Failed Back Surgery Syndrome

How Can Back Surgery “Fail” and What Are My Options if it Does?

Dr. Rob Gessman

by Dr. Robert Gessman,
Board Certified Anesthesiology, Pain Management Fellow

How Common is Back Pain?

Low back pain is one of the most common conditions in adults. More than one in three adults say back pain impacts everyday activities, including sleep, and back pain is one of the most common conditions that send us to our doctors every year. Most back problems respond to non-surgical alternatives (such as anti-inflammatory medications, chiropractic adjustment, massage, injections, and physical therapy).

Back pain is a complex issue, and spine surgery has significant risk of complications and so is often a last resort. Some doctors may recommend surgery if back pain fails to respond to conventional treatments and a patient’s life is disrupted by severe pain.

Up to 40% of surgery patients report ongoing pain, or pain as a result of their back surgery, with each subsequent procedure increasing the chance of ongoing pain. This phenomenon is referred to as “Failed Back Surgery Syndrome” and to understand it, we must first understand why back surgery may be recommended and what it involves.

Is Back Surgery the Best Way to Cure Back Pain?

Unless a patient is experiencing severe or progressive complications from back pain (such as symptoms of weakness, or loss of bowel or bladder control), there’s no evidence that early surgery will improve conditions such as disc prolapse or spinal stenosis[i].

The American Pain Society recommends that surgery be discussed as an option only after a patient has suffered from disabling, non-radicular low pack pain for a minimum of 1 year due to the significant risks associated with surgery. Even then, the Society recommends a thorough discussion of the risks and benefits, and full consideration of the evidence that alternative therapies might be just as effective as surgery.

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What are the Types of Back Surgery?

Depending on the condition, back surgery aims to relieve pressure of discs or joints contributing to narrowing of the space where the spinal nerve roots exit the spinal canal, or to decompress the central spinal canal itself. Sometimes surgery can involve removal of the entire disc and fusing the bones with or without placement of a spacer in place of the disc. There is also an option in a small subset of patients for an artificial disc replacement.

Different types of back surgery include:

Discectomy involves removal of the herniated portion of a disk to relieve irritation and inflammation of a nerve. Discectomy typically involves full or partial removal of the back portion of a vertebra (lamina) to access the ruptured disk.
Laminectomy involves the removal of the bone overlying the spinal canal. It enlarges the spinal canal and is performed to relieve nerve pressure caused by spinal stenosis.
Fusion permanently connects two or more bones in the spine. It can relieve pain by adding stability to a spinal fracture. It is occasionally used to eliminate painful motion between vertebrae that can result from a degenerated or injured disk.

Artificial disc replacement is a newer alternative to fusion. A prosthetic disc could help preserve normal range of motion and spine mechanics. This could reduce the long-term degenerative changes in adjacent vertebral segments following spinal fusion. However, the evidence suggests that the efficacy of this approach is similar to that of spinal fusion.

What is Failed Back Surgery Syndrome?

failed back surgery syndrome causing pain

Failed Back Surgery Syndrome is an umbrella term that covers a group of conditions that cause persistent back pain (with or without sciatica) following one or more spine surgeries[ii]. An estimated 30-40% of back surgery patients can suffer from Failed Back Surgery syndrome in the long term. Each successive surgery after the first increase this estimate, with up to 85% of patient reporting Failed Back Surgery Syndrome symptoms after four surgeries[iii].

How Does Back Surgery “Fail”?

What are the Causes of Failed Back Surgery Syndrome?

Failed Back Surgery Syndrome symptoms are generally caused by residual scarring, inflammation, or anatomical abnormalities that alter the normal mechanics of the spine and create pressure on the nerves. A more comprehensive list of causes includes:

  • Psychological and mood factors (depression, anxiety, or other mood disorders) and tobacco use may decrease response to surgical and non-surgical treatment
  • Obesity increases risk of intraoperative and postoperative complications
  • Scar tissue formation after back surgery
  • Recurrent or persistent disc herniation
  • Spinal stenosis
  • Post operative infection
  • Epidural post-operative fibrosis

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How Does Back Surgery “Fail”?

What are the Causes of Failed Back Surgery Syndrome?

Failed Back Surgery Syndrome symptoms are generally caused by residual scarring, inflammation, or anatomical abnormalities that alter the normal mechanics of the spine and create pressure on the nerves. A more comprehensive list of causes includes:

  • Psychological and mood factors (depression, anxiety, or other mood disorders) and tobacco use may decrease response to surgical and non-surgical treatment
  • Obesity increases risk of intraoperative and postoperative complications
  • Scar tissue formation after back surgery
  • Recurrent or persistent disc herniation
  • Spinal stenosis
  • Post operative infection
  • Epidural post-operative fibrosis

Can Failed Back Surgery Syndrome be Treated?

Treatments or Failed Back Surgery Syndrome follow the same basic progression as treatments for acute or chronic back pain. The short-term goal is to reduce the pain from the syndrome, with a long-term goal of correcting dysfunction in spine mechanics and increasing core strength to reduce the stress on the spine structure.This process may include one or more of the treatments listed on the right.

What is the Recovery Time from Failed Back Surgery Syndrome?

Given the complex nature of Failed Back Surgery Syndrome’s causes and symptoms, recovery time varies widely from patient to patient. The recovery time depends on the nature of the pain, the condition of the patient, and how involved the patient chooses to be in their recovery process. Spinal Cord Stimulation has been shown to have lasting relief from Failed Back Surgery Syndrome symptoms, with up to 53% of patients reporting sustained pain relief and satisfaction, even years after their implant, while only 22% of patients who opted for other treatments reported similar success in long-term follow-up.

When Can I Return to Work After Failed Back Surgery Syndrome?

Although the time frame for when a Failed Back Surgery Syndrome patient can return to work varies as widely as the projected recovery time. However, most people who leave work on disability for failed back surgery syndrome struggle to return to their full-time jobs. However, a five-year follow-up study showed that 25% of disabled patients receiving Spinal Cord Stimulation treatment for Failed Back Surgery symptoms were able to return to work.

Common Treatments for Failed Back Surgery Syndrome

A heating pad on a low setting for 20 minutes every two hours (followed by gentle stretching) is low risk and can improve blood flow to a painful area and can aid during painful flares.
Home exercise is a safe way to alleviate pain symptoms and improve function in patients with low back pain. The general aim of home exercise (such as the McKenzie Maneuvers) is to improve posture, stabilize hypermobile segments, improve fitness, and reduce mechanical stress on the spine. Consult a physician before beginning a home exercise routine.

Manipulation of the lumbar spine may reduce mechanical stress on spinal structures, and is felt to be a relatively safe procedure, although it may be associated with a number of minor complaints and (rarely) seriously adverse events. Short-term benefits have been shown in multiple studies. Many physicians believe chiropractic adjustment may offer long-term benefits when combined with other active therapies (such as physical therapy)

Acupuncture as an analgesic approach to acute pain, chronic pain, and specific pathologies continues to be scrutinized to determine if the effects are statistically significantly compared to placebo or “sham” acupuncture. Modest but statistically significant differences have been observed between acupuncture versus simulated acupuncture approaches, and larger differences have been observed between patients who received acupuncture versus patients who received none.

With its focus on core strength, flexibility, and mental health, yoga has shown strong results for short term and long-term benefits against pain and associated disability. Yoga may lead to a significantly greater reduction in pain when compared to home exercise, therapeutic exercise, or manipulation.

TENS is a safe, non-invasive treatment that can be self-applied. A small, battery-operated device delivers low-voltage electrical current through the skin via electrodes placed near the source of pain. This electrical current stimulates the nerves in the area causing pain and disrupts transmission of the pain signals to the brain. Studies have shown that TENS may provide relief for pain and stiffness, although patients will need to administer their own treatments throughout the day.

Interventional approaches, such as minimally invasive injections, complement other treatment options by giving targeted relief to the precise area causing pain. The most common areas that cause pain are the Facet Joints (15-45% of patients[i]) and the Sacroiliac Joint and nearby structures (up to 21% of patients). Depending on the origin and nature of the pain, there are a number of options that have shown evidence of benefit, including Epidural Steroid Injections, Selective Nerve Root Blocks, Facet Joint Injections, Diagnostic Medial Branch Blocks, Radiofrequency Ablation, Lumbar Discogram, Peripheral Nerve Root Blocks, and Kyphoplasty.

Treating Failed Back Surgery Syndrome with Opioids is far from the first option. Only 12% of patients who receive long-term opioids experienced significant improvement in their pain, and only 8% reported better function. Opioids do not show improvement in pain or physical functioning more than NSAIDs, but are associated with side effects and potential risk of dependence and addiction. Opioids are not superior to non-opioid treatment for long-term treatment of moderate to severe chronic back pain.

With this treatment, small electrical leads are placed in the epidural space just above the dysfunctional spine structures that are causing pain. Electrical current then reduces the pain signals before they reach the brain, offering lasting pain relief and a return to normal function. Most patients experience significant reduction in pain from Failed Back Surgery symptoms, as well as improvement in day-to-day activities, and reduction or elimination their opioid reliance.