Case of the Month #32: Spinal Cord Stimulation (SCS) for Persistent Pain Following Spinal Surgery; presented by Owain Davies

The patient describes left leg pain in a similar distribution to before her surgery. The pain runs from the left buttock, down the posterior thigh and leg into the top of the foot. There is associated numbness in the top of the foot. The patient describes the pain as sharp, shooting, burning and near constant with exacerbations which can be provoked with movement. The lower back pain experienced by the patient is a constant ache in the lumbar region, exacerbated by movement, and weight bearing. 

The patient has previously been referred to physiotherapy, to no effect, and currently is taking a combination of neuropathic and opiate analgesia. The leg pain is intolerable, limiting the patient’s activities, and they are unable to work.  Living with chronic pain has caused the patient to become depressed, and their GP has started an anti-depressant. 

• What is failed back surgery syndrome (FBSS)?

Failed back surgery syndrome (FBSS) or post-laminectomy syndrome, is a term describing persistent or recurring lower back pain, with or without sciatica following one or more spinal operations. A modern nomenclature is persistent spinal pain syndrome (PSPS) type 2, which reflects that it is a condition of continual pain (for which surgery was performed), rather than due to fault or problem during surgery. 
Persistent or recurring pain following spinal surgery is common, affecting 20-40% of patients (Treede 2019). These patients often have chronic opiate use and addiction and are unable to work, causing a significant impact on their quality of life with resultant wider economic ramifications (Taylor 2012). With lumbar surgery referrals increasing year on year, the incidence of FBSS is due to increase, and well as the resultant demand on pain specialists to manage these patients. 

• Assessment prior to SCS

A multidisciplinary pain management team approach is recommended for assessment of suitability for SCS. This team usually comprises of a consultant in pain medicine, a spinal/neurosurgeon, pain specialist nurses and allied healthcare professionals such as psychologists and physiotherapists.  Psychological assessment is often required as this is helpful to manage patient expectations of treatment and to development other pain management strategies. The MDT should have access to a spinal/neurosurgeon who can manage the operative complications of SCS.