Causes of FBSS: Why Does Back Surgery Fail?

Two spine surgeons operating.
Two spine surgeons operating. BSIP/UIG/Collection:Universal Images Group/Getty Images

Up to 74.6 percent of low back spine surgeries fail to completely relieve pain, according to a 2016 review published in the published in the Journal of Pain Research.

Believe it or not, there's a medical name for this—failed back surgery syndrome. FBSS as it is often called for short, refers to persistent pain following a back surgery. The pain can be in your back, in your leg, or both. FBSS has an imprecise definition, and as you will see, can quickly become a complex condition.

Other names for failed back surgery syndrome include: Post-lumbar surgery syndrome, post-laminectomy syndrome, failed back syndrome, and post operative persistent syndrome. (A syndrome is a collection of signs and symptoms).

Which Back Surgeries Can Give You Failed Back Syndrome?

While failed back surgery syndrome may result from any type of back surgery, the most common include laminectomy and discectomy. Laminectomy, which is also known as decompression, is a procedure in which a part of the bony ring in the back of the vertebra is removed to make room for nerves to pass unimpeded. Laminectomy is often used for managing the symptoms of spinal stenosis.

In a discectomy, fragments of a herniated disc are removed from your spine. Removing disc pieces can help take pressure off spinal nerves. This is because fragments often "land" on spinal nerve roots, irritating them and often causing pain as well as other symptoms.

One reason why laminectomy and discectomy have higher rate of failures may have to do with the fact that these spinal surgeries overall are among the most commonly given to patients.

What Happens After a Failed Back Surgery?

Exactly what happens to people whose back surgery "fails?" Unfortunately, the picture can be bleak; this is because there's no real cure for FBSS.

 Your doctor may suggest having a 2nd surgery, which is called a revision surgery, but, of course, this depends on many things including the type of surgery you had originally, the type of pain you experience afterwards and more. And if the revision surgery doesn't relieve your symptoms, your doctor may even encourage you to undergo yet another invasive procedure.

By the way, between 13 percent and 35 percent of people who get back surgeries also get revision surgeries, according to the 2016 review mentioned above.

The review points out that repeated surgeries not only lead to high medical costs, but as each successive procedure is done, the odds of a satisfactory outcome diminishes.

There is some good news in all this, though. Many people who get 2nd and 3rd surgeries report that the subsequent procedures work just fine—their pain and other symptoms are finally gone, and their backs feel as good as new.

But people with failed back surgery syndrome who have undergone multiple revision surgeries with little or no improvement are often relegated to pain management.

 In this case, pain medicine and neuromodulation—which consists of either an implanted spinal cord stimulator, or, generally as a last resort, an implanted pain (drug) pump—are often tried, as well as exercise, holistic therapies and cognitive behavioral therapy. Learning how to manage pain on a daily basis is a key skill that's developed when you're in a pain management program.

The use of implanted spinal cord stimulation systems for pain control is exploding in the industry right now. Begun in the mid-20th century, it is very effective as part of an overall treatment plan for pain following a back surgery. This type of pain generally is a mix of nerve pain, in particular radiculopathy, and pain from tissue damage (called nocioceptive).

Now that you know a bit about failed back surgery syndrome, you may be wondering what happens "under the hood" so to speak; in other words, why would you get pain after a surgery? Shouldn't the surgery relieve your pain?

Failed Back Surgery Syndrome Causes

Generally speaking, failed back surgery pain can be understood as occurring during one of three phases: The planning phase, the operating room phase and the post-surgical phase.

The Planning Phase

The planning phase includes things like: Were you a good candidate for surgery in the first place?

If your spine is unstable even before surgery becomes an option (i.e. during the time you're making the rounds to talk to specialists, surgeons and other members of the treatment team in an attempt to figure out what's going on,) a back surgery is likely not for you.

If your pain is not caused by mechanical things like herniated disc, again, you may not be a good candidate for the surgery. Health conditions that fall into this category include metabolic problems such as diabetes, as well as vascular (blood vessel) problems, viruses and tumors.

Previous trauma is another reason you may be precluded from back surgery, despite your pain.

And finally, if, along with your leg or back pain, you also have depression, anxiety or other psychological problems, you may be at a higher risk for failed back surgery syndrome. (Something to consider before deciding to go forward with the procedure).

During the Back Surgery

The 2nd phase of FBSS causes—which occurs while you're on the operating table—includes things like surgeon error and the type of surgery you're having (particularly as it relates to the type or severity of FBSS symptoms that occur later).

What types of mistakes might a surgeon make while you're "under?" She may operate on the wrong level, or the wrong side of your body. Or she may either over or under operate, meaning she removes either too much or too little of a spinal structure.

If she over operates, this is sometimes considered aggressive, and it can lead to spinal instability that was not there before the surgery. If she under operates, she may fail to remove some or all of the things that are the source of your pain (called "pain generators").

And a word of warning. If you've opted for a minimally invasive procedure such as a microdiscectomy—maybe because you were told it would be easier on you than the traditional open kind—your FBSS symptoms (if you get them) may not be so easy. Although some in the profession disagree, many spine experts believe that having a minimally invasive procedure does not automatically mean that FBSS will be mild, as well. In fact, the Journal of Pain Research review mentioned at the top of this article says there are no surgical techniques that, when used, will guarantee that FBSS doesn't happen.

The 3rd phase when FBSS is caused occurs once the procedure is done. Called post-operative, this group of health issues can be anything from infection, wound drainage or hematomas to recurring disc herniation, muscle spasm, and much more. Here is the short list of things that can cause pain after lumbar spine surgery.

  • Infection. A 2016 study that tried to determine what made people check back into the hospital found infection to be the most commonly encountered complication.
  • Pseudoarthrosis, is the general term used for a bone fracture that doesn't heal. A pseudoarthrosis after a spine surgery is generally related to a spinal fusion procedure and points to a failure of the bones to fuse the way they are supposed to.
  • Epidural fibrosis is a fancy medical name for scar tissue that forms around the spinal nerve root. It is extremely common following a back surgery.
  • Changes in your anatomy and/or body biomechanics can lead to spinal instability, sacroiliac joint dysfunction, foraminal stenosis (i.e., a narrowing of the "holes" at the side of the spine through which nerves pass). Such structural changes also may put extra pressure on some areas of spinal bones over others, leading to more problems in spine later. In fact, when this happens, you may find that the pain and problems that originally led you to seek surgery return.
  • Muscle spasm affecting paraspinal muscles, the diaphragm muscle and others.
  • Changes in your myofascial tissue (myofascia refers to connective tissue covering around muscles that help the body keep its form and integrity) can cause referred pain that may be easily confused with radiculopathy. (Radiculopathy refers to the pain and electrical sensations, as well as numbness and weakness that may go down one leg when a spinal nerve root is irritated or pressured. Many people call this "sciatica").

    Myofascial changes can occur near the vertebral level that is operated on, especially in the paraspinal muscles that go into spasm.
  • Your forward-to-back balance may be disrupted after a back surgery, and in turn, your stability and coordination as you go about your daily activities may be altered.

The Future of FBSS

Up until recently (2016), the use of the phrase, "failed back surgery syndrome" implied that pain, symptoms and/or new or recurring medical problems after a spine surgery was the fault of the surgeon. As you can see from the above, that is sometimes true, but often there are other reasons for FBSS.

The industry is currently in flux as it seeks a consensus on a new definition for FBSS. This involves, among other things, possible renaming of the condition as well as coming up with language that is more future-focused (what to do next) and less surgeon-blaming.

Source:

Blond S., Mertens P., David R., Roulaud M., Rigoard P. From "mechanical" to "neuropathic" back pain concept in FBSS patients. A systematic review based on factors leading to the chronification of pain (part C). Neurochirurgie. March 2015. Accessed: Oct. 2016. https://www.ncbi.nlm.nih.gov/pubmed/25596973 Rigoard P., 

Blond S., David R., Mertens P. Pathophysiological characterisation of back pain generators in failed back surgery syndrome (part B). Neurochirurgie. March 2015. Accessed: Oct 2016. https://www.ncbi.nlm.nih.gov/pubmed/25456443

Bordoni B., Marelli F. Failed back surgery syndrome: review and new hypotheses. J Pain Res. Jan 2016. https://www.ncbi.nlm.nih.gov/pubmed/26834497 

Durand G., Girodon J., Debiais F. Medical management of failed back surgery syndrome in Europe: evaluation modalities and treatment proposals. Neurochirurgie. March 2015 https://www.ncbi.nlm.nih.gov/pubmed/25676909

Rigoard P., Desai M., Taylor R. Failed back surgery syndrome: what's in a name? A proposal to replace "FBSS" by "POPS" Neurochirurgie. March 2015. Accessed: Oct 2016. https://www.ncbi.nlm.nih.gov/pubmed/25665773

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