Failed Back Surgery Syndrome

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Failed back surgery syndrome (FBSS) is a condition where pain begins to appear after back surgery or persists despite having undergone spinal surgery intended to alleviate it. This complex condition can arise due to various factors, including surgical complications, scar tissue formation, misdiagnosis, or even the progression of degenerative conditions. It is estimated that 10-40% of patients^[1] undergoing spine surgery may develop FBSS.

At Compass Pain and Wellness, we recognize that each patient’s experience with FBSS is unique. That is why we design personalized treatment plans tailored to your specific needs and wants. By utilizing evidence-based, comprehensive treatments, we aim to ease your symptoms, improve function, and empower you to pursue a higher quality of life. We are here to provide the support and care you need to navigate the complexities of FBSS and restore your well-being.

Understanding Failed Back Surgery Syndrome

Rather than a specific syndrome, FBSS is a general term used to describe the chronic pain that many patients experience after spinal surgery. The International Association for the Study of Pain defines FBSS^[2] as pain of unknown origin, which can:

Originate after a patient has undergone spinal surgery, or
Become persistent or worsen after a surgical intervention has been performed to alleviate it.

This can happen due to underlying spinal issues that are not effectively addressed by the surgery, complications like scar tissue formation and infection, or the presence of degenerative conditions. The risk of FBSS increases alongside the level of complexity of the surgery. For example, FBSS rates for microdiscectomy—a minimally invasive surgery to remove an intervertebral disc—range between 19% and 25%^[2]. More complex procedures like lumbar spinal fusion can have rates as high as 46%.

Research ^[3] also suggests that FBSS is more common in:

Inpatient procedures
Surgeries that affect multiple levels of the spine
Certain demographic groups, especially elderly patients aged 70-74.

It’s important to understand that FBSS doesn’t necessarily mean the surgery itself was unsuccessful. Even if successful, surgery can still lead to extensive rehabilitation periods, and, sometimes, chronic pain and dysfunction. Below, we’ll look at how surgery can affect the spine and where FBSS may stem from.

Exploring The Spinal Structure And Its Functions

The spine is a complex structure composed of 33 bones, called vertebrae, stacked vertically. These bones form a passageway that runs from the base of the skull to the lower back. This passageway, called the spinal canal, houses and protects the spinal cord, a bundle of nerves that connects the brain to the rest of the body.

The spine is subdivided into distinct sections:

Cervical: the neck area
Thoracic: the middle section
Lumbar: the low back
Sacral: the bottom of the spine

The spine’s complex anatomy also includes ligaments, facet joints, and an intricate network of nerves. Spinal surgery may be recommended for certain conditions or problems. For example, surgical intervention can help when degenerative conditions, like degenerative disc disease and arthritis, cause severe pain and disability. Surgery is also often part of a treatment plan for traumatic spinal injuries or spinal cord compression.

Spinal surgery may sometimes be necessary, but invasive interventions can sometimes lead to side effects and complications. These include failed back surgery syndrome, which can arise from issues like nerve damage, scarring, or spinal misalignments, causing ongoing discomfort and dysfunction.

Components of the spine that may be affected include:

Vertebrae And Discs

The vertebrae are the bones that make up the spinal column, providing structure and protection for the spinal cord. Between each pair of vertebrae lies an intervertebral disc, a disc of cartilage that acts as a cushion, absorbing shock, distributing loads, and protecting the spinal bones from friction damage.

Surgery might involve removing or replacing one or more of these discs or fusing vertebrae to stabilize the spine. Potential complications that may translate into FBSS include the following:

When a disc is removed, changes in the mechanical structure can cause adjacent discs to degenerate more rapidly, a condition known as adjacent segment disease (ASD). Rates of ASD after fusion surgery in the lower spine may range between 5% and 49%^[4], according to different studies.
Altered alignment during surgery can lead to imbalances, contributing to chronic pain and FBSS.

Nerves And Spinal Cord

The spinal cord is a vital structure composed of nerve fibers that transmit signals between the brain and the rest of the body. These nerves control movement and sensation in the extremities, including arms, legs, hands, and feet.

Surgery may be used when these nerves become compressed, which can happen due to a narrowing of the spinal canal (spinal stenosis), anomalies in the spine’s structure, and tumors or herniated discs that push against nerve roots.

However, surgical procedures to relieve nerve pressure can also pose risks, including:

Nerve damage
Nerve scarring and scar tissue formation
Failure to decompress nerves effectively

Recognizing The Signs And Symptoms

In the hours or days immediately after surgery, it is natural and expected to experience some degree of pain around the surgical site. The intensity and location of pain will depend on the complexity of your surgery. However, this type of pain should subside as the spine begins to heal. Your physician will be able to advise you regarding recovery expectations and timelines.

However, if the pain, discomfort, and mobility issues don’t ease down as you recover, you may be experiencing the signs of failed back surgery syndrome. Common symptoms include:

Chronic Back Pain

Chronic back pain may result from degeneration, nerve issues, or strain, impacting posture and mobility.

Chronic Leg Pain

Chronic leg pain may result from nerve, circulation, or joint issues, often affecting comfort and mobility.

Muscle Weakness

Muscle weakness may stem from nerve, muscle, or joint issues, making movement and activity more difficult.

Pain With Movement

Pain with movement may stem from joint, nerve, or muscle issues, making activity more difficult.

Lower Back Pain

Lower back pain may arise from strain, disc issues, or nerve compression, often limiting movement.

Tingling And Numbness

Restricted range of motion may result from stiffness, inflammation, or damage, making movement difficult.

Muscle Spasms

Muscle spasms are sudden contractions from nerve issues, dehydration, or fatigue, causing pain and stiffness.

Restricted Range Of Motion

Difficulty moving the neck, back, or affected limbs due to pain or stiffness.

Difficulty Standing Or Walking

Difficulty standing or walking may result from muscle, joint, or nerve issues, affecting daily mobility.

What Causes Failed Back Surgery Syndrome?

Anyone who undergoes spinal surgery can experience the symptoms of FBSS. However, some causes and risk factors make it more likely to suffer from persistent or chronic pain after surgery.

Incomplete Relief From The Original Condition

Surgery can be performed to address spinal issues like herniated discs or nerve compression. If these are not fully addressed during surgery, pain can persist after the operation. This may occur from misdiagnosis or inefficient surgery, resulting in ongoing pain and symptoms.

Nerve Damage During Or After Surgery

Nerve damage can occur if nerves are accidentally severed, stretched, or compressed during surgery. Post-operative inflammation or surgical errors might also lead to nerve damage.

This damage can interfere with the ability of the nerves to transmit sensation and motor signals to and from the brain. This can result in chronic pain, numbness, or loss of function, aggravating back conditions after surgery and prolonging recovery.

Scar Tissue Formation

Scar tissue, or epidural fibrosis, can develop after surgery as the body attempts to heal the damage from the surgical incisions. This scar tissue is tougher and less flexible than other soft tissue, and it adheres to nerves and surrounding structures.

The formation of scar tissue is a natural part of the healing process. However, it can constrict and press on nerves, causing chronic pain and restricted movement.

Recurrent Disc Herniation

The discs of cartilage between adjacent vertebrae play a key role in absorbing shock, protecting the bones from friction damage, and maintaining the spine’s flexibility. These discs have an outer ring-shaped exterior and a softer, gel-like core. Due to age-related wear and tear or sudden injury, the core can start to protrude into the spinal canal, compressing nerves.

Surgery may be recommended to decompress nerves and improve function. However, surgical intervention may not prevent herniation from happening again. This is especially true if a herniated disc occurs due to structural weakness or from a degenerative condition such degenerative disc disease.

Spinal Instability

Instability occurs when some of the spine’s structures are unable to maintain alignment and balance, leading to mechanical pain and potential nerve compression. This risk increases in open or very invasive surgery or when significant tissue is removed. It can also occur due to surgical errors or complications, such as a failed spinal fusion procedure.

Age-Related Degeneration

Due to aging and natural wear-and-tear, the intervertebral discs lose elasticity and height, exposing adjacent bones to friction and shock damage. Weaker discs are also more prone to damage, which can lead to disc herniation. These conditions can narrow the spinal canal, possibly compressing nerves and leading to ongoing pain.

Chronic Physical Strain

Ongoing physical strain can weaken spinal components, increasing wear and, in turn, the risk of injury. Occupations or lifestyles that involve heavy lifting and manual labor can speed up degeneration and worsen existing conditions. This strain can prolong recovery from surgery and increase the risk of re-injury.

Repetitive Movements

Repeated movements, like those involving bending or lifting, can exacerbate spinal conditions by causing wear on specific spinal areas. They may lead to progressive degeneration and increase the likelihood of surgical complications.

Previous Spine Injury

A history of spine injury can increase the risk of complications because past injuries can compromise the structural integrity of components of the spine, such as discs and bones.

Previous spinal injuries, especially if not properly treated, can increase the risk of complications after surgery, like adjacent segment disease and scar tissue formation. Having a clear idea of previous injuries is essential when planning a surgical approach and optimizing recovery.

How Is Failed Back Surgery Syndrome Diagnosed?

Diagnosing FBSS involves a comprehensive approach, which can help differentiate this condition from other potential causes of pain. Your physician may use different diagnostic tools to determine factors like anatomical changes, nerve involvement, and decreased functionality. These tools include:

Physical exam: A physical examination helps assess pain levels, spinal alignment, and muscle strength. It helps physicians pinpoint areas of pain or abnormal and restricted movement.
Review of medical history: A medical history review helps to take into consideration critical aspects such as previous surgeries and treatments. Understanding past interventions and their outcomes can also guide physicians in identifying potential causes of ongoing pain.
Imaging techniques (MRI, CT scan): MRI and CT scans provide detailed visuals of the inner aspect of the spinal structures. They help identify any anatomical changes such as disc herniations, scar tissue, or misalignments.
Neurological tests: Tests such as electromyography (EMG) or nerve conduction studies evaluate how well nerves work. They help in identifying nerve damage or dysfunction. In turn, this is important to set apart FBSS-related nerve issues from other neuropathic conditions that may contribute to chronic pain.
Range of motion tests: These tests measure spinal and joint flexibility, helping pinpoint any movement restrictions or mechanical issues. Assessing the range of motion helps identify areas of stiffness or instability that may be contributing to pain.

Complications If Left Untreated

If left untreated, FBSS can lead to a range of mental and physical health complications that can significantly affect your quality of life in the long term. These include:

Chronic pain: Untreated FBSS can lead to persistent or worsening pain due to unresolved issues or surgical complications. The pain makes daily activities more difficult, often adding stress and reducing overall well-being. Early intervention is key to managing pain effectively and improving quality of life.
Reduced mobility: Unaddressed spinal issues or surgical complications, such as scar tissue formation, can impair mobility. Additionally, ongoing pain and muscle weakness can limit mobility and make everyday movements more challenging. This restriction can lead to stiffness, loss of muscle tone, and increased dependency on others, affecting independence and daily routines.
Nerve damage: Ongoing nerve compression and irritation can lead to permanent nerve damage, which can result in irreversible numbness, tingling, or severe pain. As nerve function is affected over time, patients also risk losing sensation or motor control, complicating recovery and leading to disability.
Development of scar tissue: Persistent post-surgical irritation can cause excessive scar tissue formation, compressing nerves, and worsening pain. This can restrict movement and impact everyday activities.
Psychological effects (e.g., depression, anxiety): FBSS is often accompanied by psychological complications, which can worsen pain perception and even affect treatment outcomes. An assessment ^[5] using the Beck Depression Inventory (BDI) showed that patients with FBSS had higher depression and pain at rest and at night, compared to those with non-surgical chronic back pain. Both groups experienced increased rates of depressive symptoms compared to patients not suffering from chronic pain.
Increased reliance on medications: Medications play a role in the management of chronic pain. However, it is important that treatments involving medications precisely target the root cause of pain and are supervised by a physician to avoid side effects. Additionally, using medications without understanding the cause of FBSS may lead to overreliance on pain relief. This dependency can increase tolerance, side effects, and potential for medication misuse.
Potential for additional surgeries: Experiencing poor surgical outcomes or surgical complications may push patients to seek revision surgeries. However, repeat spinal surgeries tend to offer diminishing returns. Initial procedures achieve only about 50% success ^[6], and success rates drop to 30%, 15%, and 5% for second, third, and fourth surgeries, respectively. Additionally, each of these surgeries may come with risks and extended recovery times.
Impaired quality of life: The cumulative effects of untreated FBSS, from chronic pain to reduced mobility and psychological stress, can profoundly impact quality of life. Daily tasks become challenging, affecting physical and emotional health and, potentially, leading to disability.

We provide evidence-based treatments for failed back surgical syndrome.

At Compass Pain & Wellness, we recognize the complex nature of failed back surgery syndrome—no two patients’ experiences are alike. Our multidisciplinary, comprehensive, and evidence-based approach ensures that our treatment plans are fully tailored to your unique needs and wants. By considering both the physical and emotional impacts of FBSS, we aim to guide you along a personalized path to wellness and empower you to boost your health and quality of life.

Mindfulness and Meditation

Mindfulness and meditation help manage chronic pain by reducing stress and promoting emotional resilience.

Physical Therapy

Physical therapy improves strength, flexibility, and mobility while addressing pain from injury or chronic conditions.

Epidural Steroid Injection

Epidural steroid injections reduce spinal inflammation to ease pain radiating from nerve compression or irritation.

Massage

Massage therapy eases muscle tension and improves circulation to support pain relief and overall well-being.

Nerve Block

Nerve blocks interrupt pain signals from specific nerves to reduce chronic or procedure-related discomfort.

Peripheral Nerve Stimulation

Peripheral nerve stimulation sends mild electrical signals to disrupt chronic pain from damaged peripheral nerves.

Radiofrequency Ablation

Radiofrequency ablation targets specific nerves to interrupt pain signals and provide lasting pain relief.

Intracept

Intracept targets nerves inside the vertebrae to relieve chronic low back pain linked to vertebral endplate changes.

Spinal Cord Stimulation

Spinal cord stimulation delivers electrical pulses to block nerve pain and reduce discomfort in the back or limbs.

Sacroiliac Joint Fusion

SI joint fusion stabilizes the pelvis to relieve lower back or hip pain caused by joint dysfunction or instability.

Our Providers

Meet our experienced and compassionate team of doctors who specialize in helping you manage your condition. With a patient-centered approach, our doctors work to understand your unique needs and provide compassionate, personalized care. Trust our providers to guide you on your journey to better health and improved well-being.

Dr. Kristi Reed, MD

Dr. Randolph Cribbs, MD

Dr. Carl Balog, MD

References

Get in touch with Compass Wellness and Pain today and find out how we can help relieve your failed back surgery syndrome.

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