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Epiduroscopic adhesiolysis for failed back surgery syndrome
- Naozumi Takeshima (1 April 2009)
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Evaluation of the therapeutic results of epiduroscopic adhesiolysis for failed back surgery syndrome
- Johann N Emmanuel (2 March 2009)
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Naozumi Takeshima, Oita University Faculty of Medicine Department of Anesthesiology and Intensive Care Medicine
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I would agree with your assessment that radicular and facet joint related pain can be differentiated according to clinical symptoms and diagnostic nerve blocks. However, low back pain in patients with Failed Back Surgery Syndrome (FBSS) involves facet joint related pain and adhesion of epidural space, among other factors. Thus, even though facet joint related pain could be excluded by the use of a placebo-controlled diagnostic medial branch block, there are cases which cannot be addressed using instruments for orthopaedic surgery. As such, we were unable to exclude patients with pain due to disease in their facet joints. In the Discussion section, I speculate that persistent back pain and ADL impediments in the E group may be due to facet joint impairment. Your suggestion would imply that therapeutic effectiveness of epiduroscopic adhesiolysis for patients with FBSS should be evaluated following a medial branch block around the facet joint region such that facet joint-related pain may be excluded. I also agree that there is evidence supporting the use of spinal cord stimulation for FBSS, so I created an Algorithm (see Figure 1). However, in my experience, epiduroscopic adhesiolysis improved the clinical symptoms such that further spinal cord stimulation was superfluous. Spinal cord stimulation is expensive and requires implantation of an electrode and pulse generator time. I am not certain that epiduroscopic adhesiolysis is more effective than spinal cord stimulation, but I would recommend performing epiduroscopic adhesiolysis prior to spinal cord stimulation in patients with FBSS. Conflict of Interest:None declared |
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Johann N Emmanuel, Anaesthetic Registrar
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Editor- Though radicular and facet joint related pain can have indistinguishable patterns of referral I believe some attempt should have been made to differentiate, and so exclude the latter pain condition. This could have been achieved with the use of placebo controlled diagnostic medial branch blockade. Epidural adhesiolysis has no place in the management of facet joint related pain, and so it should be a exclusion criteria, not an inclusion criteria. Secondly the introduction mentions that there is no effective treatment for Failed Back Surgery Syndrome. There is high quality evidence for the use of spinal cord stimulation in this particular pain condition. Conflict of Interest:None declared |
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