What is Failed Back Surgery Syndrome?
Failed Back Surgery Syndrome, or FBSS, is a term used to describe an ongoing back pain that continues even after having a back surgery. According to the International Association for the Study of Pain, FBSS is characterized as a lower back pain that either persists after surgery or starts after having a surgery for a previous back pain located in the same area. This means, the pain can either start after the surgery or the surgery may not be able to relieve or may even worsen the pre-existing pain. Therefore, FBSS can be caused by a variety of factors and looks different in different people who suffer from it. Despite the significant impact FBSS can have and the number of people having back surgeries that might experience this, there are few good quality studies that look into the treatment for this condition.
What Causes Failed Back Surgery Syndrome?
Failed back surgery syndrome (FBSS) is a condition with a complex origin. Many factors can make individuals more likely to experience chronic pain following back surgery. These factors broadly fall into three categories: factors present before surgery, those that occur during surgery, and those that appear after surgery.
Before surgery, certain things may point towards a higher chance of developing FBSS. These can include mental health matters like anxiety or depression, obesity, smoking, legal or worker’s compensation claims, and certain physical or imaging findings like a narrow spinal canal (stenosis), scar tissue (fibrosis), and slipped discs (disc herniation). The stronger links to FBSS were found with factors relating to a patient’s mental and social wellbeing. Moreover, if the wrong patient is chosen for surgery, or if the wrong surgical approach is taken, the risk of FBSS can go up. People who have had many back surgeries previously tend to have a higher risk of FBSS and a lower chance of successful pain relief from surgery.
During surgery, the risks of developing FBSS include operating on the incorrect part of the vertebra, or operating on just one level when the pain is spread out over several levels, leading to inadequate pain relief. Operating on the wrong part could relate to things like the improper identification or alteration of the vertebra in the lower back. The challenge of precisely pinpointing the source of the problem in patients with changes in multiple parts of the spine could also be a factor. If the surgery is not performed correctly, it may not relieve pain or it might even cause new pain.
In the long term, complications from the surgery, whether inevitable or avoidable, could also lead to FBSS. The surgery might worsen existing symptoms or create new ones by causing a narrowing of the spinal canal (spinal stenosis), an unstable spine, scar tissue around the spine (epidural fibrosis), or damage to the nearby discs.
Risk Factors and Frequency for Failed Back Surgery Syndrome
Chronic lower back pain is a common problem among adults, with studies showing that anywhere from 51% to 84% of adults will experience this issue at some point in their lives. Lower back pain is more common as you get older and is more prevalent in women. The need for surgery for lower back pain also increases with age. For example, the number of primary lumbar fusions, a type of back surgery, increased by over 170% between 1998 and 2008.
Unfortunately, not all back surgeries are successful. A condition known as Failed Back Surgery Syndrome (FBSS) can occur, affecting between 10% to 40% of patients. However, it’s tough to estimate how frequently FBSS occurs as it’s defined broadly and can be caused by various things.
- Complex back surgeries are more likely to result in FBSS, with failure rates of 30% to 46% for lumbar fusion
- Microdiscectomy, a less complicated type of surgery, has failure rates of 19% to 25%
Signs and Symptoms of Failed Back Surgery Syndrome
It’s vital to gather a detailed background and conduct a thorough examination of patients who still have pain after lower back surgery. This helps in diagnosing what’s wrong. To do this, it’s necessary to identify the nature and location of the patient’s pain and compare that to the pain they had before surgery. If the pain didn’t immediately go away after surgery, it could be that surgery was done at the wrong spot. On the other hand, if the patient started experiencing new pain after the operation, this could signal damage to the nerves caused by the surgery itself.
- Pain in the leg typically indicates pressure on the nerves from issues like narrowing of the spine, buildup of scar tissue around the spinal nerves, or a slipped disc.
- Lower back pain is more common if the issue lies in the facet joints (the joints that let your spine move), the sacroiliac joint (where your lower spine and pelvis connect), or the soft tissues that support your muscles.
Patients should be asked about specific “red flag” symptoms that may indicate severe conditions. These severe conditions can include feeling numbness in the region that would contact a saddle (“saddle anesthesia”) or losing control of bowel or bladder functions (a condition called “cauda equina syndrome”), experiencing fever, chills, or loss of weight (which might point to an infection), and signs that could indicate cancer. It’s also important to assess patients for mental health conditions like anxiety and depression, as these are often found alongside persistent post-surgical pain.
A physical exam generally doesn’t determine the exact cause of persistent pain, but it could provide some clues. For instance, patients with spinal narrowing typically find their symptoms worsen when they extend their spine and are relieved when they bend forward. If the issue is a slipped disc, the patient might feel pain when they straighten their leg. If the patient has weakness or changes in sensation in their lower limbs, it could help identify which nerve roots are affected. There are also tests to check if psychological factors play a role in the pain, especially when it’s possible there might be a secondary gain. These tests are a bit contentious when it comes to their interpretation, but they could still prove useful.
Testing for Failed Back Surgery Syndrome
X-rays are a common and cheap initial imaging test for suspected Failed Back Surgery Syndrome (FBSS), a condition where the outcome of back or spine surgery doesn’t meet the expected results. X-rays can spot issues with the backbone and pelvic area like defects or misalignments. They are better than MRIs (Magnetic Resonance Imaging) at detecting spondylolisthesis, a condition where one bone in your back slides forward over the bone below it. Changes in the curvature of your spine and wear and tear on the joints near where surgery was performed are just a few of the irregularities that could show up on an X-ray.
However, X-rays do have their limitations. For instance, they can’t detect spinal stenosis, a condition where the spaces within your spine narrow, which is a common finding in FBSS. Also, X-rays aren’t efficient at examining soft tissues like the discs between your vertebrae or any scarring or fibrous tissue that may have formed after surgery.
The best imaging technique for FBSS is still the MRI, with and without a dye (gadolinium contrast) that makes certain tissues, abnormalities or diseases more clearly visible. This imaging technique is excellent at spotting soft tissue issues such as fibrous tissue forming in the outer covering of the spine (epidural fibrosis) and any slipped discs. The contrast is specially needed in patients who have had a slipped disc surgery. If a patient has metal implants from previous surgeries, they may have a CT myelogram. This type of CT scan involves injecting a contrast material into the space around your spinal cord and nerves. This makes it easier to view the spinal cord and nearby nerves more clearly.
For FBSS, several other tests can help determine the cause, and help doctors tell it apart from other causes of lower back pain. For instance, erythrocyte sedimentation rate and C-reactive protein tests can help figure out if an infection could be on the cards, especially in patients with general symptoms or a higher risk of infection. Diagnostic nerve blocks can isolate specific causes of FBSS such as facet joint arthropathy (arthritis in the joints between the vertebrae in your spine), sacroiliac joint pain (pain in the joint at the bottom of the spine), and foraminal stenosis (narrowing in the openings along your spine), and can pinpoint specific nerves associated with a patient’s symptoms. These diagnostic procedures can be combined with steroids not only to diagnose but also to offer some relief from pain. However, these procedures need to be done precisely, using a limited amount of active agent, to improve their accuracy and reliability. The focus on these procedures as a diagnostic tool is very essential for the patient, and the use of steroids should be minimized to avoid any incorrect positive results.
Treatment Options for Failed Back Surgery Syndrome
If you’ve had back surgery that didn’t fix your pain, you’re suffering from what’s known as Failed Back Surgery Syndrome (FBSS). This condition can be treated in two main ways: non-invasive methods, like physical therapy and taking medication; and invasive methods, such as additional surgical or interventional procedures. Ideally, the non-invasive methods like physical therapy or medication should be tried first, before opting for further surgical procedures unless an emergency requires immediate surgery.
However, it’s important to note that research on these non-invasive treatments for FBSS has been limited and results are often contradictory. Medications like non-steroidal anti-inflammatory drugs (NSAIDs), opioids, anticonvulsants, and antidepressants are commonly used. NSAIDs are often prescribed for lower back pain of various causes and have been shown to be more effective than not taking anything. Opioids, while they may be used for treating chronic pain, should be used cautiously in FBSS cases due to concerns around dependency and addiction, and should only be used as a last resort with careful monitoring. Trials with anticonvulsants like gabapentin and antidepressants have shown some promising results, yet the effectiveness of these over the long-term is still unclear.
Physical therapy can also help, but it needs to be tailored to the patient, focusing on tolerance, adjustment, conditioning, and exercises. It’s best supervised by an experienced physical therapist. Cognitive behavior therapy, a type of psychological therapy, can also lead to better outcomes for FBSS sufferers and may enhance the effectiveness of other treatments.
In terms of invasive treatments, options depend on the specific cause of the patient’s pain and what doctors can see on imaging scans. If joint inflammation is detected, techniques like medial branch blocks (an injection of local anesthetic) or radiofrequency ablation (a procedure using electrical current to destroy the nerve fibers) can be helpful. If epidural fibrosis (a build-up of scar tissue) is identified as a contributing factor, adhesiolysis (a procedure to remove this scar tissue) can be effective. Likewise, an epidural steroid injection could help with epidural fibrosis and other related conditions such as disc disruption or herniation, and spinal stenosis (narrowing of the spaces within your spine).
Another option is spinal cord stimulation (SCS), which involves implanting a device to help control the patient’s pain. Good evidence supports SCS as a more effective option than both non-invasive treatment and repeated surgery for FBSS. However, it’s not a cure-all, and in about 40% of patients, permanent implantation may not provide reliable long-term pain relief.
Lastly, another surgery could be an option if specific issues have been identified that might be solved surgically. However, it’s worth noting that repeat back surgery in general is associated with less successful outcomes and higher morbidity (more health problems) compared to options like SCS. Yet in cases with certain symptoms – like bowel/bladder impairment, motor weakness, or nerve deficit – immediate surgical intervention might be needed.
What else can Failed Back Surgery Syndrome be?
Back pain is a pretty common issue. For people who haven’t had any sort of back surgery, the prime cause of this pain usually relates to discogenic pain syndrome. This can be followed by pain connected to the facet and sacroiliac joints. Using careful testing, doctors can often identify the source of this lower back pain for most patients.
However, for people who have had back surgery and are still experiencing pain—a situation known as failed back surgery syndrome (FBSS)—the reasons for the pain can be different and a bit more complex. The most important thing to consider here is a condition known as epidural fibrosis, which can lead to neuropathic back pain.
Basically, with FBSS, the diagnosis is more about the patient’s history (like, whether they’ve had back surgery) than about identifying a specific cause. So diagnosing FBSS is essentially the same as figuring out a more specific issue that can guide the treatment. Interestingly, a clear diagnosis is eventually provided for almost 95% of FBSS sufferers.
When evaluating back pain, doctors should always aim to rule out serious conditions such as cauda equina syndrome, infection, or cancer as quickly as possible.
What to expect with Failed Back Surgery Syndrome
Failed back surgery syndrome is a tricky problem for both patients who have to deal with it and doctors who have to treat it. Compared to patients coping with other long-term pain disorders, like rheumatoid arthritis, osteoarthritis, or fibromyalgia, those dealing with failed back surgery syndrome tend to have a lower quality of life. They may also deal with more pain, joblessness, reliance on strong painkiller drugs like opioids, and disability.
It’s worth noting that the type of treatment chosen for this issue can drastically affect the patient’s outcome. Based on studies, there’s solid evidence that patients who are treated with spinal cord stimulation often see better results. On the other hand, as the number of revision surgeries (or do-over surgeries) increases, the chances of effectively relieving the pain decreases.
Given this information, spinal cord stimulation is now preferentially used as a treatment option once all the mental and social factors have been considered and after all other reasonable efforts have failed to produce desired results. These efforts can include aggressive physical therapy and diagnostic blocks followed by suitable treatment methods as required. This treatment should be considered as a possible option where suitable, and before starting long-term strong painkiller therapy.
Possible Complications When Diagnosed with Failed Back Surgery Syndrome
Patients who experience ongoing lower back pain after back surgery, a condition called Failed Back Surgery Syndrome (FBSS), often also struggle with related health issues. Notably, mental health conditions are usually found in FBSS patients and these conditions are linked to worse pain results. In fact, a study showed that of 78 surveyed FBSS patients, 67 suffered from depression, and most began experiencing these symptoms after the start of their pain.
Furthermore, FBSS patients may encounter health problems due to their attempts to treat their pain. Persistently using Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can badly affect stomach and kidney health. Painkillers, like opioids, are strongly addictive, leading to risks such as overdosing. In fact, one study found that overdosing on opioids was the leading cause of death after lumbar fusion surgery. Additionally, the surgery itself involves weaknesses such as the potential for problems related to anesthesia and the risk of catching an infection.
Here are the potential issues linked with Failed Back Surgery Syndrome:
- Mental health conditions
- Depression
- Stomach and kidney issues due to persistent NSAID use
- Addiction to painkillers
- Risk of opioid overdose
- Anesthesia-related issues
- Infection
Recovery from Failed Back Surgery Syndrome
If you’ve had an appendectomy for a simple case of appendicitis, you can usually expect a straightforward healing period and you won’t need to take antibiotics. But if your appendicitis was more severe, your doctor will likely prescribe you a 4-day course of antibiotics.
If you notice any issues with your wound, like an infection, your doctor will make sure it’s cleaned out and appropriately dressed. However, if you’re having more serious problems such as an abscess (a collection of pus that can develop in your body) or deep fascial plane involvement (a serious complication that can affect the deep layers of tissue), you’ll need to take antibiotics as part of your treatment plan.
Preventing Failed Back Surgery Syndrome
In simpler terms, treating a condition known as failed back surgery syndrome can be quite tricky. So, it’s often best to focus on preventing the pain from happening in the first place. This can lessen the impact of the condition on the general public. When possible, non-surgical measures should be attempted first. These could be less intrusive treatments that can be done without a major operation.
It’s crucial to carefully choose who undergoes surgery, and what technique is used. In fact, when the wrong candidate is chosen or technique used, it can often result in unsuccessful back surgery syndrome. Special attention is needed when considering operating on patients experiencing lower back pain and also dealing with mental health issues.
If surgery is necessary, it’s recommended to use the least invasive method possible. This helps limit damage to the surrounding tissues. Also, surgical mistakes like operating on the wrong vertebra, improperly placing screws, not relieving enough pressure, or failing to remove all necessary tissue should be avoided.
It’s also important for patients to be appropriately educated about the potential risks and complications of lower back surgery. A combination of doctors, nurses, and physical therapists can provide this education before and after the operation. One research study noted that patients appreciated receiving proper education before their procedure and having realistic expectations set. They found that this made them view their surgeon more favorably, even if they experienced long-lasting pain after the surgery. A team-based education approach can result in the best possible outcome for the patient.
