Teleexercise for geriatric patients with failed back surgery syndrome

What is it about?

Introduction: Failed back surgery syndrome (FBSS) is defined as back pain which either persists after attempted surgical intervention or originates after a spine surgery. There is a high risk of perioperative morbidity and a high likelihood of extensive revision surgery in geriatric patients with FBSS or post-laminectomy foraminal stenosis. Methods: There is a need for less invasive methodologies for the treatment of FBSS, such as patient-tailored exercise training, with attention to the cost and special needs of the geriatric patients with FBSS. This commentary will provide some background regarding teleexercise (utilizing an internet-based platform for the provision of exercise-related care) for FBSS and will propose three exercises which are easy to administer over online-based platforms and can be the subject of future investigation. Results: Given the documented benefits of regular rehabilitative exercises for patients with FBSS, the high cost of face-to-face services, and the need for infection mitigation in the wake of the COVID-19 Pandemic, teleexercise may be a practical and cost-beneficial method of exercise delivery, especially for geriatric patients with limitations in mobility and access to care. It should be noted that, prescription of these exercises should be done after face-to-face evaluation by the physician and careful evaluation for any “red flag” symptoms. Conclusion: In this commentary, we will suggest three practical exercise training methodologies and discuss the benefits of teleexercise for geriatric patients with FBSS. Future research should aim to assess the efficacy of these exercises, especially when administered through telehealth platforms.

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Photo by Brian McGowan on Unsplash

Photo by Brian McGowan on Unsplash

Why is it important?

Lower back pain is one of the leading causes of disability worldwide resulting in widespread social and economic implications (1). Failed back surgery syndrome (FBSS) or post laminectomy syndrome (PLS) describes the condition of persistent pain following spine surgery, such as laminectomy, discectomy, or fusion-related procedures. FBSS is extremely common, with 74.6% of patients undergoing discectomy for lumbar disc herniation reporting residual lower back pain and 12% requiring an additional procedure (2). The potential etiologies of FBSS are complex and multifactorial, but residual lumbar foraminal stenosis is thought to contribute (3, 4). Symptoms related to FBSS can vary substantially across patients, but generally consist of pain and functional limitation (5). Geriatric populations have an increased risk for degenerative spinal disease leading to FBSS and foraminal stenosis. Moreover, higher rates of perioperative complications have been identified in geriatric patient populations undergoing spinal procedures (6, 7). Although recent investigations have explored endoscopic procedures for FBSS (3, 8, 9), noninvasive techniques have become a focal point of interest in the wake of the COVID-19 Pandemic. Repeat spinal surgery as a treatment option does not guarantee a successful outcome: only 30, 15, and 5% of patients experience a good outcome after their second, third, and fourth surgery, respectively, (10). Therefore, due to the uncertainty of a good outcome in a repeat procedure, noninvasive techniques are favored when appropriate for management of FBSS. A systematic review found spinal cord stimulation to be an effective conservative treatment in decreasing disability and pain scores (11). Likewise, Lee et al. investigated the use of non-invasive painless signaling therapy with FBSS patients and found a decrease in cerebral pain perception (12). Wippert et al. did a randomized trials and found strong evidence supporting use of multidisciplinary rehabilitation exercises as an effective way to restore spinal function (13). Other non-pharmacological interventions such as hydrotherapy and guided strength training/stretching require specific facilities or in-person instruction. In addition, numerous reports have shown that multimodal exercises with cognitive behavioral therapy and intensive interdisciplinary pain rehabilitation can be utilized to improve disability in patients with FBSS (14, 15). In an effort to encourage the use of teleexercise for geriatric patients with FBSS, this commentary will (1) discuss the use of exercise for FBSS in geriatric patients and (2) propose 3 exercises for the treatment of FBSS which can be readily administered through online-based platforms.

Perspectives