Failed Back Surgery Syndrome

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 Defenition/description

“Failed back surgery syndrome (FBSS) is a term embracing a constellation of conditions that describes persistent or recurring low back pain, with or without sciatica following one or more spine surgeries.” A more functional definition is that FBSS results when the outcome of lumbar spinal surgery does not meet the pre-surgical expectations of the patient and surgeon [1].

Clinically Relevant Anatomy

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Mechanism of Injury / Pathological Process

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Clinical Presentation

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Diagnostic Procedures

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Outcome Measures

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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.(4) Second, the diagnosis (either initial or subsequent) may not be clear and whereby further treatment may be difficult to plan (level of evidence 1a)[4].

The general management plan in this group of patients should not focus solely on medical therapy. The objectives of management (grade of recommendation) should be directed to restoration of functional ability, improvement of quality of life, coping strategies, and pain self-management. An optimal care is often difficult because the evaluation of FBSS depends of the subjective symptoms of the patient. (14)

There was strong evidence that function improved with intensive interdisciplinary rehabilitation with functional restoration (grade of recommendation A) (level of evidence 1a).(1)

1 Conservative treatments

Sometimes drug therapy combined with physical reeducation had excellent results, but the success rate is variable and depends from patient to patient.(16)

1.1 Pharmacological

Medication should not only be prescribed to reduce pain, it should also facilitate exercises, therapy and enable improvements. Used pharmacological are (grade of recommendation A):
• Acetaminophen [5,6]
• Nonsteroidal anti-inflammatory drugs (NSAID’s) [6]
• Cyclooxygenase-2 (COX-2) inhibitors [6]
• Tramadol [5,7]
• Muscle relaxants
• Antidepressants [5,8]
• Gabapentinoids
• Opioids [5]

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

1.2Exercise Therapy/Physiotherapy

It’s 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 [1] . There is however little evidence of the added value of physiotherapy. [9]
The best exercise program consists of an individualized, stretching and strethening program under supervision. Core strethening can help to reduce pain and to improve the stability. Other forms of physical therapy that can be used are spinal manipulation, massage, acupuncture and Tens (grade of recommendation A) (level of evidence 1a). (12)

1.3 Psychological 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 (grade of recommendation A) (10):
• teaching and maintenance of relaxation skills
• behavioral 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 [10,11], but no studies specifically addressed the patients with FBSS.

2 Non-conservative treatment

The non-conservative treatment options are:

• Medial Branch Blocks and Radiofrequency Neurolysis

• Epidural injections (grade of recommendation c) (20):
o 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 (grade of recommendation A)(17), (22) 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.(17)

• Surgical options (grade of recommendation A):
o Spinal cord stimulation (SCS)(13),(14): This technique consists of inserting electrodes into the posterior epidural space of the thoracic or cervical spine ipsilateral to the pain (if unilateral) and at an appropriate rostro-caudal level to evoke the topographically appropriate paraesthesiae which are a pre-requisite for (but not a guarantee of) success. (12) For this form of treatment there is moderate evidence. (12) When the patients are appropriately selected there is high evidence. (13) They also noted that SCS not only reduces pain(20), but has several opportunities (14):
 It improves functions
 It improves quality of life
 Allows to return faster at work
 It reduces analgesic consumption
 Minimally invasive
 Fewer permanent complications
 Completely reversible
 Can be screened for responsiveness before placing the electrodes
 Parameters adjustable after implantation
 Improvement in gait and muscle strength after 7 days (18)

o 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.
o 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.

Differential Diagnosis

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Key Evidence

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Resources

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Case Studies

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References

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