What is post-nucleotomy syndrome?

After surgery on the spine, we expect an elimination or significant relief of pain, immediately after surgery. Fortunately, that is the case in the majority of cases. If pain persists even after the operation or if it returns, we refer to it as the post-nucleotomy syndrome or a post-discectomy syndrome. In English, it is also called “Failed Back Surgery Syndrome”. About 15 % of all patients undergoing spinal surgery develop a post-nucleotomy syndrome. Pain often radiates into the arms or legs - even if the operation was anatomically successful. The pain persists and returns.

There are several possible reasons, why patients complain of pain despite a "successful" operation: delay of necessary surgery leads to permanent and chronic damage to the neural structures. In some of these cases the severe pre surgical affection of the nerve fibers before surgery because of long waiting could leave permanent traces of damage, so that patient would complains of further pain. In other cases, there are significant adhesions after surgery so that these scars are presented like a wall, which puts pressure on the neural structures. In other cases, the patient lacks individual psychosocial care and support. In fact, familial or occupational dissatisfaction or the lack of a suitable job can create or manifest a negative atmosphere and thus be a contributor to the post-nucleotomy syndrome. Pain memory is also considered as a reason for post-nucleotomy syndrome.

So many people have recurring back pain

In Germany as an example, statistically, about 80% of people suffer from occasional pain and around 40% feel regular recurring back pain. The diagnosis disc hernia is made 800,000 times a year, but surgery was performed in 50,000 cases. Only the 15 percent of them face pain again.

Which symptoms should I pay attention to?

When preoperative pain persists even after a successful operation, if you feel the same one or one similar, in this case, we should think about the possible diagnosis: post-nucleotomy syndrome (FBSS).

Pain persistence after the operation can be related to different causes

There are many possible causes for the development of post-nucleotomy syndrome:

  • adhesions and instability,
  • insufficient relief of the nerve roots after surgery,
  • in addition, after an intervention, sometimes the load on the adjacent segments of the spine increases. They can be overloaded and cause pain;
  • psychosocial factors such as personal and professional stress may favor the presence of a postnucleotomy syndrome,
  • pain memory: Inadequately treated severe pain eventually leaves traces in the spinal cord of the patient as well as in the brain. These pain marks are called "pain memory" which is a complicated process in nervous life that makes pain cells to send pain signals to the brain, causing spontaneous pain that has no organic cause;
  • wait a long time for the operation to be performed, as this can cause permanent damage to the nerve fibers.

Post-nucleotomy syndrome - that is why the diagnosis is important

Finding the reasons for your post-nucleotomy syndrome is not easy. On the contrary - it is versatile, requires a lot of specialist knowledge, empathy of the doctor and the sensible use of technology. As always, this diagnosis starts with personal questions, which you should answer as sincerely and concretely as possible. Your doctor will need to know how and where was the pain before surgery, where is it after the operation, if they are as intense as before the operation, if you have muscle cramps, discomfort, if pain can be somehow influenced by running, sitting, or analgesics, and which therapies you completed so far.

Your answers will allow your doctor to draw a preliminary diagnosis. Your medical reports are also important, that is why you should always bring them with you. This conversation is usually followed by a physical-neurological examination which includes imaging techniques: X-rays, magnetic resonance imaging (MRI), computed tomography (CT). Scintigraphy may be helpful, especially if you suspect an inflammatory cause of the pain. This is a nuclear medicine examination that can assess the metabolism of tissues.
If the doctor has detected any neurological deficits, he can measure the nerve conduction velocity (NCV) for clarification.

If one doctor is not able alone, adequately to get to the bottom of the problem, he will order a so-called multimodal interdisciplinary diagnosis. This means that the final diagnosis will be made by a team of doctors (including psychotherapists and physiotherapists). As always, in order to help you, the cause must be researched and identified. And that's the only thing that matters to your doctor, whom you obviously trust.

Possible therapies for post-nucleotomy syndrome

Optimization of pain therapy, physiotherapy, CT-guided infiltration (PRT), facet infiltration, psychological care, and job optimization could be possible therapies for this syndrome. If the pain predominates in the lumbar spine (lumbar spine syndrome), cervical spine (cervical spine syndrome), thoracic spine (thoracic spine syndrome), coccyx or in the iliac sacral region, the best option is thermo-denervation. If nerves are compressed (recurrence, remnants of an old disc herniation, still existing stenosis), a new operation (microsurgery) would be a good alternative, but in order to avoid recurrences, a fiber ring closure could be a good solution. In such a case, we would apply an anti-scar gel by the microsurgery. If there is instability then the best option would be a spinal fusion (stabilization). If there is no clear cause of the pain, spinal cord stimulation would be a good alternative. It offers very good results. Often a combination of multiple approaches is required.

Prognosis? The best way to help yourself...

Notice: Life belongs not only to the present but also and especially to the future. And if you want to make a positive prognosis for yourself after a postnucleotomy syndrome, it is up to you! Accelerate your pain relief by reprogramming the memory of pain. Usually, behavioral measures (such as pain management training, body awareness training, breathing training) can help. The same applies to physiotherapy measures. Promote the development of the back and abdominal muscles in a back school.

And, what you should know and keep in mind: the post-nucleotomy syndrome can gradually turn into chronic pain syndrome.

Dr. med. Munther Sabarini

Author
Dr. med. Munther Sabarini
Specialist in Neurosurgery

Hans-Heinrich Reichelt

Co-author
Hans-Heinrich Reichelt
Chief Editor of Medizin für Menschen

The Avicenna Clinic in Berlin is always willing to help you

Since the year 2001, the Avicenna Clinic is based in Berlin. Our doctors have at least 25 years of international experience in their respective fields (neurosurgery, spinal surgery, anesthesia, and orthopedics).

If you have severe back pain, a herniated disc or a suspected herniation, please contact us using the following information:

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