Failed Back Surgery Syndrome

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Intoduction

Failed Back Surgery Syndrome (FBSS) is a condition where patients experience persistent or new lumbar spinal pain following surgical intervention. This pain may either continue despite surgery or emerge after the procedure, occurring in the same area as the original discomfort. FBSS encompasses a wide range of potential causes and varies significantly among affected individuals. Although it significantly impacts patients' quality of life and is relatively common among those who undergo back surgery, there is a lack of high-quality research on effective treatments for this condition.

Watch this informative 6 minute video on FBSS

Etiology

The etiology of Failed Back Surgery Syndrome (FBSS) can be classified into three main categories:

1. Preoperative factors:

• Psychological issues such as anxiety, depression, and poor coping strategies
• Social factors like litigation and worker compensation claims
• Surgical factors including repeated surgeries, inappropriate patient or surgery selection

1. Intraoperative factors:

• Poor surgical technique (e.g., misplaced screws, inadequate decompression)
• Surgery performed at the incorrect level
• Inability to achieve the intended surgical goal

1. Postoperative factors:

• Progressive disease (e.g., new disc herniation)
• Epidural fibrosis (responsible for 20-36% of FBSS cases)
• New spinal instability due to altered biomechanics
• Surgical complications such as nerve injury, infection, or hematoma
• Development of myofascial pain

Initial Approach to Failed Surgery Patient

History Taking:

1. Allow extra time for initial evaluation
2. Obtain and review prior medical records
3. Compare preoperative and postoperative complaints
4. Assess if surgery provided initial relief
5. Identify any new problems immediately after surgery
6. Evaluate current medication usage and potential dependency
7. Assess psychological status
8. Review vocational status and workers' compensation situation
9. Note any post-operative systemic complaints
10. Distinguish between back and leg pain
11. Look for unusual pain patterns (e.g., reflex sympathetic dystrophy, complex regional pain)
12. Discuss postoperative rehabilitation efforts
13. Identify relieving and exacerbating factors

Physical Examination:

1. Observe pain behavior
2. Perform a thorough neurological exam
3. Evaluate major joints as potential pain sources
4. Palpate the surgery site for complications
5. Examine extremities for sympathetic or RSD-type changes
6. Screen for neural tension signs
7. Check for long tract signs
8. Perform vascular assessment (especially in diabetics and elderly patients)
9. Evaluate local soft tissues

This structured approach helps ensure a comprehensive evaluation of FBSS patients, covering both their medical history and physical condition.

Prevention

Failed Back Surgery Syndrome (FBSS) is a condition with significant impact on both patients and healthcare systems. Its prevalence is increasing in parallel with rising rates of spine surgery. The effects of FBSS on an individual's quality of life and functionality are substantial, often proving more disabling than other chronic pain conditions. Given these impacts, it's crucial to focus on two key areas:

1. Prevention Strategies:
   • Ensure clear communication and patient education about realistic surgical outcomes
   • Provide psychological support for patients with social and psychological stressors
   • Employ meticulous surgical techniques during interventions
2. Effective Management Guidelines:
   • Develop and implement comprehensive protocols for managing established FBSS cases

By addressing both prevention and management, we can potentially reduce the incidence of FBSS and improve outcomes for those affected. This approach is essential given the condition's significant impact on individual well-being and healthcare resources.

The high impact of FBSS underscores the importance of thorough preoperative assessment, realistic expectation setting, and careful consideration of surgical indications. It also highlights the need for ongoing research into more effective treatments and management strategies for this challenging condition.

Diagnostic Procedures

A detailed assessment is necessary as it provides information in a lot of areas.

History

The most important part of the diagnosis of FBSS is the history, especially :
• The status before the operation
• The type of surgery that was performed
• The pain characteristics: location, time course
• Assessment of red and yellow flags
• Comorbid treatments and history

It is also good to look if the pain is either predominantly in the back or in the leg. Because this gives a high probability of where the pain comes from.

Further the examination has 2 purposes:
1. Ruling out serious pathology
2. Identify the source of pain

Inspection and examination

This inspection includes an assessment of the posture and functions. The lumbar spine has to be well inspected and there have to be taken note of surgical scars and alignment of the vertebrae. Palpation can identify points that elicit pain. Next, the range of motion should be assessed. Muscle power is assessed by resistance testing of each muscle group with a comparison with the corresponding group on the contralateral side. When there is evidence of nerve tension, special tests can be done.

Radiological evaluation of failed back surgery

1. X-rays:
   • Standard radiographs with standing flexion and extension lateral views
   • Assess alignment, degeneration extent, and instability
   • Can detect spondylolisthesis
   • Cannot show spinal stenosis or soft tissue details
2. MRI:
   • Optimal exam for most FBSS patients
3. CT with multiplanar reformations:
   • Preferred for suspected pseudarthrosis

Diagnostic injections

1. Anesthetic diagnostic injections:
   • Definitive role in diagnosing facet and sacroiliac joint pain
   • Useful to determine if nerve root compression/inflammation causes pain
2. Discography:
   • Helps determine if a particular disc is a pain generator
   • Must be interpreted alongside history, examination, radiological tests, and other diagnostic injections

Management / Interventions

The management of patients with FBSS can be challenging for a number of reasons. First, the patient is usually aggrieved about having undergone significant invasive surgery without achieving any symptom reduction or resolution. Not only are they left with the persistent pain for which the surgery was initially offered, but it may seem that there are no other options left. Second, the diagnosis (either initial or subsequent) may not be clear and whereby further treatment may be difficult to plan .

The general management plan for this group of patients should not focus solely on medical therapy. The objectives of management should be directed to the restoration of functional ability, improvement of quality of life, coping strategies, and pain self-management. Optimal care is often difficult because the evaluation of FBSS depends on the subjective symptoms of the patient.

There was strong evidence that function improved with intensive interdisciplinary rehabilitation with functional restoration.

Conservative Treatments

Sometimes drug therapy combined with physical reeducation had excellent results, but the success rate is variable and depends from patient to patient.

Pharmacological

Medication should not only be prescribed to reduce pain, it should also facilitate exercises, therapy and enable improvements. Used pharmacological are :
• Acetaminophen. Recent research shows paracetamol alone is ineffective for chronic low back pain. However, combining paracetamol with tramadol is effective. Paracetamol remains a key component in multimodal pain management strategies for chronic back pain, despite its limitations as a standalone treatment.
• Nonsteroidal anti-inflammatory drugs (NSAID’s)
• Cyclooxygenase-2 (COX-2) inhibitors
• Tramadol
• Muscle relaxants
• Antidepressants
• Gabapentinoids
• Opioids

The problem with these medications is that their efficacy is often disputed and most of them have considerable side effects

Physiotherapy

It is common that patients with FBSS will become deconditioned. This leads to weakness of the musculature (e.g., transverses abdominis, paraspinal muscles) responsible for maintaining spinal stability. Though different approaches exist, the general aim of exercise therapy is:
• Decrease pain
• Improve posture
• Stabilize the hypermobile segments
• Improve fitness
• Reduce mechanical stress on spinal structures.
An additional benefit is that patients are taught active coping mechanisms with pain, which gives them a sense of control over their predicament . There is however little evidence of the added value of physiotherapy. The best exercise program consists of an individualized, stretching and strengthening program under supervision. Core strengthening can help to reduce pain and to improve stability. Other forms of physical therapy that can be used are spinal manipulation, massage, acupuncture and Tens.

Psychological Therapy: Cognitive behavioral therapy (CBT)

Considering the influence of psychological factors on chronic low back pain (CLBP), it is not surprising that psychological therapy is an accepted component of therapy.

The common components of CBT include the following:
• teaching and maintenance of relaxation skills
• behavioural activation such as goal setting and pacing strategies
• interventions to change perception such as visual imagery, desensitization, or hypnosis
• promotion of self-management perspective

The effectiveness of this therapy in CLBP and chronic pain, in general, has been supported by recent reviews , but no studies specifically addressed the patients with FBSS.

Non-conservative Treatment

The non-conservative treatment options are:

• Medial Branch Blocks and Radiofrequency Neurolysis

• Epidural injections :
The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief in chronic lumbar radicular pain and radicular pain associated with FBSS.

• Percutaneous  epidural adhesiolysis aims to reduce epidural fibrotic tissue and improve the delivery of epidurally administered drugs to their target tissue. This treatment option has strong evidence for short- and long-term pain relief .Also the functional status improved.

• Surgical options. Revision surgery: The success-rate (22-40%) after reoperation is low and declines after each additional procedure. Probably the most important aspect of the decision for reoperation is for consultation with an expert spine surgeon with experience with FBSS.

1. Spinal cord stimulation: Spinal cord stimulation (SCS) is a treatment for Failed Back Surgery Syndrome involving implanted electrodes and a pulse generator. It's shown to be more effective than repeated surgery or conventional management for radicular pain, especially when there's no clear anatomical cause. SCS offers better quality of life outcomes and cost-effectiveness long-term. Patient selection involves a trial period where at least 50% pain relief must be achieved, along with patient satisfaction and understanding of the device. If successful, permanent implantation may be considered.
2. Intrathecal analgesic delivery implant systems: This form of therapy is efficacy, but there is a lack of long-term evidence and some side effects can appear.

Resources

• Chan CW, Peng P. Failed back surgery syndrome. Pain medicine. 2011 Apr 1;12(4):577-606..
• Chou R, Huffman LH. Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of internal medicine. 2007 Oct 2;147(7):505-14.
• Hayek SM, Helm S, Benyamin RM, Singh V, Bryce DA, Smith HS. Effectiveness of spinal endoscopic adhesiolysis in post lumbar surgery syndrome: A systematic review. Pain Physician. 2009 Mar 1;12(2):419-35.
• Schofferman J, Reynolds J, Herzog R, Covington E, Dreyfuss P, O'Neill C. Failed back surgery: etiology and diagnostic evaluation. The Spine Journal. 2003 Sep 1;3(5):400-3.