be complex to diagnose and difficult to treat, but hopefully with the right pain specialist and surgeon, you can find the best options for you.