nucleotomy syndrome

Postnucleotomy syndrome: description

Physicians speak of a postnucleotomy syndrome when patients complain of persistent pain in the back after spinal disc surgery, which can radiate to the leg. About 30 percent of all patients who undergo disc surgery then develop a postnucleotomy syndrome.

But other back surgeries can also cause a postnucleotomy syndrome. These include, for example, procedures such as those performed in narrowing the spinal canal (spinal canal stenosis) or a tumor in the spinal column area.

Other names

Postnucleotomy syndrome is sometimes referred to as post-discectomy syndrome or post-discomfort syndrome. In the English-speaking world, the term “failed back surgery syndrome” (FBSS) is used for this clinical picture.

Postnucleotomy syndrome: symptoms

The Postnukleotomiesyndrom is characterized by persistent pain in the back and leg area. Even sensations of sensation (paraesthesia) can occur. The symptoms may be the same as before the operation or may be altered – possibly more than before. Optionally, neurological deficits also occur.

In the context of physical ailments, some patients develop concomitant problems such as sleep disorders, depression, alcohol and drug abuse, and, due to severe physical limitations, social or even financial problems.

Postnucleotomy syndrome: causes and risk factors

In some cases, a postnucleotomy syndrome arises because the surgery did not eliminate the actual cause of the pain. This may be the case, for example, if the affected disc could not be sufficiently relieved (decompressed) or operated at the wrong spinal column height.

In other cases, the postnucleotomy syndrome arises because the intervention has created a new cause of pain. Examples include scarring, postoperative instability with injury to a nerve root or inflammation of the arachnoid (arachnoiditis). It is the middle meninges that surround not only the brain, but also the spinal cord. In addition, after the surgical removal of damaged discs, the vertebral joints may become painfully wedged, causing a postnucleotomy syndrome.

Psychosocial factors such as stress and stress in one’s private life or job may favor the development of a postnucleotomy syndrome.

pain memory

With persistent pain after back surgery also mental factors play an important role, more precisely the pain memory:

Inadequately treated severe pain will leave traces in the spinal cord and, most likely, in the brain as well. These pain marks are called “pain memory”. They lower the pain threshold, which means that the nerve cells in the spinal cord, which are responsible for the transmission of pain signals to the brain, are overly sensitive and interpret even harmless, non-painful stimuli as pain signals that need to be passed on. The nerve cells can even send pain signals to the brain without any stimulus. Then spontaneous pain occurs that has no organic cause.

Even if an operation has been able to eliminate the underlying cause of back pain (such as a herniated disc), patients may continue to complain of back pain due to pain memory.

Postnucleotomy syndrome: diagnosis and examination

To clarify a Postnukleotomiesyndroms the doctor will first talk extensively with the patient on his medical history (anamnesis). He can, for example, ask:

• What complaints do you have? Where exactly do these occur?
• Since when do the complaints exist?
• Are the symptoms the same (in type and strength) as before the back surgery?
• Have you tried any therapeutic measures to relieve the symptoms?

The doctor will also look at the patient’s existing medical records as well as the pre-operative findings. Therefore you should bring as much information as possible to the doctor’s visit.

This is followed by a physical (orthopedic) examination. These include imaging techniques:

The spinal column is X-rayed, whereby often so-called functional images are made – so X-rays of the spine in certain functional postures such as flexion or lateral tilt. Sometimes a special radiograph of the spinal canal (myelogram) is also displayed. Other imaging techniques include computed tomography (CT) and magnetic resonance imaging (MRI). Scintigraphy can be helpful, especially if there is a suspicion of an inflammatory cause of the pain – a nuclear medicine examination that can assess the metabolism of a tissue.

In the case of neurological deficits, the physician can measure the nerve conduction velocity (NLG) or conduct an electromyography (EMG) for clarification. At EMG, we measured the electrical muscle activity.

As part of the diagnosis, the doctor will try to rule out all other possible causes of the symptoms. These include other diseases such as inflammation of the intervertebral disc and adjacent vertebrae due to pathogens (infectious spondylodiscitis) or psychological stress situations.

Postnucleotomy syndrome: treatment

The manifestation and cause of a postnucleotomy syndrome are very diverse. Therefore, the treatment must be tailored to the individual patient.

Most attempts are made to alleviate the ongoing complaints with conservative measures. Important is an adapted, effective pain therapy. For painkillers (analgesics) are used, which can also come from the group of synthetic opioids.

Combinations of drugs with different approaches, such as analgesics plus active ingredients, such as those used in mental illness (such as antidepressants) often prove successful. The treating physician will determine the type, time of administration and dose of the active ingredients in a personalized treatment regimen (“pain scheme”).

Behavioral interventions (such as pain management training) can also help reduce symptoms of postnucleotomy syndrome. The same applies to physiotherapy measures and back training (with targeted build-up of the back and abdominal muscles). In addition, existing excess weight should be reduced to relieve the spine.

The learning of relaxation exercises can be especially helpful if the emergence of the Postnukleotomiesyndroms also has a psychological component (such as occupational or family stress). If necessary, psychosomatic or psychotherapeutic care can be useful.

Reoperation is rarely necessary and successful in a postnucleotomy syndrome, such as instability in the affected spine segment.

Epidural spinal cord stimulation (SCS)

Studies have also shown that epidural spinal cord stimulation (SCS) in post-nociceptory syndrome may be attempted if other therapies (such as medications) have failed. Electrodes are pasted next to the spine, into which electrical impulses of low intensity are directed, in order to stimulate the nerves in the spinal cord. This stimulation superimposes the transmission of the pain signals to the brain.

The SCS may only be performed after exclusion of certain factors that are against an application (contraindications). These include, for example, an inadequately treated current mental disorder (such as drug abuse or dependence), severe coagulation disorders, and certain forms of cardiac pacemakers. Before using the SCS, the physician must carefully weigh the benefits and risks of the treatment.

Postnucleotomy syndrome: disease course and prognosis

The Postnukleotomiesyndrom can gradually turn into a chronic pain syndrome. To prevent this, the persons concerned should be carefully looked after and treated. This is especially true when psychiatric comorbidities such as alcohol or drug addiction, depression or anxiety disorders are present.

With another surgery, the pain in a nucleotomy syndrome usually not relieve.