Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Proposal of a Standardized Multidisciplinary Team Care Pathway

Abstract

Failed back surgery syndrome (FBSS) is a major, worldwide health problem that generates considerable expense for healthcare systems. A number of controversial issues concerning the management of FBSS are regularly debated, but no clear consensus has been reached. This pitfall is the result of lack of a standardized care pathway due to insufficient characterization of underlying pathophysiological mechanisms, which are essential to identify in order to offer appropriate treatment, and the paucity of evidence of treatment outcomes. In an attempt to address the challenges and barriers in the clinical management of FBSS, an international panel of physicians with a special interest in FBSS established the Chronic Back and Leg Pain (CBLP) Network with the primary intention to provide recommendations through consensus on how to optimize outcomes. In the first of a series of two papers, a definition of FBSS was delineated with specification of criteria for patient assessment and identification of appropriate evaluation tools in order to choose the right treatment options. In this second paper, we present a proposal of a standardized care pathway aiming to guide clinicians in their decision-making on how to optimize their management of FBSS patients. The utilization of a multidisciplinary approach is emphasized to ensure that care is provided in a uniform manner to reduce variation in practice and improve patient outcomes.

Figure 1

Diagram summarizing literature searches: FBSS management. The electronic and hand literature searches yielded 424 titles. Following a review of full-text versions of the 177 (NN) + 16 (GB) residual publications, after discarding duplicates and initial exclusion of 231 titles/abstracts, 95 (NN) + 16 (GB) papers were finally selected and 6 were retained. These are presented in Table 1.

Figure 2

The proposed standardized multidisciplinary team's failed back surgery syndrome care pathway, as recommended by the Chronic Back and Leg Pain Network. FBSS, failed back surgery syndrome; IDD, intrathecal drug delivery; MDT, multidisciplinary team; SCS, spinal cord stimulation; SIJ, sacroiliac joint; TENS, transcutaneous electrical nerve stimulation; WHO, World Health Organization. Note. In cases of new pain and/or exacerbation of original pain at any stage of this flow, reimaging and spine expertise is required. ¹Best practice is for the psychosocial evaluation to be performed by a psychologist or psychiatrist with specific experience in the field of pain. Assessments may include the relevant tests and questionnaires aiming to identify patients with major psychological or psychiatric contraindications [23]. ²Best practice is to avoid long-term use of WHO Step III analgesics and review ineffective long-term use of antineuropathic pain medication [–30]. ³There is limited evidence supporting a prolonged effect of epidural injections, selective nerve root blocks, and radiofrequency denervation in an FBSS population [20, 25, 31, 32]. Despite this lack of clinical evidence, these therapies may be tried/reserved for the management of acute exacerbation in pain.