Fibrosis that forms after lumbar surgery and produces pain and limitation is known as epidural fibrosis. The reality is that the formation of fibrosis is a normal process after surgery. When we have a wound we heal and what is formed is fibrotic tissue. When we talk about epidural fibrosis we are referring to when this fibrosis is giving problems. Fibrosis, as we have commented, is also present in the imaging tests performed on patients who have had a good result from the surgery. This makes it a controversial issue to blame the fibrosis for pain symptoms that persist after an intervention. That does not mean I cannot produce it. I explain:
The pain that persists after lumbar surgery can be divided into lower back pain and root pain (pain that goes through the leg). Just as low back pain is very complex and many factors influence, root pain is usually because something is compressing the nerve. In this sense, fibrosis may be compressing the nerve in its pathway from the spinal canal.
In general, the problem of nerve roots emerging from the spinal cord and running the lumbar area to the legs is a space problem. They have reserved a place by which to leave the vertebrae that are sufficiently broad while there are no guests. When we have a hernia or other cause that diminishes this space the nerve is going to complain. You can do it in many ways but it is usually with leg pain, tingling and / or lack of strength. Fibrosis is one more factor that can diminish this space besides forming adhesions that limit the mobility of the nerve root.
What are the symptoms of fibrosis surgery?
The body heals its wounds by forming scars. If we make a deep skin wound, it will heal us but leave a scar. It is no longer the same skin, it does not have the same elasticity, it does not sweat, it does not grow hair. In short, it does not have the same properties of healthy skin. The repair is effective but it is a patch. When this scar is in a moving area, such as a finger, it may happen that it does not let the joint move normally because of its lack of elasticity. If we suffer a burn in a wide area of the body it is easy to see that the scar does not have the properties of healthy skin. That is to say, a scar is a fibrotic tissue that in bad place or when it is very extensive, can give problems.
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The healing process is not immediate, as we can check when we make a skin wound, for example. This causes the symptoms of a fibrosis that compresses the root to appear after several weeks of surgery and usually before three months. The usual is that after a period of relief after surgery, gradually begin to appear again symptoms in the leg.
So, my pain is because of fibrosis?
Although fibrosis is a cause of pain following spinal surgery, there are many other causes that produce the same symptoms. The diagnosis is often made because we have an MRI in which fibrosis appears and we find no other cause in the image that justifies the pain. As we have commented, we will find fibrosis in almost all the operated ones so that we cannot stay so easily with this diagnosis.
There are many factors that cause pain to persist or return after surgery. On the one hand we have factors related to surgery such as a bad indication of the case to be operated or errors during the same intervention. On the other hand, there is a frequent lack of information regarding how the patient
should be cared for and the physical recovery after surgery. This often leads to new hernias or chronic pain for not doing the right thing or not correcting the factors that led us to need an intervention.
What can we do with fibrosis if it is finally the cause of our pain?
The first thing to evaluate is the consequences of nerve compression. If there is no functional impairment or other signs of complication and “only” there is a problem of pain, we can treat it initially conservatively.
Adequate rehabilitation with progressive relaxation in an attempt to release the nerve smoothly and progressively can be very helpful. It is advisable to do it with a trained physiotherapist and with proper medical follow-up because inappropriate pulling of a nerve root that is trapped can cause a worsening of the injury. In addition it is important a proper education of the patient to avoid the habits that produce injury and a muscular training that recovers the protective capacity of the stabilizing musculature lumbar. During this stage there is specific medication that improves pain related to nerve injury that can help us cope with the situation.
If the situation does not improve or the pain is limiting our daily life, our doctor or surgeon can offer us an epidural infiltration (see post). This technique infiltrates corticosteroids in the affected area. Corticosteroids are potent anti-inflammatories that will lower the inflammatory reaction of the nerve and its surroundings. They can also help rid the nerve of fibrosis during physical therapy. The anti-inflammatory effect can give the nerve the space it needs to get back on the path of healing.
Surgery to remove fibrosis is not a recommended a priori option because fibrosis is most likely to re-form. Even so, in deciding to reinter- gate a patient many factors come in and we should consult with our surgeon.
In recent years percutaneous techniques have emerged to release the adhesions, when all of the above has failed, with good results.
Can we prevent epidural fibrosis?
Nerve roots move when we move our legs. These roots need to slide freely along their path to avoid damage. If they are trapped at one point, when moving the leg we are pulling a rope that does not slip. If our back has been operated on, in the first few weeks the affected tissues will heal. During this time it is important that the nerve slide frequently so that no adhesions are formed. This is achieved with physiotherapy treatment and a proper education of the patient so that he can care and work his back.
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Proper postoperative treatment is not a guarantee of success, but it will certainly reduce the chances of subsequent chronic pain.