中壢高正雄骨科復健診所

  最近門診在大醫院手術後仍疼痛的病人有增多的趨勢.病人相當沮喪本以為開刀後會好.認知跟

事實差距過大導致病人身心煎熬.長時間輾轉流落各醫院診所間.怨天尤人有之.自我放棄有之.

收集資料有之.有必要正視此問題.資訊網路爆炸的今日.醫師不必為5斗米誇大療效掛保証.不必

包醫造成醫糾.

文獻上探討此症候群可能的原因如下：

(1)在手術附近出現與術後有關的變化，例如疤痕組織包圍了神經。

(2)開刀部位原本問題復發，例如椎間盤再度突出。

(3)在另外一個位階的地方出問題，引起類似的症狀。

(4)手術前的診斷不正確。

(5)手術的節位不正確或手術方法不正確。

(6)手術的併發症，如傷害到神經或各種感染等。

(7)非器質性問題，如歇斯底里症或精神異常等。

(8)較長程的問題，如骨頭未融合或支架鬆脫。

(9)預期中的疾病進展，如被切割過的椎間盤會持續退化。

然而，對於有些診斷與症狀相當清楚，且手術很順利的個案，也有可能發生術後仍有症狀存在或發作的情況，最近的研究顯示，可能與下列三種情形的發生有其關係：

(1)術後椎間盤發炎：較少見，發生機率低於1〜2%，需使用抗生素。

(2)脊髓蜘蛛膜發炎：通常有嚴重的灼熱感，從背部至單側或雙下肢，休息或止痛藥通常無效，小腿可能會抽筋，治療上相當困難。

(3)術後發作的筋膜疼痛症：可能因術前或術中對肌肉的創傷或外力，造成疼痛板機點(Trigger point)，指特別痠痛且痠痛會傳導至其他部位的點。另外，在手術皮膚疤痕附近，也常發生此類筋膜疼痛症。術後疼痛，不僅造成病人的困擾，同時對醫療人員也是一大考驗，此時有賴病人與專業醫師耐心的配合，才能一步步找出治療方法。

1. Etiology: pain may arise from visceral, blood vessels, nerves, bones, muscles or joints
2. ligaments and muscles of the spine and annulus of the disc are all innervated and contain nociceptive nerve terminals
3. most common causes of FBSS are lateral spinal stenosis, fusion overgrowth, adhesive arachnoititis, recurrent or persistent disc herniation and epidural fibrosis
4. spinal instability may also cause back pain
   1. it is generally agreed that spondylolisthesis with 5 mm of motion on flexion and extension of the lumbar spine indicates an unstable motion segment (2-3 mm of motion is common)
   2. spondylolisthesis pain (commonly anterolisthesis) usually gets better when lying down
   3. Spondylolisthesis without a defect in the neural arch is about 10 times more common in women as in men with the most common level of subluxation occurring at the L4-5 interspace followed by L3-4 and L5-S1
   4. 30% of patients with degenerative spondylolisthesis will have progressive slippage
5. pain may also originate from the facetmyositis, fasciitis may cause back pain that have trigger points that are palpable
   1. joint capsue is innervated by a medial branch of the posterior ramus of the segmental nerve and stretching of this capsule by intraarticular injections has been shown to reproduce low back pain and root tension signs with buttock and proximal leg radiation
   2. tends to be worse with rotation of the back or extension
7. epidural scarring around the nerve roots may displace or compress the nerve roots; epidural scarring might be minimized by maintaining good hemostasis because the blood clot provides a lattice for fibroblatic proliferation and subsequent scar formation; Note: the presence or absence of scar nor the amount of scar can be correlated reliably with pain

There are many reasons that a back surgery may or may not work, and even with the best surgeon and for the best indications, spine surgery is no more than 95% predictive of a successful result.