Failed back surgery syndrome (FBSS) and lumbar pain

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  1. Term used to describe a heterogenous group of patients who have persistent symptoms of back and leg pain despite surgical therapy
  2. Etiology: pain may arise from visceral, blood vessels, nerves, bones, muscles or joints
    1. ligaments and muscles of the spine and annulus of the disc are all innervated and contain nociceptive nerve terminals
    2. most common causes of FBSS are lateral spinal stenosis, fusion overgrowth, adhesive arachnoititis, recurrent or persistent disc herniation and epidural fibrosis
    3. spinal instability may also cause back pain
      1. it is generally agreed that spondylolisthesis with 5 mm of motion on flexion and extension of the lumbar spine indicates an unstable motion segment (2-3 mm of motion is common)
      2. spondylolisthesis pain (commonly anterolisthesis) usually gets better when lying down
      3. Spondylolisthesis without a defect in the neural arch is about 10 times more common in women as in men with the most common level of subluxation occurring at the L4-5 interspace followed by L3-4 and L5-S1
      4. 30% of patients with degenerative spondylolisthesis will have progressive slippage
    4. pain may also originate from the facet
      1. joint capsue is innervated by a medial branch of the posterior ramus of the segmental nerve and stretching of this capsule by intraarticular injections has been shown to reproduce low back pain and root tension signs with buttock and proximal leg radiation
      2. tends to be worse with rotation of the back or extension
    5. myositis, fasciitis may cause back pain that have trigger points that are palpable
    6. epidural scarring around the nerve roots may displace or compress the nerve roots; epidural scarring might be minimized by maintaining good hemostasis because the blood clot provides a lattice for fibroblatic proliferation and subsequent scar formation; Note: the presence or absence of scar nor the amount of scar can be correlated reliably with pain
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