Ketamine Infusion Therapy for Failed Back Surgery Syndrome with Neuropathic Pain

Evidence Against Ketamine Infusion for FBSS

The American College of Chest Physicians guidelines note "insufficient evidence upon which to base a recommendation" for ketamine in chronic pain management 1

First-line therapy for neuropathic pain should include anticonvulsants such as pregabalin or gabapentin, which is planned to be initiated at 75mg BID, as recommended by the American Society of Anesthesiologists 2
Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors should be considered as part of a multimodal strategy for neuropathic pain, as suggested by the American Society of Anesthesiologists 2
Physical or restorative therapy is strongly recommended for patients with low back pain as part of a comprehensive treatment plan, according to the American Society of Anesthesiologists 2
Cognitive behavioral therapy, biofeedback, or relaxation training should be performed for chronic pain conditions, as recommended by the American Society of Anesthesiologists 2

Pregabalin should be initiated at 75mg BID and titrated based on response, as recommended by the American Society of Anesthesiologists and supported by evidence from Annals of Oncology 2, 3
Tricyclic antidepressants may be added if pregabalin provides insufficient relief, as suggested by Annals of Oncology 3
Opioids may be combined with gabapentinoids for possible additive effects and lower individual doses, as recommended by Clinical Infectious Diseases 4, 5
Spinal cord stimulation has shown efficacy for FBSS and may be more appropriate than ketamine infusion, as recommended by the American Society of Anesthesiologists 2

Long-term opioid therapy has shown limited efficacy for chronic neuropathic pain and may actually worsen outcomes through opioid-induced hyperalgesia, as noted by Clinical Infectious Diseases 5

Current clinical practice guidelines do not recommend ketamine infusion as a standard treatment for chronic neuropathic pain associated with failed back surgery syndrome 6
The Society of Critical Care Medicine guidelines suggest low-dose ketamine as an adjunct to opioid therapy for postoperative pain management in surgical ICU patients, not for chronic pain conditions 6
The American College of Critical Care Medicine recommends using neuropathic pain medications with opioids rather than ketamine infusions for neuropathic pain management 6

Clinical guidelines strongly recommend using neuropathic pain medications (gabapentin, pregabalin, carbamazepine) with opioids for neuropathic pain management 6
The planned treatment with Lyrica (pregabalin) 75mg BID is consistent with evidence-based recommendations for neuropathic pain management 6
Diagnostic imaging is appropriate to further evaluate the structural causes of the patient's persistent pain, as recommended by the Mayo Clinic 7

Pregabalin (Lyrica) is an evidence-based first-line treatment for neuropathic pain associated with failed back surgery syndrome 6
Multimodal analgesia incorporating anti-inflammatory medications, neuropathic agents, and carefully monitored opioid therapy is the standard approach for failed back surgery syndrome, as recommended by the Society of Critical Care Medicine and the Mayo Clinic 6, 7
A structured opioid taper with adjunctive medications is recommended for patients on long-term opioid therapy with diminishing effectiveness, as recommended by the Mayo Clinic 7

Failed back surgery syndrome and lumbosacral radiculopathy appear to be relatively refractory to many pharmacological interventions that work for other neuropathic pain conditions, according to the Mayo Clinic Proceedings 8
Continuation of ketamine treatment beyond the perioperative period increases the risk of hallucinations without significantly enhancing analgesic effect, as reported in Anaesthesia 9
For surgery with high risk of acute pain or for patients with vulnerability to pain, perioperative ketamine may be appropriate, but should be limited to the surgical period with a maximum dose of 0.5 mg/kg/h, as suggested by Anaesthesia and World of Neurosurgery 9, 10