Failed back surgery syndrome (FBSS) is persistent or recurring low back pain following spine surgery. It can be caused by non-surgical factors like facet arthrosis or surgical complications like infection. Diagnosis involves assessing the history of present and past symptoms, examining for neurological problems, and obtaining imaging. Management is multimodal, including medications, physiotherapy, psychological therapy, and interventional procedures like spinal cord stimulation or revision surgery. The goals are improving function, quality of life, and pain self-management through a combination of conservative and non-conservative approaches.

2. Failed Back
SurgerySyndrome
Presented By,
Dr.Sajid Hasan
MBBS
Army Medical College Chattogram

3. What is Failed Back Surgery
Syndrome (FBSS) ?
Definition: Failed back surgery syndrome (FBSS) is a term embracing a
constellation of conditions that describes persistent or recurring low back
pain, with or without sciatica following one or more spine surgeries.

4. Etiology
The most non-surgical causes includes:
 Herniated nucleus propulsus (HNP) at a non-surgical site
 Facet arthrosis
 Spinal Stenosis
 Spondylolysis with or without Spondylolisthesis
 Referred pain
 Myofascial pain
 Segment instability

5. Cont.
Surgically related causes includes:
 Epidural haematoma
 Recurrent HNP at the operative site
 Infection such as diskitis
 Osteomyelitis or Arachnoiditis
 Epidural scar
 Meningocele or Cerebrospinal fluid (CSF) fistula

6. Cont.
Etiology of FBSS (surgically related causes) can be done, based on
preoperative, intraoperative, and postoperative factors:
Preoperative factors:
 Patient
 Psychological (which are very powerful): anxiety, depression, poor coping
strategies, hypochondriasis
 Social: litigation, worker compensation
 Surgical
 Repeated surgery (50% increase in risk in spinal instability ≥ 4 revision)
 Inappropriate candidate selection
 Inappropriate surgery selection

7. Cont.
Intraoperative factors:
 Poor technique (e.g., misplaced screw, inadequate decompression)
 Incorrect level of surgery
 Inability to achieve the aim of surgery (e.g., foraminal stenosis)

8. Cont.
Postoperative factors:
 Progressive disease (e.g., recent disc herniation )
 Epidural fibrosis (this is the cause of 20-36% of the FBSS-patients)
 New spinal instability secondary to altered biomechanics (e.g.,
discectomy)
 Surgical complications (e.g., nerve injury, infection, and hematoma)
 Myofascial pain development (During surgery, dissection and
prolonged retraction of the paraspinal musculature result in
denervation and atrophy, this leads to postural changes)

9. Initial Approach to Failed Surgery
Patient
History:
 Allow extra time to evaluate initially.
 Essential to have prior records.
 Preoperative vs. Postoperative complaints.
 Did surgery help initially? A period of relief followed by recurrence may
indicate: a) recurrence of herniated nucleus pulpous, b) development of
lateral stenosis.
 Was there a new problem immediately after surgery?
 Current medication usage and issues of dependency.

10. Cont.
History:
 Careful assessment of the psychological status
 Vocational status and workers' compensation
 Post-operative systemic complaints (often subtle)
 Back vs Leg pain.
 Unusual pain pattern (reflex sympathetic dystrophy, complex
regional pain)
 Postoperative rehabilitation (aerobic, flexibility, strengthening, body
mechanics, physical therapy).
 Relieving and exacerbating positions and activities.

11. Cont.
Physical Examination:
 Observe closely for pain behaviour as a warning of associated problems.
 Careful neurologic exam for focal localizing findings.
 Evaluate for potential major joint problems as a referral source (hip, knee)
 Palpation at surgery site for hematoma, local fluid, abscess and pseudo
meningocele.

12. Cont.
Physical Examination:
 Examination of extremity for sympathetic or Reflex sympathetic dystrophy
(RSD) -type changes.
 Screening for neural tension signs (SLR, Adson's test)
 Long tract signs (Babinski's sign, Clonus, Hoffman's sign)
 Vascular assessment (diabetics, elderly patients)
 Local soft tissues (psoas muscle, iliotibial band, gluteal muscles)

13. Prevention
 This condition has a high impact on the patient and the healthcare
system. It is good to know that this condition has a higher prevalence
with increasing rates of spine surgery.
 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.

14. Cont.
 Sometimes surgery doesn’t meet the pre-operative expectations of
the patient and surgeon, good communication and education on
probable success are 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.

15. Diagnosis
History: The most important part of the diagnosis of FBSS is the history
especially:
 The status before the operation
 The type of surgery that was performed
 The pain characteristics: location, time course
 Assessment of red and yellow flags
 Comorbid treatments and history
Further the examination has 2 purposes:
1. Ruling out serious pathology
2. Identify the source of pain

16. Inspection & Examination
 Inspection includes an assessment of the posture and functions.
 The lumbar spine has to be well inspected and there have to be
taken note of surgical scars and alignment of the vertebrae.
 Palpation can identify points that elicit pain.
 The range of motion should be assessed.
 Muscle power should be assessed by resistance testing of each
muscle group with a comparison with the corresponding group on
the contralateral side.
 When there is evidence of nerve tension, special tests can be done.

17. Radiological Evaluation of Failed
Back Surgery
 Radiological examination usually includes X-rays and either MRI or CT
scans.
 Standard radiographs with standing flexion and extension lateral views
are used to assess alignment, the extent of degeneration and instability.
Plain radiographs can detect spondylolisthesis, but are unable to show
spinal stenosis and give information on soft tissues.
Unless the issue is pseudarthrosis, MRI is the optimal exam for most
patients with FBSS, in which case CT with multiplanar reformations
(CT/multi-planar reconstructions [MPR]) is preferred.

18. Role of Diagnostic Injections
 The definitive role in the diagnosis of facet (zygapophysial or z-joint)
and SIJ pain is played by the anesthetic diagnostic injections. It may be
valuable to establish if nerve root compression or inflammation is
causing pain.

19. Discography
 Because some discs that look abnormal on MRI are pain generators, but
others are not, we can use discography to help determine if a particular
disc is the pain generator. One cannot rely on the discography on its own,
it must be interpreted in light of the history, examination, radiological
testing and other diagnostic injections.

20. Management
 The management of patients with FBSS can be challenging for a number
of reasons. First, the patient is usually aggrieved about having undergone
significant invasive surgery without achieving any symptom reduction or
resolution. Not only are they left with the persistent pain for which the
surgery was initially offered, but it may seem that there are no other
options left. Second, the diagnosis (either initial or subsequent) may not
be clear and whereby further treatment may be difficult to plan.

21. Cont.
 The general management plan for this group of patients should not focus solely on
medical therapy. The objectives of management should be directed to the
restoration of functional ability, improvement of quality of life, coping strategies,
and pain self-management. Optimal care is often difficult because the evaluation of
FBSS depends on the subjective symptoms of the patient.
 There was strong evidence that function improved with intensive interdisciplinary
rehabilitation with functional restoration.

22. Conservative Treatments
Pharmacological: Medication should not only be prescribed to reduce pain, it
should also facilitate exercises, therapy and enable improvements. Used
pharmacological are :
• Acetaminophen
• Nonsteroidal anti-inflammatory drugs (NSAID’s)
• Cyclooxygenase-2 (COX-2) inhibitors
• Tramadol
• Muscle relaxants
• Antidepressants
• Gabapentinoids
• Opioids

23. Physiotherapy
It is common that patients with FBSS will become deconditioned. This leads
to weakness of the musculature (e.g., transverses abdominis, paraspinal
muscles) responsible for maintaining spinal stability. Though different
approaches exist, the general aim of exercise therapy is:
• Decrease pain
• Improve posture
• Stabilize the hypermobile segments
• Improve fitness
• Reduce mechanical stress on spinal structures.

24. Psychological Therapy: Cognitive
Behavioral Therapy (CBT)
 Considering the influence of psychological factors on chronic low
back pain (CLBP), it is not surprising that psychological therapy is an
accepted component of therapy.
 The common components of CBT include the followings:
• Teaching and maintenance of relaxation skills
• Behavioural activation such as goal setting and pacing strategies
• Interventions to change perception such as visual imagery,
ddesensitization, or hypnosis
• Promotion of self-management perspective

25. Interventional
 Facet medial branch blocks and rhizotomy
 Sacroiliac joint blockade
 Epidural Steroids
 Percutaneous epidural adhesiolysis

26. Non-Conservative Treatment
The non-conservative treatment options are:
 Medial Branch Blocks and Radiofrequency Neurolysis
 Epidural injections
 Percutaneous epidural adhesiolysis

27. Cont.
Surgical options:
 Spinal cord stimulation (SCS)
Benefits:
- It improves functions
- It improves quality of life
- Allows to return faster at work
- It reduces analgesic consumption
- Minimally invasive
- Fewer permanent complications
- Completely reversible
- Can be screened for responsiveness before placing the electrodes
- Parameters adjustable after implantation
- Improvement in gait and muscle strength after 7 days

28. Cont.
 Intrathecal analgesic delivery implant systems: This form of therapy is
efficacy, but there is a lack of long-term evidence and some side effects
can appear.
 Revision surgery: The success-rate (22-40%) after reoperation is low and
declines after each additional procedure. Probably the most important
aspect of the decision for reoperation is for consultation with an expert
spine surgeon with experience with FBSS.

29. Take Home Messages
 LBP is very common is Failed back surgery syndrome (FBSS)
 Frequent surgery – High rate FBSS
 Multimodal treatment is necessary
 Revision surgery may needed in few cases.

31. References:
 https://www.physio-pedia.com/Failed_Back_Surgery_Syndrome
 https://www.spine-health.com/treatment/back-surgery/failed-back-surgery-
syndrome-fbss-what-it-and-how-avoid-pain-after-surgery
 https://academic.oup.com/painmedicine/article/12/4/577/1868602
 https://www.researchgate.net/publication/222345188_The_failed_back_surge
ry_syndrome_Definition_and_therapeutic_algorithms_-_An_update