Postlaminectomy syndrome is referred to the continuous pain in the back experienced after a laminectomy (spine surgery). The chronic pain related to laminectomy has no definitive cause and is said to be a product of various conditions and complications. There are various treatment options available which include pain management through medication and also surgery in some cases.In the US, on an average, 450 cases out of 100,000 are considered for surgery. Based on this data, we could estimate the number of cases of postlaminectomy syndrome of which an estimated 10% to 15% are considered to be unsuccessful.Some studies have also reported this number to go up to 20% of total number of cases, increasing the total number of failed surgeries and postlaminectomy syndrome.
Aetiology
If you have observed your back carefully, you would know that our spine is a bony vertical structure which stretches from the pelvic region to the base of the skull. The primary function of this bony vertebra is to protect the spinal cord and all of its nerve roots. These vertebrae have an opening in the center for the spinal cord to fit in. The portion that connects the vertebrae to the main body of the bone is called as Lamina. When the lamina or any of its associated bone spurs cause pressure on the spinal nerves, a surgery is performed to relieve this pressure known as laminectomy.
- The exact cause of the postlaminectomy syndrome is still disputed, but there are various conditions and complications which might lead to chronic back pain. Since there is no definitive cause theory, the following are a few of the proposed causes:
- Epidural fibrosis is considered as a prominent cause of the pain as the development of scar tissue during the healing stage of the surgery compresses nearby nerve roots and causes pain.
- In some cases, the vertebrae attached to surgical site change structurally, causing pain in the back.
- Nerve root injury at the time of the surgery or infection of the epidural space (disc space) may cause postlaminectomy syndrome.
- Sometimes the surgery and related processes go as per planned, but the psychological health of the patient takes a toll on his back causing pain.
Symptoms
The pain experienced during postlaminectomy syndrome is very much the same as experienced before the surgery. A dull and achy pain is experienced in the spinal column or an acute shooting pain is experienced downwards from the spine spreading to the legs. The pain inflicted by postlaminectomy ranges from mild to severe and abnormal sensitivity to heat and pressure is also experienced. Neuropathic pain might be caused by the nerve injury which might have occurred during the surgery process. Neuropathic pain is generally accompanied by central sensitization of the pain pathways which is the major reason of the hypersensitive skin causing pain.
Diagnosis
The diagnosis of postlaminectomy syndrome depends on three parameters and them being patient history, physical assessment and clinical tests.
- Patient history is a considered before recommending physical or clinical tests as there are chance of patients with previous failed surgery attempts to have developed it. In some cases there are patients who have had other back problems leading to lower back pain and sciatica (leg pain).
- The physical exam involves assessment of the individual in three positions – lying, sitting and standing. The examiner locates the area of tenderness through palpation (touching). The physical exam is an evaluation of posture, gait and range of motion caused by the syndromes as well as asymmetry, deformity or spinal curvature.
- X-rays of the spine are recommended to observe the post-operative instability which is a primary cause of chronic pain. Imaging tests like MRI and CT scan of the spinal region are recommended to determine nerve compression, disc diseases and also a confirmation for differential diagnosis, ruling out epidural infection or tumors. Blood tests are done to determine the white blood cell count and the erythrocyte sedimentation rate. In cases of infection, a bone scan through nuclear imaging or MRI is recommended to closely evaluate the status of bone and soft tissue. Psychological evaluation is recommended for patients repeating the surgery after initial failure.
Treatment
- The first line of treatment for patients suffering from postlaminectomy syndrome is the traditional treatment. Traditional treatment process includes a combination of physical therapy related exercises and oral medication like analgesics, NSAIDs, antidepressants, muscle relaxants, etc for pain management.
- Narcotics therapy may be recommended to suppress pain. Though these opioids are good at pain management, they do not cure the disability. These chronic opioids are administered orally. Long-term therapy is common for treating non-malignant conditions, though its benefits and side effects are highly debated.
- Spinal stimulation is used to manage the chronic pain by placing a battery powered device which constantly stimulates the spinal cord, bringing relief to almost 50% of the patients.
- The last resort for treating this syndrome is by surgical intervention (additional laminectomy), which is only indicated after a confirmed diagnosis has been achieved.
Life after surgery
The rehabilitation process of this syndrome involves working around the pain to accomplish everyday goals. Occupational therapy is recommended for patients who could maximize their functional abilities for completing everyday chores. The chronic pain causes severe mental trauma and hence various patients are placed into peer groups for experience sharing and psychological strength building.
