Failed Back Surgery Syndrome

Failed back surgery syndrome (FBSS) is the term used for continued pain a patient has after an unsuccessful back surgery. The patient is usually referred to a pain management specialist to treat existing pain. 

The goal of spinal surgery is to decompress a nerve root or to stabilize a painful joint. FBSS occurs when surgery is unsuccessful or when the surgery negatively affects a structure near the problem area. 

Spinal surgery is complicated because it can be hard to diagnose the cause of the pain. X-Rays and MRIs limit what doctors can see because many times, the pain occurs when the patient is moving and active. Imaging only provides still images. 

Signs & Symptoms of FBSS

One common complaint physicians hear from patients is chronic back pain. However, not everyone experiences the same pain, and the type of pain they experience can vary, based on their spinal disorder, their previous procedure, or underlying cause of FBSS. 

Other types of pain that can be associated with FBSS are: 

• Nociceptive Pain – Localized pain that may be dull or sharp. 

• Neuropathic Pain – Nerve-related pain is caused by damage to the nerves or spinal cord.

• Radicular Pain – Radicular pain radiates from one area to another

Other common symptoms of Failed Back Surgery Syndrome include:

• Return of original symptoms & pain – When the symptoms return that the original procedure was intended to correct, it may be a sign of FBSS.

• Reduced mobility – Recovering from back surgery is a process. However, if mobility is reduced or limitations arise that are different than predicted by your physician, it could be a sign of FBSS. 

• New problems arise – While the original symptoms may be corrected by the surgery, new pain in a different part of the spine should be discussed with your doctor. 

• Onset of Headaches – If headaches were not a part of your medical history prior to having surgery, this may be a sign of nerve damage after a spinal procedure. 

Diagnosing Failed Back Surgery Syndrome

The first step to diagnosing FBSS pain is to see a doctor for a physical exam. Motion, sensitivity, and strength help doctors decide the next steps to correctly diagnose the pain. Your medical history, pain levels, and previous treatments are discussed with your doctor to help them define the pain and decide on a treatment method. 

Having tests like CT scans, MRIs, and X-Rays help doctors take an inside look at your pain. The images don’t always show the root cause of the pain, making FBSS hard to diagnose. 

Since imaging is not always reliable, doctors may use another form of testing to diagnose your pain. This is called an aware state surgical examination. A doctor uses a small probe and stimulates the spinal cord, mimicking the pain, and triggering a response from the patient. This informs the doctor as to what type of pain the patient is having and how it is caused. 

Back pain patients are referred to pain management specialists who treat their pain and help improve their quality of life through short-term techniques. 

Conservative Treatments for Failed Back Surgery Syndrome

There are many conservative treatments for FBSS.Besides the physical therapy and pharmacological therapy with over the counter or prescription medications, doctors use minimally invasive interventional modalities such as epidural steroid injections and injections of the lumbar facet joints or associated medial branches, with or without radiofrequency ablation rhizotomy (RFA).What makes these a conservative first choice option is the minimally invasive nature of the procedures.These therapeutic interventions are designed to treat the pain and provide temporary symptomatic relief. 

Neuromodulation in the Treatment of FBSS

In the treatment of Failed Back Surgery Syndrome, one of the most successful treatment options is Spinal Cord Stimulation. Treatment efficacy for FBSS has increased over the years with the majority of patients experiencing pain relief and reduced medicinal load. Improved quality of life can also be achieved using SCS.

For patients with unrelenting back pain due to mechanical instability of the spine, degenerative disc disease, spinal injury, or deformity, spinal surgery is a well-accepted treatment option; however, even after surgical intervention, many patients continue to experience chronic back pain that can be notoriously difficult to treat. Clinical evidence suggests that for patients with FBSS, repeated surgery will not likely offer relief. Additionally, evidence suggests long-term use of opioid pain medications is not effective in this population, likely presents additional complications, and requires strict management.

SCS has been shown to be a safe and efficacious treatment for this patient population. Recent technological developments in SCS offer even greater pain relief to patients’ refractory to other treatment options, allowing patients to regain functionality and improve their quality of life with significant reductions in pain (1).

Sources: 

https://expertpaincare.com/treatments/spinal-cord-stimulation/

https://www.neuromodulation.com/failed-back-surgery-syndrome-definition

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5106227/

https://www.pennmedicine.org/updates/blogs/neuroscience-blog/2018/september/failed-back-surgery-syndrome

https://www.theacpa.org/conditions-treatments/conditions-a-z/failed-back-surgery-syndrome-fbss/

References

• Spine (Phila Pa 1976). 2017 Jul 15;42 Suppl 14:S61-S66. doi: 10.1097/BRS.0000000000002213.Clinical Evidence for Spinal Cord Stimulation for Failed Back Surgery Syndrome (FBSS): Systematic Review.

Kapural L1, Peterson E, Provenzano DA, Staats P.

•  North RB, Campbell JN, James CS, et al. Failed back surgery syndrome: 5-year follow-up in 102 patients undergoing repeated operation. Neurosurgery. 1991;28:685–690. 

• Van Buyten JP, Linderoth B. “The failed back surgery syndrome”: definition and therapeutic algorithms: an update. Eur J Pain Suppl. 2010;4:273–286

• Kumar K, Toth C. The role of spinal cord stimulation in the treatment of chronic pain post laminectomy. Curr Rev Pain. 1998;2:85–92.