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Failed Back Surgery Syndrome

Failed Back Surgery Syndrome (FBSS) refers to a subset of patients who have new or persistent pain after spinal surgery for back or leg pain.  The pain can be reduced but still present, or may get worse within a few months after surgery due to a buildup of scar tissue around spinal nerve roots, along with persistent tissue pain and muscle spasm. The term refers to a condition of continuing pain and is not meant to imply there was necessarily a problem during surgery. While published reports estimate the incidence of failed back surgery syndrome to be between 20 – 40%, the likelihood is considered greater with repeated surgery, and the condition will be more prevalent in regions where spinal surgery is more common. Are you still feeling pain after spine surgery? Spinal cord stimulation may be the only treatment option at times.

What is the failed back syndrome?

Persistence of pain after spine surgery or appearance of new pain and disability after back surgery is known as failed back surgery syndrome (FBSS). The same condition is also known as a failed back syndrome. This condition is most commonly seen after laminectomy surgery of the spine and thus it is also known as a post-laminectomy syndrome.

Reasons for Failed Back Surgery and Pain after Surgery

Spine surgery is basically able to accomplish only two things:

  1. Decompress a nerve root that is pinched, or
  2. Stabilize a painful joint.

Unfortunately, back surgery or spine surgery cannot literally cut out a patient’s pain. It is only able to change anatomy, and an anatomical lesion (injury) that is a probable cause of back pain must be identified prior to rather than after back surgery or spine surgery.


What are the causes or reasons behind it?

There are many reasons and not a single reason and that is why the condition is known as a syndrome and not a disease. The reasons are as follows:

  1. The most common reason is the mismatch between the structural source of pain and the target of surgery. The structure creating pain may appear normal in X-ray, CT scan, or MRI images and at the same time, the abnormal degenerated structures seen in these images may remain asymptomatic. The surgeon may therefore operate on the abnormal pathologic structure and perform a perfect operation, but the structure that generates pain remains the same. Thus, the persistence of the same pain can occur.
  2. Another reason may be that after surgery dense fibrosis generates that entangles the nerves and creates a new type of pain. Fibrosis may also cause the narrowing down of the spinal canal and produce pressure on the spinal cord. This pressure on the spinal cord may damage the nerves of the spinal cord or the nerve roots.
  3. Few other factors that may be responsible for FBSS are infection, pseudoarthrosis, load redistribution after surgery, etc. All these may finally lead to FBSS.

Treatments of FBSS

Since FBSS has many reasons, the treatment depends on the cause. Multiple treatment options are therefore available. Conservative management or management without surgery or intervention is most preferred by the patients and is of the first choice. This conservative management consists of reassurance of the patients, medicines such as analgesics, gabapentin, or pregabalin, antidepressants such as amitriptyline, and duloxetine must be tried first and combined. If the symptoms are not well controlled, interventional procedures should be considered. Repeat operations are avoided and with more operations are carried out, the chances of success are reduced.

Interventional procedures for FBSS?

s are few interventional procedures for the treatment of pain in FBSS. The frequently done interventional procedures are epidural adhesiolysis with epidural steroid injection and spinal cord stimulation implantation. 

Epidural Adhesiolysis

Epidural adhesiolysis and epidural steroid injection together is the most common procedure for this. The epidural space is distended by local anesthetic and saline injection into the epidural space. Then steroid in injected. The steroid helps to reduce nerve root inflammation that is associated with nerve root compression. Sometimes Racz catheter, a special epidural catheter loaded with a guidewire and a stylet is used to break the epidural adhesion. This procedure is also called caudal neuroplasty of Racz adhesiolysis. Gabor Racz is a great pain physician and he invented this catheter and the procedure.

Spinal Cord Stimulation

The other way to treat FBSS is by stimulating the spinal cord. It’s like a cardiac pacemaker and is therefore called a spinal pacemaker. Here a battery is implanted under the skin which generates a mild electrical current at specific parameters. This current is delivered at epidural space through a special array of electrodes inside an epidural catheter which is known as spinal cord stimulator lead. Depending on the number of electrodes inside the lead can be bipolar, quadripolar, octopolar leads. The lead in the epidural area electrodes is implanted through a special type of epidural needle and attached with the power generator or battery.

The electrical current at a specific frequency stimulates A-beta fibers and stimulation of A-beta fibers close the gate for pain carrying A-delta and C type nerves This is a small operation done under local anesthesia to create a subcutaneous pocket to implant the power generator. Very recently spinal cord stimulators are available without an implantable power generator where electrodes are stimulated with an external energy source.

Spinal cord stimulation is the best form of treatment in failed back surgery syndrome and the most commonly done procedure. This is a non-surgical interventional procedure that can give a new life to the patient who had one or multiple spine surgeries. The only disadvantage of this procedure is the cost involved, the implantable system is very costly, and the total cost of treatment in Bangladesh is about 12-14 lakh.

Intrathecal Therapy Option

Some patients will be recommended to undergo intrathecal medication therapy, which is the other neuromodulation treatment option.

This involves placing a small hollow catheter into the fluid around the spinal cord and infusing medication from a small reservoir via an inbuilt computer that is placed in the fat of the abdominal wall. 

Again, this treatment can be trialed with their implant in place to see if the patient would benefit before deciding on this. So you see far from it being the end of the road when surgery does not lead to desired outcomes there are other options that have been shown to help patients and reduce their pain.