J Clin Med Res
Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
Journal website http://www.jocmr.org

Original Article

Volume 7, Number 6, June 2015, pages 460-463


Does the Removal of Spinal Implants Reduce Back Pain?

Hakan Aka, d, Ismail Gulsenb, Tugay Atalaya, Muzaffer Gencerc

aDepartment of Neurosurgery, School of Medicine, Bozok University, Yozgat, Turkey
bDepartment of Neurosurgery, School of Medicine, Yuzuncu Yil University, Van, Turkey
cDepartment of Anesthesiology, School of Medicine, Bozok University, Yozgat, Turkey
dCorresponding Author: Hakan Ak, Department of Neurosurgery, School of Medicine, Bozok University, Yozgat, Turkey

Manuscript accepted for publication March 17, 2015
Short title: Removal of Spinal Implants
doi: http://dx.doi.org/10.14740/jocmr2141w

Abstract▴Top 

Background: The importance of the removal of spinal implants is known in the presence of infection. However, the benefits and/or risks of the removal of spinal implant for the management of back pain are not clear.

Methods: In this retrospective study, we aimed to evaluate the beneficial effects of the removal of spinal implants for back pain. Study included 25 patients with thoracolumbar instrumentation.

Results: Seventeen (68%) of them were male. Indications for spinal instrumentation were vertebra fracture (n = 9), iatrogenic instability due to multiple segment laminectomy (n = 12), and instrumentation after recurrent disk herniations (n = 4). Mean visual analog score (VAS) before the removal was 8.08. Mean VAS was 3.36 after the removal. Spinal instruments were removed after the observance of the presence of fusion. All patients were prescribed analgesics and muscle relaxants for 3 weeks before removal. Back pain did not decrease in five (20%) patients in total. Four of them had been instrumented due to recurrent lumbar disk herniation. None of the patients reported the complete relief of pain.

Conclusion: In conclusion, patients should be cautioned that their back pain might not decrease after a successful removal of their instruments.

Keywords: Spinal instrumentation; Back pain; Visual analog scale; Disk herniation; Vertebra fracture

Introduction▴Top 

The application of spinal instrumentation plays a significant role in today’s spine surgery. It is performed for different indications such as vertebra fracture, revision operations, cases of degenerative spondylolisthesis, fusion over multiple levels, scoliosis, stenosis with scoliosis or lateral slip or in cases where iatrogenic instability is created at the time of an operation [1]. The removal of posterior spinal instrumentation is not always an easy and benign application. Its exact indications are still in debate [2]. The removal of spinal instruments may be needed due to late surgical site infection or late operative site pain (Karl Rathjen). The importance of the removal of spinal instruments for the management of infection was shown by different studies [3, 4]. However, there are no clear results about the benefits and risks of removal of instrumentation for pain.

In the present study, we aimed to evaluate whether the removal of spinal instruments decreases back pain or not.

Materials and Methods▴Top 

The present study included a retrospective analysis of patients in whom the posterior instrumentations were removed in Teaching and Research Hospitals of Bozok University and Yuzuncu Yil University. Hospital folders of 40 patients were retrospectively searched for demographic data such as age, gender, previous indication for posterior segmental instrumentation, and visual analog score (VAS) before and after removal of spinal instruments. Ten patients in whom removal had been performed due to infection and instrument-related problems such as malposition and/or breakage of the instruments were excluded from the study. Five patients with inadequate data or those who could not be reached were also excluded from the study; thereby 25 patients were enrolled into the study. Pediatric patients were also excluded from the study. All patients whose instruments were removed had been treated with analgesics and muscle relaxants for 3 weeks before removal. Computed tomography images of spine were obtained in all patients with the aim of the observance of the development of the adequate fusion. Spinal instruments were removed in patients with adequate fusion.

Results▴Top 

Twenty-five patients were included in the study. Seventeen (68%) of them were male and the remaining were female. The mean age was 44.40 (min. 27 - max. 65, standard deviation: 11.76). The mean VAS was 8.08 (min. 7.0 - max. 9.0) before removal of instruments. The mean VAS was 3.36 (min. 1 - max. 9.0) after removal. The mean decrease in VAS was 4.72 (min. 0 - max. 7) (Table 1).

Table 1.
Click to view
Table 1. Descriptive Statics of the Patients
 

Indications for posterior segmental instrumentation were vertebra fracture (n = 9, 36%, group I), iatrogenic instability due to multiple segment laminectomy (n = 12, 48%, group II), and instrumentation after recurrent disk herniations (n = 4, 16%, group III). The mean age was 37.56, 51.50, and 38.50 in groups I, II, and III, respectively. The mean VAS before removal of instruments was 7.8, 7.9, and 9.0 in groups I, II, and III, respectively. The mean VAS was 2.11, 3.08, and 7.0 in groups I, II, and III, respectively after removal of instruments. The mean decrease in VAS was 5.7, 4.83, and 2.0 in groups I, II, and III, respectively. ANOVA showed statistically significant differences between groups in terms of age, VAS before removal, VAS after removal, and decrease in VAS (P = 0.009, 0.003, 0.003, and 0.23, respectively) (Table 2).

Table 2.
Click to view
Table 2. Results of the ANOVA
 

Patients were divided into three groups according to the indications of posterior spinal segmental instrumentation: vertebra fracture (group I), iatrogenic instability due to multiple segment laminectomy (group II), and instrumentation after recurrent disk herniations (group III). There was a statistically significant difference in group I and group II in terms of age (P = 0.01). However, there was no significant difference between other groups in terms of age. Statistically significant differences were observed between groups I - III and groups II - III in terms of VAS before removal (P = 0.04, for each group). When groups were compared in terms of VAS after removal of instruments, a statistically significant difference was observed between groups I - III and groups II - III (P = 0.003 and P = 0.01, respectively). A statistically significant difference was detected only between groups I and III in terms of decrease in VAS (P = 0.018) (Table 3).

Table 3.
Click to view
Table 3. Results of Multiple Comparisons of Groups
 

Statistical analysis

Quantitative variables were expressed as mean ± standard deviation (SD) or median with range, and were analyzed by Student’s t-tests, one-way ANOVA, Mann-Whitney U tests or Kruskal-Wallis tests as appropriate. Statistical analyses were performed using the statistical package SPSS, version 15.0 (SPSS Inc., Chicago IL, USA); a value of P < 0.05 was used to define statistical significance.

Discussion▴Top 

The results of the present study indicate that the removal of posterior instruments does not lead to back pain free life especially in patients who have been instrumented after recurrent disk herniations. We saw that in 20% of our patients, no change was observed in their back pains.

Reoperation after posterior segmental instrumentation is not a rare application. Reoperation indications include delayed surgical site infection, breakage of instruments, malposition of instruments, development of adjacent segment disease, implant prominence, and operative site pain [2]. It was reported that the rate of delayed surgical site infection after posterior spinal instrumentation is about 5% [5]. The importance of the removal of the posterior spinal instruments for the management of infection was shown by different studies [3, 4].

The removal of spinal instrument for the pain management is a known application. Reoperation rates for the management of pain range between 8% and 19% [6]. However, there are no clear results about the benefits and risks of removal of instrumentation for pain. The data about this topic mainly come from the studies which include patients who had been operated due to scoliosis. In those studies authors reported the deterioration of curve after removal of instruments in scoliosis patients [7-9]. However, in our study, patients had been operated due to different indications other than scoliosis.

In a similar study, Stavridis et al reported that 12% of their patients (seven of 57) were free of pain. They stated that the 61% of their patients showed some benefit. Authors also reported the occurrence of complication in 8.8% of patients [10]. However, in our study, no complication occurred. However, none of our patients were free of pain. Five patients reported no change in VAS. Three of them had been instrumented after recurrent disk herniation. A possible explanation of the pain mechanism in those patients may be recurrent stripping of back muscles. Alanay et al reported that VAS decrease after implant removal was 50% in a different study [11]. The mean decrease in VAS was 4.72 in all of our patients (Table 4).

Table 4.
Click to view
Table 4. Data of Patients
 

In conclusion, the results of the present study and previous studies clearly show that the removal of instruments for the management of back pain does not lead to free of pain in all patients. Because of this reason, patients should be strictly informed that their back pain may sustain in spite of a successful surgery.

Acknowledgement

Thanks are given to Sebahattin Albayrak, MD, for contributing statistical analysis.

Competing Interests

The authors declare that they have no competing interests.

Conflict of Interest

We have no conflict of interest.


References▴Top 
  1. Garfin SR. Surgical indications for spinal instrumentation in degenerative diseases. West J Med. 1995;163(6):571.
    pubmed
  2. Alpert HW, Farley FA, Caird MS, Hensinger RN, Li Y, Vanderhave KL. Outcomes following removal of instrumentation after posterior spinal fusion. J Pediatr Orthop. 2014;34(6):613-617.
    doi
  3. Ho C, Skaggs DL, Weiss JM, Tolo VT. Management of infection after instrumented posterior spine fusion in pediatric scoliosis. Spine (Phila Pa 1976). 2007;32(24):2739-2744.
    doi pubmed
  4. Rihn JA, Lee JY, Ward WT. Infection after the surgical treatment of adolescent idiopathic scoliosis: evaluation of the diagnosis, treatment, and impact on clinical outcomes. Spine (Phila Pa 1976). 2008;33(3):289-294.
    doi pubmed
  5. Richards BR, Emara KM. Delayed infections after posterior TSRH spinal instrumentation for idiopathic scoliosis: revisited. Spine (Phila Pa 1976). 2001;26(18):1990-1996.
    doi
  6. Cook S, Asher M, Lai SM, Shobe J. Reoperation after primary posterior instrumentation and fusion for idiopathic scoliosis. Toward defining late operative site pain of unknown cause. Spine (Phila Pa 1976). 2000;25(4):463-468.
    doi
  7. Potter BK, Kirk KL, Shah SA, Kuklo TR. Loss of coronal correction following instrumentation removal in adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2006;31(1):67-72.
    doi
  8. Deckey JE, Court C, Bradford DS. Loss of sagittal plane correction after removal of spinal implants. Spine (Phila Pa 1976). 2000;25(19):2453-2460.
    doi
  9. Rathjen K, Wood M, McClung A, Vest Z. Clinical and radiographic results after implant removal in idiopathic scoliosis. Spine (Phila Pa 1976). 2007;32(20):2184-2188.
    doi pubmed
  10. Stavridis SI, Bucking P, Schaeren S, Jeanneret B, Schnake KJ. Implant removal after posterior stabilization of the thoraco-lumbar spine. Arch Orthop Trauma Surg. 2010;130(1):119-123.
    doi pubmed
  11. Alanay A, Vyas R, Shamie AN, Sciocia T, Randolph G, Wang JC. Safety and efficacy of implant removal for patients with recurrent back pain after a failed degenerative lumbar spine surgery. J Spinal Disord Tech. 2007;20(4):271-277.
    doi pubmed


This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Journal of Clinical Medicine Research is published by Elmer Press Inc.



 

 

 

 

Browse  Journals  

 

Journal of clinical Medicine Research

Journal of Endocrinology and Metabolism

Journal of Clinical Gynecology and Obstetrics

 

World Journal of Oncology

Gastroenterology Research

Journal of Hematology

 

Journal of Medical Cases

Journal of Current Surgery

Clinical Infection and Immunity

 

Cardiology Research

World Journal of Nephrology and Urology

Cellular and Molecular Medicine Research

 

Journal of Neurology Research

International Journal of Clinical Pediatrics

 

 
       
 

Journal of Clinical Medicine Research, monthly, ISSN 1918-3003 (print), 1918-3011 (online), published by Elmer Press Inc.                 
The content of this site is intended for health care professionals.
This is an open-access journal distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Creative Commons Attribution license (Attribution-NonCommercial 4.0 International CC-BY-NC 4.0)


This journal follows the International Committee of Medical Journal Editors (ICMJE) recommendations for manuscripts submitted to biomedical journals,
the Committee on Publication Ethics (COPE) guidelines, and the Principles of Transparency and Best Practice in Scholarly Publishing.

website: www.jocmr.org   editorial contact: editor@jocmr.org
Address: 9225 Leslie Street, Suite 201, Richmond Hill, Ontario, L4B 3H6, Canada

© Elmer Press Inc. All Rights Reserved.