Failed back surgery syndrome: what's in a name? A proposal to replace "FBSS" by "POPS" .

BACKGROUND: The current definition of Failed Back Surgery Syndrome (FBSS) has a pejorative and restrictive connotation of blame and failure. Optimally, the evaluation of FBSS patients might be based on a multidimensional approach, involving an array of practitioners including spine surgeons, pain physicians, physiotherapists and behavioural specialists. Even though these clinical interactions should lead to a unique approach, one main problem comes from the fact that FBSS definition has varied over time and remains extremely controversial. There is now a need for global consensus about what we call FBSS, why, when and how. Discussing the name of this syndrome appears to be a logical starting point. DISCUSSION: "PostOperative Persistent Syndrome", summarised by the acronym "POPS", could be an appropriate term to not only encapsulate failure but pain, function and psychosocial dysfunction following unsuccessful spine surgery whether from a technical or expectation standpoint. A return to the source might help to identify the real clinical problem, i.e. the pain mechanism: nociceptive, neuropathic pain or mixed. A clinical and radiological spine assessment is key to ensure that no further surgery is required, by distinguishing within the so-called FBSS population, "true" FBSS patients and "potential" FBSS patients, who are actually not FBSS patients, as an aetiological treatment of potential pain generators still remains possible. CONCLUSION: We propose to replace the FBSS acronym by POPS. The ultimate goal of this redefinition would be to guide the patient towards the future rather than the past and to reach a consensus, based on network discussions, concerning the following items: integrate pain mechanisms into the diagnostic process; implement the notion of a predominant ratio between mechanical/neuropathic pain mechanisms, which defines the potential target for treatment options; create a network supported by a database, to prospectively pool and analyse data, using homogeneous evaluation tools and ultimately define outcome predictors in this population.

Failed back surgery syndrome: who has failed?

INTRODUCTION: Failed back surgery syndrome (FBSS) results from a cascade of medical and surgical events that lead to or leave the patient with chronic back and radicular pain. This concept is extremely difficult to understand, both for the patient and for the therapist. The difficulty is related to the connotations of failure and blame directly associated with this term. The perception of the medical situation varies enormously according to the background and medical education of the clinician who manages this type of patient. Eight health system experts (2 pain physicians, 1 orthopaedic spine surgeon, 1 neuro spine surgeon, 1 functional neurosurgeon, 1 physiatrist, 1 psychologist and one health-economic expert) were asked to define and share their specialist point of view concerning the management of postoperative back and radicular pain. Ideally, it could be proposed that the patient would derive optimal benefit from systematic confrontation of these various points of view in order to propose the best treatment option at a given point in time to achieve the best possible care pathway. CONCLUSION: The initial pejorative connotation of FBSS suggesting failure or blame must now be replaced to direct the patient and therapists towards a temporal concept focusing on the future rather than the past. In addition to the redefinition of an optimised care pathway, a consensus based on consultation would allow redefinition and renaming of this syndrome in order to ensure a more positive approach centered on the patient.

Optimal medical, rehabilitation and behavioral management in the setting of failed back surgery syndrome.

INTRODUCTION: Failed back surgery syndrome (FBSS) constitutes a constellation of symptoms grouped together and attributed to prior surgical intervention. Clinicians often poorly understand the heterogeneity of this condition combined with the etiological factors responsible for its development. Therefore, it would follow that an algorithmic treatment approach to patients diagnosed with this syndrome might pose challenges. The clinical work-up of the patient involves history, examination and appropriate diagnostic imaging as well as behavioral assessment. MATERIALS AND METHODS: We sought to conduct a narrative review of the available literature focused on the medical, rehabilitative and behavioral treatment of FBSS. To that end, we conducted a literature search using PubMed (through March 2013). We focused on studies published over the last 20years. Only English language articles were included. Search terms included "failed back surgery syndrome", "FBSS", "failed back syndrome", and "post-laminectomy syndrome". Studies included in our review focused on randomized controlled trials (RCTs), prospective cohort studies, and case series (retrospective and prospective). Studies were organized by intervention (e.g. medical management, physical therapy and rehabilitation, and psychosocial) and presented to emphasize the quality of evidence (e.g. RCTs, prospective studies, etc.). CONCLUSION: Overall, the literature provides very limited guidance on the comprehensive management of patients suffering from FBSS. There are rehabilitative interventions and behavioral protocols that demonstrate promise. Pathways based on medication management remain difficult to clearly define.

Three-step treadmill test and McKenzie mechanical diagnosis and therapy to establish directional preference in a patient with lumbar spinal stenosis: a case report.

BACKGROUND: Lumbar spinal stenosis (LSS) is defined as narrowing of the spinal canal. LSS is commonly treated conservatively, primarily with flexion-based exercises. We present a patient diagnosed with LSS, refractory to a flexion-based protocol who ultimately responded to an extension-based protocol following establishment of directional preference with three-step treadmill testing. DESCRIPTION: A 64-year-old male was diagnosed with LSS with a 2-year history of bilateral neurogenic claudication unresponsive to flexion-based exercises. Initially, distinct directional preference or centralization was not demonstrated on repetitive movement testing. Ultimately, preference towards extension was established through a three-step treadmill test. An extension-based treatment plan was recommended, which provided significant relief despite focusing on exercises that are commonly avoided during traditional treatment for LSS. OUTCOMES: He began to centralize pain to his lower back after 2 weeks and denied neurogenic claudication on repeat three-step treadmill test at 3 weeks. His drastic improvements in pain levels and functional status continued throughout four sessions. DISCUSSION: Although the patient's initial diagnostic label may bias towards a spinal flexion protocol, further mechanical testing revealed an extension directional preference. The three-step treadmill test was crucial in establishing his directional preference and guiding his treatment. Treadmill testing may be useful in a subset of patients who do not demonstrate distinct directional preferences on mechanical testing.