Etiology of post-fusion back pain

[manowar rules]

This is a piggy-back of the facet pain after fusion thread. I get a ton of patients who have persistent back pain after posterior lumbar fusion. I understand adjacent level facet pain, including SI pain. However many of these patients have incomplete response to facet targeted therapy.

I understand pain from neurogenic claudication, but the vast majority of these patients seem to have nociceptive pain. Common symptoms are equally painful lumbar flexion/extension, and sometimes tenderness over the fusion site even 1+ years after surgery. Any other ideas what can be helpful for these patients? If the pain source is altered biomechanics, are certain PT modalities helpful?

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[willabeast]

This is a piggy-back of the facet pain after fusion thread. I get a ton of patients who have persistent back pain after posterior lumbar fusion. I understand adjacent level facet pain, including SI pain. However many of these patients have incomplete response to facet targeted therapy.

I understand pain from neurogenic claudication, but the vast majority of these patients seem to have nociceptive pain. Common symptoms are equally painful lumbar flexion/extension, and sometimes tenderness over the fusion site even 1+ years after surgery. Any other ideas what can be helpful for these patients? If the pain source is altered biomechanics, are certain PT modalities helpful?

Well first of all it can take a long time to feel better after a fusion. So question if patient is improving. If yes, then wait. If not then 1+ year is a long time so...Next question is the pain different than before surgery? Sometimes the wrong thing gets "fixed". If it is a new pain that is one differential. If it is an old pain that is worse, that is a different differential. Based on those questions, etc. is the next step but in general
need to update the data base . Obtain flexion ext films to r/o macro instability, screws getting loose. New MRI with added sequences looking at inflammation to see if there is new pathology or old pathology that was missed or something lighting up (we used to get those sequences on everyone but some radiology MRI do not). ESR IMHO always helpful to r/o infection, malignancy etc.
In general the DDX is going to be one of the following. 1. surgeons did not fix the pathology, it is still there. 2. the fusion is failing/failed/broken 3. there is a new problem related to the fusion . 4. there is a new problem unrelated to the fusion. I would guess the most common problem as you describe the Sx is discogenic pain above the fusion. If this is the case then theoretically weight loss and PT will help. I would stress to the patient that another fusion is probably not going to help, and that most discogenic pain gets significantly better with time.

 

[NJPAIN]

Reasons for persistent pain that is unchanged post spine surgery:

Wrong diagnosis
Wrong surgery
Wrong level
“Wrong” patient


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[nvrsumr]

Fusion itself. Back is supposed to bend

 

[epidural man]

Watch a fusion.

The paraspinals muscle are completely torn away from their spinal attachments. All those small nerves that are running up and innervating those muscles are ripped right in half.

That has got to cause a lot of on-going pain. Those muscles are never going to function the same again and that also probably causes some pain.

 

[SSdoc33]

nobody really knows, but i suspect it is a combination of the above. a lot of it depends on the type of fusion and techniques used. surgeons think that just because you take away any motion from that segment, that pain will disappear. clearly not always the case.

 

[Timeoutofmind]

How about discogenic
The discs can be nociceptive, right?

And they put spacers/devices in the discs at least from the anterior approach at times

And even if they dont touch the disc, it is likely still a source of pain, the same as it was pre-fusion

 

[lonelobo]

Watch a fusion.

The paraspinals muscle are completely torn away from their spinal attachments. All those small nerves that are running up and innervating those muscles are ripped right in half.

That has got to cause a lot of on-going pain. Those muscles are never going to function the same again and that also probably causes some pain.

shouldn't really be the case with TLIF, anterior approaches

 

[clubdeac]

It's often hard to tell and multifactorial. For that reason, in all my post fusion patients with lbp, I put 4 peripheral field leads in the subq overlying the fusion and then 2 nevro leads epidurally. Works like a charm and pays really well 😉

 

[NJPAIN]

It's often hard to tell and multifactorial. For that reason, in all my post fusion patients with lbp, I put 4 peripheral field leads in the subq overlying the fusion and then 2 nevro leads epidurally. Works like a charm and pays really well 😉

You get paid for peripheral field stim??


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[clubdeac]

You get paid for peripheral field stim??


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I should've used magenta.... I was obviously kidding

 

[DODOCSS]

good relief with the trinity

 

[Ducttape]

It's often hard to tell and multifactorial. For that reason, in all my post fusion patients with lbp, I put 4 peripheral field leads in the subq overlying the fusion and then 2 nevro leads epidurally. Works like a charm and pays really well 😉

jeez. too bad you aren't a real IPM, I mean after all, no mention about the bilat DRG leads?

 

[IN2B8R]

Always tell your patients about the golden formula:
Back pain + fusion = worse back pain = obtain opioids from your surgeon who did this to you, not from me.


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[Dr. Ice]

Always tell your patients about the golden formula:
Back pain + fusion = worse back pain = obtain opioids from your surgeon who did this to you, not from me.
Or you can strike a deal with the surgeon whereby you manage the failed surgery and you can borrow his masserati for a few days a week

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