Management of Back Pain in Patients with Previous Back Surgery

Anatomical abnormalities of the spine for which back surgery is frequently performed. The upper figure is a lateral representation of the spine with a normal intervertebral disc and a normal articulation of the inferior articular process of L3 and the superior articular process of L4 to form the L3-L4 facet joint. There is anterior displacement of L4, a condition called spondylolisthesis, and degeneration of the L4-L5 facet joint. Spondylolisthesis may cause no symptoms or entrapment of the spinal nerve, causing sciatica, while osteoarthritis of a facet joint can cause no symptoms or chronic low back pain, sometimes accompanied by spinal stenosis (lower figure). With weakening of the annulus fibrosus and herniation of an intervertebral disc (lower figure) sciatica, spinal stenosis and chronic low back may occur. Reproduced from Deyo RA. Back surgery—who needs it? N Engl J Med. 2007;356(22):2240.⁷ Used with permission.

Spinal fusion is performed to relieve pain and other neurologic symptoms of spondylolisthesis. When spondylolisthesis is present, the entrapped nerves are decompressed by laminectomy before the placement of bone-grafts between transverse processes of adjacent verterbrae and between the posterior elements of the vertebrae. If there is disc herniation, the protruding disc segment is removed at the same time. Various metal devices may also be used to stabilize the vertebrae. Reproduced from Deyo RA. Back surgery—who needs it? N Engl J Med. 2007;356(22):2242.⁷ Used with permission.

Algorithm for management of failed back surgery syndrome.