Ask the Expert: Post-Laminectomy Syndrome
Q1. What is post-laminectomy syndrome and why does it occur?
This is not a simple question, because post-laminectomy syndrome is very complex even though it’s referred to as a single entity. Strictly speaking, post-laminectomy syndrome means that a person is experiencing pain, and that they had a prior spinal surgery (not necessarily even a laminectomy). As such, there are many different forms that this condition can take. Some possible variations include:
- The patient had spinal surgery, recovered well, and now has developed a new and unrelated spinal problem.
- The patient had spinal surgery, and despite the procedure going well, the original pain did not go away.
- The patient had spinal surgery, and developed a complication such as an infection, nerve injury, or failure to heal.
The problem becomes even more complicated when you consider the role that human behavior plays in the expression of pain. People express pain differently, and sometimes for different reasons at different times.
It is also important to consider the effect of the long-term use of narcotic pain medications in people with persistent pain, including post-laminectomy syndrome. Narcotic medications (opioids such as oxycodone or morphine) work by binding to the body’s natural endorphin system- the mechanism by which our brain interprets a sensation as painful or not. In fact, most prescribed opioids bind to the endorphin system so well that they crowd out our body’s naturally-produced endorphins, and inhibit the brain’s ability to produce these natural pain-relieving substances.
In the long term, this can lead not only to the development of tolerance to opioid medications, but an increase in the overall sense of pain. This paradoxical phenomenon is called opioid-induced hyperalgesia. When possible, patients and their doctors should moderate the use of pain medications due to the increased risk for developing increased pain with long-term use; and be careful of the serious short-term risk that these medications pose in terms of addiction, respiratory suppression, constipation, nausea, itching, etc.
Q2. What are the symptoms of post-laminectomy syndrome?
The symptoms of post-laminectomy syndrome are highly variable, but broadly include low back or neck pain and pain in the extremities.
Low back or neck pain- what we call axial spinal pain- is a common symptom in post-laminectomy syndrome. We usually attribute this pain to an abnormality in one of the structures in or around the spinal column, and it has several possible causes, including:
- Muscle spasm due to trauma or poor muscle conditioning
- Arthritis of the spinal (facet) joints
- Disc herniation
- Painful instrumentation (for example, when metal has been used to secure a spinal fusion)
- Surgical complications such as bleeding or infection
Patients with post-laminectomy syndrome may also complain of neurologic symptoms radiating to areas distant from the spine- most often the arms or legs. Neurologic pain can reproduce any normal sensation such as heat, cold, or electricity, but is being produced by the injured nerves themselves, rather than by sensing an actual problem in the extremity.
Neurologic symptoms are not limited to sensations and can include feelings of heaviness, actual loss of strength, or less commonly, dysfunction of the bladder or bowel. Sometimes, these symptoms come from an identifiable problem with a specific nerve or group of nerves such as with a recurrent disc herniation, or arachnoiditis, an often painful inflammation of the cells lining the nerve itself, but they can present without an apparent initial cause as well, sometimes making neurologic pain difficult to identify and treat.
Q3. What can you do if you have post-laminectomy syndrome?
The most important thing you can do is to get a thorough evaluation. This means reassessing the current status of your situation- even if you have done so before- with a physician experienced in evaluating this condition. A careful physical examination and high quality radiologic imaging is essential to make sure that there are no outstanding mechanical or neurological issues, which could generate pain.
Physical exercise and rehabilitation, particularly core stabilizing exercise, stretching to improve joint mobility, and weight bearing strength training for the extremities, are essential components of a multi-modal treatment of persistent spinal pain. It is when the pain becomes too severe, or does not respond to initial treatment such as nonsteroidal anti-inflammatory medication, that more thorough evaluation (possibly including interventional procedures) becomes necessary.
Spinal pain is often generated from inside the vertebral column itself and can often be diagnosed and treated by using fluoroscopically guided injections. These can include common procedures such as epidural steroid injection to more complicated methods like radiofrequency facet ablation.
Neurological pain, which is pain generated from within damaged nerves, can respond to removal of a compressing structure or relief of surrounding inflammation. Again, sometimes this can be treated with targeted injection of anti-inflammatory medication around the affected nerve. For more persistent issues resulting from nerve injury, it is sometimes necessary to use medication, which reduces the abnormal firing of the injured nerve such as anti-convulsant medication, or changes the way the brain and spinal cord process the abnormal pain signals such as anti-depressant medication. In circumstances in which a patient with neurologic pain either does not respond or cannot tolerate these medications, treatment with an implanted spinal cord stimulator may be effective in controlling these symptoms.
Q4. Is there any recent research available?
Because of the diverse nature of this group of conditions, the literature is sometimes confusing. I have included a few reviews of specific subjects, such as spinal cord stimulation and interventional pain management in general, but it is important to remember that this area of medicine is not completely understood, in rapid evolution, and that there are sometimes competing interests. Systemic research reviews, which connects the data from multiple randomized controlled studies and provide information about their quality, are generally reliable sources if they have been published in peer-reviewed journals:
- Spinal Cord Stimulation for Patients with Failed Back Surgery Syndrome: A Systematic Review, ME Frey, L Manchikanti, RM Benyamin, DM Schultz, HS Smith and SP Cohen, Pain Physician 2009; 12: 379-397
- Interventional Pain Management for Failed Back Surgery Syndrome, A Hussain, M Erdek, Pain Practice, Volume 14, Issue 1, pages 64-78, January 2014
Dr. Seth Waldman is the Director of the Division of Pain Management at Hospital for Special Surgery. Dr. Waldman has more than 15 years of experience in the field of interventional and medical pain management. He specializes in therapeutic and diagnostic spinal injections and the management of neurologic pain.