Failed Back Surgery 

By: Ricardo A Riefkohl, M.D., Department of Orthopedics and Pain Management, Bronx-Lebanon Hospital Center
Friday, March 8, 2013

While the results of spinal surgery remain excellent for properly identified patients who have failed to improve with extensive conservative treatment, an estimated 20–40% of spinal surgery operations may result in failed back surgery syndrome (FBSS) accompanied by complaints of persistent pain or new-onset pain after a period of pain relief. Many of these patients undergo additional surgeries to correct the situation. However, success rates decrease significantly with each subsequent surgery.

FBSS refers to a condition in which a patient has undergone back surgery with a poor outcome. Patients with FBSS are diverse — with complex and varied etiologies and pain sources. They also vary with regard to their clinical complaints and psychological statuses. Common symptoms associated with FBSS include diffuse, dull and aching pain involving the back and/or legs. Abnormal sensations may include sharp, pricking and stabbing pain in the extremities. Patients with FBSS typically experience a decrement in their functional capacity, morale and productivity. They are also more vulnerable to developing psychosocial problems and addiction to pain medication. Health care providers treat these chronic pain patients with various medical procedures, counseling, physical therapy, medication and psychiatric care as needed. However, questions remain about how best to help those who have experienced poor surgical outcomes. It has been observed that patients who have a predominant painful presentation in a radicular pattern will have a better result than those who have predominant complaints of axial back pain.

The most common reason for FBSS is poor selection for surgery. This means the patient may have had a psychological profile or physical pathology that was contraindicated or not appropriate for the surgical intervention. Unnecessary surgery is a second potential cause of FBSS. Unnecessary surgery not only fails to treat the problem appropriately but may worsen the patient’s condition. The third most common cause of FBSS is improper or inadequate surgery, such as incomplete neural decompression during laminectomy or diskectomy.

There are three possible diagnostic scenarios that occur in FBSS patients complaining of low back pain. First, the pain may be the same pain that was occurring prior to surgery but was inadequately treated with surgery. The second is that the problem was treated properly by the surgery but continues to cause pain. Third, the problem may be newly acquired.

Current treatment recommendations for FBSS include an interdisciplinary approach. As with the majority of chronic pain conditions, conservative treatment should be attempted first. This includes physical therapy, pharmacotherapy, psychiatric/psychological treatment and other noninvasive options. If conservative therapy is not effective, the patient should be evaluated for mildly invasive procedures, such as epidural or facet block injections. If injections are inadequate and pain is intractable, neuroablative and neuroaugmentative pain procedures may be used. Spinal cord stimulation is an increasingly popular neuroaugmentative procedure that works by blocking transmission of pain at the level of the spinal cord dorsal horn via electrical stimulation.