"Failed back surgery syndrome", "Failed Back syndrome", "Post Laminectomy Syndrome", is a misnomer. It’s really not a syndrome as there is no typical scenario. Each patient’s continued work up and treatment must be individualized. FBSS is a much generalized term that is applied to patients who fail to have resolution or return of pain postoperatively.
The first step is a comprehensive history and physical exam, typically followed by spinal imaging. Our initial goal is to rule out any prior or new pain generating pathology that is best treated with surgery. The common situations encountered here can be broadly placed into three categories 1. Recurrent or new disc herniations, 2. Continued or new central or lateral spinal stenosis, or 3. Persistent or new spinal instability from failure of the spinal bones to fuse, hardware or implant failure or when the spinal level above a prior successful fusion breaks down and becomes a pain generator.
After being cleared by our spinal surgeons the pain medicine physicians will likely be an integral part of a multi discipline approach to the management of these often complex situations. With ongoing conservative treatment usually encompassing physical therapies and medication management our pain medicine physicians will seek to identify and treat the often multiple sources of ongoing pain. Typically this involves injection therapy for myofascial or muscle pain with trigger point injections, epidural steroid injections for pain mediated by chronic inflammation or swelling of nerves as well as facet joint and sacroiliac joint nerve blocks and ablations for pain coming from these structures which can mimic nerve root impingement, muscle pain, or disc pain. Our pain medicine physicians also provide specific treatments for persistent pain after spine surgery secondary to scar tissue formation (epidural fibrosis) and complex regional pain syndrome (CRPS) with epidural lyses of adhesions and sympathetic nerve blocks respectively. Lastly if patients have exhausted all surgical and nonsurgical options and continue to suffer intractable pain our pain medicine physicians will consider a trial of spinal cord stimulation or intrathecal drug administration and if helpful will implant these devices for long term use.
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About 80% of the population will experience a common headache disorder and 20% of adult women a migraine disorder in their lifetime. The economic and quality of life burden is substantial and made worse by poor diagnosis, underestimation of headache induced morbidity and denied access to appropriate treatment.
Headaches are classified into two broad entities: primary and secondary. Primary headaches are those in which a primary dysfunction of the nervous system predisposes to increased vulnerability to headache attacks. Included in the primary headaches are
 Tension headaches
Migraine headaches &
Cluster headaches.
Secondary headaches are those in which the headache is secondary to other pathology which has headache as part of its presentation. Secondary headaches have more then 300 separate causes, some of which include infectious, vascular, metabolic, endocrine, inflammatory, dental, ocular, posttraumatic and cervicogenic disorders. Optimal treatment begins with specific diagnosis. Your primary care doctor and neurologist are best equipped to establish this diagnosis and commence therapy.
The vast majority of headaches will be best managed by behavioral therapies and medications. Occasionally, patients will be referred to our pain medicine physicians for specific and specialized interventions which may be appropriate in certain refractory patients. These are typically secondary headaches which are thought to have pain generators in the cervical (neck) structures. Common treatments provided include trigger point injections for myofascial (muscle) pain, facet joint nerve blocks and ablations for post whiplash and arthritis pain, epidural steroid injections for some pain states mediated by inflammation and specific nerve blocks or neurostimulation for conditions such as intractable headache from occipital neuralgia.
Our pain medicine physicians are pleased to explore the potential benefits of these interventions with all referred patients after full medical and neurological evaluations and treatment protocols have been exhausted.
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Post-herpetic neuralgia
Diabetic neuropathy
Trigeminal neuralgia
Post surgical neuroma
Other types of neuropathic pain include
This is usually due to spinal cord lesion or brain and brain stem lesions.
Peripheral Nervous System Pain
This category includes diabetic neuropathy, alcoholic neuropathy, uremic neuropathy.
Cranial Nerve Pain
This category includes Trigeminal Neuralgia, Post Herpetic neuralgia as well as Glossopharyngeal Neuralgia.
Phantom Pain
This if often due to neuroma formation as well as short circuiting involving the central and peripheral nervous  system.
What are some of the medications used to treat neuropathic pain?
Antidepressants, sedatives, anticonvulsants, muscle relaxants, opioids, NSAIDS, and local anesthetics can be used to treat neuropathic pain.
What are some of the nerve blocks that are used to treat neuropathic pain?
Nerve blocks by themselves are not the be all end all treatment for neuropathic pain. Nerve blocks are done to help control the pain so that the cycle of the pain can be broken. This allows the patient to use the affected
part of the body so that the patient can preserve the function of the affected part of the body. Type of the
nerve block is tailored to the underlying body part that is affected as well as underlying condition. Please refer to the nerve block section.
Frozen shoulder syndrome
Muscular pain
Tendonitis and bursitis
Cancer Pain
Virtually all cancer pain can be adequately managed using noninvasive and invasive therapeutic modalities.
Despite that, moderate to severe pain is reported by 40% of all cancer patents at the time of their diagnosis
and in up to 90% of patients with advanced cancer pain.
Why is cancer pain under-treated?
Unfortunately cancer pain is often under-treated. There are many factors behind that, some of which include
Physician knowledge.
One factor has to do with a physician's knowledge and ability to treat and recognize pain. Some physicians
and other health care professionals may not specifically ask about pain, which should be a normal part of every cancer patient's visit. Cancer patients should be asked if they are having any pain.
If they are, the physician should stop there and deal with the issue. Some doctors don't know enough about
proper pain treatment. If this is the case, your doctor might refer you to a pain specialist.
Patient reluctance.
A second factor might be a patient's own reluctance. Some people might not want to "bother" their doctors
with the information, or they may fear that the pain means that their cancer is getting worse. Some are
reluctant to report it or report it as thoroughly as they should because they're worried about what doctors or other people might think of them if they complain. They might feel that because they have cancer, they're
supposed to have pain and be able to deal with it. That simply isn't true.
Fear of addiction.
Another factor might be a person's fear of becoming addicted to the pain medications. This is something that we know doesn't typically happen if you take medications for pain. If you take them when you're not in pain or to get high, then, yes, you can get addicted. But the risk of addiction for people who take pain medications in an appropriate fashion — for pain — is very low, so this shouldn't be a concern.
Fear of side effects.
Some people fear the side effects of pain medications. Many are afraid of being sleepy, unable to
communicate with family and friends, acting strangely, or being seen as dependent on medications.
People are
also sometimes afraid that taking morphine may shorten their life.
There is no evidence of any of these happening if the medication is dosed appropriately. And although strong pain medications can cause drowsiness when you first take them, that side effect usually goes away with
steady dosing. When side effects become severe, medication delivery using opiod pumps can give
tremendous relief while minimizing side effects.
What causes cancer pain?
Cancer pain usually results from the cancer growing into or destroying tissue anywhere near the cancer.
Cancer pain can come from the primary cancer itself where the cancer started or from other areas in the
body where the cancer has spread (metastases). As a tumor grows, it may put pressure on nerves, bones
or other organs, causing pain.
Cancer treatments such as chemotherapy, radiation and surgery are another potential source of cancer pain.
Surgery can be painful, and it may take time to recover. Radiation may leave behind a burning sensation or
painful scars. And chemotherapy can cause many potentially painful side effects, including mouth sores,
diarrhea and nerve damage.
How do you treat cancer pain?
Remove the source of the pain.
The Ideal way to treat cancer pain is to remove the source of the pain, for example, through surgery, chemotherapy and radiation. However, in some patients, these modalities may create a new set of pain.
Treat with medication.
If this cannot be done or it is inadequate, pain mediations (by mouth, through the skin, or even directly injected)can usually control the pain.
First, non-narcotic medicines are used. These include analgesics (Tylenol), non-steroidal anti-inflammatory
drugs (Motrin, Celebrex, and aspirin), and adjuvants (Elavil, Neurontin, and Xanax).
If these fail, weak narcotics are often prescribed. These narcotics are usually combined with Tylenol or
aspirin. They include Tylenol #3, Vicodin, Darvocet, and Percocet. These are not used for long periods
because of potential for side effects.
The strongest narcotics are reserved for severe pain. They are short-acting (Actiq and Oxy IR); intermediate-acting (Oxycontin, Dilaudid, and Morphine); as well as long-acting (Methadone and morphine sustained
release). These too are not used for long periods due to side effects. These side effects include nausea,
itching, constipation and bowel obstruction, and in some cases tolerance and addiction.
Utilize specialized pain medication delivery systems.
In some instances, patients with severe cancer pain cannot be controlled with even strong narcotics and require specialized pain medication delivery systems.
Nerve blocks, such as celiac plexus blocks, are local anesthetics injected around a nerve. This local anesthetic prevents pain messages traveling along that nerve pathway from reaching the brain.
Implanted opiod pumps deliver very small quantities of narcotics just outside the spinal cord, where pain is centrally processed. Because very small quantities of narcotic are used, the side effects of orally ingested or intravenous narcotics are alleviated. Minor surgery is involved to implant the device.
When is a cancer pain patient a candidate for an implanted opiod spinal pump?
Implanted opioid pumps can be the best option when even strong narcotics are not optimal for cancer pain.
In some cases, cancer pain can be so severe that these strong narcotics do not help. This can happen when the cancer spreads so quickly or to many parts of the body. In some cases long-term use of narcotics can lead to tolerance of the medicine. This also results in inadequate treatment of pain.
Side effects can make narcotics intolerable. These side effects may include severe constipation leading to bowel obstruction. Also sedation and depression of breathing can occur with high doses of narcotics. When the side effects of the narcotics make the treatment as bad as the disease, then implanted opiod pumps should be considered.
Finally, overall cost of treatment is reduced over time when expensive narcotics taken for long periods of time are replaced with very concentrated drugs refilled every one to two months.
What side effects can you expect from cancer pain treatment, and what can you do about them?
Each pain treatment may be accompanied by its own unique side effects. For example, radiation treatments may cause redness and a burning sensation of the skin. And, depending on what part of the body the radiation is applied to, the radiation may cause diarrhea, mouth sores or other problems, such as fatigue. Chemotherapy certainly can cause side effects, such as nausea, fatigue, infection and hair loss, but it can be effective in relieving pain if it shrinks the tumor. There are medications to help with nausea. Relaxation techniques also may help.
Pain medications each have their own unique side effects that should be reviewed with your physician before taking them. One of the common side effects of the stronger pain medicines is constipation—common to opioids. It can be treated with appropriate bowel regimens as prescribed by your doctor, such as adding a stool softener and something to stimulate the bowels. Preventing constipation is much easier than treating it, so anyone who takes these strong pain medications should automatically begin a regimen to keep their bowels moving. Some of the other side effects of the strong pain medications include confusion, lethargy and sleepiness. The severity of these effects varies from person to person and commonly occurs with the first several doses. But once a steady amount of the medicine stays in your body, the side effects usually resolve. Hallucinations and behavior changes are uncommon.
The less potent pain medications actually may have more side effects, which also should be discussed with your physician before taking them. For instance, anti-inflammatory drugs might damage your kidneys, cause ulcers or increase your blood pressure. Aspirin can cause gastrointestinal bleeding, and acetaminophen (Tylenol, others) can cause liver damage if you take too much.
When should you discuss cancer pain with your doctor, and what points should you bring up?
Report any bothersome pain to your physician. If there is a minor pain that goes away, don't worry about it. But if the pain interferes with your life or is persistent, it needs to be reported and should be treated. Although no one can guarantee that all pain can be completely eliminated, most pain can be lessened to the point where you can be comfortable.
It may help to keep track of your pain by noting how strong it is, where it's located, what makes it worse, what brings it on, what makes it better and anything else that happens when you have the pain. A pain-rating scale from 0 to 10—with 0 being no pain and 10 being the worst pain you can imagine—may be helpful in reporting pain to your doctor. In addition, pay attention to what happens when you attempt to relieve your pain. If you take medicine, do you feel any ill effects from it? If it's a massage or something physical that relieves the pain, those therapies are important to report, too. Note whether they cause any ill effects.
What steps can you take to make sure you're receiving adequate cancer pain treatment?
First, you need to talk to your doctor or health care provider if you're having pain. Second, you and your doctor should set a goal for pain management and monitor the success of the treatment against that goal. Your doctor should track the pain with a pain scale, assessing how strong it is. The goal should be to keep the pain at a level with which you're comfortable. If you aren't achieving that goal, talk to your physician. If you're not getting the answers you need, request a referral to a facility more skilled in the care of pain, particularly a major cancer center. All major cancer centers have pain management programs. For the most part, the medications and treatment for pain are covered by standard insurance.
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