<unk>  <unk>  is a well-recognized complication of surgery of the lumbar spine. It can result in chronic pain and disability, often with disastrous emotional and financial consequences to the patient. Many patients have traditionally been classified as "spinal cripples" and are consigned to a life of long-term narcotic treatment with little chance of recovery. Despite extensive work in recent years,<unk>  remains a challenging and costly disorder. Opioids A study of chronic pain patients from the University of Wisconsin found that methadone is most widely known for its use in the treatment of opioid dependence, but methadone also provides effective analgesia. Patients who experience inadequate pain relief or intolerable side effects with other opioids or who suffer from neuropathic pain may benefit from a transition to methadone as their analgesic agent. Adverse effects, particularly respiratory depression and death, make a fundamental knowledge of methadone's pharmacological properties essential to the provider considering methadone as analgesic therapy for a patient with chronic pain. Patient selection Patients who have sciatic pain (pain in the<unk> , radiating down the buttock to the leg) and clear clinical findings of an identifiable radicular nerve loss caused by a herniated disc will have a better post operative course than those who simply have low<unk>  pain. If a specific disc herniation causing pressure on a nerve root cannot be identified, the results of surgery are likely to be disappointing. Patients involved in worker's compensation, tort litigation or other compensation systems tend to fare more poorly after surgery. Surgery for spinal stenosis usually has a good outcome, if the surgery is done in an extensive manner, and done within the first year or so of the appearance of symptoms. Oaklander and North define the<unk>  as a chronic pain patient after one or more surgical procedure to the spine. They delineated these characteristics of the relation between the patient and the surgeon: # The patient makes increasing demands on the surgeon for pain relief. The surgeon may feel a strong responsibility to provide a remedy when the surgery has not achieved the desired goals. # The patient grows increasingly angry at the failure and may become litigious. # There is an escalation of narcotic pain medication which can be habituating or addictive. # In the face of expensive conservative treatments which are likely to fail, the surgeon is persuaded to attempt further surgery, even though this is likely to fail as well. # The probability of returning to gainful employment decreases with increasing length of disability. # The financial incentives to remain disabled may be perceived as outweighing the incentive to recover. In the absence of a financial source for disability or worker's compensation, other psychological features may limit the ability of the patient to recover from surgery. Some patients are simply unfortunate, and fall into the category of "chronic pain" despite their desire to recover and the best efforts of the physicians involved in their care. Even less invasive forms of surgery are not uniformly successful; approximately 30,000–40,000 laminectomy patients obtain either no relief of symptomatology or a recurrence of symptoms. Another less invasive form of spinal surgery, percutaneous disc surgery, has reported revision rates as high as 65%. It is no surprise, therefore, that<unk> S is a significant medical concern which merits further research and attention by the medical and surgical communities. Total disc replacement Lumbar total disc replacement was originally designed to be an alternative to lumbar arthrodesis (fusion). The procedure was met with great excitement and heightened expectations both in the United States and Europe. In late 2004, the first lumbar total disc replacement received approval from the U.S. Food and Drug Administration (FDA). More experience existed in Europe. Since then, the initial excitement has given way to skepticism and concern. Various failure rates and strategies for revision of total disc replacement have been reported. The role of artificial or total disc replacement in the treatment of spinal disorders remains ill-defined and unclear. Evaluation of any new technique is difficult or impossible because physician experience may be minimal or lacking. Patient expectations may be distorted. It has been difficult to establish clear cut indications for artificial disc replacement. It may not be a replacement procedure or alternative to fusion, since recent studies have shown that 100% of fusion patients had one or more contraindications to disc replacement. The role of disc replacement must come from new indications not defined in today's literature or a relaxation of current contraindications. A study by Regan found the result of replacement was the same at L4-5 and L5-S1 with the CHARITE disc. However, the ProDisc II had more favorable results at L4-5 compared with L5-S1. A younger age was predictive of a better outcome in several studies. In others it has been found to be a negative predictor or of no predictive value. Older patients may have more complications. Prior spinal surgery has mixed effects on disc replacement. It has been reported to be negative in several studies. It has been reported to have no effect in other studies. Many studies are simply inconclusive. Existing evidence does not allow drawing definite conclusions about the status of disc replacement at present. Electrical stimulation Many<unk> <unk>  patients are significantly impaired by chronic pain in the<unk>  and legs. Many of these will be treated with some form of electrical stimulation. This can be either a transcutaneous electrical nerve stimulation device placed on the skin over the<unk>  or a nerve stimulator implanted into the<unk>  with electrical probes which directly touch the spinal cord. Also, some chronic pain patients utilize fentanyl or narcotic patches. These patients are generally severely impaired and it is unrealistic to conclude that application of neurostimulation will reduce that impairment. For example, it is doubtful that neurostimulation will improve the patient enough to return to competitive employment. Neurostimulation is palliative. TENS units work by blocking neurotransmission as described by the pain theory of Melzack and Wall. Success rates for implanted neurostimulation has been reported to be 25% to 55%. Success is defined as a relative decrease in pain. Chiropractic Limited case series have shown improvement for patients with<unk> <unk>  surgery who were managed with chiropractic care.
Failed back syndrome
Löfgren syndrome
Radial tunnel syndrome
Facet syndrome
Carpal tunnel syndrome
Heel pad syndrome
Snapping scapula syndrome
Snapping hip syndrome