Surgery always carries with it some risk, by its very nature. The complexity of spinal surgery in particular adds to the associated risk. Even with the best surgeon, procedures and outcomes, surgery is no more than 95 percent effective.

In some cases (up to 10 to 40 percent of patients), a back surgery may not yield the anticipated benefits. A patient may continue to feel pain and experience the effects of nerve damage. This is often referred to as failed back surgery syndrome (FBS) or post-laminectomy syndrome.

It is not actually a syndrome at all, but the presence of chronic pain in the wake of a back surgery. There can be a variety of causes, including certain disorders and diseases that may increase the risk of experiencing FBS:

• Diabetes
• Autoimmune disorders
• Peripheral artery disease

Typically, there are two primary groups of patients who are at risk for FBS:

• Patients whose surgery was never likely to deliver the desired outcome, or for whom surgery was never indicated as a therapeutic option in the first place
• Patients whose surgery did not deliver the desired outcome, either from an incomplete and/or inadequate procedure

Smokers are also at higher risk of failed back surgery syndrome, as smoking inhibits healing. Studies have shown that smoking is a definitive impairment to successful recovery from spinal surgery. Nicotine interferes with the body’s ability to heal bone and is particularly problematic in the matter of successful bone fusion. The restriction of small blood vessels associated with smoking leads to scar formation. Cigarette smoking has been tied to back pain and chronic pain in general.

Causes of failed back surgery syndrome

There are numerous factors that can contribute to or cause FBS and may be difficult to isolate. Some of these may include:

• Formation of scar tissue at the surgical site
• Surgical error causing damage at the site
• Failure of the spine to properly fuse
• Failure of a spinal implant or hardware
• Recurrence of disc herniation
• Referred pain/surgery was performed at a site that was not actually causing the pain
• Unnecessary surgery
• Patient’s medical condition makes a successful outcome less likely
• Incorrect diagnosis
• Complications of spine surgery

In most cases, patients with FBS may have additional vocational, social or psychological conditions that are concurrent with the spine condition, which makes for additional diagnostic challenges on the part of the physician.

Diagnoses and testing

One of the key methods of both preventing and dealing with FBS is to receive a clear and correct diagnosis of your condition at the outset, and this involves:

• Thorough examination of the patient
• Expert understanding of the affected region and therapeutic options available
• Use of state-of-the-art diagnostic imaging tools
• Careful consideration of the patient’s mental and physical health as well as medical and personal history, as they may impact surgery and recovery

This will allow your surgeon to have the most precise and accurate modeling of the injury site, the course of treatment recommended, and the proper preparations for the best possible outcome.

Some of the diagnostic technologies your physician may use include:

• Computed tomography (CT) scans: Determine that bones have fused and there are no new fractures
• Magnetic resonance imaging (MRI) scans: Spot compression of nerves or herniated discs
• X-rays: Verify alignment and ensure that hardware is intact
• Electromyography (EMG): Study nerve function
• Bone scans: Rule out infection

Treatment

Because chronic pain and physical disability are the most common symptoms of FBS, management of these symptoms is of greatest importance for the patient to have some hope of restoring quality of life and return to normal activity.

However, before another surgery is considered, your physician may recommend pain management and rehabilitation as a way of addressing FBS. Rehabilitative therapy may include stretching and exercising, as well as management of pain medication options. Treatments for FBS include:

• Medications: Narcotics may be used for pain management in patients with FBS, but there are problems with long-term use, particularly since they are habit-forming.
  • Anti-inflammatory drugs: Ibuprofen, aspirin, acetaminophen, naproxen
  • Narcotics: Morphine, codeine, hydrocodone, oxycodone, fentanyl
  • Neuromodulatory drugs: Gabapentin, amitriptyline, pregabalin, duloxetine
• Surgical treatments:
  • Nerve blocks: Injections of steroids to reduce inflammation and pain
  • Spinal cord stimulation: Use of electrodes placed in the spinal canal to provide relief
  • Intrathecal drug infusion: Use of pumps and implanted catheters (thin tubes) to deliver pain medication into the spinal fluid