Failed back syndrome

Overview

Failed Back Syndrome (FBS), also known as Failed Back Surgery Syndrome (FBSS), refers to a condition where a patient continues to experience persistent or recurrent back and/or leg pain after undergoing spinal surgery. Despite its name, the term does not imply that the surgery was performed incorrectly but rather that the expected pain relief was not achieved. FBS is a complex, multifactorial condition that can be frustrating for both patients and clinicians.

Causes

Failed Back Syndrome can result from a variety of factors before, during, or after spinal surgery. Common causes include:

• Recurrent disc herniation: The disc may re-herniate at the same or a different level.

• Scar tissue formation: Epidural fibrosis can compress or irritate spinal nerves.

• Incorrect diagnosis: Surgery may have targeted the wrong spinal level or missed the actual pain generator.

• Adjacent segment degeneration: Stress on segments above or below a fused area can lead to new pain.

• Nerve damage: Nerve root injury during surgery can cause ongoing neuropathic pain.

• Spinal instability or hardware failure: Fusion failure or instrumentation issues may contribute to continued symptoms.

Symptoms

The symptoms of Failed Back Syndrome vary depending on the underlying cause but typically include:

• Persistent low back pain: Aching or sharp pain in the lumbar region following surgery.

• Leg pain (sciatica): Radiating pain, numbness, or tingling down one or both legs.

• Limited mobility: Stiffness and difficulty in performing daily activities.

• Neuropathic pain: Burning or shooting pain indicating nerve involvement.

• Emotional distress: Depression, anxiety, or frustration due to chronic pain and functional impairment.

Diagnosis

Diagnosing Failed Back Syndrome involves a comprehensive evaluation to determine the source of ongoing pain. Diagnostic steps include:

• Detailed medical history and physical examination: To assess the nature and distribution of pain.

• Imaging studies: MRI or CT scans can reveal structural problems such as scar tissue, hardware issues, or recurrent disc herniation.

• Electrodiagnostic tests: EMG and nerve conduction studies to evaluate nerve damage.

• Diagnostic injections: Nerve blocks or facet joint injections can help pinpoint the pain source.

Treatment

Treatment of Failed Back Syndrome is usually individualized and multidisciplinary. Options include:

• Medications: NSAIDs, opioids (short-term), antidepressants, and anticonvulsants for neuropathic pain.

• Physical therapy: Strengthening, stretching, and aerobic exercises to improve function and reduce pain.

• Cognitive behavioral therapy (CBT): Helps patients cope with chronic pain and improve mental health.

• Interventional procedures: Epidural steroid injections, facet joint injections, or nerve blocks.

• Spinal cord stimulation (SCS): An implanted device that delivers electrical impulses to block pain signals.

• Revision surgery: May be considered if a clear anatomical cause of pain is identified and amenable to correction.

Prognosis

The prognosis for individuals with Failed Back Syndrome varies widely depending on the cause and effectiveness of treatment. While some patients achieve meaningful relief with conservative or interventional management, others may continue to experience chronic pain and disability. A multidisciplinary approach involving pain specialists, physical therapists, and psychologists can help improve quality of life, even when complete pain elimination is not possible.