FAQS on Failed Back Surgery Syndrome

Failed back surgery syndrome (FBSS) is a medical term used to describe the chronic severe pain experienced after unsuccessful back surgery. Surgery on the back is done when there is an identifiable source of pain, such as a pinched nerve root or unstable joint.

Over 500,000 surgeries for low back pain are performed each year in America. However, approximately 40% of patients who undergo lumbar surgery continue to report back pain after the surgery. The incidence of FBSS is about 15%, and many factors contribute the development of this syndrome, such as persistent post-operative radiculopathy, recurrent disc herniation, scar tissue formation, joint instability, and/or muscular deconditioning.

Who is at risk for FBSS?

Many patients are predisposed to FBSS due to systemic disorders such as autoimmune disease, diabetes, psychiatric disease, or vascular conditions. While spinal fusion surgery is a procedure that is quite successful, it does carry the risk for FBSS.

The procedure is used to stabilize spinal joints, and hooks, rods, and screws are used to repair spine damage along with a piece of bone taken from another area of the body. However, there is a chance that the metal implants will fail, or the bones will not fuse for unknown reasons. In addition, repair of one or more joints could increase the strain on other vertebral joints, which leads to ongoing pain.

What causes failed back surgery syndrome?

The original cause of pain can simply recur after back surgery, or the pain could be due to complications during surgery. Joints or nerves may become irritated during the surgical procedure, or development of scar tissue can lead to compression of nerve roots.

Nerve damage is an issue after back surgery, as well. Furthermore, inadequate rehabilitation in patients with out of shape back muscles can result in chronic pain. Common causes of FBSS include:

  • Recurrent or persistent disc herniation
  • Failure of the spine to fuse
  • Nerve damage
  • Continued nerve compression
  • Failed spinal implant
  • Pain from another area of the spine

What are the symptoms of FBSS?

The pain associated with FBSS varies depending on the surgical procedure performed. In addition, the original spine disease or condition contributes to the symptoms.

Back pain can range from a dull, mild ache to a sharp, severe, and stabbing pain. It can be localized to one area of the back, or it may radiate down to the buttocks, thighs, and legs. With nerve involvement, it is not unusual to have burning, stinging pain of the legs and/or feet, which can be accompanied by leg weakness and numbness.

How is failed back surgery syndrome diagnosed?

To conclude a diagnosis of failed back surgery syndrome, the doctor will conduct a physical examination and order diagnostic tests. X-rays, MRI scans, and CT scans are used to visualize the back structures in hopes of identifying the source of pain. Facet joint injections and epidural steroid injections are useful in finding the exact source of pain, while offering relief of pain as well.

What are the treatment options for FBSS?

If you have persistent back pain that remains after corrective surgery, the doctor may recommend an interventional pain technique. Treatment options include:

  • Facet joint injection (FJI) – Usually given in a series of three, these injections involve the insertion of a small needle directly into one or more facet joints using x-ray guidance. A long-acting numbing agent, with or without a steroid, is injected into the joint space near the nerves that branch off the spinal cord. In a recent clinical study, FCIs showed moderate evidence of short- and long-term pain relief in study subjects.
  • Facet joint denervation – With this procedure, the pain specialist uses x-ray guidance to insert a needle into the facet joint. Once the needle is in place, radiofrequency energy heats the tissue to coagulate and deaden the nerves. This is often done once the FCI confirms the exact source of back pain.
  • Epidural steroid injection (ESI) – This involves injecting the epidural space with a steroid medication to reduce inflammation and provide pain relief. The space is between the epidural layer and the spinal cord. This injection has an 80-90% success rate, according to clinical studies.
  • Spinal cord stimulation – With this procedure, the doctor surgically implants a small unit near the spinal cord to deliver electrical currents. In recent studies, patients reported long-term pain relief with SCS.
  • Physical therapy – Because rehabilitation is important after back surgery, the patient works with a physical therapist to build strength of the muscles, as well as to improve endurance and flexibility.
  • Acupuncture – When performed by a skilled practitioner, acupuncture is effective for the pain of FBSS. Small needles are inserted into acupoints, which are located on the back along twelve meridians. A review of numerous randomized control trials, where acupuncture was used to treat chronic pain, proved this treatment to be superior to controls for each pain condition.
  • Transcutaneous electrical nerve stimulation (TENS) – With this treatment, electrodes are placed on the skin of the back to deliver tiny electrical impulses that relieve pain. Many clinical studies of TENS for chronic low back pain show that this treatment provides initial relief of pain in 70-95% of patients.