Tannoury C Failed Back

8/7/2019 Tannoury C Failed Back

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Workup for Failed Back Syndrome

Orthopeadic Chief Resident at ThomasJefferson University Hospital and theRothman Institute Administrative and Academic Chief Resident 2010-2011 Interest :

Spine Surgery Medical Illustrations Medical education

Medical Leadership Emergent Leader Physician Enjoys Arts, Music, Martial Arts, Travel,Social Networking

C h di @ il

Chadi Tannoury, MD


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Failed Back Surgery Syndrome: The Workup

Chadi Tannoury, M.D. Thomas Jefferson University Hospital

& The Rothman InstituteS.P.I.N.E. Meeting Lebanon June 2010


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Disclosure

* Disclosure of Financial Interest

The author have not received nothing of value from or does not own stock (or stock options) in a commercial company or institution related directly or indirectly to the subjecof this topic.


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!!Failed Surgery!!

Patient: Anxiety Repeat Surgery

PainDebilitationPoor Outcome

Surgeon: Anxiety Hit to the E

Revision Sx Technical dGrief !!!!


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Failure what failure?


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FBSS:Unresolved symptoms

New Symptoms


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What caused the Perfectsurgery to Fail?

Bad Patient selectionIncorrect DiagnosisInappropriate surgery

Technical errorsNonunion of the fusionImbalanceMissed pathology

ArachnoiditisProgression of disease


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Poor Pt Selection

Intrinsic Pathological xMMPI: Psych disturb

Hysteria, hypochodriasis

Depression, Anxiety Workmans compensatNon-compliance


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Incorrect/Incomplete Diagnosis

Failure to address:Foramin/lat recessstenosis

Unnecess Rx: AsympRadiog findingsMisdiagnosis: conj NR

Far lat HNP


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Wrong Surgical Procedure

Wrong LevelPoor Technique:

Battered NR syndrome

Iatrogenic Instability Inappropriate hardwareplacement


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Progressive Disease

Recurrent Sx:Ongoing DDDRecurrent HNP (5-15%)

Scar formation NR tethering

Adjacent DD (35%)


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Workup

Careful Thorough EvaluationResults of Revision Surgery:Poorer than index surgery

Etiologies:R/o Non-spinal causesPsychological Sources

Spinal workup


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History

Symptoms relation to index surgery Review of Med Records / OR Reports /Imagings:

Wrong level surgery vs. Incorrect initial diagnosisROS Social hx:

Identify co-morbidities: Somatizat Addictions Depression Personality disordersConstitutional Sx: Malig vs. Infections


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Physical Examination

Non-Organic Physical Findings (Waddell signs):Superficial or non-anatomic distribution of symptomsOver-reaction to stimuliPain out of proportion to non painful stimuli

> 2 above Strongly predicts Poor Outcome Waddell Spine 1980

Standard Tests: Posture, Gait, Tenderness, ROM, NRtension signs, NeuroExam, Hips/knee


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ImagingBiplanar Standing Rad:

Site of Surgery BalanceProgressive Degeneration

Flex/ext Rad (post Fusion):Instability Hardware Loosening/ subsidence

SI joints eval Hip/Knee eval

ICBG site: r/o pelvic frx


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Standing 36 Radiog


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Imaging Contd

MRI: w-w/out GadEnhancement (scar) vs.Nonenhancement (recurr HNP)

Post op infection?!


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Imaging Contd

CT Myelo: if MRI is contraindicated Assess fusion vs. PseudarthrosisHardware placement Loosening

/Subsidence


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Electrodiagnostic Studies

EMG, NCV Rarely IndicatedEvaluate extra-spinal etiologies:

Peripheral neural compressionPeripheral Neuropathy


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Laboratory Tests

ESR, CRP:NonspecificEval for Occult Infx in Pts w diffrt quality LBP

CRP returns to Nl in 14 days postop, ESR laterGood Indicators: response to treatment


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Psychological Assessment

Psychological distress measurement:MMPI: high scores Poor outcome

(Minnesota Multi-phasic Personality Inventory) Wiltse75, Spengle

Pts w h/o Chronic pain: Referral to aPsychologist/Psychiatrist can be helpfulPts with Depression + Sleep disturbances:

should be treated before and after surgery


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Diagnostic Blocks

Selective Nerve Root Blocks:Help Confirm culprit level~ Predict outcomes of surgery

Provocative diskography:Controversial useHelp localize Adjacent segment disease

Diagnostic Facet Blocks:

Used to Identify painful transitional motion segments


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Expectations

For some diagnosis:Recurr HNP Pseudarth Adjacent SDRevision Surgery GRATIFYING

Arachnoiditis epid/perin Fibrosis Spinal cordStimulation SUCCESSFULChronic Pain: Preop screening by a PsychologistHelp avoid additional Surg in pts high risk for

unfavorable outcomes!


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Best Management = Prevention

Pre-surgical thorough Assessment:Good IndicationsPE: Red Flags (Waddell sings Pain Behavior, etc..)

At Surgery: Correct Level

After decompression: adequate Foraminal decomp After fusion: Inspect Hardware for misplacementIf Complications happen: Rx Promptly + Aggressively DNot Delay!!!

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