Failed Back Surgery Syndrome: No Longer a Surgeon's Defeat-A Narrative Review

Efficacy of Epidural Pulsed Radiofrequency Treatment in Persistent Spinal Pain Syndrome: A Prospective Clinical Study

Background: Persistent spinal pain syndrome type-2 (PSPS-II) is a chronic condition that is characterized by severe pain and results in disability and a significant reduction in quality of life. Despite the wide range of interventional pain treatments that are applied, depending on the complexity of the etiology, epidural pulsed radiofrequency (EPRF) application has emerged as an approach that has gained popularity in recent years. Objective: The objective of this study is to examine the efficacy of EPRF in patients diagnosed with PSPS-II. Methodology: In this prospectively designed study, patients with PSPS-II who had not responded to conservative treatments and epidural steroid injections were subjected to fluoroscopy-guided EPRF. Patients were evaluated with the Numeric Rating Scale (NRS) for pain severity and the Douleur Neuropathique-4 (DN-4) questionnaire for presence of neuropathic pain before the procedure and at one and three months after. Although the change in NRS score was established as the primary outcome measure, the change in the number of patients with neuropathic pain according to the DN-4 was determined as the secondary outcome measure. Result: In the final analysis, data from 42 patients were evaluated. The analysis of the time-dependent change in NRS revealed a statistically significant reduction in the scores for the first and third months, in comparison with the initial measurement. A significant decrease was observed in the number of patients diagnosed with neuropathic pain according to the DN-4 questionnaire in the first month, in comparison with the baseline. However, no significant change was noted in the third month. Conclusion: The utilization of EPRF for the treatment of chronic radicular pain in the setting of PSPS-II appears to be effective in the short term. Further studies are required to ascertain its long-term effects. Trial Registration: ClinicalTrials.gov identifier: NCT06239857.

Endoscopic Epidurolysis for the Management of Chronic Spinal Pain: A Delphi-Based Italian Experts Consensus

INTRODUCTION

Endoscopic epidurolysis (EE) is a minimally invasive procedure used to manage chronic spinal pain, particularly in cases unresponsive to traditional treatments. Despite its growing recognition, the literature lacks comprehensive guidelines on its optimal use. This study utilized a modified Delphi approach to gather expert consensus on best practices for EE in the Italian pain therapy network.

METHODS

The study's scientific board conducted an extensive literature review to define key investigation topics, including clinical indications, preoperative assessments, and technical aspects of EE. A semi-structured questionnaire was developed and administered to a panel of experts. A two-round Delphi process was implemented, with consensus defined as at least 70% agreement on a 7-point Likert scale (agree or strongly agree). Statements that did not reach consensus in the first round were rephrased and resubmitted in the second round.

RESULTS

Twenty-six clinicians participated in the study, with a 100% response rate in both rounds. In the first round, consensus was achieved for 9 out of 19 statements. In the second round, 8 out of 10 rephrased statements reached the consensus threshold. Key areas of agreement included the clinical indications for EE, the importance of preoperative imaging and anesthetic assessments, and the use of specific techniques and tools for EE. However, consensus was not reached on the use of EE for disc herniation with radicular pain and the safety of interlaminar access compared to sacral hiatus access.

CONCLUSION

The study highlights the need for standardized protocols in EE to ensure consistent and effective treatment of chronic spinal pain. The consensus reached by the expert panel provides a framework for best practices, which can guide clinical decision-making and improve patient outcomes. Further research is necessary to validate these findings and address areas where consensus was not achieved.

Catastrophizing as a Predictor for Pain Perception and Disability Among Patients Undergoing Spinal Cord Stimulation

Background and Objectives: The International Society for Modulation defines persistent spinal pain syndrome type 2 (PSPS-type 2), formerly known as failed back surgery syndrome, as a condition where patients continue to experience pain or develop new pain following spinal surgery intended to alleviate back or lower-limb discomfort. PSPS-type 2 is characterized by pain and significant disability, affecting quality of life. Spinal cord stimulation has proven effective in treating this syndrome, although the role of psychological factors, such as pain catastrophizing and central sensitization, remain unclear. This study seeks to examine the potential connection between psychosocial responses and both functionality and pain perception in patients with persistent spinal pain syndrome type 2 who have undergone spinal cord stimulation treatment. Materials and Methods: A single-site, cross-sectional study was conducted on individuals diagnosed with persistent spinal pain syndrome type 2 who were receiving spinal cord stimulation. Study participants were required to meet specific eligibility criteria and were assessed for disability, pain perception, fear of movement, pain catastrophizing, and central sensitization. The spinal cord stimulation procedure involved the placement of electrodes at vertebral levels T8-T11 for precise pain control, with a particular focus on targeting the dorsal root ganglion to alleviate chronic pain. Results: Thirty-seven patients with persistent spinal pain syndrome type 2 have undergone spinal cord stimulation treatment for 4.68 ± 5.25 years. Clinical assessments indicated a pain perception score of 5.6 ± 1.96, Central Sensitization Inventory score of 42.08 ± 18.39, disability score of 37.62 ± 16.13, fear of movement score of 33.11 ± 8.76, and pain catastrophizing score of 28.43 ± 13.14. Finally, pain catastrophizing was significantly associated with pain perception (β = 0.075 and p = 0.008) and disability (β = 0.90 and p < 0.01). Conclusions: Catastrophizing plays a crucial role in pain perception and disability among patients with persistent spinal pain syndrome type 2 receiving spinal cord stimulation. Integrating psychological interventions may improve clinical outcomes for these patients.

An AI-Driven Framework for Detecting Bone Fractures in Orthopedic Therapy

This study presents an advanced artificial intelligence-driven framework designed to enhance the speed and accuracy of bone fracture detection, addressing key limitations in traditional diagnostic approaches that rely on manual image analysis. The proposed framework integrates the YOLOv8 object detection model with a ResNet backbone to combine robust feature extraction and precise fracture classification. This combination effectively identifies and categorizes bone fractures within X-ray images, supporting reliable diagnostic outcomes. Evaluated on an extensive data set, the model demonstrated a mean average precision of 0.9 and overall classification accuracy of 90.5%, indicating substantial improvements over conventional methods. These results underscore a potential framework to provide healthcare professionals with a powerful, automated tool for orthopedic diagnostics, enhancing diagnostic efficiency and accuracy in routine and emergency care settings. The study contributes to the field by offering an effective solution for automated fracture detection that aims to improve patient outcomes through timely and accurate intervention.

The Use and Benefits of Focused Shockwaves for the Diagnosis of Myofascial Pain Syndrome by Examining Myofascial Trigger Points in Low Back Pain

Background/Objectives: Low back pain (LBP) is a widespread public health issue, with myofascial pain syndrome (MPS) being a common cause, affecting 67-100% of patients. However, there are significant challenges in the diagnostic process due to the subjective and unreliable nature of manual palpation. Focused Extracorporeal Shockwave Therapy (F-ESWT), traditionally used for MPS treatment, offers a reproducible and non-invasive mechanical stimulus, making it a potential diagnostic tool. This study evaluated F-ESWT's diagnostic efficiency in chronic LBP patients by focusing on "recognition" and "referral" of pain. Methods: twenty-eight participants were screened for myofascial trigger points (MTrPs) in the lumbar, gluteal, and thigh regions. Identified MTrPs were stimulated using F-ESWT, and patient feedback was recorded. Results: data showed high diagnostic accuracy for muscles such as the quadratus lumborum, gluteus medius, and gluteus minimus muscles, achieving "referral" rates of 96%, 95%, and 92% and "recognition" rates of 84%, 86%, and 85%, respectively. Other structures like adductors, iliopsoas, erector spinae, and biceps femoris muscle showed consistent but lower diagnostic rates. Conclusions: the study's findings indicate that F-ESWT effectively reproduces pain patterns, offering a precise, reproducible, and non-invasive diagnostic approach for MPS in chronic LBP. However, they also highlight the necessity for detailed diagnostic criteria in managing myofascial pain.

Changed resting-state connectivity of anterior insular cortex affects subjective pain reduction after knee arthroplasty: A longitudinal study

The mechanism of chronic knee osteoarthritis (OA) pain and postoperative pain due to knee arthroplasty has not been elucidated. This could be involved neuroplasticity in brain connectivity. To clarify the mechanism of chronic knee OA pain and postoperative pain, we examined the relationship between resting-state functional connectivity (rs-FC) and clinical measurements in knee OA before and after knee arthroplasty, focusing on rs-FCs with the anterior insular cortex (aIC) as the key region. Fifteen patients with knee OA underwent resting-state functional magnetic resonance imaging and clinical measurements shortly before and 6 months after knee arthroplasty, and 15 age- and sex-matched control patients underwent an identical protocol. Seed-to-voxel analysis was performed to compare the clinical measurements and changed rs-FCs, using the aIC as a seed region, between the preoperative and postoperative patients, as well as between the operative and control patients. In preoperative patients, rs-FCs of the aIC to the OFC, frontal pole, subcallosal area, and medial frontal cortex increased compared with those of the control patients. The strength of rs-FC between the left aIC and right OFC decreased before and after knee arthroplasty. The decrease in rs-FC between the left aIC and right OFC was associated with decreased subjective pain score. Our study showed a correlation between longitudinally changed rs-FC and clinical measurement before and after knee arthroplasty. Rs-FC between the aIC and OFC have the potential to elucidate the mechanisms of knee OA pain and postoperative pain due to knee arthroplasty.

Immune response and cytokine profiles in post-laminectomy pain syndrome: comparative analysis after treatment with intrathecal opioids, oral opioids, and non-opioid therapies

INTRODUCTION

This study explores the interaction between cytokines, cell-mediated immunity (T cells, B cells, and NK cells), and prolonged morphine administration in chronic neuropathic pain patients without cancer-related issues. Despite evidence of opioid immunomodulation, few studies have compared these interactions.

METHODS

In a cross-sectional and comparative study, 50 patients with chronic low back radicular pain ("Failed Back Surgery Syndrome") were categorized into intrathecal morphine infusion (IT group, n = 18), oral morphine (PO group, n = 17), and non-opioid treatment (NO group, n = 15). Various parameters, including plasma and cerebrospinal fluid (CSF) cytokine concentrations, lymphocyte immunophenotyping, opioid escalation indices, cumulative morphine dose, and treatment duration, were assessed.

RESULTS

CSF IL-8 and IL-1β concentrations exceeded plasma levels in all patients. No differences in T, B, and NK lymphocyte numbers were observed between morphine-treated and non-treated patients. Higher plasma IL-5 and GM-CSF concentrations were noted in IT and PO groups compared to NO. CSF IFNγ concentrations were higher in PO and NO than IT. Positive correlations included CD4 concentrations with opioid escalation indices, and negative correlations involved NK cell concentrations, CSF TNFα concentrations, and opioid escalation indices. Positive correlations were identified between certain cytokines and pain intensity in IT patients, and between NK cells and cumulative morphine dose. Negative correlations were observed between CSF IL-5 concentrations and pain intensity in IT and PO, and between opioid escalation indices and CSF cytokine concentrations in PO and IT.

CONCLUSION

Associations between cytokines, cellular immunity, and prolonged morphine treatment, administered orally and intrathecally were identified.

Sagittal Full-Spine vs. Sectional Cervical Lateral Radiographs: Are the Measurements of Cervical Alignment Interchangeable?

(1) Background: This study assessed the relationship between cervical spine parameters taken on standing full-spine lateral radiographic images compared to sectional lateral cervical radiographs. (2) Methods: Full-spine (FS) and sectional lateral cervical (LC) radiographs from four spine treatment facilities across the USA retrospectively provided data collected on 220 persons to assess the comparison of three sagittal cervical radiographic measurements between the two views. The measures included cervical lordosis using the absolute rotation angle from C2-C7, sagittal cervical translation of C2-C7, and atlas plane angle to horizontal. Linear correlation and R2 models were used for statistical comparison of the measures for the two views. (3) Results: The mean values of the three measurements were statistically different from each other: C2-C7 translation (FS = 19.84 ± 11.98 vs. LC = 21.18 ± 11.8), C2-C7 lordosis (FS = -15.3 ± 14.63 vs. LC = -18.32 ± 13.16), and atlas plane (FS = -19.99 ± 8.88 vs. LC = -22.56 ± 8.93), where all values were p < 0.001. Weak-to-moderate-to-strong correlations existed between the full-spine and sectional lateral cervical radiographic variables. The R2 values varied based on the measurement were R2 = 0.768 (p < 0.001) for sagittal cervical translation of C2-C7 (strong), R2 = 0.613 (p < 0.001) for the absolute rotation angle C2-C7 (moderate), and R2 = 0.406 (p < 0.001) for the atlas plane line (weak). Though a linear correlation was identified, there were consistent intra-person differences between the measurements on the full spine versus sectional lateral cervical radiographic views, where the full-spine view consistently underestimated the magnitude of the variables. (4) Conclusion: Key sagittal cervical radiographic measurements on the full spine versus sectional lateral cervical radiographic views show striking intra-person differences. The findings of this study confirm that full spine versus sectional lateral cervical radiographic views provide different biomechanical magnitudes of cervical sagittal alignment, and caution should be exercised by health care providers as these are not interchangeable. We recommend the LC view for measurement of cervical sagittal alignment variables.

Multimodal management strategies for chronic pain after spinal surgery: a comprehensive review

"Chronic pain after spinal surgery" (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.

The Subjective and Objective Improvement Using Chiropractic Biophysics® Protocols

The aim of this study is to describe the Chiropractic BioPhysics® (CBP®) (Chiropractic BioPhysics, Eagle, USA) technique in alleviating the persistent spine pain syndrome (PSPS) and dysfunction in a 50-year-old female who suffered for many years. The purpose of this study is to provide clinicians with a potential treatment option for failed back surgery syndrome (FBSS) and PSPS that doesn't respond to other treatments. The patient did not receive benefits from pharmaceutical and conservative therapies following a low back lifting injury in 2004. After several years of suffering from widespread spinal pain and dysfunction, she received a lumbosacral pedicle screw surgical fixation. The initial surgery was unsuccessful and a follow-up revision and expansion of the fusion failed to alleviate the pain and dysfunction as well. After treatment using CBP, the patient received subjective, objective, and radiographic improvements with long-term stability measured at follow-up. Given that spine pain and low back pain are the number one cause of disability in the world, having economical, repeatable, and measurable techniques to improve even difficult cases is important for astute clinicians treating spine pain.