Manual Current Perspectives in Clinical Treatment and Management in Workers’ Compensation Cases

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Current Perspectives in Clinical Treatment and Management in Workers' Compensation Cases. by. Chris E. Stout, Matt Kruger, Jeff Rogers DOI: / .
Table of contents

The only clinical examination finding that correlates with facet arthropathy is paraspinal tenderness. In addition, myofascial referred pain can be mistaken for radicular pain on physical examination. Because of the limitations of the physical examination, the practitioner must rely on other diagnostic modalities like imaging and diagnostic procedures. In terms of imaging, X-rays are a simple first step in the evaluation of chronic postoperative back pain.

Full spine standing flexion and extension X-rays can be used to assess spinal deformities, changes in lordosis, and sagittal balance and can demonstrate spondylolisthesis even with normal magnetic resonance imaging MRI findings. The gold standard for visualization of the spine is Gadolinium-enhanced MRI. Nerve blocks can be used for both diagnostic and therapeutic purposes.

Selective nerve root blocks with only local anesthetic have been done historically as a mode of diagnosis and as a predictive guideline for patients considering lumbar decompression surgery despite its accuracy having been questioned. Consequently, the efficacy of IA versus EA injection is controversial. SIJ pain frequently occurs with lumbosacral fusion. The procedure can be used for both diagnostic and therapeutic purposes. Diagnostic blocks of the facet joints have been done historically by two approaches; either by blocking the medial branches MBs innervating the joint or by directly injecting local anesthetic into the joint.

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It is widely considered that medial branch block MBB is a superior approach since in some patients the facet can be aberrantly innervated by other nerves. This may be a reason why MBBs are considered to be more predictive of successful radiofrequency ablation RFA , although there have been no head to head studies directly comparing the two Figure 2. Notes: Fluoroscopic images of intra-articular facet blocks A and a lumbar medial branch block B. Both the procedures are used as a prognostic indicator for a medial branch radiofrequency ablation. Debate as to which procedure is more accurate remains controversial.

The approach toward FBSS involves conservative management that first followed minimally invasive procedures, including injections, and finally surgical options as a last line therapy. In general, revision surgeries are not associated with improved pain scores and have a higher rate of comorbidities including increased bleeding, infections, acute respiratory distress syndrome, and longer hospital stays and even have higher mortality rates than the primary surgeries.

These risks include a return of symptoms and even an exacerbation of pain. All of these factors should be discussed with the patient and a consensus between the patient and physician should be made after careful consideration of the risks and benefits. Physical therapy and medication management are the cornerstone of first-line management of FBSS. Physical therapy can help the patient optimize gait and posture and can improve muscle strength and physical function.

Oral pharmacological treatment of FBSS is multimodal and increasingly controversial. Treatments include antiepileptics, Non-steroidal anti-inflammatory drugs, oral steroids, antidepressants, and opioids. Antiepileptics such as Gabapentin and Pregabalin can be used to treat neuropathic pain with FBSS and may play a role in preventing pain after surgery.

Chronic opioid therapy for noncancer pain is associated with an increased morbidity and mortality and does not reliably improve long-term pain and function scores. As a result, there has been an increasing push by the government and medical community to minimize or even completely avoid the use of opioids for long-term pain. Epidural steroid injections ESIs are the most commonly performed procedure in pain clinics around the world. Radicular symptoms in the failed back patient may be due to a multitude of reasons including herniated disc, postoperative adhesions, a thickened ligamentum flavum, spondylolisthesis with or without an associated pars defect, osteophyte formation from facet arthropathy or other degenerative changes that may lead to central or transforaminal stenosis.

ESI can be a useful tool for both treating the symptoms of radicular back pain after surgery and preventing or delaying the need for surgery. Optimization of analgesia with ESIs in patients with FBSS can be achieved when performed in conjunction with pharmacologic agents aimed at treating neuropathic pain.

Zencirci et al 54 demonstrated that adding Gabapentin to ESI in patients with FBSS from at least two prior surgeries for lumbar disc herniation had significantly lower pain levels at 1 and 3 months compared with those who received ESI while taking naproxen sodium, tizanidine, and vitamin B and C complex.

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Postoperative scar formation is a natural part of tissue healing after any surgery. Naturally, spine surgery will result in the formation of fibrotic adhesions within the epidural space. These adhesions may cause back and leg pain by compressing nerve roots, decreasing range of motion in the back and inducing pain with movement.

Lysis of adhesions typically occurs by delivering hyaluronidase with hypertonic saline into the epidural space. The use of hyaluronidase with steroid may be more effective and have longer duration of effect than either one alone. 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.

After a positive response, an RFA of the corresponding MBs is expected to provide pain relief for 6—12 months up to 2 years. It has been proposed that SCS-induced analgesia occurs not only by its effects on the spinal cord but supraspinal components of the central nervous system as well as by inducing descending inhibitory pathways and inhibiting pain facilitation. Metric measures included pain scores, quality of life, functional capacity, and patient satisfaction. This study underscores the continued costs of untreated FBSS on society as a whole, including loss of productivity, costs associated with disability, emergency room visits, imaging costs, and costs of medications and hospitalizations.

The study aims to compare the outcomes such as pain scores, functional disability, return to work, and functional utilization between the two groups. Recruitment will end in As mentioned earlier, surgical revision for FBSS is associated with a high morbidity with corresponding low rates of success. These poor results demonstrate that the surgical option for the treatment of FBSS should be limited to last line therapy.

With that being said, there are times when reoperation is mandated, such as loss of bowel or bladder function, motor weakness, and progressive neurological impairments from spinal cord injury, with relative indications being severe incapacitating radiculopathy, pseudoarthrosis, instability, and surgical hardware malfunction Table 5. Note: Reproduced with permission from Pain Practice. Hussain A, Erdek M. Interventional pain management for failed back surgery syndrome. John Wiley and Sons. The global burden of low back pain: estimates from the Global Burden of Disease study.


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