Failed back surgery syndrome (FBSS)

• What is Failed Back Surgery Syndrome (FBSS)?
• Statistics
• Risk Factors
• Progression
• Symptoms
• Clinical Examination
• How is it Diagnosed
• Prognosis
• Treatment
• References

What is Failed Back Surgery Syndrome (FBSS)?

Failed back surgery syndrome (FBSS) is a syndrome characterised by continuing back and/or leg pain despite undergoing lower spinal surgery. FBSS is diagnosed when the outcome of such surgery does not meet the expectations of the patient or the surgeon that were outlined before the surgery.

Statistics

FBSS occurs as a complication in 5–40% of patients undergoing lower spinal surgery.

Risk Factors

It is thought that patients undergoing spinal surgery may be more likely to develop FBSS if they have:

• Epidural fibrosis (development of hard connective tissue around one of the layers surrounding the spinal cord and part of the nerves coming from it)
• Recurrent disc herniation
• Instability of a segment of spine
• Incorrect initial diagnosis of the back problem
• Incomplete decompression (reduction in pressure on the nerve root)
• Decompression at the wrong level
• Poor patient selection for surgery
• Arachnoiditis (inflammation of one of the layers surrounding the spinal cord and part of the nerves coming from it)
• Permanent nerve root damage
• Facet joint disease

Progression

The progression of FBSS varies between individuals. It is probably influenced by factors such as the underlying problem with the back before surgery, what kind of surgery was performed, why and when FBSS develops, and how it is managed.

Symptoms

Individuals with FBSS usually experience significant long term back or leg pain following surgery. This may occur in the early stages after surgery, or some time later. Often medication and physiotherapy do not fully relieve this pain, which may result in a reduced level of function.

FBSS is commonly associated with conditions such as depression, anxiety disorder and substance abuse. These conditions need to be identified and managed in order to best treat the pain associated with FBSS.

All chronic pain conditions are significantly impacted by, and have a large impact on, the state of mind of the person experiencing the pain. How the person feels about the pain and how they approach it psychologically plays a significant role in how they function.

Clinical Examination

The doctor will examine the patient’s back, as they would for all patients presenting with back pain. This includes feeling for painful structures, testing range of movement, testing reflexes (by tapping places such as the knees and ankles), checking sensation (touch, hot/cold, pain), and checking leg strength.

How is it Diagnosed

There are many tests that may be carried out to determine the underlying cause of FBSS, though the diagnosis can usually be made on the basis of what the patient is feeling (their symptoms).

Possible tests that may be suggested include CT, MRI, CT, and injection of structures in the back (e.g. the discs and joints).

Prognosis

Unfortunately, FBSS is very difficult to treat effectively, and there is no one treatment known to effectively cure the pain that accompanies FBSS. The likelihood of reducing the pain depends on the underlying cause, and the methods used to treat that cause.

Treatment

No one treatment is effective for all people with FBSS. Treatment will vary according to the individual, and the underlying cause of FBSS.

Conservative management

Pharmacotherapy

Medication may be used in pain management. Opioid medication should be used with caution, as it can be habit-forming, and the long term outcome of its effectiveness in FBSS is not clear. GPs or specialists (surgeons, pain specialists, etc) will prescribe medication if it is appropriate.

Exercise/physiotherapy

Gentle exercise programs assist with return to function and psychological wellbeing. It is best if this exercise is tailored to the individual by a physiotherapist or exercise physiologist;

Counselling

Counselling may help with pain management and control strategies. The GP or specialist may arrange a referral to a clinical psychologist to provide this counselling.

Pain clinic

Each of the options outlined above may be combined and provided in the setting of a specialist pain clinic. A GP or specialist may arrange a referral to a pain clinic, which is usually based at a tertiary hospital.

Spinal cord stimulation

Spinal cord stimulation (SCS) involves electrodes being implanted next to the spine, and an electric current applied. This current modifies the pain signals that are sent by damaged structures. This is an effective option for some individuals with FBSS, as it has been shown to improve health related quality of life in this group.

Injections

Injecting anaesthetic or steroids into the structures around the spine may provide short term relief. Injecting saline or other substances to physically break up scar tissue, a process called lumber percutaneous adhesiolysis, may be effective in some cases.

Further surgery

Some causes of FBSS may be treated with further surgery. For example, if a disc bulge has re-occurred following surgery, it may need to be repaired again. Cutting certain nerves from the spine (medial branch neurotomy) may occasionally be suggested.

For more information about spinal cord stimulation devices, click here.

References

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