Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome

Abstract

The study aimed to review the etiology of failed back surgery syndrome (FBSS) and to propose a treatment algorithm based on a systematic review of the current literature and individual experience. FBSS is a term that groups the conditions with recurring low back pain after spine surgery with or without a radicular component. Since the information on FBSS incidence is limited, data needs to be retrieved from old studies. It is generally accepted that its incidence ranges between 10% and 40% after lumbar laminectomy with or without fusion. Although the etiology of FBSS is not completely understood, it is possibly multifactorial, and the causative factors may be categorized into preoperative, operative, and postoperative factors. The evaluation of patients with FBSS symptoms should ideally initiate with reviewing the patients' clinical history (observing "red flags"), followed by a detailed clinical examination and imaging (whole-body X-ray, magnetic resonance imaging, and computed tomography). FBSS is a complex and difficult pathology, and its accurate diagnosis is of utmost importance. Its management should be multidisciplinary, and special attention should be provided to cases of recurrent disc herniation and postoperative spinal imbalance.

Keywords: Electrostimulation; Failed back surgery syndrome; Postural balance.

Fig. 1.

An 81-year-old male underwent laminectomy with L3–L5 fusion 15 years ago. He presented with lumbar back pain with bilateral numbness and paresthesia in his 5th toes aggravated over the past 2 years and was resistant to medical treatment. (A) Complete spine X-ray and (B) computed tomography scanning and magnetic resonance imaging showed adjacent segment disease and degenerative scoliosis. (C) He underwent corrective osteotomy, and the postoperative course was unremarkable. (D) One month later, he presented with back pain and lower limb weakness following an abrupt movement. X-ray showed proximal junctional kyphosis. (E) He underwent an extension of his arthrodesis to T2.

Fig. 2.

A 24-year-old woman presented 2 years after L5–S1 discectomy. She had intense low back pain with no lower limb involvement. (A) MRI showed Modic 1 changes at the L5–S1 level, with no neural element compression. Diagnostic discography was positive at this level. She was operated on via a posterior minimally invasive transforaminal lumbar interbody fusion and arthrodesis. She had intense left lower limb radicular pain on postoperative day 1. (B) Emergent computed tomography scanning showed an intracanalar left L5 screw. (C) She underwent repositioning of the incriminated screw. At the last follow-up, she had persistent moderate low back pain (Visual Analog Scale=3/10), which did not affect her daily activities. MRI, magnetic resonance imaging.

Fig. 3.

Proposed algorithmic approach for FBSS. FBSS, failed back surgery syndrome; MRI, magnetic resonance imaging; CT, computed tomography; MPR, multiplanar reconstruction; OMM, optimal medical management.