Chronic Lumbar Radiculopathy

2019 ◽  
pp. 95-104
Author(s):  
Brian J. A. Gill ◽  
Farhan A. Khan ◽  
Christopher J. Winfree
Keyword(s):  
Infusion Pump ◽  
Failed Back Surgery Syndrome ◽  
Neurological Deficits ◽  
Lumbar Radiculopathy ◽  
Lumbar Surgery ◽  
Failed Back Surgery ◽  
Pump Placement ◽  
Surgical Options ◽  
Intrathecal Infusion

Failed back surgery syndrome (FBSS), or post-laminectomy syndrome, is a form of chronic lumbar radiculopathy characterized by persistent pain following spinal surgery. When medical management for FBSS fails, three surgical options remain: revision lumbar surgery, spinal cord stimulation (SCS), or intrathecal infusion pump placement. If faced with neurological deficits and correlative compressive lesions, revision lumbar surgery is often indicated. But in the absence of such complications, surgeons and their patients can explore the two latter options. Thus, this chapter will implement a case study to navigate the decision making involved when choosing either SCS or intrathecal infusion pump placement.

scholarly journals Factors Predicting the Success of Adhesiolysis Using a Steerable Catheter in Lumbar Failed Back Surgery Syndrome: A Retrospective Study

2021 ◽  
Vol 10 (5) ◽  
pp. 913
Author(s):  
Ji Yeong Kim ◽  
Yong Ho Lee ◽  
Subin Yoo ◽  
Ji Young Kim ◽  
Mina Joo ◽  
...  
Keyword(s):  
Poor Response ◽  
Failed Back Surgery Syndrome ◽  
Foraminal Stenosis ◽  
Outer Diameter ◽  
Lumbar Surgery ◽  
First Line ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
Reasonable Evidence ◽  
Reduction Effect

Failed back surgery syndrome (FBSS) is a commonly encountered disease after lumbar surgery. There are many cases where it is difficult to choose a treatment because no specific cause can be found. Nevertheless, according to recent reports, adhesiolysis has shown reasonable evidence. However, considering its poor cost-effectiveness, adhesiolysis cannot be used as the first line of treatment. FBSS patients often suffer from chronic pain; accordingly, they become frustrated when this treatment produces a poor response. Therefore, before the procedure, the target group must be selected carefully. We sought to identify the pre-procedure factors predicting the effect of adhesiolysis in FBSS. A total of 150 patients were evaluated and analyzed retrospectively. Of these 150 patients, 69 were classified as responders three months after the procedure (46%). The outer diameter of the catheter during the procedure and grade of foraminal stenosis were correlated with the procedure effect. In conclusion, of the 2.1 mm diameter of the catheter, 1.7 mm of it was used during the procedure, and the milder the foraminal stenosis, the greater the pain reduction effect was three months after the procedure.

Edema caused by continuous epidural hydromorphone infusion: A case report and review of the literature

2018 ◽  
Vol 4 (4) ◽  
pp. 255 ◽  
Author(s):  
Xiulu Ruan, MD ◽  
Riaz Tadia, MD ◽  
Hainan Liu, MS ◽  
John Patrick Couch, MD ◽  
John Keun-Sang Lee, MD, PhD
Keyword(s):  
Case Report ◽  
Infusion Pump ◽  
Failed Back Surgery Syndrome ◽  
Outpatient Setting ◽  
Leg Pain ◽  
First Case ◽  
Epidural Opioid ◽  
Failed Back Surgery ◽  
Catheter Tip ◽  
Lockout Interval

Background: Intraspinal drug delivery (IDD) therapy has been increasingly employed in patients with intractable, nonmalignant pain. Before implantation of permanent intraspinal pump, an intraspinal opioid screening trial is conducted to demonstrate the efficacy. The patient-controlled continuous epidural opioid infusion trail, performed in an outpatient setting, is widely accepted by many interventional pain specialists.Objective: To report a case of severe edema observed during the continuous epidural hydromorphone infusion trial.Case Report: An otherwise healthy 68-year-old lady with a 5-year history of severe low back pain and bilateral leg pain because of failed back surgery syndrome was referred to our clinic for IDD therapy.A tunneled lumbar epidural catheter was placed at L2- L3 with catheter tip advanced to L1 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone (0.1 mg/ml) at basal rate of 0.3 ml/h. The bolus dose was 0.1 ml with a 60-minute lockout interval. The patient was instructed how to operate the infusion pump. During the following infusion trial, she reported satisfactory analgesia (>70 percent pain reduction) and was able to wean off her other systemic opioids. However, she developed diffuse edema and gained over 16 pounds during the 5-day infusion trial. Her edema finally resolved 3-4 days after termination of the epidural infusion.Conclusion: Edema may occur and persist during epidural hydromorphone infusion. This report represents the first case report, to the best of our knowledge, describing severe edema in a patient on continuous epidural hydromorphone administration during an outpatient epidural infusion trial.

scholarly journals A Rare Case of Spinal Subdural Hematoma Complicating Minimally Invasive Lumbar Micro Discectomy and Decompression for Recurrent Lumbar Disc Herniation

2019 ◽  
Vol 4 (3) ◽  
Keyword(s):  
Lumbar Disc Herniation ◽  
Disc Herniation ◽  
Lumbar Disc ◽  
Failed Back Surgery Syndrome ◽  
Neurological Deficits ◽  
Unusual Complication ◽  
Lumbar Region ◽  
Failed Back Surgery ◽  
Spinal Subdural Hematoma ◽  
Recurrent Lumbar Disc Herniation

Spinal subdural hematomas is a very rare and unusual complication of spinal interventions. We present a case of subacute SSDH in the lumbar region of a 60 year-old woman following microdiscectomy for recurrent lumbar disc herniation. By presenting this rarely seen case of postoperative subacute SSDH, we want to bring attention to the possible postoperative complications like spinal hematomas in the differential diagnosis of failed back surgery syndrome in patients who do not respond to conservative treatment or develop neurological deficits and to the importance of radiological imaging in such cases.

Intractable pruritus during outpatient epidural hydromorphone infusion: A case report and a focused review of the literature

2015 ◽  
Vol 11 (2) ◽  
pp. 184 ◽  
Author(s):  
Xiulu Ruan, MD ◽  
Li Ma, MD, PhD ◽  
J. Patrick Couch, MD ◽  
Tao Chen, MD, PhD ◽  
Gary W. Bumgarner, PhD
Keyword(s):  
Drug Delivery ◽  
Opioid Analgesic ◽  
Infusion Pump ◽  
Failed Back Surgery Syndrome ◽  
Outpatient Setting ◽  
Leg Pain ◽  
Opioid Dose ◽  
Epidural Opioid ◽  
Failed Back Surgery ◽  
Catheter Tip

Background: Intraspinal drug delivery therapy has been increasingly used in patients with intractable, nonmalignant pain who have failed to respond to conventional treatment or cannot tolerate systemic opioid(s) due to adverse events. By infusing a small dose of an opioid analgesic directly into the cerebrospinal fluid, near opioid receptors, profound spinal analgesia can be obtained. Before the implantation of permanent intraspinal pump, a neuraxial opioid infusion trial is usually conducted to demonstrate the effectiveness of neuraxial opioid for analgesia. Patient-controlled epidural opioid infusion trial, performed in an outpatient setting, is one of the approaches used to conduct such a trial.Objective: To report a case of severe pruritus observed during the continuous epidural hydromorphone infusion trial and to conduct a focused review of the literature.Case report: An otherwise healthy 56-year-old lady, with a 4-year history of severe low back pain and bilateral leg pain due to failed back surgery syndrome, was referred to our clinic for intraspinal drug delivery therapy. Following a preimplantation psychological evaluation confirming her candidacy, she consented to an outpatient patient-controlled continuous epidural hydromorphone trial. A tunneled lumbar epidural catheter was placed at L3-L4 with catheter tip advanced to L2 under fluoroscopic guidance. Satisfactory catheter placement was confirmed by epidurogram. The catheter was then tunneled subcutaneously and connected to a Microject™ patient-controlled epidural analgesia (PCEA) pump (Codman, Raynham, MA). The pump was programmed to deliver hydromorphone 0.3 mL/h (0.06 mg, concentration 0.2 mg/mL) at basal rate of 0.3 mL/h, with bolus dose set at 0.2 mL (0.04 mg) and 30-minute lockout interval. The patient was instructed how to operate the infusion pump prior to discharging home. During the infusion trial, she reported satisfactory analgesia (>90 percent pain reduction) and was able to reduce her oral opioid dose by more than 80 percent. However, she developed severe, persistent itching, unresponsive to meticulous epidural infusion titration or various antipruritic treatments. Her pruritus remained severe and unabated until a few hours after the termination of the epidural hydromorphone infusion.Conclusion: Pruritus may occur and persist during epidural hydromorphone infusion. This report describes severe pruritus in a patient on epidural hydromorphone administration, in the setting of an outpatient infusion trial.

scholarly journals Systematic Review of Percutaneous Adhesiolysis and Management of Chronic Low Back Pain in Post Lumbar Surgery Syndrome

2009 ◽  
Vol 2;12 (2;3) ◽  
pp. 361-378 ◽  
Author(s):  
Richard Epter
Keyword(s):  
Chronic Low Back Pain ◽  
Observational Studies ◽  
Randomized Trials ◽  
Failed Back Surgery Syndrome ◽  
Epidural Fibrosis ◽  
Low Back ◽  
Lumbar Surgery ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
Level I

Background: Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy syndrome include acquired stenosis, epidural fibrosis, arachnoiditis, radiculopathy, and recurrent disc herniation. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome. Percutaneous epidural adhesiolysis has been employed in interventional pain management in the treatment of chronic, refractory low back and lower extremity pain after back surgery. Study Design: A systematic review of randomized trials and observational studies. Objective: To evaluate the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain due to post lumbar surgery syndrome. Methods: A comprehensive literature search was conducted utilizing electronic databases, as well as systematic reviews and cross references from 1966 through December 2008. The quality of individual articles used in this analysis was assessed by modified Cochrane review criteria for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for assessment of observational studies. Clinical relevance was evaluated using 5 questions according to the criteria recommended by the Cochrane Review Back Group. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. Outcome Parameters: The primary outcome measure was pain relief (short-term relief of at least 6 months and long-term relief of more than 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and change in opioid intake. Results: Of the 13 studies considered for inclusion, 3 randomized trials and 4 observational studies met the inclusion criteria for methodologic quality assessment and evidence synthesis based on methodologic quality scores of 50 or more. Evidence of percutaneous adhesiolysis in the management of chronic low back pain in post-lumbar surgery syndrome is Level I to Level II1, with evidence derived from 3 randomized trials. Limitations: There is a paucity of efficacy and pragmatic trials. No trials have been published after 2006. Conclusion: The indicated level of evidence for percutaneous adhesiolysis is Level I or II-1 based on the US Preventative Services Task Force (USPSTF) criteria. Key words: Chronic low back pain, post lumbar surgery syndrome, post surgery syndrome, failed back surgery syndrome, spinal stenosis, epidural fibrosis, interventional techniques, percutaneous adhesiolysis, hypertonic saline neurolysis

scholarly journals Use of Spinal Cord Stimulator for Treatment of Lumbar Radiculopathy in a Patient with Severe Kyphoscoliosis

2008 ◽  
Vol 4;11 (8;4) ◽  
pp. 555-559 ◽  
Author(s):  
Joseph Atallah
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Stimulation ◽  
Failed Back Surgery Syndrome ◽  
Radicular Pain ◽  
Activity Level ◽  
Spinal Cord Stimulator ◽  
Lumbar Radiculopathy ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
Technical Considerations

Spinal cord stimulation (SCS) has been a therapeutic option for chronic pain for over 40 years with a common indication being failed back surgery syndrome (FBSS). This case reports the successful implantation of a spinal cord stimulator in a patient with FBSS and kyphoscoliosis for treatment of radicular pain. Technical considerations and anatomical difficulties that may be encountered during placement with kyphoscoliosis will be discussed. This patient had failed other therapies including oral medications, epidural steroid injections, spinal surgeries, and physical and aquatic therapies. On physical examination the patient had a severely deformed lumbar spine. Careful review of the spine radiographs and CT scan revealed lead placement might be possible at the level of T12-L1 or L1-2. A Medline search did not reveal a case of kyphoscoliosis with radicular pain treated with SCS. After a successful percutaneous trial, a SCS was implanted. Fourteen weeks later, the patient reported being pain free with an increased physical activity level and opioid discontinuation. Technical considerations with kyphoscoliosis may discourage pain physicians from attempting SCS. This case illustrates that with careful selection, some of these patients may be candidates for SCS with good results. Key words: Spinal cord stimulator, spinal cord stimulation, failed back surgery syndrome, kyphoscoliosis, back pain, lumbar radiculopathy

Body Mass Index: A Central Indicator for Alternative Intrathecal Infusion Pump Placement

2012 ◽  
Author(s):  
Maegan Wagner ◽  
Meghan Carlin ◽  
Pennie Seibert ◽  
Jennifer Valerio ◽  
Yustina Rafla ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Body Mass ◽  
Infusion Pump ◽  
Pump Placement ◽  
Intrathecal Infusion

A tranilast and BMP-2 based functional bilayer membrane is effective for the prevention of epidural fibrosis during spinal lamina reconstruction

2019 ◽  
Vol 7 (19) ◽  
pp. 3075-3087
Author(s):  
Chen Han ◽  
Xunlin Li ◽  
Tangjun Zhou ◽  
Chen Chen ◽  
Kai Zhang ◽  
...  
Keyword(s):  
Failed Back Surgery Syndrome ◽  
Bilayer Membrane ◽  
Epidural Fibrosis ◽  
Lumbar Surgery ◽  
Common Complication ◽  
Failed Back Surgery ◽  
Back Surgery ◽  
Spinal Lamina

Failed Back Surgery Syndrome (FBSS) is a common complication of lumbar surgery.

Infraclavicular Fossa as an Alternate Site for Placement of Intrathecal Infusion Pumps

Neurosurgery ◽  
2010 ◽  
Vol 66 (2) ◽  
pp. E402-E403 ◽  
Author(s):  
Brandon G. Rocque ◽  
A. Leland Albright
Keyword(s):  
Abdominal Wall ◽  
Infusion Pump ◽  
Drug Infusion ◽  
Respiratory Compromise ◽  
Infusion Pumps ◽  
Joint Contractures ◽  
Severe Scoliosis ◽  
Pump Placement ◽  
Intrathecal Infusion

Abstract OBJECTIVE Intrathecal infusion using an implantable pump is a common method of delivering medication for spasticity or chronic pain. The classic site for placement of the pump is in the abdominal wall. In some patients, there are confounding factors that make placement of an abdominal pump impractical. The purpose of this study was to report the implantation of Synchromed II pumps (Medtronic, Inc, Minneapolis, Minnesota) in the infraclavicular fossa. METHODS Four patients, aged 13 to 33 years, underwent infraclavicular placement of a Synchromed II infusion pump. In one patient, severe scoliosis and hip joint contractures precluded placement of the pump in the traditional position. Another patient had several ostomies on the abdominal wall, leaving no place for the pump. In a third, a combination of scoliosis and ostomy rendered the abdomen inappropriate for pump placement. RESULTS In 3 patients, a 20-mL pump was placed in the infraclavicular fossa. In the fourth, a 40-mL pump was placed in the left infraclavicular fossa. All patients tolerated the operation well. There were no postoperative reports of local pain or discomfort. One patient died from unrelated respiratory compromise several months after pump placement. At last follow-up (average of 11 months), the pumps were functioning well, and there were no wound-related complications. Selected pre- and postoperative photographs are presented. CONCLUSION The infraclavicular fossa is a viable alternative to the abdomen as the site for placement of a drug infusion pump.

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