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  • Updated 08.15.2022
  • Released 12.08.1999
  • Expires For CME 08.15.2025

Failed back surgery syndrome



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 may result in improved pain scores in a limited group of patients with more leg than back pain related to failed back surgery syndrome. Function, return to work, and opioid use reduction are not consistently demonstrated in studies of this population. Increased cost of care is seen in all, except for those who experience improved pain scores who go on to use the device for ten years or more. Attention to psychosocial risk factors improves patient selection.

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 (53). However, late followup revealed that his patient required a cane to walk and had permanent motor deficits (40). Failures were common in the earlier surgical series (08; 51; 73; 28; 65), prompting some to recommend routine spinal fusion (05). 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 (64). 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 (44).

As part of the International Classification of Diseases-11 as accepted by the World Health Organization, the International Association for the Study of Pain published a revised classification of pain that included the term “chronic pain after spinal surgery” as a replacement for failed back surgery syndrome. A Delphi process with a workshop of content matter experts recommended the term “persistent spinal pain syndrome” as a replacement for failed back surgery syndrome, with chronic pain after spinal surgery consisting of a subset of those patients with new or enhanced pain after surgery (16).

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