Failed Back Surgery Syndrome

Overview

Failed Back Surgery Syndrome (FBSS) refers to persistent or new pain that continues despite one or more surgical procedures intended to address spinal problems. It represents a complex condition where patients experience ongoing symptoms even after technically successful surgery. FBSS can manifest as chronic back pain, leg pain, or both, and may be accompanied by reduced mobility and function. The condition can result from various factors including surgical complications, incorrect diagnosis of the original pain source, inadequate decompression, spinal fusion failure, adjacent segment disease, or the development of scar tissue around nerve roots. FBSS is not necessarily a reflection of surgical error but rather highlights the complex nature of spinal pathology and the limitations of surgical interventions in addressing all aspects of spinal pain.

Symptoms

The typical presentation of Failed Back Surgery Syndrome (FBSS) includes persistent or recurrent pain following spine surgery. Patients may experience ongoing back pain, leg pain (radicular symptoms), or both despite having undergone procedures intended to alleviate these issues. The pain patterns often resemble those that were present before surgery, though they may appear in new locations or with different characteristics. Many patients report increased pain with certain movements or positions, such as sitting for extended periods, bending, or lifting.

FBSS symptoms can significantly impact daily functioning and quality of life. Unlike conditions with clear diagnostic markers, FBSS represents a complex clinical challenge that requires comprehensive evaluation. When persistent post-surgical pain occurs, doctors typically consider several possibilities: inadequate decompression of neural structures, recurrent disc herniation, surgical hardware complications, adjacent segment degeneration, or development of epidural fibrosis (scar tissue). Diagnosis often involves detailed imaging studies such as MRI with contrast, CT scans, or specialized nerve studies to determine the specific cause of ongoing symptoms and guide appropriate treatment approaches.

Diagnoses

Failed Back Surgery Syndrome (FBSS) is most commonly diagnosed following spine surgery that has not achieved the desired pain relief. However, it is challenging to establish FBSS as the definitive cause of pain because patients may have ongoing structural abnormalities visible on imaging without experiencing pain, or conversely, may have significant pain with minimal visible abnormalities. The presence of abnormal findings on post-surgical imaging does not necessarily indicate these are the source of continued symptoms. Further complicating diagnosis, FBSS can exacerbate other underlying conditions or create new pain generators through biomechanical changes in the spine.

Pain patterns in FBSS vary widely among patients. Some experience persistent pain similar to their pre-surgical symptoms, while others develop new pain distributions or characteristics. Pain may worsen with specific activities or positions and improve with rest or certain postures. Many patients report increased discomfort with prolonged sitting, standing, or walking, with relief obtained by changing positions or lying down. The pain may occur in the back, radiate into the legs, or present as a combination of both.

Differential diagnosis is essential to determine whether persistent pain stems from surgical failure, new pathology, or alternative pain sources. One diagnostic approach involves selective nerve blocks with local anesthetic to identify pain generators. If a diagnostic injection provides significant temporary pain relief, this suggests the targeted structure is contributing to the pain syndrome. Comprehensive evaluation typically includes detailed physical examination, review of prior surgical records, advanced imaging, and sometimes electrodiagnostic studies to develop an appropriate treatment strategy.

Treatment

By the time a patient with FBSS seeks care at a pain clinic, they have typically already undergone various conservative management approaches. The procedures that address the underlying spinal issues include targeted interventions and, in some cases, revision surgery. Treatment options include:

Physical Rehabilitation: Structured physical therapy programs focusing on core strengthening, flexibility, and proper body mechanics can help manage symptoms and improve function. Aquatic therapy may be particularly beneficial as it reduces gravitational stress on the spine while allowing movement.
Medication Management: This may include analgesics, anti-inflammatory drugs, muscle relaxants, and medications specifically targeting neuropathic pain components such as gabapentinoids or tricyclic antidepressants.
Cognitive Behavioral Therapy: Addressing the psychological aspects of chronic pain can significantly improve coping mechanisms and functional outcomes for FBSS patients.
Interventional Procedures: These include epidural steroid injections, facet joint blocks, radiofrequency ablation of medial branches, or sacroiliac joint injections depending on the identified pain generators.
Adhesiolysis: For patients with epidural fibrosis (scar tissue), procedures to break down adhesions may provide relief when other interventions have failed.
Spinal Cord Stimulation: This neuromodulation technique has shown particular efficacy for FBSS and is often considered when other treatments have not provided adequate relief. It involves implanting electrodes that deliver mild electrical impulses to interrupt pain signals.
Revision Surgery: Carefully selected patients may benefit from additional surgery, particularly those with identifiable structural issues such as hardware failure, adjacent segment disease, or recurrent disc herniation. However, success rates diminish with each subsequent procedure, and patient selection is critical.
Intrathecal Drug Delivery: Implanted pump systems that deliver pain medication directly to the spinal fluid may be appropriate for patients with severe, intractable pain who have exhausted other options.

The management of FBSS typically requires a multidisciplinary approach tailored to the individual patient's specific pain generators, functional limitations, and goals. Treatment plans often combine several modalities to address both the physical and psychological aspects of chronic pain.

Disclaimer
Please note the contents contained in this Patient Fact Sheet are not intended as a substitute for your own independent health professional’s advice, diagnosis or treatment. Our specialists assess every patient’s condition individually. As leaders in pain intervention, we aim to provide advanced, innovative, and evidence-based treatments tailored to suit each patient. As such, recommended treatments and their outcomes will vary from patient to patient. If you would like to find out whether our treatments are suitable for your specific condition, please speak to your doctor at the time of your consultation.