Neurochirurgie
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Failed back surgery syndrome (FBSS) is defined as persistent pain more than 3 months after any form of spinal surgery. Due to its multifactorial origin, FBSS is often difficult to treat. In this context of failed back surgery, a very thorough assessment must be conducted concerning the site and characteristics of the pain (nociceptive or neuropathic), its mode of onset (presence or absence of pain-free intervals), and its impact on the patient's work and social life. ⋯ The treatment of failed back surgery syndrome with a predominant neuropathic component is based on the use of analgesics, especially antiepileptics, antidepressants or transcutaneous electrical stimulation. Epidural spinal infiltration should be considered as second-line treatment in view of the risk of serious neurological complications. Management must be based on a global, multidisciplinary approach with identification of any cognitive or behavioural disorders in combination with an appropriate functional rehabilitation programme.
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Observational Study
The Franco-Canadian multicolumn spinal cord stimulation prospective study: a subgroup analysis focusing on the decisive role of lead positioning.
Multicolumn spinal cord stimulation (SCS) is now considered to be effective for the treatment of the radicular and back component in refractory Failed Back Surgery Syndrome (FBSS) patients. The relationship between the paresthesia coverage of the back and clinical outcomes has recently been confirmed by an international prospective study. However, significant disparities in outcomes were identified and could result from the heterogeneity of lead implantation parameters which are dependant on local practices and experience. We therefore sought to analyse the impact of lead implantation level and its lateralization on the ability to address back pain with multicolumn SCS leads. ⋯ Despite limitations in this retrospective subgroup analysis, this study suggests that the vertebral level (T8-T9) and midline positioning of the lead during implantation could be decisive factors to optimize paresthesia coverage and finally, clinical and functional outcomes. While sophistication has been responsible for an increase of the size and the programming possibilities of surgical SCS leads during the past years, multicolumn SCS lead implantation should in fact be considered as a "functional neurosurgical" procedure and could benefit from intraoperative patient cooperation, as in the case for deep brain stimulation procedures, due to minimally invasive implantation techniques.
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One of the major challenges of neurostimulation is actually to address the back pain component in patients suffering from refractory chronic back and leg pain. Facing a tremendous expansion of neurostimulation techniques and available devices, implanters and patients can still remain confused as they need to select the right tool for the right indication. To be able to evaluate and compare objectively patient outcomes, depending on therapeutical strategies, it appears essential to develop a rational and quantitative approach to pain assessment for those who undergo neurostimulation implantation. ⋯ The Neuro-Pain'T is an original software designed to objectively and quantitatively characterize reduction of a painful area in a given individual, in terms of intensity, surface and pain typology, in response to a treatment strategy or implantation of an analgesic device. Because pain is a physical sensation, which integrates a psychological dimension, its assessment justifies the use of multidimensional and global evaluation scales. However, in the context of neurostimulation and comparative clinical trials designed to test the technical efficacy of a given device, a simple, objective and quantitative evaluation tool could help to guide tomorrow's treatment options by transforming personal convictions into a more robust scientific rationale based on data collection and data mining techniques.
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Low back surgery, including as many type of spine procedures as the multitude of failed back surgery syndrome (FBSS) etiologies, is not always the answer for patients with chronic low back pain. Paradoxically, although a patient is considered to present FBSS because he has already undergone spinal surgery, any new symptom in the back or deterioration of back pain must not be immediately attributed to FBSS, but could be related to another cause independently of the initial mechanical problem. The aim of this paper is to extensively review the potential back pain generators in FBSS patients and to discuss their respective roles and interactions in back pain pathophysiology. ⋯ Clinical investigations of the low back pain component in FBSS patients should be based on meticulous dissection of all potential triggers that could be a source of the nociceptive pain characteristics and possibly amenable to further aetiological treatment. Clinicians should therefore refine pain management strategies to ensure that the chronic nature of the pain becomes the guiding principle for multidisciplinary assessment.
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The solution to the failed back syndrome will come from the surgeon who masters the technology, the pathology and the surgery and who understands the patient. The back is normally dynamic and the failed back is no longer dynamic. ⋯ Welfare systems that promote disability may undermine successful therapy. Solutions to great problems usually come from men who are passionate, observing and skilful.