Failed back surgery syndrome – Diagnosis, Treatment and Prevention

Definition

Failed back surgery syndrome (FBSS) refers to chronic back or neck pain, with or without extremity pain, that can occur if a spine surgery does not achieve the desired result. Contributing factors to pain that returns following spine surgery include but are not limited to recurrent disc herniation, further degeneration causing pressure on a spinal nerve, altered joint mobility, scar tissue around or within the nerves, muscle de-conditioning, facet joint degeneration or sacroiliac joint degeneration. Common symptoms associated with Failed Back Syndrome include diffuse, dull and aching pain involving the back and/or legs. Patients may also complain of sharp, pricking, burning or stabbing pain in the extremities.

Causes of failed back surgery syndrome

Failed back surgery syndrome is a complex condition, so there are many forms and variations it can assume. Additionally, there may be a wide variety of causes, and some of the most common may include:

  • Scar tissue formation
  • Recurrent disc herniation
  • Structural changes below spinal fusion
  • Spinal disc fragments still remaining
  • Inadequate recovery from surgery
  • Post-operative damage to area surrounding the surgical site

Failed back surgery syndrome risk factors

Risk Factors of FBSS includes:

  • Smoking
  • Formation of scar tissue
  • Recurring or persistent disc disease at adjacent levels
  • Continued pressure from spinal stenosis
  • Instability or abnormal movement
  • Pseudoarthrosis or failure of the fusion
  • Nerve damage within the nerve, arachnoiditis

Symptoms of failed back surgery syndrome

The most obvious sign of failed back surgery syndrome is persistent, dull, and aching pain involving the back or legs not associated with the healing process. Other symptoms include:

  • New pain at a level different from the location treated
  • Inability to recuperate
  • Restricted mobility
  • Sharp, stabbing back pain
  • Numbness or pain radiating through the lower back into the legs
  • Back spasms
  • Anxiety, depression, and sleeplessness
  • Potential dependence on pain medication

Complications

In addition to intractable low back pain, patients with failed back surgery syndrome often suffer from associated disorders. Psychiatric comorbidities are common in FBSS patients and correlate with worse pain outcomes. A survey of failed back surgery syndrome patients by Long and colleagues found that 67 of 78 patients with FBSS suffered from depression, with the vast majority experiencing an onset of depressive symptoms following the initial onset of pain.

Patients with failed back surgery syndrome may also experience complications from attempted treatment of their pain. Prolonged NSAID use has significant adverse effects on gastrointestinal and renal health. Opioids also have significant addictive potential; one study found that opioid overdose was the most common cause of death following lumbar fusion surgery. Back surgery itself also has several significant complications, including anesthesia-related complications and infection.

Diagnosis and test

In order to find the best option for back pain relief, our doctors will need to take you through a comprehensive workup. This could include any or all of the following:

Taking your medical history: This includes assessing your current symptoms, previous back pain treatments, and what kind of care you’ve received for your back pain in the past.

A physical examination: Your spine specialist will do a careful exam that looks for limits to your range of motion, issues with your balance, and identifying pain points. They will also examine your reflexes, identify muscle weakness, or any other signs that could indicate spinal cord damage.

Testing: Your spine specialist might wish to have x-rays done on your back to look for signs of infection or other issues. They may also wish to have a CT scan or MRI done in order to give them a 3D view of the spine. This can help them identify problem areas such as herniated discs.

Treatment and medications

In many cases, a second surgery is not recommended. In fact, statistics show that the rate of success decreases with each additional surgery performed. FBSS is more commonly managed with conservative treatment measures. Treatments can include:

Medications

Over-the-counter anti-inflammatories can provide relief for pain, swelling and inflammation. If you’re experiencing significant pain, your doctor may prescribe stronger medications or muscle relaxants.

  • Anti-inflammatory drugs: Ibuprofen, aspirin, acetaminophen, naproxen
  • Narcotics: Morphine, codeine, hydrocodone, oxycodone, fentanyl patches
  • Neuromodulatory drugs: Gabapentin, amitriptyline, pregabalin, duloxetine

Physical therapy

Physical therapy and rehabilitation is a common treatment course for FBSS. During physical therapy, you’ll work on strengthening your back and core muscles, increasing flexibility and range of motion in the spine, and improving balance and endurance.

Injections

A corticosteroid injection directly into the spine can reduce pain and inflammation around irritated nerve roots. While the effects of an injection are temporary, the period of pain relief will give you time to become stronger and more mobile in physical therapy.

Nerve ablation

If a corticosteroid injection is effective, you may be a candidate for a longer-lasting nerve ablation procedure, which destroys nerves and prevents the transmission of pain signals.

There will be some cases where a second surgery is required.

Surgical options

A surgical revision is not usually recommended. Statistics show that the chances of a successful procedure drop with each subsequent surgery performed. However, if you develop incontinence, progressive weakness, worsening pain or hardware malfunction, a second surgery may be a treatment option.

Nerve blocks: Injections of anesthetic or steroids into the spine can provide significant relief. Injections of steroids will reduce inflammation and thereby decrease pain.

Spinal cord stimulation: This minimally invasive technique, in which electrodes are placed in the spinal canal but not on the spinal cord, offers relief for many people without medication-related side effects. It also allows patients significant control over the device.

Spinal cord stimulation

Intrathecal drug infusion: This therapy uses pumps and implanted catheters to continuously send pain-relieving medication into the spinal fluid, which enables the patient to receive a significantly enhanced effect from the medication at a much lower dose and without the usual side effects like drowsiness.

Prevention of failed back surgery syndrome

This condition has a high impact on the patient and the healthcare system. It’s good to know that this condition knows a higher prevalence with increasing rates of spine surgery. Like this good selection criteria’s are necessary (grade of recommendation A), for this there is a good guideline. The impact of FBSS on an individual’s quality of life and individual’s functions are considerable and more disabling when compared with other chronic pain conditions. These findings emphasize the importance of identifying strategies to prevent the development of FBSS and effective management guidelines for the management of established FBSS.

Sometimes surgery doesn’t meet the pre-operative expectations of the patient and surgeon, a good communication and education on probable success is necessary to lower the unrealistic expectations.

Other prevention strategies are:

  • Give psychological aid to patients with social and psychological stressors.
  • Use a meticulous technique during intervention

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