脊髓电刺激治疗腰椎手术失败综合征的疗效分析

目的:探讨脊髓电刺激(SCS)治疗腰椎手术失败综合征(FBSS)的临床疗效评定。方法:选取FBSS患者31例,随机分为两组:A组进行连续硬膜外腔镇痛联合胶原酶注射或椎间盘射频联合臭氧注射等传统介入手术治疗组(16例)。B组进行硬膜外腔SCS治疗组(15例)。在治疗前、治疗后1周、1个月、6个月、12个月,分别采用视觉模拟评分法(VAS)、Oswestry功能障碍指数(ODI)、日本骨科学会(JOA)腰痛评估表进行疗效分析。结果:两组治疗后1周、1个月、6个月、12个月VAS值均较治疗前明显降低(P<0.01),ODI指数均较治疗前明显降低(P<0.01),JOA值均较治疗前明显提高(P<0.01)。B组在治疗后12个月的VAS值、ODI指数、JOA值较A组明显改善(P<0.05)。结论:脊髓电刺激(SCS)治疗腰椎术后失败综合征(FBSS)疗效优于传统的微创介入手术。     

Functional magnetic resonance imaging of cerebral activation during spinal cord stimulation in failed back surgery syndrome patients

Spinal cord stimulation (SCS) consisting of electrical stimulation of the dorsal spinal cord using epidural electrodes has been shown to relieve chronic neuropathic pain. To analyze the cerebral activation patterns related to SCS, and to evaluate the effects of SCS on the processing of acute experimental pain, we performed functional magnetic resonance imaging (fMRI) on eight patients suffering from failed back surgery syndrome who were also being treated with SCS for severe pain in their legs and lower back. Three types of stimulation were used, each lasting 36s: (i) SCS, (ii) heat pain (HP) applied to the leg affected by neuropathic pain, and (iii) simultaneous HP and SCS. During SCS, we found increased activation of the medial primary sensorimotor cortex somatotopically corresponding to the foot and/or perineal region, contralateral posterior insula, and the ipsilateral secondary somatosensory cortex (S2). Decreased activation was seen in the bilateral primary motor cortices and the ipsilateral primary somatosensory cortex corresponding to the shoulder, elbow and hand. Compared to separately presented HP and SCS, simultaneous HP and SCS showed statistically significant activation of the bilateral inferior temporal cortex and the ipsilateral cerebellar cortex. The activation of the primary motor cortex, insula and S2 during SCS may directly interfere with the processing of neuropathic pain. When SCS is associated with heat pain, the paralimbic association cortex and cerebellum show activation exceeding the sum of activations resulting from separate SCS and heat pain stimulation. The explanation of this could possibly rest with the continuous comparisons of simultaneous pain and somatosensory sensations occurring in a single dermatome.     

Spinal cord stimulation for failed back surgery syndrome: Outcomes in a workers’ compensation setting

Questions remain concerning effectiveness and risks of spinal cord stimulation (SCS) for chronic back and leg pain after spine surgery (“failed back surgery syndrome” [FBSS]). This prospective, population-based controlled cohort study evaluated outcomes of workers’ compensation recipients with FBSS who received at least a trial of SCS (SCS group, n = 51) versus those who (1) were evaluated at a multidisciplinary pain clinic and did not receive SCS (Pain Clinic, n = 39) or (2) received neither SCS nor pain clinic evaluation (Usual Care, n = 68). Patients completed measures of pain, function, medication use, and work status at baseline and 6, 12, and 24 months later. We also examined work time loss compensation over 24 months. Few (<10%) patients in any group achieved success at any follow-up on the composite primary outcome encompassing less than daily opioid use and improvement in leg pain and function. At 6 months, the SCS group showed modestly greater improvement in leg pain and function, but with higher rates of daily opioid use. These differences disappeared by 12 months. Patients who received a permanent spinal cord stimulator did not differ from patients who received some pain clinic treatment on the primary outcome at any follow-up (<10% successful in each group at each follow-up) and 19% had them removed within 18 months. Both trial and permanent SCS were associated with adverse events. In sum, we found no evidence for greater effectiveness of SCS versus alternative treatments in this patient population after 6 months.     

Efficacy of spinal cord stimulation: 10 years of experience in a pain centre in Belgium.

Spinal cord stimulation is a minimally invasive mode of treatment in the management of certain forms of chronic pain that do not respond to conventional pain therapy. Several authors have reported encouraging findings with this technique. Over a 10-year period in a single centre, 254 patients were subjected to a trial period of spinal cord stimulation with an externalized pulse generator. Two hundred and seventeen of the patients showed satisfactory results justifying permanent implantation of a spinal cord stimulation system. In 1998, an independent physician invited 153 patients (155 pain cases), who still had the system in place and who could be contacted, for an interview. The aim of this study was to evaluate the efficacy of an implanted spinal cord stimulation system in terms of pain relief and quality of life and to assess the accuracy of the patient selection criteria. The results of this study demonstrate a high success rate as evaluated by the patients' own assessments--68% of the patients rated the result of the treatment as excellent to good after an average follow-up of almost 4 years. The resumption of work by 31% of patients who had been working before the onset of pain supports these positive findings.     

High-frequency (10 kHz) spinal cord stimulation (SCS) as a salvage therapy for failed traditional SCS: A narrative review of the available evidence

Introduction

Traditional spinal cord stimulation (t-SCS) has been used to treat chronic pain for over 50 years. However, up to 30% of patients undergo explant, with the main indication being loss of efficacy (LoE), and few alternative treatment options exist for these patients. Strategies to mitigate LoE commonly include conversion to another type of SCS (termed ‘salvage’ or ‘rescue’). This review summarizes the existing literature concerning the efficacy and safety of 10 kHz SCS as a salvage therapy.

Methods

We searched PubMed, the Cochrane Library, ClinicalTrials.gov , and other sources between January 2009 and April 2021. Records were retained if the authors reported clinical outcomes with a minimum of ≥ 3 months of follow-up in patients implanted with a Senza® 10 kHz SCS system in an effort to treat t-SCS LoE.

Results

Ten articles were eligible for inclusion, reporting 3 prospective studies and 7 retrospective reviews. In the single study that salvaged patients without a repeat trial prior to surgery, 81% of patients were responders (≥ 50% pain relief from baseline), with mean pain relief of 60%. Among repeat-trial studies, the responder rate ranged from 46% to 80%, and mean pain relief from 47% to 68%. No unanticipated therapy-related safety issues were reported among the included articles.

Conclusion

Preliminary data suggest that chronic back and/or leg pain patients with t-SCS LoE can experience improved and durable pain relief after conversion to 10 kHz SCS. However, additional research is needed to define predictors of success and establish whether salvage without a repeat trial is a viable conversion method.     

“The failed back surgery syndrome”: Definition and therapeutic algorithms – An update

Approximately 30% of patients experience persistent or recurrent low back and/or pain projecting into the legs following technically adequate lumbosacral surgery. Such pain conditions are often alluded to as the failed back surgery syndrome (FBSS). FBSS represents a significant clinical and economic concern. The treatment of FBSS presents a challenge to physicians, as conservative therapies and spinal reoperations are often unsuccessful – if not a significant cause (besides fibrosis) of the persistent pain syndrome is found at the post-operative examinations. Neuropathic pain radiating into the leg(s) is often the main component of this persistent and disabling syndrome. In this case, spinal cord stimulation (SCS) has been shown to be a successful therapeutic option. Studies have demonstrated that up to 60% of implanted patients experience 50% or more pain relief following SCS. Moreover, SCS has been shown to improve both quality of life and functional status in a significant number of patients. In order to address the challenge of managing both chronic back and leg pain, a multidisciplinary group of physicians experienced in pain management and spinal surgery assembled to discuss and formulate a treatment strategy for FBSS, based on a systematic review of the literature that focused on the role of SCS. The outcome of these discussions however remained unpublished why an update, taking into account also the moderns technologies has been performed.The development of new treatment algorithms should allow, easier, more rational and effective management of this common and clinically – as well as economically – important problem.     

Concerns and expectations about returning to work with low back pain: Identifying themes from focus groups and semi-structured interviews

Purpose. Studies of occupational low back pain (OLBP) have shown that return to work after injury is influenced by workers' concerns and expectations; however, these theoretical constructs have not been explored. The specific aim of this study was to identify themes related to self-efficacy and outcome expectancy for returning to work using qualitative research methods.

Method. Twenty-eight individuals who recently returned to work (<6 months) after an onset of OLBP responded to a newspaper advertisement and participated in focus groups. In a second phase of the study, patients with OLBP and an impending return to work (n=23) were referred by their physiotherapists and interviewed to provide more immediate accounts of their concerns and experiences. Notes and recordings from both sources were searched for utterances describing beliefs about self-efficacy or outcome expectancy for returning to work.

Results. Two primary self-efficacy constructs emerged: self-efficacy for resuming physical activity and self-efficacy for resuming work. Self-efficacy for resuming physical activity included 8 sub-domains: lift, carry, sit, stand, push/pull, bend, climb, and reach. Self-efficacy for resuming work included 3 sub-domains: pain control, obtaining help, and meeting job demands. Outcome expectancy included four sub-domains: financial/job security, re-injury, workplace support, and self-image.

Conclusions. Hesitation to return to work after OLBP involves not only concerns about pain and re-injury, but also the perceived ability to perform physical tasks, meet role expectations, obtain workplace support, and maintain job security.     

Beneficial response to gabapentin portraying with interval change of brain SPECT imaging in a case with failed back surgery syndrome

What is known and Objective: Failed back surgery syndrome (FBSS) is a well‐recognized consequence of surgery of the lumbar spine. Here, we present a case with FBSS associated neuropathic pain. Case summary: During hospital stay, the patient was stabilized with gabapentin 200 mg twice a day and this was titrated to a dose of 1200 mg per day over the period of 1 week. The treatment produced a substantial reduction in his episodic pain. We assessed regional cerebral blood flow (rCBF) by using brain single photon emission computed tomography (SPECT) scans, which were performed before and after gabapentin treatment 1 week later. The examination of the first SPECT showed decreased uptake in left fronto‐temporal‐parietal region. The latter one showed much improvement of the above areas. What is new and Conclusion: The gabapentin has beneficial effect in the FBSS associated neuropathic pain. Besides, this case suggests the association between rCBF and pain associated with FBSS, as well as the association of gabapentin and altered blood flow of brain cortex.     

经络脉冲电刺激治疗腰椎手术失败综合征疗效及机理探讨

目的：总结脉冲调制中频电刺激对腰椎手术失败综合征的治疗效果,探讨其治疗机制。方法：用多电极脉冲调制中频电同时刺激腰背部和膀胱经委中等腧穴的方法治疗35例腰椎手术失败综合征患者,并与仅刺激腰背部治疗的26例进行对比观察,用“腰腿痛治疗成绩评分表”评定疗效,20只家兔分为两组,分别将10％根过氧化物酶100ul注入兔后腿委中穴或兔一侧腰部,在镜下观察HRP标记细胞在腰骶后根神经节及脊髓的分布。结果：观察组有效率94．3％,对照组有效率77％,（P＜0．05）,动物实验发现兔委中穴的神经和腰背部肌肉神经投射到后根神经节和脊髓有相重叠部位。结论：应用多电极脉冲调制中频电对腰腿部及足太阳膀胱经同时进行多穴位电刺激是一种较好的治疗腰手术失败综合征的方法,并有神经生物形态学依据。     

参与式人体工效学干预对腰背损伤患者复工意愿的影响

摘要目的：探讨参与式人体工效学干预方案对腰背损伤患者复工意愿的影响。方法：将符合标准的64例腰背损伤患者,随机分成对照组（33例）和试验组（31例）。对照组给予常规职业康复训练,试验组给予常规职业康复训练+参与式人体工效学干预,分别在干预前和干预4周后对两组患者进行腰背功能评估（SFS）、就业意愿评估（LASER）、恐惧-回避信念评估（FABQ）。结果：干预前,两组患者在各项指标上没有明显差异（P>0.05）。干预4周后,两组患者在腰背功能自评、就业意愿评估上都有明显改善（P<0.05）,且试验组的评价指标显著优于对照组（P<0.05）。试验组恐惧-回避信念明显下降（P<0.05）,对照组下降不明显（P>0.05）。结论：参与式人体工效学干预结合可提高腰背痛患者对腰背功能的自我感知、降低恐惧-回避信念,提高就业意愿。     

Spinal cord stimulation in the treatment of failed back surgery syndrome

A significant number of patients undergoing lumbar spine surgery do not obtain pain relief. Such patients with chronic low back or lower extremity pain may be difficult to treat. A frequent component of therapy is the use of spinal cord stimulation to help control pain. With careful patient selection, many patients can achieve reasonable levels of pain relief. We review recent clinical reports, including prospective and randomized studies, that demonstrate up to three quarters of patients implanted with a spinal cord stimulator for the treatment of failed back surgery syndrome may benefit from its use. This technology must not be indiscriminately applied. Careful patient selection and a period of trial stimulation are vital to the successful use of spinal cord stimulation as treatment for chronic pain.