Sadly conventional open spinal surgery may not provide the benefits desired by the patient. Our experience since 1990 treating failed open discectomy, failed microdiscectomy, failed open decompression and laminectomy, failed Dynesis fusion, failed posterior or anterior lumbar interbody fusion and failed total disc replacement has shown a number of common causes underlying the failure. The most important factor is Perineural scarring The nerve may be tethered to the disc wall, boundaries of the foramen such as the pedicles, the Superior Foraminal Ligament, posterior vertebral surface, the facet joint capsule, vertebral shoulder or facet joint osteophytes. The normal exiting or transiting (descending) nerves are mobile within the spinal canal or foramen but once tethered are subject to repeated irritation resulting from repeated resisted traction. This accounts for continuing or recurrent symptoms following surgery where the tethering was either never treated or reformed.
The symptoms of perineural scarring replicate the predominant presenting symptoms sfter an interval at which point the original symptoms recur. If the symptoms were diminished following surgery but recurred at an interval (commonly 3 -9 months) then this suggests that perineural scarring has developed following surgery.
Thecauses may be peroperative or postoperative bleeding whicvh consolidates in to scarring. There may be a proclivity amongst some patients to develop scarring.
Perineural scarring presents a therapeutic challenge. Most cases will be referred for careful conservative management (Orthopaedic Therapy with core spinal muscle and postural rehabilitation, pain killers, anti-inflammatory and anti-irritation drugs) and Intervertebral Differential Dynamics (IDD) and Therapeutic injections (facet joint injections, root blocks, therapeutic discograms), Chronic Pain Management, Cognitive Behavioural Therapy and Coping courses.
Transforaminal Endoscopic Minimally Invasive Spine Surgery using the discrete targeted solutions of TELDF (Foraminoplasty) with side firing laser ablation of the scarring offers an encouraging alternative because the transforaminal endoscopic approach allows the nerve to be thoroughly explored and mobilised.