Failed back surgery syndrome is the diagnosis given to people who continue to have pain after back or neck surgery.
It is not really a syndrome, but a tentative acknowledgement that surgery failed to relieve the person’s symptoms. It is notorious for being difficult to treat—largely because it’s treated as a syndrome rather than its individual symptoms or underlying cause. The causes of FBS are numerous, and successful treatment requires more than a broad label and a rush to judgment.
Over 25 years of practicing spinal neurosurgery, I have seen scores of patients seeking treatment for it. In most instances, patients relay the diagnosis given from someone else; specifically told their FBSS is caused by scar tissue. Sure enough, when looking through the notes, I see “epidural fibrosis.” Not only is epidural fibrosis not one of the main causes, but this diagnosis keeps people from seeking and receiving life-changing treatment because they are told "nothing can be done."
When I dig deeper, I often discover that either the surgery was not what was needed, or other causes for pain were not treated. I want to share my approach to FBS developed over nearly the past three decades in hopes that my colleagues will look at FBS (and patients) a little differently.
An evaluation of failed back surgery takes time
When I see someone for FBS for the first time, I usually spend about an hour with them. I am not in the business of treating films, but patients. The MRI is only one piece of information I need to do that. I don’t just look at the potential cause of the failed surgery and the post-operative studies. I conduct the FBS visit as I would a pre-surgical visit. I ask the patient about their original symptoms, how they have changed, and how they’ve stayed the same. I look at the original films and studies, along with the post-op radiology. Most of all, I talk to the patient.
Learning about your patient with failed back surgery syndrome
Not only do I try to get the clearest conception of their symptoms, but I also try to determine how these problems affect their lives. What is the precise back problem they are experiencing? What is important to them? What do they want to do with their life? Are they active? Do they want to be? What surgery (if any) can help them reach their goals?
Rethinking the initial surgery
I usually start by determining if the patient was appropriately assessed before the initial surgery. Many types of spine surgeries can be performed: decompression, microdiscectomy, spinal fusion, artificial disc replacement, or some combination of these. Sadly, I often find that patients with FBS were poorly selected for the type of surgery they had. As part of my evaluation, I determine if the surgeon dismissed the possibility of motion preservation technology and jumped straight to fusion.
I try to determine the type of surgery that would have been best. Was it ultimately done properly? Was it evaluated properly afterwards? Did the surgeon appropriately plan and correct for angulations in the spine, curves, stresses afforded to the spine related to the angles or each spinal segment and discs or other parts of their anatomy? Have the areas of nerve compression been correctly identified? I often find these details overlooked or incorrectly addressed.
The postoperative evaluation may be the problem
Not every patient with FBSS had the wrong surgery. Some may get the correct one for their symptoms and goals, but were not properly or completely evaluated. I commonly see surgeons order a simple x-ray for final surgical evaluation. It is my opinion that x-rays are not enough to evaluate the proper healing of the bone. While MRI is very good at showing soft tissues, discs, and nerves, it does not provide good detail of bone, bone healing and bone spurs, and these findings could be missed. It also does not show detailed views of metal and mixed material implants. And it is performed with the patient lying down, with no load on the spine and usually in a state that does not evoke symptoms.
I usually order a CT scan at three-month postoperative intervals. CT is the best study to identify non-healing bone, small cracks or breakages in the hardware, or bone fragments that might still be impinging on a nerve. I also order standing x-rays with bending forwards, backwards, side-to-side that reveal the load on the neck or low back. Scoliosis or long view x-rays reveal curvatures and alignments.
Scar tissue is (almost) never the cause of failed back surgery
I have perhaps seen one or two patients with true granulation scar tissue as the primary cause of their symptoms. I have come to realize that scar tissue is a sort of “wastebasket” diagnosis. Through careful postop evaluation, I more often find residual fragments of disc material, extant osteophytes and occasionally new onset disc herniation. I also find that the disc surgery has changed bone angulations such that stresses on adjacent discs and joints are the source of new pain. There are several reasons patients have pain after the original surgery—and those potential causes should be evaluated—but scar tissue is almost never the primary cause of FBSS.
Spinal fusion failure is a common cause of failed back surgery syndrome
One of the primary causes of FBSS in patients with spinal fusion is that the bone has not properly healed. Nonunion or poor bone healing with or without subsidence (i.e., sinking in on the fusion graft material) are common reasons for pain after spinal fusion surgery. I routinely order a thin-slice CT scan through the treated area along with standing x-rays in flexion, extension, and lateral bending positions to evaluate this possibility. This and X-ray imaging also help me to assess the curvature, considering that just 10° of change in angulation can make an enormous difference in the patient's postoperative neck pain.
Standard spinal decompression surgery may have been inadequate
Patients who have undergone spinal decompression surgery and laminectomy for spinal stenosis and degenerative spine generally have two possible reasons for FBSS. On the one hand, spine surgeons may have failed to properly account for curvature, disk space heights and angles, and angulations. On the other hand, severe degenerative disc disease may have caused a collapse of the neural foramen, which is not a target of standard decompressive surgery. FBSS in this patient population may be successfully treated with a more macro level surgery targeting small nerve impingements.
Failed back surgery syndrome may occur in artificial disc surgeries
It is no secret, I am a strong proponent of artificial disc replacement surgery. I have four discs in my own body, three in my back and one in my neck. I have also had fusion and laminectomy, so I know firsthand that ADR surgery is superior at relieving pain while allowing maximum spinal mobility and range of motion. That said, people do fail to achieve pain relief from ADR. In virtually all of these cases, I find that the device has not failed, but rather was not properly placed or the patient was a poor candidate.
For FBSS secondary to ADR surgery, I find SPECT CT scanning may be appropriate to identify “hot spots” in facet joints or other areas. In my experience, these areas of increased metabolic activity indicate inflammation and are the main pain generators after artificial disc replacement.
Summary
FBSS does not have to be a clinical quandary that many believe it to be. Through proper evaluation—listening and understanding the patient—surgeons can minimize the risk of patients developing FBSS and can properly identify the cause, should it occur. Scar tissue formation or epidural fibrosis is hardly ever the actual cause. Moreover, the value of standing and bending plain film x-rays and CT scan in postop evaluation cannot be overstated. While patients may be understandably hesitant to undergo a second surgery to correct failure of an initial surgery, proper patient evaluation and treatment selection can provide relief in many instances.
About Dr. Todd H. Lanman
One of the world’s foremost spine surgeons and artificial disc replacement innovators, Dr. Lanman has been a specialist in the advancement of spinal health and surgery for more than 25 years. He is a regular media contributor and has published more than a dozen peer-reviewed clinical articles. His clients include many high profile celebrities from the worlds of music, film, theater and television, as well as business leaders from around the world. Lanman Spinal Neurosurgery is affiliated with Cedars-Sinai Medical Center’s Institute for Spinal Disorders, UCLA Medical Center and Saint John’s Medical Center. For more information, visit http://www.spine.md.
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