The International Association for the Study of Pain defines failed back surgery syndrome (FBSS) as lumbar spinal pain that “persists despite surgical intervention” or develops after surgery. But endoscopic spine surgery expert Kaixuan Liu, MD, PhD, calls it “one of the most difficult and perplexing conditions for a physician to treat” and says the term itself, “failed back surgery”, is an inaccurate description of a problem with multiple causes.
“A misdiagnosis of the source of a patient’s back or nerve pain, surgical errors, and failure of implanted hardware are only a few of the factors that can lead to FBSS,” explains Dr. Liu, founder of the New York- and New Jersey-based Atlantic Spine Center and Advanced Spine and Outpatient Surgery Center.
Complications, such as the buildup of postoperative scar tissue, which can compress spinal nerves; development of spinal instability following surgery; re-herniation of a repaired disc or re-injury at the surgical location during recovery and rehabilitation; presence of spinal disease adjacent to the surgical site; the redistribution of load to another spinal disc; and a host of patient-related psychosocial and behavioral factors, all affect the outcome of back surgery, Dr. Liu states.
And Dr. Liu expects the incidence of FBSS to rise, both in the United States and globally, as an increasingly older population prompts greater demands for surgery to relieve the pain of an aging, deteriorating spine. Failure rates for lumbar spine surgery have changed little during the past 20 years, remaining as high as 40 percent or more following index (initial) surgery, says Dr. Liu, citing statistics presented by authors of a study in a 2018 issue of the Asian Spine Journal (10.4184/asj.2018.12.2.372). But those rates are likely to change as the average age climbs.
In that same study, scientists write: “The prevalence and incidence of patients with FBSS are comparable [to] those of patients with rheumatoid arthritis. However, patients with FBSS and neuropathic pain experience higher levels of pain and a poorer quality of life and physical function compared with those with osteoarthritis, rheumatoid arthritis, complex regional pain syndrome, and fibromyalgia.”
Although FSBB can be disabling, “the jury is still out on the most effective therapies,” Dr. Liu says. “Patients may initially believe a second spinal procedure is the immediate answer to relieving their pain, but additional surgery is often a least-advised option.”
Other scientists concur. In a report appearing in a 2019 issue of the European Spine Journal (10.1007/s00586-018-05871-5), experts conclude that the rate of persistent postoperative pain following reoperation is “much higher” than after a first surgery to correct a spinal problem. In the patient group studied, the rate of chronic pain was approximately 20 percent after first surgery versus 40 percent after a second operation. “High rates of [persistent pain] and associated health care costs suggest that returning to the operating room is a complex and challenging decision. Spinal surgeons should review whether the potential benefits of additional surgery are justified when other approaches to managing and relieving chronic pain have demonstrated superior outcomes,” the authors’ state.
Those “other approaches” for FBSS range from returning the patient to conservative management using a combination of physical therapy, exercise, pharmacological treatments, and epidural steroid injections to resolve persisting pain or applying more advanced options, such as spinal cord stimulation, requiring implantation of a stimulatory device.
Dr. Liu refers to a continuing education article published in 2021 on the National Institutes of Health books website. In it, authors suggest “spinal cord stimulation is now the treatment of choice, once [patient] psychosocial factors are accounted for, and after the failure of reasonable measures, including aggressive physical therapy [and] diagnostic blocks followed by therapeutic modalities.” Corroborating evidence of the effectiveness of spinal cord stimulation is offered by a 2019 study review in Bioelectronic Medicine (10.1186/s42234-019-0023-1), where investigators say, “novel spinal cord stimulation methods, including burst, high-frequency and dorsal root ganglion [stimulation], provide the clinician with multiple options to treat refractory chronic pain.”
“Of course, every patient is different, which is why the best treatment approach may not be immediately obvious,” Dr. Liu says. “Determining the reasons for a patient’s failed back surgery often requires a bit of Sherlock Holmes type detective work. In some instances, a patient’s own psychiatric health, cognitive and behavioral stability, and lifestyle can enhance or get in the way of recovery.”
Dr. Liu offers the following tips to increase the possibilities of a successful back surgery outcome:
- If you smoke, stop. “Not only are cigarettes a risk factor for developing disc disease and back pain, but research has demonstrated that smokers are more likely to fail spinal surgery,” Dr. Liu says.
- Modify lifestyle behaviors before and after back surgery. Eat nutritionally, exercise, and maintain an appropriate weight. Obesity puts unnecessary strain on the spine and can be a factor in failed back surgery.
- If experiencing depression or anxiety, talk to a psychiatrist, counselor, or behavioral therapist. Authors of an article in the Journal of Pain Research (10.2147/JPR.S92776) say, “multiple studies have demonstrated that depression is one of the strongest prognostic indicators of a negative outcome after spinal surgery. Depressed patients generally feel more pain and weakness…”
- Know what symptoms to expect after the operation and follow the surgeon’s postoperative instructions. Re-injury occurs when a patient fails to follow medical advice or tries speeding up his or her own recovery.
For further reading on this subject, or to explore other spine care related items, visit our website page at: What is Failed Back & Neck Surgery?