Post Lumbar and Cervical Laminectomy Syndrome treatment options

Ross A. Hauser, MD.

Post Laminectomy Syndrome treatment options

A laminectomy is a surgical procedure to relieve “pinched nerves.” Since the nerve is “compressed,” the surgical procedure is also called “Decompression Surgery.” The procedure removes bone from the spinal vertebrae, the portion called the Lamina, to take the pressure off the affected nerves. This article will examine what happens when the laminectomy procedure is not as successful as the doctor and patient hoped for and examines the resulting Postlaminectomy Syndrome and what treatments can be offered for it.

Many people have successful laminectomy procedures. These are typically not the people we see in our office. We see the people who suffer from Post Laminectomy Syndrome or Failed Back Surgery Syndrome who are looking for non-surgical options to help their back pain. All these people have unique challenges, their stories go something like this:

I had successful surgery but I still have pain

I went in for the surgery because I had terrible nerve pain shooting into my legs. I was told that my surgery was successful but I continued to have pain. It was not the same pain as before the surgery, it is a different pain that centers in my back at the L4/L5 site where I had the laminectomy. I traded one pain for another. 

Following the surgery, I still had the same pain.

I had a laminectomy for lightning bolt type pain in my lower back. Following the surgery, I still had the same pain. I was given spinal block injections that did not help. I tried a variety of conservative treatments, including physical therapy, which I tried even though it did not help me before my surgery, acupuncture, and yoga. I am being told now that spinal fusion is my best option. I just can’t see myself going through another surgery.

Following the surgery, I had worse pain.

I was in a rear-end car accident. I have had low back pain ever since. Last year I finally decided to have surgery. My doctors decided on a rhizotomy (cut the nerve roots) during my procedure in which I also had a laminectomy and discectomy. Following the surgery, I have had a terrible pain in my lower back that radiates all the way up to my neck. No one can tell me why I have this pain. My entire spine feels like it’s out of joint and certain moves come with sharp pain.

In cases like this, many problems can be causing this person’s pain. In cases like this, we would examine the possibility that muscle and ligament damaged caused widespread spinal instability and this could be causing nerve compression throughout the spine. That is one possibility.

I had a lumbar spinal fusion for symptoms of low back and hip pain that radiated into my legs. Following the surgery, I was in much worse pain and the pain now reaches from my neck to my feet. Diagnoses range from post-laminectomy syndrome to failed back surgery syndrome. Other doctors suggest nerve compression caused by femoral acetabular impingements, ischiofemoral impingements, small fiber neuropathy, and other possible conditions. I had none of these diagnoses prior to the surgery.

When we have a difficult to determine case or treat a problem such as those this person just mentioned, including small fiber neuropathy we may find a possible solution in damage to the lumbar and spinal ligaments. This may have created a situation of spinal hypermobile allowing the bones to press down and disrupt nerve pathways. This problem is typically seen in patients exhibiting the symptoms described above. We would also have to take into account that the impingement conditions may have been the actual cause of the patient’s discomfort from the beginning.

This illustration demonstrates the areas of the vertebral bone removed with the various types of spinal surgery. Here we can see that typically, the most bone is removed in a laminectomy procedure as compared to a hemilaminectomy, Hemi meaning one side, or Hemilaminotomy, Facetectomy, or Foraminotomy.

 “Degenerative processes may result in foraminal stenosis development over time, even after a successful surgery.”

The problem with Laminectomy is that it removes structure from the spine. When you remove one supporting structure from anything, another supporting structure is going to take on added stress and pressure. So is the case for Laminectomy.

This problem is addressed in an October 2019 study. Here neurosurgeons from some of South Korea’s leading medical universities discussed the realistic surgical options for patients with an average age of 72 who suffered from Post Laminectomy Syndrome. The study appears in the journal World Neurosurgery.(1) Again, they are talking about a successful surgery that led to the problem of stenosis because of a compromise of structural integrity. Listen to the complexity of the surgery to fix this.

“Post Laminectomy Syndrome (PLS) or failed back surgery syndrome is a condition characterized by persistent pain following back surgery. Degenerative processes may result in foraminal stenosis development over time, even after a successful surgery.

Percutaneous endoscopic lumbar foraminotomy (PELF) offers a minimally invasive means of treating foraminal stenosis after back surgery. The transforaminal endoscopic approach can provide a better access angle to achieve a sophisticated foraminal decompression with less facet and dural injury.”

The recommendation to have a second surgery to alleviate pain caused by the first surgery is a very tricky procedure as outlined in the above study. Even with good success rates in the second surgery, pronouncing it successful, what happens if, the second successful surgery eventually develops into a painful spinal problem? In the above research, the neurosurgeons described their own technique as a “sophisticated foraminal decompression with less facet and dural injury.” There is still an injury. Can these patients then handle a third procedure? There is of course great concern with what to do with patients with continue to suffer from chronic pain following back surgery, even after successful back surgery. This is why patients explore non-surgical options.

Degenerative processes may result in foraminal stenosis development over time, even after a successful surgery. The narrowing of the intervertebral foramina is illustrated to the right.

Now let’s move to an April 2020 study published in the Journal of Clinical Medicine. (2) Here again, surgeons look for even the smallest success in helping patients with Post-laminectomy syndrome. Small success is hard to find. Here is what the surgeons wrote:

• Post-laminectomy syndrome (PLS) is characterized by chronic pain and complex pathological entity after back surgery. An epidural adhesiolysis (removal of scar tissue that has formed because of the surgery that surrounds the spinal nerves) is considered an effective treatment option for lumbar Post-laminectomy syndrome.
• In this study, 147 patients were retrospectively analyzed following combined epidural adhesiolysis and balloon decompression using inflatable balloon catheters in lumbar Post-laminectomy syndrome cases. (The balloon acts to move bone off nerves).

Here are the results:

• At 1 month post-surgery: 32% of patients had some positive result
• At three months, that number dropped to 24.5%,
• At six months, that number dropped to 22.4%

The surgeons concluded: Our results suggest that an early intervention using combined epidural adhesiolysis and balloon decompression in lumbar PLS patients may be associated with a favorable outcome, even though it has limited effectiveness. (That would be about 1 in 4 patients at 6 months post another surgery).

Treating Post-Surgical Proximal Junctional Kyphosis: Excessive spinal curvature following surgery

Doctors at the University of Iowa summarized the reasons for laminectomy for cervical stenosis and possible complications of an excessive spinal curvature. (3) In their study they report:

Laminectomy has been regarded as a standard treatment for multi-level cervical stenosis. Concern for complications such as kyphosis (Hunchback syndrome) has limited the indication of multi-level laminectomy; hence it is often augmented with an instrumented fusion.

Laminectomy resulted in a 57% increase in flexion (bending) as compared to the normal intact state, creating a concern for eventual kyphosis–a known risk/complication of multi-level laminectomy in the absence of fusion.

Increased disc stresses were observed at the altered and adjacent segments post-laminectomy during flexion.

In a May 2020 study from the Department of Neurosurgery, the University of Iowa Hospitals and Clinics published in the journal World Neurosurgery (4) surgeons describe the need in some patients for both an anterior (front) and posterior (rear) cervical surgery approach. More commonly known as Anteroposterior Cervical Spine Surgery. This is a very complicated surgical procedure and is sometimes performed on the same day. This study examines the challenges and complications these people may face post-surgery.

In this study, the patient charts of 37 patients who had “contemporaneous anterior + posterior approaches” (at the same time) or kyphosis, stenosis, and subluxation were examined at an average follow-up of 20 months.

The anteroposterior cervical spine surgery was performed for:

• 12 of the 37 patients because of severe kyphosis
• 9 of the 37 patients because of severe stenosis
• 7 of the 37 patients because of subluxation

Post-surgery

• Proximal junctional kyphosis was the indication in 4 cases
  • Proximal junctional kyphosis is considered a common complication of multi-level cervical fusion. For some, fractures in the vertebrae wall aggravated, worsened, or created during the surgery causes an outward or hunchback curvature to develop.
• Failure of instrumentation (hardware failure) with kyphosis in 3 cases,
• Adjacent segment degeneration in 2 cases.
• Kyphosis was corrected in all. Nine patients suffered a total of 14 complications.
• Six patients developed dysphagia (swallowing difficulties), two developed spinal fluid leaks, one meningitis, two wound dehiscence (wound separation), and one C5 palsy. None were life-threatening and all resolved with appropriate management.

The key to this study was the need to correct the abnormal curvature of the neck.

BruceBlaus, CC BY-SA 4.0, via Wikimedia Commons

If you want to avoid another surgery, Intensive Interdisciplinary Pain Rehabilitation treatment will be needed after the failed laminectomy

The above study is from 2020. Now we are going to go back to a 2010 study published in the medical journal Canada Physiotherapy, (5) the Journal of the Canadian Physiotherapy Association. It gives an outline of what Intensive Interdisciplinary Pain Rehabilitation is and what a patient with failed laminectomy syndrome may face.  We are going to use this knowledge to discuss new and recent studies on Post-laminectomy syndrome treatment and to show how difficult this problem has been to treat and why people would like to avoid further surgeries.

Rehabilitation became a full-time job for patients

• If you were one of these patients followed in this research study, you attended 7–8 weeks of outpatient treatment, which consisted of 3–4 clinical contact hours per day, usually 5 days per week.
  • The total clinical contact time ranged from 130 to 150 hours per patient.
• Patients were also asked to perform additional exercises and related homework for approximately 1–2 hours per day, and their compliance was monitored. Program cost ranged from $8,000 to $12,000 per patient. (That is in 2010 Canadian dollars).

The treatment team consisted of:

• cognitive-behavioral therapists, kinesiologists (movement specialists), occupational therapists, physiotherapists, physicians, psychologists, biofeedback therapists, and massage therapists.
• Supplemental team members included chiropractors, dietitians, physiatrists, and psychiatrists.

Together, these components were designed to enhance each patient’s understanding of chronic pain and to promote effective use of pain-management skills. Patients were taught effective physical and mental pain-coping techniques within a supportive, goal-oriented atmosphere to increase self-efficacy in pain management.

Let’s point out again, the aptly described intensity of this program for failed surgery patients and the hours dedicated towards rehabilitation was, in effect, a full-time job.

• You have a failed back surgery problem – Post-laminectomy syndrome
• You do 7 to 8 weeks, 5 days a week, 3-4 hours a day of intensive rehabilitation.
• You are taught to manage your failed surgery pain on your own for the rest of your life.

This is a suggested successful pain management plan for post-laminectomy syndrome. Certainly, it is better than another surgical attempt.

Nurses tell an even more confusing, demanding, and complicated story about what patients go through in the multidisciplinary approach to treating post-laminectomy syndrome

In April 2019, nine years after the above study, a survey was taken of nurses caring for patients with chronic pain syndromes. This survey’s results were published as a research study in the International Journal of Nursing Sciences. (6)

• The nurses experienced the allocation of limited resources as challenging, especially when the dilemma between accepting new patients from the waiting list and offering a follow-up to existing patients became apparent. Multifaceted treatment was perceived as vital, although resources, priorities, and theoretical understanding of pain within the team were challenging.
• The needs for multifaceted and integrated treatments in chronic pain management were obvious, although this approach appeared to be too demanding of resources and time. Stronger cooperation between pain clinics in specialist care and health care providers in primary care to ensure better patient flow and treatment is required.

Is a Spinal Cord Stimulator A Better Answer?

For more information, please see our article When Spinal Cord Stimulators are not helping

Let’s look at an April 2020 collaborative study (7)  from the Russian Ministry of Healthcare and the Department of Neurosurgery, the University of Illinois at Chicago. Here the researchers pushed the idea that failed spinal cord stimulation treatment is a problem of not correctly identifying who spinal cord stimulation can help and who it cant. Spinal cord stimulation does not help everyone. Here is what they wrote:

“Based on recent clinical experience, it may be possible to create an algorithm for choosing the optimal approach to each clinical situation (patient). . .Overall, 50 years after its introduction, Spinal cord stimulation has come out of a period of relative stagnation, and is rapidly advancing towards diversification and the creation of the strong evidence base necessary for making science-based decisions in choosing the optimal approach in individual clinical cases.”

So, Spinal cord stimulation has not had technical advances until just recently and exiting the “stagnation” period and this may bring success to some people if they are chosen correctly.

In April 2017, researchers at the Mayo Clinic published similar findings. Of note in their research is the study title: The Effectiveness of an Intensive Interdisciplinary Pain Rehabilitation Program in the Treatment of Post-Laminectomy Syndrome in Patients Who Have Failed Spinal Cord Stimulation. (8)

The Mayo doctors looked at patients who had Post-laminectomy syndrome and were first treated with Spinal Cord Stimulation. For whatever reason; time, ability, commitment, knowledge, the patients in this study, and their physicians believed Spinal Cord Stimulation was the way to go. It was not.

Here are the Mayo Clinic findings:

• Intensive, interdisciplinary pain rehabilitation provides an effective therapeutic modality for patients with post-laminectomy syndrome who have failed spinal cord stimulation by decreasing pain levels and by increasing functional status and self-efficacy.

A January 2022 paper (4) in the publication JAMA network open comes from  Penn State College of Medicine. In this paper researchers examined laminectomy outcomes the need for long-term opioid usage. In this large study of 26,179 patients who received an SCS implant after developing post laminectomy syndrome researchers found: “among all patients, SCS implant for Post-laminectomy Syndrome resulted in statistically significant reductions in the number of opioid prescriptions in some comparisons, but the reduction was small and its clinical relevance is questionable. However, SCS was associated with a lower rate of new opioid use in patients who were previously (non opioid users).”

Causes of Chronic Post-Surgical Spinal Pain and why another surgery is being recommended

In this video, Ross Hauser, MD describes the 5 main reasons that back surgery failed to help the patient’s condition.

1. The surgery did not address the actual cause of the patient’s pain. The diagnosis is wrong.  The main cause of  “missed” low back pain is an injury to the Sacroiliac Joint. If your MRI showed disc degenerative disease and you had the discs operated on but the Sacroiliac Joint was not addressed, the pain will continue after the surgery.
2. The surgery made the lower back MORE unstable. Foraminotomy, Laminectomy, Microdiscectomy, disc surgery, all have to remove parts of bone from the spine.
3. The “missed secondary problem.” The surgery may have successfully addressed what was considered your primary problem, but, you really had two problems. This could be a multi-segmental problem that was not discovered until after the first surgery.
4. Too much sitting after surgery, possibly too much bed rest.
5. Rarer, scar tissue pinches on the nerves. This is discussed at length below.

Looking for treatment answers: Misinterpretation that a herniated disc is causing low back pain is the most common reason behind the spinal surgeries that result in post-laminectomy chronic pain syndrome

In the above video, Ross Hauser, MD explains five common reasons that a patient suffered from Failed Back Surgery Syndrome. A primary reason was that the surgeon may have chased the wrong thing.

In Brazil, doctors write in the medical journal BMC Research (9) notes that as many as one-third of the patients undergoing surgery for the correction of lumbar disc conditions experience recurrent postoperative symptoms. The cited research suggests that upwards of 40% of the patients undergoing lumbar surgery will not experience benefits from the procedure and that the condition will worsen in up to 10%.

The high prevalence in this study, the Brazilian team noted was perhaps due to inaccurate indications for surgery. They note several studies as having suggested that the misinterpretation that a herniated disc is causing low back pain is the most common reason behind the spinal surgeries that result in post-laminectomy chronic pain syndrome beginning immediately after the procedures.

This misinterpretation may be partially caused by an overestimation of the anatomical findings that are revealed during the imaging evaluations but are not related to lumbago and usually do not explain the pain or justify surgical intervention.

Hasty diagnoses using MRI or other imaging methods rather than clinical observations can lead to unnecessary treatments (including back surgery) that, in turn, cause iatrogenic conditions.

More findings:

• The prevalence of post-laminectomy pain was 60 %.
• All of the patients presented with chronic, intense pain that had lasted an average of 7.22 years.
• The prevalence of neuropathic pain was 89.9 %.
• None of the patients exhibited high levels of physical fitness.
• There was a strongly positive and significant relationship between anxiety and depression scores.

The patients in this study are patients typical of what we see in our clinics and hope to help. If the surgery did not address the correct issue we hope that we can with non-surgical regenerative medicine injections to include Prolotherapy and PRP. We will now explain these treatments.

Comprehensive Prolotherapy for failed disc surgery: the realistic goals of non-surgical treatments

Comprehensive Prolotherapy is a treatment designed to strengthen weakened soft tissue in the spine and bring stability to the area through injections, not surgery. We recommend a consultation for those on narcotics and those with spinal cord stimulators. In the case of spinal stimulators, we ask patients to bring in their X-rays showing exactly where the spinal cord stimulator is placed. As long as we can see where the stimulator electrodes are located we can safely do Prolotherapy.

Prolotherapy can be effective at treating Failed Back Surgery and Post Laminectomy Syndrome

In research from Harold Wilkinson MD, published in the medical journal Pain Physician, (10) Dr. Wilkinson looked at difficult back pain cases to see if simple dextrose Prolotherapy would be of benefit. “Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery,”

Here are some learning points:

• Thirty of the 35 patients in this study had been referred to a neurosurgeon because of persistent pain and disability despite prior low back surgery and were referred for consideration for possible additional surgery.
• After inclusion in this study, only four patients subsequently underwent additional surgery, though 29 patients requested repeat injections.
• This suggests that painful enthesopathies can be major pain generators for some patients and that diagnosing their condition as being due to a focal problem and treating those sites with prolotherapy can be an effective and “minimally invasive” treatment alternative. (The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone.)

Please refer to for more discussion Cervical pain Adjacent segment disease following neck surgery for a discussion of the cervical spine.

Platelet Rich Plasma Therapy in combination with Prolotherapy

Some doctors may recommend the use of Platelet Rich Plasma to help patients with failed back surgery syndrome. Platelet Rich Plasma is an injection of your concentrated blood platelets into the area of pain. The concentrated blood platelets bring healing and regenerating growth factors to the areas possibly damaged or affected by surgery.

Recent research says that  Platelet-rich plasma (PRP) represents an additional approach, as it has shown some promise in bone regeneration, and should be explored for its potential role in limiting spinal fusion surgery failures. (11)

This was also alluded to in a July 2019 study (12)  lead by Harvard Medical School, Beth Israel Deaconess Medical Center researchers. The researchers wrote: “A small number of prospective trials have suggested there may be some benefit to using PRP injections in the treatment of pain or functional decline caused by facet joint arthropathy. These commonly used modalities require further study to improve the quality of evidence and to investigate the safety and efficacy of PRP injections for various common causes of chronic low back.”

In our practice, PRP is used in conjunction with dextrose Prolotherapy to stimulate healing of the ligament and tendon attachments of the spine that cause pain, muscle spasms, degenerative disc, and other conditions.

Summary

The laminectomy procedure involves removing some of the bone, called lamina, from the supporting structure of the back. Its removal creates stress on other areas of the lumbar spine. Because some of the lamina are removed, the discs, ligaments, and muscles have to do more work. As a result, the vertebral discs degenerate. The vertebral segments then move closer together and eventually become hypermobile. Back muscles tense to stabilize the segment. When they cannot stabilize the segments, the vertebral ligaments are then forced to do this alone. They eventually become lax or loose and subsequently cause further instability in the spine and cause more pain. This is probably why back and neck pain are so commonly occurs several years after this operation. If the muscles and ligaments cannot stabilize the joints in the lower back, the vertebrae loosen and eventually rub together and crack, causing excessive bone growth in order to stabilize the joint. The stabilization results in spondylosis, or arthritis of the lumbar spine. Often the person then succumbs to another operation for the arthritis that formed as a result of the first operation. Unfortunately for the patient, the second operation is not a panacea of pain relief either. A simpler approach is for Prolotherapy to correct the underlying ligament laxity that was causing the pain in the first place. This sequence of events is also applicable to other areas of the body.

If you have questions about Post-laminectomy syndrome and back pain Get help and information from our Caring Medical staff

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This article was update January 7, 2021

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.