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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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