Management of failed back surgery syndrome with transforaminal epidural steroid and epidural saline adhesiolysis

Kalpana Rajendra Kulkarni; Shirish Kumar Talakanti

doi:10.4103/0970-5333.132853

Users Online:132

CASE REPORT

Year : 2014 | Volume : 28 | Issue : 2 | Page : 117-120

Management of failed back surgery syndrome with transforaminal epidural steroid and epidural saline adhesiolysis

Kalpana Rajendra Kulkarni, Shirish Kumar Talakanti
Department of Anesthesiology and Pain Management, D. Y. Patil Medical College and Hospital, Kolhapur, Maharashtra, India

Date of Web Publication

20-May-2014

Correspondence Address:
Kalpana Rajendra Kulkarni
1168, A-5, "Chaitanya", Takala Square, Kolhapur - 416 008, Maharashtra
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/0970-5333.132853

Abstract

Failed back surgery syndrome (FBSS) is a condition of persistent pain following spine surgery as a result of epidural adhesions, nerve root entrapment/inflammation. Transforaminal epidural steroid (TFES), interlaminar/caudal epidural (CE) with local anesthetic, saline, steroid and hyaluronidase are established therapeutic options over re-surgery. We report a 55 years old male patient with FBSS since 10 years. Following informed consent, under fluoroscopy guidance TFES given at L4/5, L5/S1 foramina with 1.5 ml 0.25% bupivacaine + triamcinolone 20 mg. Besides, CE injection of 10 ml 0.25% bupivacaine with 50 mcg fentanyl given using 18 gauge Tuohy's needle. Fifteen minutes later 20 ml of 0.9% cold (2^°C) normal saline with hyaluronidase (on day 1) was injected forcefully through epidural catheter, repeated on 2 ^nd and 3 ^rd day with triamcenolone 20 mg. 90% pain relief persisted till 8 months with improved quality of life. TFES with successive CE saline can be a good therapeutic option for long term relief in FBSS.

Keywords: Cold saline, failed back surgery, transforaminal and epidural steroid

How to cite this article:
Kulkarni KR, Talakanti SK. Management of failed back surgery syndrome with transforaminal epidural steroid and epidural saline adhesiolysis. Indian J Pain 2014;28:117-20

How to cite this URL:
Kulkarni KR, Talakanti SK. Management of failed back surgery syndrome with transforaminal epidural steroid and epidural saline adhesiolysis. Indian J Pain [serial online] 2014 [cited 2023 Mar 22];28:117-20. Available from: https://www.indianjpain.org/text.asp?2014/28/2/117/132853

Introduction

Failed back surgery syndrome (FBSS) is one of the most common causes of persistent low back pain with or without radicular leg pain. Laminectomies and spinal fusion surgeries are performed for herniated disc diseases but later results in eventual destabilization, intrathecal scarring, pseudoarthrosis, malposition of screw or cage. There could be a recurrent herniated disc, spinal stenosis, nerve root entrapment/injury, soft tissue edema around the cord or could be due to inappropriate surgery. The treatment options are conservative medical management, interventional blocks, neuromodulation techniques or re-surgery. Traditionally caudal epidural adhesiolysis with hypertonic saline has been found to be effective and safe for chronic low back pain not responding to conservative line of management. ^[1],[2],[3] We report a case of FBSS having low back pain with radiculopathy managed with fluoroscopic guided transforaminal epidural steroid (TFES) and successive caudal epidural (CE) injection of local anesthetic, steroid and hyaluronidase in cold normal saline.

Case Report

A 55-year-old male referred from orthopedic department presented with low back, buttock, thigh pain with radicular pain in the legs since 10 years following lumbar laminectomy, which was incapacitating since one month. His recent magnetic resonance imaging (MRI) depicted degenerative disc at L3/4, reduced disc height, pseudo bulge with osteophytes, paravertebral soft tissue and marrow edema, facetal effusion at L4/5 and L5/S1 level causing compression of exiting L4 nerve root and bilateral encroachment of neural foramina at L5/S1 with marginal anterior listhesis of L4 over L5 vertebral body.

Doppler study of lower limbs was normal.Electromyography (EMG) studies were not done. He received analgesics, anticonvulsants, antidepressants, oral/IV steroids, physiotherapy on and off since 10 years. He was alright for one month after surgery gradually developed low back pain later radiation to lower limbs Lt >Rt, visual analog scale (VAS) score of 6-8 with functional disability and depression. There was no sensory loss or weakness in the limbs, bowel/bladder habits were normal. On examination generalized bilateral paravertebral mild tenderness in the lumbar region, straight leg raise test was 45° for left leg and 80° for right leg, Faber test was negative for both SI joints. Present VAS score was 7. After explanation he opted for the interventional block over re-surgery. Considering the available resources, strategy was to control back, buttock pain and left radicular leg pain initially with transforaminal epidural injection at L4/5 and L5/S1 level and epidural saline adhesiolysis through caudal route. If still back pain persists it was decided to repeat epidural saline adhesiolysis with facet joint block at later date. Following routine examination, blood investigations and informed consent procedure were done in operation theatre with appropriate procedural intravenous sedation and vital monitoring. In prone position under aseptic precautions and fluoroscopic guidance,transforaminal epidural block was given with 22-guage 15-cm spinal needle at 'safe triangle (formed by pedicle as roof, lateral border of vertebra and exiting nerve root as tangential base). Epidurogram (in AP/LAT fluoroscopic view) obtained using 0.5 ml of omnipaque dye, then 1.5 ml of local anesthetic (LA) 0.25% bupivacaine with triamcinolone acetonide 20 mg each at level of L4/5, L5/S1 foramina injected after after-ve aspiration test for cerebro-spinal fluid (CSF) or blood. [Figure 1]a-d ] Besides, following confirmation with dye study, caudal epidural injection of 10 ml 0.25% bupivacaine with 50 mcg fentanyl was given using 18 guage Tuohy's needle and 18 guage epidural catheter passed 10 cm inside [Figure 2]a-d]. About 15 minutes later 20 ml of cold (2°C) 0.9% normal saline with hyaluronidase 1500 IU was injected forcefully through the epidural catheter on 1 ^rst day. On 2 ^nd day 0.125% bupivacaine 10 ml + triamcinolone 20mg followed by 20ml cold (2°C) 0.9% normal saline injected through catheter and again repeated the same dose on 3 ^rd day and the epidural catheter was removed. Patient was observed for vitals, for any side-effects or complications and followed weekly for 1 month then monthly till date.

Figure 1: (a and c) Neddle position at L4, (b and d) Neddle position at L5

Click here to view

Figure 2: (a) Tip of caudally placed epidural catheter, (b) Dye spread following caudal injection in lateral view, (c) Caudal epidural Injection, (d) Fixation of caudal epidural catheter for successive Injection

Click here to view

Patient received oral antibiotic cefpodium 200 mg BID for 5 days, rescue analgesia provided with oral tramadol 100 mg BID for 5 days, OD for 10 days. Pregabalin 75 mg BID and duloxetine 60 mg OD was continued for 2 months later tapered over next one month.

Physical therapy started on 6 ^th day. The patient had pain relief of 50% on the 3 ^rd day, 75% after 1week. The VAS reached 2 at 1 month, further 90% pain relief (VAS <2) persisted till >6 months of follow-up. There was increase in walking distance from 1kilometer before block to 3 kilometer after 1week of treatment with improved quality of life (functional improvement-daily activity, psychological status and return to work). No immediate or late complications occurred related to the techniques of transforaminal injection or continuous caudal epidural injections.

Discussion

The incidence of FBSS is up to 40%, where patient presents with recurrent and persistent pain with or without radiculopathy in spite of successful disc related spine surgery. There is significant psychological affection and confusion related to surgical outcomes and after treatment for disabling back pain. ^[4] There may be associated muscle spasm, sacroiliac joint pain or pain due to pseudoarthrosis. Magnetic resonance scanning is needed to differentiate epidural fibrosis from residual disc herniation, foraminal stenosis or new lateral disc prolapse in patients with failed back surgery syndrome. ^[5] If there is suspicion of a new/recurrent disc prolapse or foraminal stenosis the need for further surgery should be ruled out. However, re-surgery is complex, costly and with increased risk of complications like epidural fibrosis, arachnoiditis, bleeding, edema etc. Fager and Freidberg concluded following analysis of FBSS about poor results with recurrence of pain in 55% of cases of re-surgery. ^[6] The patients developing extensive epidural fibrosis are likely to get recurrent radicular pain, ^[7] and experimental studies have provided electrophysiological evidence of neurologic disturbances caused by peridural scar formation and abnormal dorsal root ganglion response. ^[8] Among the nonsurgical interventions in managing chronic persistent pain of post lumbar surgery syndrome, epidural steroid injections and percutaneous adhesiolysis with or without hypertonic saline are most commonly utilized interventions. ^[9],[10] The evidence for transforaminal epidural steroid injections and serial caudal epidural steroid injections in managing lumbar radicular pain with FBSS is strong for short-term and moderate for long-term reliefs. ^[11] Considering the above evidences and availability at our setup we first planned for TFES and epidural saline induced mechanical adhesiolysis in our patient. The other contributing pathology can be tackled is facetal arthropathy by facet joint denervation, which allows early exercises and decreases the dose of medications and may avoid re-surgery. ^[12],[13] In our case, there was significant MRI finding of facetal effusion causing L4 rootcompression but without localized tenderness on clinical examination. So, we decided to tackle it at later date if back pain recurs. Yousef et al., concluded in his prospective double-blind study that addition of hyaluronidase 1500 IU to fluoroscopic-guided caudalsteroid with 3% of 30 ml hypertonic saline, which provides long term pain relief in FBSS. Steroids have membrane stabilizing action resulting in inhibition of ectopic discharge along with anti-inflammatory action. Heavner et al., compared 0.9% isotonic saline with 10% hypertonic saline and supported through his study that hyaluronidase disrupts the ground substance and the isotonic/hypertonic saline mechanically disrupts the fibrotic scarring in epidural space. Besides, hypertonic saline also has local anesthetic effect and decreases the cell edema and pressure on the nerve. ^[14],[15] We preferred easily available cold (2°C) 0.9% normal saline, as the use of cold solutions enhances the analgesic effects by depressing pain carrying C fiber conduction is mentioned in earlier literature. Using 0.9% normal saline is equally effective and 10% hypertonic saline can cause hypertension, tachycardia with raised intracranial pressure and pulmonary edema. ^[15] The currently available evidence emphasizes good outcome following neuromodulation techniques in patients having neuropathic buttock and leg pain following failed back surgery, having poor response to primary pain management program or re-surgery. ^[16],[17] We opted forTFES and CE cold saline injection with the help of epidural catheter, due to non-availability of specialized catheter or neuromodulation techniques at our center.

Transforaminal epidural steroid at L4, L5 root and continuous cold epidural normal saline with addition of hyaluronidase, triamcenolone and local anesthetic for successive 3 days to produce volumetric adhesiolysis has provided 90% pain relief for >6 months with improved quality of life in a patient with FBSS for 10 years.

References

1.	Manchikanti L, Boswell MV, Singh V, Benyamin RM, Fellows B, Abdi S, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician 2009;12:699-802.
2.	Saxena AK. Lecture Abstract. Failed Back Surgery Syndrome: Current concepts, evidence and future prospective. Int J Perioper Ultrasound Appl Technol 2013;2:64-9.
3.	Turner JA, Loeser JD, Deyo RA, Sanders SB. Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: A systematic review of effectiveness and complications. Pain 2004;108:137-47.
4.	Ganty P, Sharma M. Failed back surgery syndrome: A suggested algorithm of care. Br J Pain 2012;6:153-61.
5.	Van Goethem JW, Parizel PM, van den Hauwe L, De Schepper AM. Imaging findings in patients with failed back surgery syndrome. J Belge Radiol 1997;80:81-4.
6.	Fager CA, Friedberg SR. Analysis of failures and poor results of lumbar spinesurgery. Spine (Phila Pa 1976) 1980;5:87-94.
7.	Ross JS, Robertson JT, Frederickson RC, Petrie JL, Obuchowski N, Modic MT, et al. Association between peridural scar and recurrent radicular pain after lumbar discectomy: Magnetic resonance evaluation. ADCON-L European Study Group. Neurosurgery 1996;38:855-61.
8.	Jou IM, Tai TW, Tsai CL, Tsai TM, Yung WS, Jung YC. Spinal somatosensory evoked potential to evaluate neurophysiologic changes associated with postlaminotomy fibrosis: An experimental study. Spine (Phila Pa 1976) 2007;32:2111-8.
9.	Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Management of pain of post lumbar surgery syndrome: One-year results of a randomized, double-blind, active controlled trial of fluoroscopic caudal epidural injections. Pain Physician 2010;13:509-21.
10.	Manchikanti L, Singh V, Cash KA, Pampati V. Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial. J Pain Res 2012;5:597-608.
11.	Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: A systematic review. Pain Physician 2007;10:185-212.
12.	Devulder J. Transforaminal nerve root sleeve injection with corticosteroids, hyaluronidase and local anesthestic in the failed back surgery syndrome. J Spinal Disord 1998;11:151-4. [PUBMED]
13.	Ragab A, DeShazo RD. Management of back pain in patients with previous back surgery. Am J Med 2008;121:272-8.
14.	Yousef AA, EL-deen A, AI-deeb AE. The role of adding hyaluronidase to fluroscopically guided caudal steroid and hypertonic saline injection in patients with failed back surgery syndrome: A prospective double blind, randomized study. Pain Pract 2013;10:548-53.
15.	Heavner JE, Racz GB, Raj P. Percutaneous neuroplasty: Prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase. Reg Anesth Pain Med 1999;24:202-7.
16.	Linderoth B, Foreman RD. Physiology of spinal cord stimulation: Review and update. Neuromodulation 2002; 2:150-64.
17.	North RB, Kidd DH, Farrokhi F, Piantadosi SA.Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: A randomized controlled trial. Neurosurgery 2005;56:98-106.