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Coping with Failed Back Syndrome

Recent efforts to rename "Failed Back Syndrome" to "Persistent Spinal Pain Syndrome" speaks to the problems that these patients face. Outside of efforts to better define and treat specific patient generators, FBS patients must focus on optimizing their quality of life despite their chronic pain. Importantly, the end-point of pain should not be "minimizing pain, but instead maximizing quality of life."

Medications can play a significant role in diminishing and improving quality of life. The wrong drug can wreak havoc, and proper medication can improve life. Too much or too little of the appropriate medicine can be as bad as taking the wrong medication—optimizing medical management is a process of successive iteration because what works for one patient often does not work well for another. Prescribe, assess the effect, and re-prescribe as carefully and efficiently as possible to achieve the best possible result for the patient. NSAIDs like Motrin often play a central role but have associated risks that must be recognized and managed.

Other non-narcotic drugs deserve consideration. For example, THC, the active ingredient in marijuana, is not a pain reliever but can reduce the "burden of pain" in some patients. The patient says, "yes, I have severe pain," but "it doesn't matter as much, so I can do things that I otherwise could not."

Narcotics like codeine and oxycontin are terrific for short-term use but potentially very detrimental when used long-term, greater than a couple of months. Not only does the benefit of narcotics wear off over time, requiring higher doses, but the long-term use of narcotics makes people more sensitive to every painful stimulus. In the past, some espoused the comforting thought that people in pain cannot become addicted to drugs, so prescribe freely - we know this is entirely false and, worse yet, was borne of the greed of certain pharmaceutical companies. Drug dependence on an agent that increases pain sensitivity is bound to decrease quality of life in the long term.

Physical therapy can help reduce pain, but the effect diminishes over time. Nonetheless, occasional physical therapy, chiropractic, and acupuncture treatments can be very beneficial. However, these therapies can also make the pain worse. Exacerbation of pain often requires a temporary "holiday" from the offending treatment.

Spinal cord and peripheral nerve stimulation require surgically implanted devices that can reduce pain levels. It does not work for all patients, but it does work for most. Pain is never completely alleviated using this modality, but it can be attenuated sufficiently to allow for a higher quality of life.

Psychological mechanisms also significantly optimize the quality of life and are often ignored or under-treated. Depression and anxiety potentiate pain. Treatment of depression and anxiety reduces pain.

There are many more treatments for back pain. Regardless of the modalities employed, it is most critical to recognize that the end-point of all treatments is not the control of pain but the maximization of quality of life. These are different.

Achieving the maximum quality of life can only be accomplished when a receptive and capable medical team and the patient work together closely and interactively over many months.

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