What is Failed Back Surgery Syndrome?
Written by Neil Badlani, M.D., Chief Medical Officer, North American Spine

Failed Back Surgery Syndrome, abbreviated FBSS, is a recognized medical diagnosis for chronic pain and symptoms that persist after a spinal surgery, whether to the neck or back.

Spinal surgery is typically performed to accomplish two main goals: Decompress a nerve or nerve root that is pinched or stabilize a painful or hyper-mobile joint segment. FBSS can occur when these goals are not accomplished, or when spinal surgery adversely affects a nerve root or other structure near the problem area.

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More About Failed Back Surgery Syndrome

lumbar foraminotomy

The number one reason spine surgery fails to relieve symptoms, and possibly create more symptoms, is because the surgeon missed the exact problem area. The reason for this is complicated, because the spine is a complex entity of numerous structures and mobile joints that all must work in harmony. Back pain affects up to 80% of Americans. It creates the number one disability in the world, surpassing any other condition. The possible etiology, or reason, behind the pain is difficult to diagnose, many times because pain is generated by more than one structure. A huge limitation in spine care is the lack of imaging able to be performed while the spine is in motion. Static images, such as MRI, x-rays or CT scans, are all limited by an inability to perform the study while the person is recreating a motion that triggers their symptoms. Ironically, progress intraoperatively is allowing better visualization via intraoperative imaging systems such as CT computer assisted navigation or continuous x-ray called fluoroscope. These techniques are helping to prevent Failed Back Surgery Syndrome.

In some cases, Failed Back Surgery Syndrome may be due to the formation of scar tissue–often epidural fibrosis–that can form near the nerve root and cause pain.

 

What are the symptoms?

Failed Back Surgery Syndrome refers to chronic back or neck pain, with possible arm or leg symptoms, that did not resolve with surgery. This can occur with one or more surgical interventions. Common symptoms of FBSS include: 

  • Diffuse, dull achy back pain.
  • Leg or arm pain.
  • Sharp, burning or stabbing pain to back, legs or arms.
  • Numbness and tingling in extremities.

The symptoms of Failed Back Surgery Syndrome can be very non-specific and may not seem at all similar to the symptoms that generated the surgical intervention. FBSS should always be diagnosed by a spinal care specialist.

How is Failed Back Surgery Syndrome Diagnosed? 


Pain is the first indicator of a bulging disc that needs attention. Once identified, there are typically four steps to the process

Physical, Orthopedic, and Neurologic Examination:

Evaluating mobility and tactile findings coupled with extensive physical testing to determine structures impacted comprise the physical examination. Assessment of strength, sensation and neurological signs help to guide other components of the evaluation, such as imaging required to fully diagnose FBSS. 

Medical History:

The physician will consult with the patient, exploring a detailed recount of the symptoms both pre- and post-surgery. It will review the type of surgery performed, immediate and long-term results. Be prepared to review the types of interventions explored before and after surgery and how symptoms changed with various treatments. A detailed past medical history and family history will also be discussed. 

Diagnostic Imaging:

Diagnostic testing is individualized for specific patient needs. Not all FBSS patients have the same studies. Imaging may include: 

  • X-rays, which may include bending views to assess spinal stability.
  • MRI: After surgery, many patients require 2 MRI studies of the same region to perform a complete assessment. CT imaging may be considered when MRI is unable to be utilized.

In addition to imaging, symptoms that implicate nerve involvement may require specialized diagnostic testing such as EMG (electromyography) or NCS (Nerve Conduction Studies). Diagnostic injections may be utilized to clarify the source of pain in the spine or extremities. A thorough evaluation of all components of this complicated diagnosis are essential in determining not only the etiology, but in developing the best possible plan of care. 

What Causes Failed Back Surgery Syndrome?

low back pain

Failed Back Surgery Syndrome questions the diagnosis that led to the initial surgery with as many as 58% of FBSS cases resulting from undiagnosed conditions of the spine. Contributing factors may include:

  • Recurrent Disc Herniation
  • Altered Joint Mobility
  • Scar Tissue
  • Muscular Deconditioning
  • Facet Joint Degeneration
  • Sacroiliac Osteoarthritis
  • Nerve Damage From Surgery

Individual spine surgeries have more specific risks associated with them in triggering FBSS. Spinal fusion surgery, for example, permanently fuses one vertebral level with another, with the specific intent of stopping movement between the two. This places additional stress on levels above and below the fusion, potentially increasing arthritic changes and pain to these new areas. Fusion surgery also has the inherent risk of failure to fuse properly. In the case of decompression surgery, inadequate decompression of the nerve root or recurrent stenosis are possibilities, as is the build-up of too much scar tissue.

How is Failed Back Surgery Syndrome Treated?

Conservative Options

Conservative treatment options include nerve root blocks and steroid injections. These are designed to provide temporary relief (up to one year), and you may elect to have the procedure done multiple times. Other conservative strategies may include the placement of a spinal cord stimulator–or STIM–which is designed not to correct the underlying degeneration, but to lessen the pain the condition causes.

Decompression

Minimally invasive decompression surgery aims to relieve pressure on the nerves of the spine. This pressure is often caused by stenosis, bulging or herniated discs, and more. Relieving this pressure can be achieved by reducing or removing soft tissue (disc material or scar tissue) or bone (bone spurs, a section of the lamina or foramina) to decompress the affected nerve. When the compression is caused by soft tissue material, a surgical laser may be used to shrink the impinging material.

Fusion/Stabilization

Fusion surgeries are similar in goal–to remove damaged disc tissue and fuse the bones together–but differ in approach, including the use of specialized hardware to reinforce stability, and the location used to gain access to the spine. A related procedure is an artificial disc replacement, in which a damaged cervical disc is replaced with a synthetic disc, and the vertebrae are not fused.

How Much Does Treatment Cost?

Treatment cost depends on several factors, especially what insurance you have and how much of your deductible has been met. IN the last two years, 90% of our patients have paid less than $2000 out-of-pocket. Some have paid literally nothing, and other have paid much more than that. It depends. The good news is: our Patient Care Managers will handle as much as they can directly with your insurance company, and all your costs will be known up-front.

Important note: spine surgery often pays for itself within a year or two. Many people actually spend more money trying to live with the pain than they do getting the pain fixed. The following calculator is intended to give you a sense of what you spend on managing—rather than eradicating—your pain.

 

Calculate how much you've spent on back pain this year.
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This past year you have spent on your pain treatment:

Get surgery now. Getting surgery now is the smartest financial move. Over the last two years, the average North American Spine patient spent around $2,000 out-of-pocket for treatment. You’ve spent that much or more this year to manage your back pain than you could to fix it.

Get surgery soon. Over the last two years, the average North American Spine patient spent around $2,000 out-of-pocket for treatment. At your current rate, you will spend that much or more within the next two years. The sooner you get treatment, the sooner it will pay for itself.

Keep an eye on your spending. Currently, you are managing your pain efficiently from a financial perspective but over time, your expenses could add up. Surgery should be strongly considered if you start missing more work or spending more on treatment medication.

Great job! You are spending very little on your back pain. Keep it up!

What Equipment is Utilized in the Diagnosis and Treatment of Failed Back Surgery Syndrome?

The equipment utilized for FBSS is not substantially different than the equipment utilized in the diagnosis and treatment of the original surgically altered spinal structure. Diagnostic equipment such as x-rays are easily accessible in many physician offices as well as hospital settings. MRI and CT scans are only found in more specialized centers, larger physician group offices or hospitals. Specialized diagnostic testing equipment such as EMG and NCS require specialized equipment as well as specialized providers to perform and interpret.

Treatment for FBSS also varies, with the more invasive procedures requiring more specialized equipment. Spinal injections, RFA, spinal cord stimulators and any surgical interventions require a hospital or surgical center. Less complicated procedures are able to be performed on an outpatient basis. Individual risk factors are assessed when determining the length of a hospital stay.

How Does Failed Back Surgery Syndrome Compare to Other Spinal Conditions? 

Failed Back Surgery Syndrome is a complicated process for a complicated region in the body. Countless surgeries can be performed on the human body, yet only back surgery has an official diagnosis for failure of the procedure. Many cases of FBSS are directly attributed to failure to perform surgery on the symptom generating structure. This means that the problem initiates with identifying the cause of the initial problem, not the surgery itself. Surgical complications are always a possibility, however, in this circumstance they contribute less to the failure of the treatment process. More than in any other situation, emphasis must be placed on diagnostic testing for FBSS.

When discussing any spine care, it is essential to choose only the very best specialists when considering treatment options. Multidisciplinary care that incorporates physical therapists, chiropractors, spine specialists and pain management physicians typically offers the best and most complete care as each branch of care assesses the problem from a different perspective. Keep in mind, great physicians are confident in their diagnosis and treatment recommendations.

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