Failed Back Surgery Syndrome

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The IASP term for failed back surgery syndrome (FBSS) is "Lumbar Spinal or Radicular Pain after Failed Spinal Surgery" (XXVI-10). The corresponding definition is "Lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location."

Diagnosis

The diagnostic criteria are lumbar spinal pain of unknown origin plus an unsuccessful attempt at treating the pain through surgery. The diagnosis doesn't apply if the spinal pain isn't associated both topographically and temporally with the spinal surgery, for example in those with a distant history of successful spinal surgery.

The IASP state that the term is used to encompass the belief that the failed surgical attempt makes the pain more complicated from a biomedical and/or psychosocial view.

Aetiology

The pathology of the condition is unknown. Some hypotheses include neuroma formation (e.g. from cut dorsal rami and nerves to the intervertebral discs), deafferentation, epidural scarring, etc. There are no reliable diagnostic techniques where these conjectures can be confirmed. This fact leads to the reason why the term "syndrome" is used, because patho-anatomical diagnosis is usually impossible.

The group of patients with FBSS can be divided into two main groups. The first group is where the incorrect diagnosis has been made prior to treatment. The second group comprises of those patients where the procedure was incorrectly selected or incorrectly performed.

This has been expanded upon as below[1]:

  • Correct operation, wrong diagnosis e.g Solid L4-L5 discectomy and fusion but pain arising from L3-4 disc
  • Correct diagnosis, wrong operation e.g L3-4 discogenic pain treated with a posterolateral fusion but no discectomy
  • Wrong diagnosis, wrong operation e.g Laminectomy and discectomy for asymptomatic disc bulge but the source of pain was actually the zygoapophyseal joint
  • A further subset of patients will have a new cause of pain following their procedure e.g Post-operative neuroma, arachnoiditis, nerve injury, epidural scarring, local irritation by a fusion mass/instrumentation

Wrong Diagnosis, Wrong Operation

Poor candidate selection (wrong diagnosis) in particular may be a common subcategory. In patients attending a spine clinic with at least 2 previous spinal operations, 68% did not meet the AAOS or the North American Society of Neurological Surgeons criteria for their first operation[2]

Zygoapophyseal joint

The prevalence of facet joint pain in postsurgical patients with chronic low back pain has been shown to be 16%.[3] This was based on 2 comparative local anaesthetic blocks with a positive result having at least 80% pain reduction and ability to perform previously painful movements.

Sacroiliac joint

A prospective cohort study on the prevalence of sacroiliac joint pain after lumbar and lumbosacral fusion was done.[4] 52/130 patients (40%) post lumbar/lumbosacral fusion had positive SIJ provocation testing (at least 3 of pain upon application of pressure to the sacroiliac ligaments, Patrick’s test, Gaenslen’s test, Shear test, Yeoman maneuver, or standing extension test). Among those 52 patients, 21 were considered to have SIJ pain on the basis of two positive responses to diagnostic blocks, i.e. 16% of the total cohort, or 40% of the cohort with positive SIJ provocation tests.

Correct Diagnosis, Wrong Operation

Sebaaly et al.[5] performed a review of the literature which suggested inadequate decompression in the lateral recess and particularly in the neural foramens is the most common cause of poor surgical technique leading to FBSS, representing 25%–29% of the cases. However, judicious decompression may also lead to instability if >33% of the articular surface is bilaterally removed or if 100% is unilaterally removed

Epidemiology

FBSS occurs in 10-40% of cases after lumbar laminectomy +/- fusion and 8.4-19% following microdiscectomy for sciatica[5]

Further Reading

  • Open source review of the taxonomy by Christelis et al.[6]
  • Open source review on definition, epidemiology, and demographics by Thomson.[7]

References

  1. Bogduk and McGuirk. Causes and Sources of Chronic Low Back Pain In: Medical Management of Acute and Chronic Low Back Pain. Elsevier 2002
  2. Long DM, Filtzer DL, BenDebba M, Hendler NH. Clinical features of the failed-back syndrome.J Neurosurg. 1988;69(1):61-71. doi:10.3171/jns.1988.69.1.0061
  3. Manchikanti L, Manchukonda R, Pampati V, Damron KS, McManus CD. Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks. Arch Phys Med Rehabil. 2007;88(4):449-455. doi:10.1016/j.apmr.2007.01.015
  4. Liliang PC, Lu K, Liang CL, Tsai YD, Wang KW, Chen HJ. Sacroiliac joint pain after lumbar and lumbosacral fusion: findings using dual sacroiliac joint blocks.Pain Med. 2011;12(4):565-570. doi:10.1111/j.1526-4637.2011.01087.
  5. 5.0 5.1 Sebaaly A, Lahoud MJ, Rizkallah M, Kreichati G, Kharrat K. Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome.Asian Spine J. 2018;12(3):574-585. doi:10.4184/asj.2018.12.3.574
  6. Christelis N, et al. Persistent Spinal Pain Syndrome: A Proposal for Failed Back Surgery Syndrome and ICD-11. Pain Med. 2021 Apr 20;22(4):807-818. doi: 10.1093/pm/pnab015. PMID: 33779730; PMCID: PMC8058770.
  7. Thomson S. Failed back surgery syndrome - definition, epidemiology and demographics. Br J Pain. 2013 Feb;7(1):56-9. doi: 10.1177/2049463713479096. PMID: 26516498; PMCID: PMC4590156.