Failed back surgery syndrome

Anthony E Chiodo MD (Dr. Chiodo of the University of Michigan Medical School has no relevant financial relationships to disclose.)
Matthew Lorincz MD PhD, editor. (Dr. Lorincz of the University of Michigan has no relevant financial relationships to disclose.)
Originally released December 8, 1999; last updated July 10, 2017; expires July 10, 2020

This article includes discussion of failed back surgery syndrome, failed spine surgery syndrome, post-laminectomy syndrome, and failed lumbar spine syndrome. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Failed back surgery syndrome is an imprecise term encompassing a heterogeneous group of disorders that have in common low back and leg pain with or without neurologic dysfunction after lumbar surgery. The most severely affected have cauda equina dysfunction. Lumbar spine instability has been implicated as a cause of axial pain, whereas nerve root irritation is a purported cause of radiating symptoms. A relationship to complex bio-psychosocial factors has been demonstrated. Identifying psychosocial risks factors before surgery allows the identification of patients at risk for a poorer outcome. There appears to be a relationship between surgery type and the risk of failed spine surgery syndrome. If this is not a patient-selection issue as purported by randomized trials, then attention to this risk would be prudent. Spinal cord stimulation is neither clinically effective nor cost effective in treating failed back surgery syndrome. Adhesiolysis has shown promise to reduce pain in uncontrolled studies, and further study may show this to be a treatment option where epidural fibrosis is the cause of persistent symptoms. Impact on function, medication use, and employment has not been demonstrated.

Key points

 

• Failed back surgery syndrome is a heterogeneous disorder.

 

• Purported causes include epidural fibrosis, instability, disc reherniation, spinal stenosis, discogenic pain, and infection. Psychosocial factors are related to its development.

 

• Diagnostic work-up, including diagnostic blocks, should be undertaken before treatment is pursued.

 

• Treatment should be directed at the suspected cause.

 

• Spinal cord stimulation does not appear to be successful in the treatment of failed back surgery syndrome.

Historical note and terminology

Surgical limitations and failures in disc herniation were described even before the non-neoplastic nature of failed back surgery syndrome was recognized. Krause is credited with the first successful excision of a herniated lumbar disc (then termed "enchondroma") in 1908 (Oppenheim and Krause 1909). However, late followup revealed that his patient required a cane to walk and had permanent motor deficits (Krause 1912). Failures were common in the earlier surgical series (Bradford and Spurling 1941; O'Connell 1950; Wycis 1950; Greenwood et al 1952; Torma 1952), prompting some to recommend routine spinal fusion (Barr and Mixter 1941). Fortunately, improved illumination, magnification, and surgical technique have reduced the risk of failure, although surgery for lumbar disc disease is still not always successful.

Patients with persistent or recurrent symptoms of low back and leg pain with or without neurologic dysfunction after lumbar spine surgery are described as having failed back surgery syndrome. This is an imprecise term encompassing a heterogeneous group of disorders that have in common pain symptoms after lumbar surgery (Slipman et al 2002). Because multiple etiologies may account for pain after surgical treatment, failed back surgery syndrome is actually a collection of disorders. Technical advances in spine surgery have resulted in a commensurate increase in the etiologies and broadening of the scope of evaluation and treatment of patients with the disorder. Although often thought to result primarily from incomplete removal of disc hernias, persistent stenosis, or psychosocial overlay, current considerations include those related to failed spine fusion and other more complex spine surgery approaches (Long 1991).

The content you are trying to view is available only to logged in, current MedLink Neurology subscribers.

If you are a subscriber, please log in.

If you are a former subscriber or have registered before, please log in first and then click select a Service Plan or contact Subscriber Services. Site license users, click the Site License Acces link on the Homepage at an authorized computer.

If you have never registered before, click Learn More about MedLink Neurology  or view available Service Plans.