Post Laminectomy Syndrome

What is Post Laminectomy Syndrome?

An individual who has undergone surgical treatment by Spine surgeons is called Post-Laminectomy syndrome. The treatment is given to get rid of back pain and the pain does not go away. Due to a disc protrusion the vertebrae protecting the spinal cord are removed to release pressure by a surgical procedure named Laminectomy. Individual who has undergone this surgery recovers without any potential complications under normal circumstances, but in some instances this procedure is considered as a failure. The pain does not resolve or may even get worse. This condition is called what is called Post-Laminectomy Syndrome. ⁽⁷⁾

Other names:

Post Laminectomy syndrome is also known as Failed back syndrome or Failed neck syndrome. It describes the constellation of symptoms that appear after spinal surgery on either the lumbar or cervical regions. Spinal surgery is performed to relieve the pain, but in many cases the pain gets worse. The pain doesn’t change or doesn’t go away completely.

Symptoms:

The most common symptom of Post-Laminectomy syndrome is pain in the back in the area where the surgery was performed and down the leg on that side or both sides. There would be change in the symptoms of the individual to pre and post surgery:

• Aching discomfort in the region of the spinal column that may become sharp
• Ache may radiate to the lower extremities
• Hyperalgesia with heat
• Chronic pain leads to anxiety and depression
• Change in posture and walking style
• The type may be either muscular or nerve related
• Point tenderness or muscular pain is more often a source of pain following back surgery
• Damage to nerves and the change in the mechanics of the back can lead to spasms
• Cramping, aching and soreness are experienced around the site of the surgery
• Experiencing tingling, shooting or weakness in the extremity impacted by the back surgery
• Some of the nerves around the surgical site are painful
• Localized numbness
• If the surgeon do not operate close to large and important nerves, back surgeory can cause problems
• Nerves can easily cut, stretched or bruised during the course of the procedure ⁽³⁾

Other symptoms:

Pricking and stabbing pain called neuropathic pain radiates from the back down the legs. Neuropathic pain is caused by primary injury to the nervous system. The nerve root injury caused by the spinal disorder that led to surgery may cause neuropathic pain. The Neuropathic pain is associated with an abnormal sensitization of the spinal nerves followed by central sensitization of the spinal cord that receives the initial pain signals.

Central sensitization leads to the reorganization of the pain pathways resulting in a chronic pain. One result of this reorganization is the experience of allodynia that is the interpretation of a non-painful stimulus which is painful. For instance, a light touch or brush against the skin would cause a painful experience. Hyperalgesia may also occur, that is an increased response to a painful stimulus. For example, light or a heat pinprick may be perceived as more intense pain than typically expected.

In cervical post-laminectomy syndrome, the symptoms typically involve neck or neck and arm pain persisting despite surgical intervention and adequate healing of the surgical site. These symptoms can occur after cervical discectomy or fusion and also occur after laminectomy.

In lumbar post-laminectomy syndrome the symptoms typically involve persistent low-back or low-back and leg pain despite of surgical intervention and adequate healing of the surgical site. These symptoms can occur after fusions, discectomy, and lumbar laminectomy. ⁽⁵⁾

If the disc is the reason for the pain, the surgery performed to fuse two lumbar vertebrae has a high rate of success. The success rate decreases where the herniated disc cannot be proven with radiographic imagery. Neck pain and back pain is so severe and the surgery is unable to ease the pain, such as in chronic nerve compression. This is due to the severe damage by the original injury to ever heal entirely.

Post-laminectomy is where surgery to the back results in leg or/and back pain. Laminectomy is a surgery for removing protective vertebra around the spinal cord. The surgery is performed to alleviate pressure on the spinal cord caused by a bulging disc.

Risk factors

Any individual with spinal surgery has the potential for neck or back syndrome. Fusions of the vertebrae that do not knit the way they are supposed to primarily Post-Laminectomy syndrome. Physical therapy is necessary for recovery. Several issues can be inhibited to this fusion:

• Smokers are at high risk as it affects the small blood vessels that allow the blood vessels to take place
• Individuals who fail to participate in rehabilitation exercises following back surgery
• Uncontrolled diabetes can lead to fusion failure
• Diabetes impacts the ability of small blood vessels to heal tissue
• Individuals who have severe nerve pain
• When the aetiology of the pain is not well known
• Less experienced neurosurgeon usage
• Having open instead of minimally invasive surgery ⁽⁹⁾

Factors contributing to the condition :

• bulging and recurring  disc herniation
• Retained disc fragments
• Incomplete decompression of disc
• Persistent pressure on nerves
• changed joint mobility or joint instability
• tissue Scar
• Sleep deprivation
• Weakness in muscles that support the spine
• anxiety and/or depression ⁽¹⁾

Causes

There are a variety of factors that may cause Post-Laminectomy Syndrome such as:

• The Patients who smoke are likely to develop post-laminectomy syndrome
• Scar tissue formation and nerve roots
• the surgery was done in haste and the pressure put on the spinal cord by the protruding disc was not severe enough to warrant surgery
• the patients fail to get relief due to another condition called as spinal stenosis
• severe narrowing of the spinal canal
• a small piece of disc still remaining in the spinal cord post procedure
• irritation to the cord and result in pain after the post procedure
• the spinal nerve root that has been decompressed by the surgery
• Presence of structural changes in spine that develop above or below the site of a spinal fusion
• recurrent or new disc herniation
• post-operative spinal
• pelvic ligament instability
• such as SI joint dysfunction
• Myofascial pain
• the body’s way of healing
• prior trauma continues to be a source of sciatica or chronic nerve pain
• smoking delays recovery ^{(12), (8)}

CT scan showing post operative CT scan showing two views of L4-5 disc scarring and arachnoiditis herniation

Diagnosis

In order to diagnose the Post-Laminectomy Syndrome physician will first take a look at the surgical site which in cases of the syndrome will be tender to deep palpation. The patient will complain of persistent pain in back radiating down the legs. The patient will also have an abnormal gait due to the significant pain in back. These signs are enough for a physician to diagnose the Post-laminectomy Syndrome. For further diagnosis the physician will also order radiologic studies like MRI scan or X-rays to look at internal structures of the spinal cord to check whether there are any bone fragments left that may be irritating the spinal cord and causing pain. Spinal cord compression causing unrelenting pain will also be checked.

CT scan image of large herniated CT scan of laminectomy showing scar formation

disc in the lumbar spine causing new stenosis (highlighted in red)

Epidural post-operative fibrosis:

Following a laminectomy epidural scarring for disc excision is a common feature when re-operating for recurrent radiculopathy or sciatica. The scar associated with disc herniation which is relevantly common occurs in more than 60%.Placing a fat graft over the dural could prevent post operative scarring. Most often it is seen around the L5 and S1 nerve roots. (2)

Treatment

The most important initial treatment for Post-Laminectomy syndrome is a proper evaluation with a qualified specialist who can understand how to diagnose and treat the complex chronic pain issues. The evaluation includes:

• A detailed history
• a thorough physical examination
• acquisition and review of appropriate imaging
• creating the proper long-term treatment plan with an established an accurate diagnosis
• focus on utilization of medication to temporarily alleviate
• provide some therapeutic relief
• Minimally invasive injections such as  a selective nerve root block or epidural steroid injection
• Physical therapy as a part of multi-pronged plan to restore function and mobility
• Consulting pain psychologists to address the inevitable impact chronic pain
• resistant to other treatments may be treated with a spinal cord stimulation
• specific exercises for the back and physical therapy
• Pain medications in the form of NSAIDs
• Specific medication made to inhibit the chemical TNF-a
• Etanercept
• Remicade
• Humira
• use of neuromodulator like the spinal cord stimulator
• Epidural Steroid Injections
• radiofrequency ablation treatment
• anti-inflammatory drugs
• pain-relief injections for numbing affected region
• facet block
• trigger point injections
• manipulating brain’s pain signals ⁽¹¹⁾

Treatment

Post-laminactomy syndrome should be treated with an interdisciplinary approach that works towards a common goal for the patient. The therapeutic approach could range from a non-surgical to surgical intervention. ⁽⁶⁾

The techniques include:

• • Physical therapy
  • Modalities
  • Manual therapy

Medications

• • Assessment of opioid protocol
  • Anti-depressants
  • Anti-epileptic drugs

Injection therapy

• • Epidural injections
  • Nerve root blocks

Stabilization education

• • Postural education

Non-surgical pain management procedures

• • Racz procedure (Epidural neuroloysis)
  • Pulsed radiofrequency deactivation of dorsal root ganglion
  • Spinal cord stimulation (Dorsal column stimulator) ⁽¹⁰⁾

Total disc replacement:

Lumbar total disc replacement was to be an alternative to lumbar arthodesis. The treatment remained undefined and unclear. Various failures and strategies for replacement of disc have been reported. Mixed effects have been observed on disc replacement prior to spinal surgery.

Chiropractors are another good resource to attempt recovery from back surgery which was ineffective. Pain Medicine physicians are experts in treating chronic pain. Medications such as certain antidepressants and anti-seizure medications can ease nerve pain. In case the therapy and medications do not provide enough relief a spinal cord stimulator trial can be performed. It replaces the pain signals sent from the damaged nerves with a more comfortable buzzing sensation. The process involves placing a temporary spinal cord stimulator wire with programmable electrodes at the ends into the epidural space. The electrodes are connected to an external battery operated programming device that can match the buzzing sensation to the painful area. ^{(7), (4)}

References:

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9. Mikkonen P, et al. (2008). “Is smoking a risk factor for low back pain in adolescents? A prospective cohort study”. Spine. 33 (5): 527–32.
10. Sommer C, Schafers M (Dec 2004). “Mechanisms of neuropathic pain: the role of cytokines”. Drug Discovery Today: Disease Mechanisms. 1 (4): 441–8.
11. Tropiano P, et al. (2003). “Lumbar disc replacement: preliminary results with ProDisc II after a minimum follow-up period of 1 year”. J. Spinal Disord. Tech. 16 (4): 362–8.
12. Quiles M, Marchisello PJ, Tsairis P (March 1978). “Lumbar adhesive arachnoiditis. Etiologic and pathologic aspects”. Spine.