Postoperative PLID – Causes, Symptoms, Treatment

Postoperative PLID means the displacement or prolapse to the front side and back side displacement of lumbar vertebrate and create pressure over spinal nerve root causing intance pain, paresthesia, itching, during movement after the major lumber spine operation. It is basically caused by the unsuccessful operation, blunt trauma, microtrauma, road accident, postural problem, muscle weakness in the backside, or sudden forcefully thrust. The patient may feel present with recurrent pain and persistent pain, with or without radiating pain, following spinal surgery. Pain may appear after surgery and persist intense acute pain despite the intervention for up to 3 months or more, with chronic pain.

Causes of Postoperative PLID

  • Postoperative causes – It is the basic cause of an unsuccessful operation. It may be caused by the unconsciousness of the surgeon or vertebral malformation and abnormal nerve root compression.
  • Intraoperative causes  – it is the sense or mistake of failed back surgery syndrome to include the operation in the wrong way or furthers unconsciousness of the patient not maintain the proper guideline in that are given after discharge from hospital.
  • The wrong vertebral  – It another cause of post-operative PLID. The vertebral column may have the lumberization or sacralizations means the stiffness formation in associate joints.
  • Lumbar decompression surgery – It is one of the most causes of post-operative PLID. In such a condition nerve damage, spinal canal stenosis, disc herniation, and, inadequate decompression of a nerve root, preoperative nerve damage or postoperative that does not heal after decompressive surgery, or nerve damage that occurs during the surgery.
  • Scar tissue considerations – It causes after surgery in such as forming epidural fibrosis scar tissue formation, which around the nerve root and spinal column
  • Lake of Postoperative rehabilitation – Postoperative rehabilitation is an important factor for postoperative PLID. Due to adequate consciousness of continued pain from a secondary pain generator.
  • Spasms & Joint Lockage – It is one of the bad symptoms of the possibility of another issue is joint lockage and muscle spasms. Muscle spasms and cramps are not too uncommon immediately after surgery, but they shouldn’t occur after recovery. If you struggle to bend your leg or get sudden spasms and cramps preventing you from walking, then you must immediately consult a professional.
  • Sudden forceful thrust – It is the major or vital causes of postoperative PLID. It caused by the conditions of the unconscious lifestyle, not maintain proper posture and spine positions.
  • Over Bending – Over bending also causes the post-operative PLID and back pain. In the maximum daytime and office work frequently we have to bend our spine forwardly that are causes the post-operative PLID.
  • Lake of Adequate exercise –  It is another cause of post-operative PLID, to maintain a healthy life minimum two our exercise is essential for everyone. But lake of proper time it is not possible to perform the exercise and our body, cell, muscle, ligament, tendon don’t work properly or without exercise back muscle and whole body are not flexible and it causes the post operative PLID.

The most non-surgical causes include

  • Herniated nucleus propulsors (HNP) at a non-surgical site
  • Facet arthrosis
  • Spinal Stenosis
  • Spondylolysis with or without Spondylolisthesis
  • Referred to pain.
  • myofascial pain
  • segment instability
  • Epidural hematoma,
  • Recurrent HNP at the operative site,
  • Infection such as diskitis,
  • Osteomyelitis or arachnoiditis,
  • Epidural scar
  • Meningocele or CSF fistula.

Furthers more multitude of reasons that are including herniated disc, postoperative adhesions, a thickened ligamentum flavum, spondylolisthesis with or without an associated par defect, osteophyte formation from facet arthropathy, or other degenerative changes that may lead to central or transforaminal stenosis.

Symptoms of Postoperative PLID

  • Chronic back and leg pain – It is the first symptoms that persists or recurentssymptoms of leg pain after the application of the back surgery. The pain may be radiate buttock to the leg
  • Radicular symptoms – Pain may be increase in the post oparetive back side and patient may be felt intense pain, tingling, numbness when he/she walking.
  • Right and left side back pain – It is the most common for of post oparetive back pain that may radiate to the right and left side in lower abdomen, buttock and leg.
  • Pain in the back, and sometimes all the way down to the buttocks and legs. Some back issues can cause pain in other parts of the body, depending on the nerves affected.
  • In most cases, signs, and symptoms clear up on their own within a short period.
  • Pain may be continuous, or only occur when you are in a certain position. The pain may be aggravated by coughing or sneezing, bending, or twisting.

Diagnosis of Postoperative PLID

An accurate and thorough history and physical examination of patients with persistent pain after lower back surgery are the most crucial for correct diagnosis. 

History

  • Allow extra time to evaluate initially or properly
  • Essential to have prior records of medical record
  • Preoperative vs.Postoperative complaints and associate test
  • Was there a new problem immediately after surgery or not?
  • Current medication usage and issues of dependency.
  • Careful assessment of the psychological status
  • Vocational status and workers’ compensation
  • Postoperative systemic complaints(often subtle)
  • Back vs Leg pain that radiates or not
  • Unusual pain pattern (reflex sympathetic dystrophy, complex regional pain, )
  • Postoperative rehabilitation (aerobic, flexibility, strengthening, body mechanics, physical therapy).
  • Relieving and exacerbating positions and activities.

Physical Examination

  • Observe closely for pain behavior as a warning of associated problems.
  • Careful neurologic exam for focal localizing findings.
  • Evaluate for the potential major joint problem as referral source (hip, knee)
  • Palpation at surgery site for hematoma, local fluid, abscess, and pseudo meningocele.
  • Examination of extremity for sympathetic or RSD -type changes.
  • Screening for neural tension signs (SLR, Adson’s test)
  • Long tract signs (Babinski’s sign, clonus, Hoffman’s sign)
  • Vascular assessment (diabetics, elderly patients)
  • Local soft tissues (psoas muscle, iliotibial band, gluteal muscles)

Manual Examination

  • Straight Leg Raising Test – A manual test for pain from a disc herniation or nucleus proposal may present with a positive sign on straight leg raise.  Focal neurological deficits in post oparetive back pain and PLID that patients warrant further testing. Deficits in strength or sensation in the lower extremities may help nerve roots are affected and cause pain.
  • Waddell signs –It is  are one of the vital manual tests that can be used to evaluate for psychogenic cause of lower back pain; while the interpretation of these tests is controversial, they may be useful especially if there is a suspicion of secondary gain.
  • One leg hyperextension test/stork test – It a simple and manual or home test the patient can do it own have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. If pain with hyperextension is the resulting increase positive for a pars interarticularis defect or associate abnormalities with post oparetive PLID.
  • Adam test – Patient has to bend over with feet together and arms extended with palms together. The practitioner should observe from the front side of you. If a thoracic lump is present on one left side or the other right side lower back pain, it is an indication of spine scoliosis with PLID.There are numerous other examination techniques; however, they have mixed and anonymous evidence for inter-practitioner reliability and poor sensitivities or specificities lower back pain.

Lab test

  • Blood tests – CBC, Hb, RBS, CRP, Serum Creatinine, Serum Electrolyte.
  • Erythrocyte sedimentation rate and C-reactive protein – It may be used to evaluate for possible infection, especially in patients with constitutional symptoms or a predisposition towards infection. Adherence to strict standards of accurate needle placement, contrast injection, as well as a limited active agent is essential in improving the sensitivity and specificity of these blocks.
  • Bone scan – It is a bone scan test that may be used for detecting bone tumors or compression of nerve root fractures caused by brittle bones and osteoporosis. The patient may receive an injection of a tracer (a radioactive substance) into a vein at the same time. The tracer collects or examiner in the bones and helps the doctor detect bone problems with the aid of a special camera.
  • Electromyography (EMG) – It one kind of test that helps assess the electrical activity in a muscle and nerve impulse velocity or nerve root compression and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body that are causing pain.
  • Evoked potential studies – It may involve two sets of electrodes are placed one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal that is transmitted to the brain.
  • Nerve conduction studies (NCS) – It also uses two sets of electrodes to stimulate the nerve that runs to a particular muscle and record the nerve’s electrical signals to detect any nerve damage for lower right and left side back pain.

Imaging

  • X-rays – It is a foundamental, simple and inexpensive first imaging system to evaluation to detect the bone and vertebrae related problem for suspected failed back surgery syndrome. X-rays are more specific use for detecting vertebral and sacroiliac defects and/or misalignment and are superior to MRIs for the detection of spondylolisthesis. Adjacent segment degeneration and loss of lordosis are common abnormalities found on radiography. However, X-rays are unable to detect spinal stenosis, the most common pathological finding in post oparetive PLID and are also unable to evaluate soft tissue, such as intervertebral discs, epidural scarring, or fibrosis.
  • MRI – It is the confirmation test with and without gadolinium contrast with one of the latest tests that continues to be the gold standard imaging modality for post oparetive PLID due to its excellent ability to detect soft tissue abnormalities such as epidural fibrosis and disc herniation. Contrast is especially indicated in patients with a history of disc herniation surgery. In patients with ferromagnetic implants, a CT myelogram is used to avoid implant artifacts created on MRI. It is the preferred and most sensitive study to visualize herniated disc, bulging disc, or sequestered disc. MRI findings will help to find the soft tissues, ligament, tendon, cartilage even spinal cord clearly to surgeons and other providers plan procedural for lower right and left side back pain care if it is indicated.
  • CT myelography -It is a special kind when the patient has either a contraindication to having an MRI such as heart problem, open-heart surgery, or having a pacemaker device or defibrillator or be used when a standard CT or MRI is negative or equivocal. Myelography is a CT scan or an MRI with intrathecal administration of contrast for post oparetive PLID. CT myelography visualizes a patient’s spinal nerve roots in their passage through the neuroforamina area. CT myelography can be used to assess the underlying root sleeve and nerve root compression. A CT is a poor test for the visualization of nerve roots, making it challenging to diagnose radicular disease.
  • Electromyography (EMG) – It is complete after three weeks of symptoms, not before the lower right and left back pain and post oparetive PLID. Diagnostic tests such as EMG or nerve conduction studies are accurate only after three weeks of persistent symptoms of right or left lower back pain with post oparetive PLID. The primary reason or why using an EMG or nerve conduction study is to identify the delayed three weeks or more time following the development of pain is because of fibrillation potentials after an acute injury in the brain and spinal cord lead to an axonal motor loss. These do not develop until two to three weeks following injury for the lower right and left back pain.
  • Cerebrospinal fluid analysis – It is a useful test for investigating the right and left lower back pain if there is an involvement of neoplasm or infectious cause or radiculopathy symptoms and radiating pain syndrome or post oparetive PLID. The recommendation for lower right and left back pain with post oparetive PLID in lumbar puncture is in the case of a patient with negative or nondiagnostic neuroimaging, without knowing primary cancer and its related condition, who has progressive neurological symptoms and has failed back syndrome and PLID to improve it properly.
  • Bone scintigraphy – It is a special type of test that is done when some or above mention test failed to identify the causes of right and left lower back pain, PLID with single-photon emission computed tomography (SPECT) is more sensitive in detecting facet joint lesions and bony lesion, none spurs and allows more accurate anatomical localization of lower back pain and PLID. A recent study suggested that SPECT could help to identify patients with lower back pain who would benefit from facet joint intraarticular injections []. Facet joint block (FJB)injection is an indispensable diagnostic instrument in order to identify painful or painless back pain from painless facet joints and to plan the intervention strategy.
  • Foraminal nerve root entrapment test – It is best visualized on T1-weighted MRI where are used to identify the high contrast fat tissue and the nerve root sheath that is of great help for lower and right or left ba. In here usually, a combination of hypertrophic degenerative facets with osteophytes spurs posteriorly, and vertebral osteophytes and/or disc herniation anteriorly diminishes the anteroposterior diameter of the foramen and it associate condition. Foraminal height is erased by degenerative disc disease and subsequent disc height loss or not. In this case, the normal rounded (oval) appearance of the nerve root sheath is lost in combination with loss of the surrounding fat tissue, nerve root compression should be considered to identifying the lower right and left side back pain.

Treatment of Postoperative PLID

Non-Pharmacological Treatment for failed back  surgery syndrome

  • Physical therapy – Physical therapy can help the patient optimize gait and posture and can improve muscle strength and physical function., Other conservative measures that may help postoperative back pain and post oparetive PLID involve psychotherapy measures including stress reduction and cognitive behavioral therapy to body and mind fit. Finally, noninvasive procedures or systems including acupuncture and scrambler therapy can be used to minimize the pain associated with post oparetive PLID., These conservative measures should be done in conjunction with medication management to optimize pain relief.
  • Transcutaneous electrical nerve stimulation – It may provide an alternative/complement to medication in patients with post oparetive PLID. Its effectiveness in chronic low back pain is, however, still have controversial []. Other nonpharmacological complementary therapies for post oparetive PLID, such as acupuncture, manual therapy, functional restoration, and cognitive behavioral therapy, may also be utilized, although the level and supporting team most of these therapies in the management of chronic back pain, PLID is moderate at best [].
  • High-frequency spinal cord stimulation – This technique has been shown to be of particular value in patients with post oparetive PLID with a predominant lower back pain component.A frequency of about 5000–10,000 Hz is used. A major advantage is that patients do not have to rely on the perception of paraesthesia, itching in the affected area. There are no efficacy, cost-effectiveness, or safety data from a randomized controlled trial or comparison with conventional SCS in relation to the long-term use of this technology.
  • Dorsal root ganglion stimulation – A specially designed lead is placed around the dorsal root ganglion, via the epidural space, and this produces pleasant paraesthesia in a dermatome or part of it. The major advantages seem to be that there is no change in perception of paraesthesia with posture, and it is possible to target dermatomes that would otherwise be difficult to target with conventional SCS (foot, groin, etc.) without overspill of paraesthesia into other dermatomes. There are minimal long-term data regarding efficacy, safety, and cost-effectiveness.,
  • Peripheral nerve field stimulation – Specially designed leads have been approved for this use, especially for treating the neuropathic back pain component of post oparetive PLID. The use of this technique, in combination with conventional SCS or alone, has been published with impressive results in case series.
  • Radiofrequency ablation – RFA of nerves are often used to provide sustained relief that a diagnostic block or therapeutic injection cannot provide. Successfully targeting the intended nerve is achieved, maximizing the size of the lesion. This can be done by performing multiple RFA in different locations, increasing the temperature and time of the ablation, using bipolar RF or cooled RF.,
  • Neuromodulation – Spinal cord stimulation (SCS) is a treatment modality that has shown tremendous potential in the management of FBSS. The advent of SCS came just 2 years after Melzak and Wall’s 1965 groundbreaking paper on Gate Theory with Shealy and Mortimer’s case study on the complete elimination of pain in a 70-year-old male with metastatic bronchogenic carcinoma by means of electrical stimulation of the dorsal columns.,
  • Chiropractic – The results of several studies showed significant improvement for patients with failed back surgery who were managed with chiropractic care

Medications

Oral pharmacological treatment of FBSS is multimodal and increasingly controversial.

  • Anticonvulsant drugs – It has gained popularity for neuropathic pain, with gabapentin (Neurontin) and pregabalin (Lyrica) being the most commonly used preparations in the spine relared pain, radiating pain and post oparetive PLID. Gabapentin has been shown to be superior to pain killer in alleviating back and leg pain after spinal surgery []. Pregabalin plays a role in the prevention of pain before and after surgery, with its effect apparently increasing with time [].
  • Antidepressants – It the special types of antidepressant such as amitriptyline and duloxetine []. Two-drug combinations for the treatment of neuropathic pain in adults have been shown to improve analgesic efficacy for the treatment of post oparetive PLID[].
  • Chemical neuromodulation – It is the system of  treatment for post oparetive PLID with continuous intrathecal drug delivery (IDD) based on morphine or ziconotide administration may be considered for patients preferentially with neuropathic pain who have responded to strong oral opioids in the presence of severe adverse events []
  • Epidural injections – Epidural steroid injections (ESIs) are the most commonly performed procedure in pain clinics around the world. These can be administered primarily by three approaches of transforaminal, interlaminar, or caudally, and are indicated for symptoms of radiculopathy.
  • Intrathecal drug delivery – Similar to a spinal cord stimulator, spinal drug delivery or intrathecal drug delivery involves implanting a small pump in the stomach and running a catheter to the spine to deliver pain medication. It is used for people with chronic back pain, PLID and post oparetive PLID who need large doses of narcotics to deal with the pain. Compared to oral medication, this “pain pump” requires a smaller dose of narcotics because the medication goes directly to the area of pain.
  • Long-term Oxycodone – Naloxone is given to counteract the long-term effects of narcotic use. In one case study, Spanish research Dr. Borja Mugabure Bujedo recorded that a combination of  Oxycodone – naloxone can be a good alternative for the management of Failed Back Surgery Syndrome when other interventional or pharmacologic strategies have failed in a case report in the journal Anesthesiology and pain medicine. In this case report, higher doses than those recommended as a maximum daily ceiling (80/40 mg) were used in one selected patient with severe pain.[rx]
  • Platelet Rich Plasma Therapy in combination with Prolotherapy – Some doctors may recommend the use of Platelet Rich Plasma to help patients with failed back surgery syndrome. Platelet Rich Plasma is an injection of your concentrated blood platelets into the area of pain. The concentrated blood platelets bring healing and regenerating growth factors to the areas possibly damaged or affected by surgery. Recent research says that
  • Platelet-rich plasma (PRP) represents an additional approach – as it has shown some promise in bone regenerative medicine.

References

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