Rehabilitation of a Patient with Functional Instability Associated with Failed Back Surgery, The

Journal of the American Chiropractic Association,  Dec 2004  by Adams, Vincent

• E-mail
• Print
• Link

Abstract

Objective: A report of a case of a low-tech non-dynamometric functional exercise program in the rehabilitation of a functionally unstable lower back, associated with failed back surgery.

Clinical Features: A 41-year-old female presented to a chiropractic office with severe lower-back pain, with radiation down the left leg to the calf. Seven months prior, she had an L5-S1 discectomy. Two months after the surgery, her pain in the lower back and leg returned. An MRI 6 months after the surgery showed no evidence of a recurrent disc herniation, but revealed a small image enhancement along the, posterior annulus adjacent to the right S1 nerve root, consistent with post-operative change. Plain film radiography was unremarkable.

Intervention and Outcome: The home-based therapeutic techniques used in this case were based on the patient's weaknesses demonstrated on a functional evaluation. This evaluation consisted of 4 functional tests, including the repetitive squat, Sorenson static back endurance, repetitive sit-up, and the repetitive arch-up tests. The exercises were performed over a 6-week period, and resulted in a decrease in both pain and functional disability based on visual analog scale, pain diagrams, and the Oswestry low-back pain questionnaire.

Conclusion: A home-based exercise program proved very effective in decreasing this patient's functional disability level, but was ineffective in reducing pain levels. Further investigation of chiropractic management of such cases is warranted.

Key Words or Phrases: functional instability, rehabilitation, failed back surgery

Introduction

Failed back surgery syndrome (FBSS) is a complex clinical problem that results from persistent pain following lumbar spinal surgery. The complexity of FBSS derives in part from the multidimensional nature of pain itself. FBSS is addressed with numerous therapies, including epidural corticosteroids, opioids, pedicle screws, spinal cord stimulation, exercise, and acupuncture. Outcomes for these therapies are not conclusive, and no standard treatment has been established.1

Accurate diagnosis is necessary for optimal treatment. An accurate diagnosis of FBSS can be established in more than 90% of cases-through a proper history, selected imaging studies, psychological evaluation, and, possibly, diagnostic injections. Other common problems in patients with FBSS may include foraminal stenosis, discogenic and neurogenic pain, facet and sacroiliac joint pain, residual or recurrent disc herniation, and psychological disorders.2 Medical imaging modalities, including magnetic resonance imaging, may be required to diagnose any clinically relevant abnormality and to determine if further surgical intervention is needed.3

An important factor in the genesis of FBSS can be clinical instability4-a significant decrease in the ability of the spine stabilization system to keep the intervertebral neutral zones within the physiological limits without neurological dysfunction, major deformity, or incapacitating pain. The neutral zone is a region of intervertebral range of motion around the neutral posture, where there is little resistance by the passive spinal column.5

Disc injury may alter overall spinal mechanics, including the behavior of the disc itself, as well as that of other spinal structures.6

According to McGill, "sufficient stability" is a complete concept and desirable objective that seeks the optimal balance between stability and mobility.7 The best stabilizer of the spine is no single muscle, but the "most important muscle" is a transient definition that depends on the task. All muscles virtually work together to create sufficient stability in all degrees of freedom.8

Current research has not elucidated the most optimal exercises for each individual or situation; however, the combination of science and clinical experience can improve low-back health.9 Developing therapeutic strategies based on academic and clinical evidence and utilizing them in the clinical framework are, however, in increased demand. Concurrent local and global retraining of muscles more efficiently helps functional integration than isolated training of one system, or successive training of one after the other.10

In healthy groups, researchers have tried to quantify lower-back muscles' endurance times and the ratios between extensors, flexor, and lateral flexor groups. These "normal" relative ratios are used to guide clinicians and identify any endurance deficits within specific patients." One study, Alaranta, et al.,12 established a normative database for low-tech functional tests, including sit-ups, arch-ups, squatting, and static back endurance. This study evaluated over 500 subjects of various ages and genders with good-to-excellent reliability for each of the functional tests.

Case Report

A 41-year-old female presented to a chiropractic office suffering with severe lower-back pain, radiating down the left leg to the calf. Seven months prior, she had had an L5-S1 discectomy. Two months after the surgery, her pain in the lower back and leg returned. An MRI 6 months post-surgery showed no evidence of a recurrent disc herniation, but revealed a slight amount of contrast enhancement along the posterior annulus adjacent to the right Sl nerve root, consistent with post-operative change. Plain film radiography of the lumbar spine did not demonstrate any radiological instability of the lumbar spine and was otherwise unremarkable. The radiographs did not include any stress positions, such as compression or flexion/extension views, which might have helped to demonstrate any radiological instability in this case.13