Associazione Medica per lo Studio dell’Agopuntura
Scuola Italo-Cinese di Agopuntura di Roma
Ambulatorio di Agopuntura-Dipartimento di Medicina, AUSL 04 L’Aquila

Acupuncture treatment of five cases of Failed Back Surgery Syndrome

Carlo Di Stanislao, Dennis Konopacki, Pierfrancesco Fusco

“Illnesses do not exist only ill patients”

A. Trousseau

Summary: Failed Back Surgery Syndrome is a frequent complication of the surgical treatment for herniated disks of the spinal column. This is particularly frequent in patients with hypotonic abdominal muscles along with static and dynamic alterations of the spinal column. Prior to resorting to the complex and often cruent operations, treatment with acupuncture could be tried. The clinical approach could be different according to the school one follows, but whatever the approach used it must be applied in accordance to the specific needs of the patient. Here are reported the results of treatments on five individuals.

Key Words: Failed Back Surgery Syndrome, Excess of Yang, Blood Stasis.

Senza Titolo - Roberto Pietropaoli - L'Aquila The Failed Back Surgery Syndrome groups together some of the possible consequences and/or side effects that are commonly associated with the surgical decompression of a herniated disk¹. The principal cause of this could be attributed to scar tissue formation (fibro adhesive neuropathy) at the site of incision and at the spinal column where the herniated disk was removed. This tissue could not show any signs of its presence for an undetermined amount of time, giving the patient the impression of having been healed. At times as long as years after the operation, due to various modifications that can develop at the level of the spinal column, this inelastic tissue can adhere to a series of structures (Fig.1), which not being able to yield to the modifications which can develop along the spinal column, begins to create mechanical forces along the nerve roots. This can cause the reappearance of the same symptoms for which the patient had undergone surgery initially: a CT Scan or even better an MRI can show the scar tissue that encompasses or strains the nerve root. Sometimes a radiological exam can show various levels which could be the cause of the radicular pain: in this case an electroneuromyographic study could help in removing any doubts¹. Whenever the clinical picture shown by either the MRI or CT Scan shows multiple areas of pathology, ex. Multiple disk hernias or protrusions, or the simultaneous presence of scar tissue from prior surgery (FBSS), an electroneuromyographic study can help resolve any doubts one may have as to what level one should perform a peridural infiltration or peridurolysis ^{2 3}. by doing so this study allows one to explore the motor unit, which is made up of; the cellular body of the motor neuron, located in the anterior horn the spinal cord; the motor axon, which from which originates from it; and by all the muscular fibers which are subsequently innervated (Fig.2).

Fig. 1

Fig. 2

The treatment algorithm, which is applied when a neuropathic pain component has been detected, consists of three phases as a gradual approach, which is as least invasive^{1-2, 4}.

Step 1) peridural infiltration; by means of peridural infiltration it is possible to administer analgesic, anesthetic and anti-inflammatory medications at the level of the nerve roots. In fact with this procedure, the pharmaceutical agents are introduced as close to the source of the pain as is possible, thereby minimizing the side effects while maximizing the therapeutic effect. Anesthesiologists routinely use this procedure, when they perform a peridural anesthesia. This is one of the main reasons that anesthesiologists, that practice pain therapy, frequently find themselves treating pathologies that originally where considered to be orthopedic in nature. The technique is relatively simple: the patient is seated at the edge of the bed, with the legs supported and the back flexed, so as to facilitate the localization of reference points (Fig.3). A local skin anesthesia is used to allow a painless insertion of the special Tuohy needle (Fig.4), at the level of spinal root, which, is involved, through which the pharmaceutical agents are injected. If there is at least a partial response then a second injection is done. In the case where there is no response, a second attempt is done under radiological guidance.

Step 2) if no benefit is had from the first step then a periduralysis is performed: with this method a lysis, even partial, is done on the scar adherence. Informed consent is obtained. The patient is placed in prone position and after positioning and memorizing the positions of the radiological camera (antero-posterior and lateral views) a sterile field is prepared. Local anesthesia with lidocaine 2% is given and access to peridural space is had thru the hiatus sacralis (passage point between the 5^th sacral space and the first coccige) with a Tuohy needle, as in peridural infiltration. The insertion is done under radiological guidance and with injection of contrast medium (Iopamiro 300) a Racz catheter is passed up to the area of the scar tissue. This area is shown by peridurography (Fig.5). After administering bupivacain 0.25%, a hypertonic saline solution 10% is given and then followed by hyaluronidase 900 IU, (dose determined by size of the scar lesion). Before removing the catheter, 40mg of triamcinolone and 5 ml of ropivacaina 0.2% is injected. Apart from particular situations, antibiotic prophylaxis is not foreseen. If results obtained are not satisfactory then a second treatment could be performed.

Step 3) if the prior treatments failed to improve the patient’s condition then spinal cord stimulation could be proposed. This is done by one or two electrodes, which are passed per via cutaneous, and therefore without surgery, to the spinal level involved. (Fig. 6). Access is with a Tuohy needle using a similar technique as that used in the peridural infiltration procedures. There are various hypotheses on the mechanism of action of the neurostimulation: some ascribe to the modulation of the prostaglandins, others to the production of neuropeptides. It is certain that the neurostimulation produces an important sympathomimetic block in area stimulated, that causes a localized vasodilatation that the patient perceives as warmth in that area.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

The presence of bad posture, which can develop as a result from the work one performs (at a desk, driving a car etc.), or ones personality, individuality and character, can all strongly influence the static and dynamic factors of the spinal column. The presence of a dysmorphic or paramorphic posture (scoliosis, kyphosis, inversion of the normal curvature, hypo- hyperlordosis) is all predisposing factors. These conditions along with FBSS may obtain benefits from both physical therapy and exercise, thereby preventing the development of pain. Strong and flexible muscles guarantee an adequate and stable articulation. In this regard the abdominal muscles have a fundamental function. Correct repeated movements, with time, can create adaptive forces that can compensate unsuitable stresses and strains that our daily modern lifestyle supplies us with. The abdominal muscles act as stabilizers, acting synergistically with the musculature along the spinal column and those of lower limbs (extensors and flexors of the hip, abductors and adductors of the thigh) which are inserted in the pelvis and help to maintain equilibrium. Keeping this in mind it is apparent that a good muscle tone and tropism is necessary in order to have a correct dynamic movement¹. This tonic state favors the motor coordination and synergism of these muscle groups (abdominals and those of the lower limb) with the muscles of the spinal column and thereby limits the pathological changes to occur from strain and overload. The abdominal muscles and in particular the rectus abdominus helps to limit the excessive and harmful hyperextension of the lumbar spine. The abdominal musculature, and in particular the rectus abdominis, from a biomechanical point of view, limits and opposes an excessive harmful hyperextension of the lumbar column. This muscle is an antagonist to the paravertebral musculature and has an antiversion effect on the pelvis and the hyperextension of the lumbar column. Hypotonicity of the abdominal musculature with hypertonicity of the contracted paravertebral musculature is the most common pathological condition seen. The abdominal muscles have the following effect on the equilibrium of the spinal column¹:

§ RECTUS ABDOMINIS: if contracted symmetrically the spinal column is flexed and nears the pelvis to the thorax, is contracted asymmetrically it causes a slight twisting action.

§ EXTERNAL OBLIQUE: synergistic action causes bending the trunk forward, isolated contraction causes a bending rotation of the thorax toward the opposite side of the contracted muscle

§ INTERNAL OBLIQUE: synergistic action causes bending the trunk forward, isolated contraction causes a bending rotation of the thorax toward the same side

§ TRANSVERSUS: bilateral contraction depresses the anterior abdominal wall

§ PYRAMIDAL: it places under tension the linea alba.

It is important to bear in mind the movements and the synergism of the ileopsoas, accessory, and lumbar quadratus muscles. The contraction of these muscles, in particular the ileopsoas, should be avoided due to their tendency to increase the painful symptoms.

§ LUMBAR QUADRATUS: the synergistic action lowers the 12^th rib and stiffens the lumbar tract; the isolated contraction bends the trunk to the same side.

§ ILEOPSOAS: bends, adducts e extra rotates the femur, extends the lumbar vertebrae.

Numerous clinical studies have shown that acupuncture is efficacious against neuropathic pain[1] [2] [3] [4] [5] [6] [7] [8]. The fundamental mechanisms thru which acupuncture gives analgesia are[9] ¹⁰:

1) Segmental inhibition of the afferent nociceptor, better known as the gate-control theory, this explains why points are chosen in the precise localization of the affected segment.

2) Activation of the descending inhibitory system by means of the production of serotonin, endogenous oppiods (endorphins) and noradrenalin; this system is normally proposed as control of the afferent pain system; normally by the production of these substances we can raise the threshold of pain.

In the area of pain therapy two important facts need to be highlighted^{10 11};

a) Acupuncture is to be considered as a pharmaceutical agent, as such, it is administered in a determined dosage and by a determined means; this transforms in acupunctural terms in the number and the diameter of the needles used, the frequency of the treatment sessions, the intensity and the type of stimulation used, in relation to the characteristics of the patient and the specific nature of the pain (acute or chronic, nociceptive or neuropathic etc.).

b) Acupuncture should be considered as a possible alternative therapy and not only as a complementary to the more commonly used pain treatments and should not be considered only in those cases where there are specific contraindications to these classical treatments or where they had given unsatisfactory results.

The FBSS is interpreted by some Chinese as being the result of a blockage (zhi) of blood¹⁰. Some western authorities, on the other hand, have interpreted this being an excess of Yang in the lumbar region and lower limbs due to a mechanical blockage of the rise of the Yang upward and an energetic excess along the resonances of Du Mai[*], Zu Tai Yang[†] e Zu Shao Yang[‡] [10] [11]. Neuropathic pain can be associated with dysthesia and parasthesia. Therefore both interpretations are valid and that in cases of sharp burning pain the hypothesis of an Excess of Yang is appropriate, meanwhile where there is paresthesia it could be considered to due to a blockage of blood. Both conditions can be explained according relationship between the state of the abdominal musculature and the severity of FBSS and the repercussions on the static and function of the vertebrae. With blood stasis the musculature suffers due to lack of nutrition, while in cases of Excess of Yang in the posterior part of the body this induces an excess of Yin in the anterior region with the consequent Cold, Emptiness and therefore flaccidity[12] [13] [14] [15] [16] [17].

Case Studies

We treated five patients (3 women and 2 men) having an age between 59-68 yrs with simple acupuncture. All patients suffered from FBSS, which was confirmed by clinical exam, MRI and electromyography. All the patients had refused in writing to be subjected to the stepwise treatment protocol and had accepted to be treated by acupuncture. Treatments were given every 4-5 days for a total of 8 weeks (15 treatments per patient). Seirin throwaway needles 0,30 x 30 mm were placed for 30 minutes. The needles were manipulated with both rapid and slow movements every 10 min (an average of 3 times a session). The severity of the pain was determined using a pain scale of 10 and the results are shown in graph 1. no patient abandoned the study nor did they ask for any supplemental pain medication. At the end of the treatment all patients had recovered a good range of motion and an excellent quality of life. The study did not include a follow-up period. Regarding the energetic diagnoses;(Graph 2) 4 cases were considered Excess of Yang and one case was due to Stasis of Blood. For the cases of Excess of Yang the following points were chosen: GV3, GB35, BL62[18]; and for case of Blood Stasis BL32-37 e SP6[19]. All the patients were treated on the side of the pain only. However in all the cases 3 different points were used. For an explanation relative to these points see the table below. ^{20 21 28 29 [20]
[21]}.

Symbol	Name	Indications
3GV	Yaoyangguan	Moves Yang from the lower limbs toward the lumbar region. Indicated in the burning pain located in the lumbosacral and coccigeal region.
35GB	Yangjiao	This point unblocks the Yang Wei Mai. Allows the free circulation of Yang in space. Useful in the burning pain of the lower limbs.
62BL	Shengmai	Origin and key point of Yang Qiao Mai. Regulates the Yang time periods. Is a central point in the treatment of sciatica.
32BL	Ciliao	Moves blood in the lumbar region. Treats lumbar pain associated with parasthesia due to blood stasis
37BL	Yinmen	Moves energy and blood and unblocks the Meridian. Useful in ischialgia and sciatica.
6SP	Sanyinjiao	Moves Blood in the lower part of the body. Useful in sciatica.

Comments

Our study has shown that acupuncture can be well utilized as an alternative therapy to the integrated conventional treatments. In the case of neuropathic pain derived from surgical failures, this treatment involves less blood loss and requires less investigative procedures than the conventional protocols. We have not seen the need to carry out studies with control groups, being that it is well known that FBSS does not have spontaneous cures. We recognize the fact that our study lacks an adequate follow-up period and the number of patients studied is not sufficient.

Address for clarification

Carlo Di Stanislao

E-mail: dermoaq@katamail.com

URL: www.agopuntura.org/ www.dermoaq.it

[*]

[†]

[‡]