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LETTER TO THE EDITOR | |
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Role of spinal cord stimulation in failed back surgery syndrome
Ali Ghazanfar1, Haider Ghazanfar2
1 Department of Neurosurgery, Federal Medical and Dental College, Islamabad, Pakistan
2 Department of Neurosurgery, Shifa International Hospital, Shifa Tameer-e-Millat University, Islamabad, Pakistan
Date of Web Publication | 16-Jun-2017 |
Correspondence Address:
Haider Ghazanfar
Shifa College of Medicine, Pitras Bukhari Road, Sector H-8/4, Islamabad
Pakistan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/amhs.amhs_10_17
How to cite this article: Ghazanfar A, Ghazanfar H. Role of spinal cord stimulation in failed back surgery syndrome. Arch Med Health Sci 2017;5:136-7 |
Sir,
Failed back surgery syndrome (FBSS) refers to a condition which is characterized by persistent pain following back or spinal surgeries. The term was first coined to increase awareness among physicians that repeated back surgeries were not always the best treatment options to alleviate back and leg pain. Unfortunately, the pendulum has swung back in time, and a very small number of physicians are aware of FBSS. Various studies have shown that the incidence of FBSS ranges from 4% to 50%.[1] Therefore, it is imperative to increase awareness about FBSS among physicians. Neuromodulator therapies, especially spinal cord stimulation, have been found to be an effective treatment modality for FBSS. Other indications for spinal cord stimulators include chronic painful peripheral neuropathy or plexopathy, diabetic neuropathy, upper extremity pain multiple sclerosis, and complex regional pain syndromes.[2],[3] Contraindications of FBSS include previous dorsal root entry zone surgery or disruption, critical central canal stenosis, serious neurological deficit with surgically correctable pathology, anatomical spine instability or deformity at risk for progression, need for future magnetic resonance imaging studies or cardioverter defibrillators, coagulopathy, and pregnant or pediatric patients.[4]
The spinal cord stimulator has three main types, namely, conventional implantable pulse generator, rechargeable implantable pulse generator, and radiofrequency stimulator. Low-voltage current is used in spinal cord stimulation to continuously stimulate the pain pathways of the spinal cord, which results in the inhibition of pain transmission. The spinal cord stimulation is believed to act by gate control theory of pain, which is proposed by Melzack and Wall. Other possible mechanisms of action include the release of gamma-aminobutyric acid, serotonin, and substance P. It has also been suggested that spinal cord stimulation brings about the antinociceptive effects by acting on A-beta fibers.
Other treatment options for FBSS include physical therapy, epidural steroid injections, microcurrent treatment, and nonsteroidal anti-inflammatory drugs. A study done by Manca et al. found that although the initial cost of treatment was higher in patients undergoing spinal cord stimulation than those undergoing medical management, the health-related quality of life was much higher in patients who had undergone spinal cord simulation as compared to the other group.[5] A study done by Yu et al. concluded that spinal cord stimulation helped decreased cost in long-term basis by preventing hospitalizations.[6] A multicenter, randomized controlled trial (PROCESS) concluded that 48% patients of FBSS treated with spinal cord stimulators achieved 50% or more pain relief as compared to 9% patients of FBSS treated with conventional management (P < 0.001).[7] Another study using 36-item Short-Form Health Survey (SF-36) questionnaire concluded that the SF-36 score increased from 72.8 to 108.5 in patients of FBSS treated with spinal cord stimulation.[8]
Revision or replacement of spinal cord simulator due to hardware-related complication is a fairly common complication in spinal cord simulator. These include lead connection failure, lead breakage, and lead migration. A study by Mekhail et al. found that 38% of the complication experienced by the patients with spinal cord simulator were due to hardware-related problems.[9] Other complications included pain at the site of the pulse generator, infection, and neurological damage due to an epidural hematoma.
Despite the increased prevalence of FBSS, the majority of the patients remain hidden from epidemiological surveys. This happens because these patients are seen by a variety of specialties which have their own concept and treatment modalities about FBSS. A study concluded that one of the major causes of delay in recognition of FBSS was because of poor communication between the various medicine disciplines handling these patients.[10] There is a dire need to increase awareness among physicians about spinal cord stimulators and their role in FBSS. Awareness about FBSS can be increased by inculcating FBSS and its effective treatment modalities in undergraduate and postgraduate level. It is equally vital to convey to physicians that spinal cord stimulators are more cost-effective in the treatment of FBSS.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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