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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 47-53

Management of Failed Back Surgery Syndrome (FBSS)


Spine Team, Orthopaedic Unit, Department of Surgery, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria

Date of Web Publication30-May-2019

Correspondence Address:
Dr. Mohammed K Abubakar
Spine Team, Orthopaedic Unit, Department of Surgery, Aminu Kano Teaching Hospital/Bayero University, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_38_18

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  Abstract 


This article aims to highlight the current management of failed back surgery syndrome (FBSS) based on a systematic review of current literature. Literatures reviewed were from the Internet medical search engine such as PubMed, MEDLINE, and Embase. The search was narrowed down to the topic under review. In all, 1,345 articles were initially obtained. These were subsequently narrowed to 83 reviews so as to meet the objective of the review which describes persistent or recurring low back pain with or without sciatica following one or more spine surgeries. The increase in the number of patients undergoing back surgery has led to a corresponding increase in patients whose expectations are not met. Poor outcome following back surgery ranges from 10% to 40%. Outcome worsens with increase in the number of reoperation. Evaluation of this patient should be by detailed history, physical examination, and investigation. The treatment approach should be holistic and all encompassing. Patients psychological state and expectations should be assessed. Etiology of FBSS may include wrong diagnosis, failure to address the primary pathology, and intraoperative surgical errors. Treatment of FBSS is multidisciplinary. The treatment modalities include pharmacological, physical, interventional, spinal cord stimulation, psychological, and surgical.

Keywords: Failed back surgery syndrome, etiology, management


How to cite this article:
Abubakar MK, Mohammad S. Management of Failed Back Surgery Syndrome (FBSS). Arch Int Surg 2018;8:47-53

How to cite this URL:
Abubakar MK, Mohammad S. Management of Failed Back Surgery Syndrome (FBSS). Arch Int Surg [serial online] 2018 [cited 2024 Mar 28];8:47-53. Available from: https://www.archintsurg.org/text.asp?2018/8/2/47/259461




  Introduction Top


About 40%–80% of people will have back pain at least once in their life time.[1],[2],[3] A number of patients who have surgery for their back pathologies will come back with the same, new, or exacerbated symptom. These patients are said to have developed failed back surgery syndrome (FBSS). FBSS is defined using various parameters.[4],[5],[6],[7],[8] From the spine surgeon point of view, it is defined as a condition that describes persistent or recurring low back pain with or without sciatica following one or more spine surgeries.[9] The rising prevalence of spine surgery globally[10],[11],[12] and the increase in medical tourism in developing country like Nigeria[13] have led to rise in the number of patients with FBSS. It is imperative for physicians and other health workers to apply a holistic approach in the management of FBSS.


  Etiology of Fbss Top


Poor outcome following back surgery ranges from 10% to 40%.[5],[14],[15] More so the success of spine surgery decreases with the number of reoperations.[16],[17],[18],[19],[20] The etiology of FBSS has traditionally been categorized into preoperative, operative, and postoperative.[21] However, it has also been approached from the point of diagnostic error, surgical indication error, technical error, and others.[22]

The preoperative risk factors reported include the following: (1) prior lumbosacral surgery that predisposed to spinal instability.[5],[6],[7],[18],[23] Prevalence of spinal instability following single to multiple spine surgeries ranges from 12% to 50%.[6],[7],[24],[25] (2) Poor patient selection by the surgeon.[6],[7],[22],[26],[27],[28] Poor selection of patient may lead to wrong procedure due to wrong diagnosis.[6],[7],[29] Microdiscectomy done for axial pain[7] will definitely not solve the patient's problem. (3) Failure to recognize nonsurgical causes of radiculopathy and neuropathy such as diabetes mellitus, vascular disease, infection, plexopathies from tumor or trauma in patient selection.[6],[29]

Patient psychological state is crucial in determining the outcome of surgery. Presence of psychiatric disorder, social issues, occupational disharmony, and litigations have all been shown to affect surgical outcome.[6],[7],[21],[30],[31]

Intraoperative risk factors include several factors that have been described in the literature that predispose to FBSS. Pertinent among them are intact pain generators due to inadequate decompression, spinal instability from aggressive decompression, vertical stenosis from loss of disc height, unrecognized pathology such as disc fragment, kinking of nerve root, nerve root compression, and conjoint nerve root.[6],[7],[21],[26],[30] Also implicated is the battered root syndrome, which may follow excessive traction or bleeding[7],[30] and hardware mishap such as improper screw placement.[7],[30]

Postoperative risk factors: FBSS can be caused as a result of surgery-related problem and progression of disease. A summary of postoperative causes of FBSS is given in [Table 1].
Table 1: Postoperative causes of FBSS

Click here to view



  Clinical Assessment Top


Clinical evaluation in FBSS should aim at identifying the nature of back pain in relation to pre- and postoperative states; whether the pain is persistent, worse, or new. The history should also elucidate whether the pain is predominantly axial pain or radicular.

Persistent pain may suggest poor patient selection, due to wrong diagnosis, wrong site, or wrong choice of surgery. It may be difficult to localize pathologic processes responsible for postoperative pain. As a guide, when back pain is more than leg pain or radiculopathy, then this may suggest discogenic pain at the site of surgery or adjacent levels, facet pain, sacroiliac joint, instability, or pseudoarthrosis.[6],[26],[31] When leg pain predominates, conditions such as foraminal stenosis, residual or recurrent disc herniation, and neuropathic pain should be considered.[31] When the pain is new, or where there is neurological impairment like urinary incontinence, foot drop, paraesthesia, or numbness, then diagnosis to consider should include misplaced screw, dislodge cage, bone fragment, and battered root.[26],[31]

Chronic neuronal pain is usually diffuse and not well localized. It may be described as cramming, aching, and thigh sensation.[6] Thus, it may resemble myofacial pain. Presence of fever in the immediate postoperative period may suggest infection or hematoma. The initial pre- and postoperative diagnoses should be thoroughly reviewed. Comorbidities and treatments, if any, should be reviewed.

Presence of “yellow flags” or psychological stressors as described by Kendall should be assessed.[47] These include fear avoidance behavior, back pain negative attitude, an expectation that passive rather than active treatment will be beneficial, tendency toward depression, addiction, and financial problems.[47]


  Physical Examination Top


In FBSS, the physical examination principally aims to identify the possible location of pathology and the neurological deficit. The musculoskeletal examinations should include limb length discrepancy, straight leg raising test, Lasegue test, femoral stretch test, a complete hip examination, and knee and ankle examination. The spine should be examined for deformity, tenderness, stepping, seated, and standing range of motion. Also, the sacroiliac joint and trochanter should be palpated for tenderness.[6],[7]

A full neurological examination should be carried out. The patient should be examined for tone, bulk, muscle wasting, reflexes, clonus, and Babinski reflex. Also, sensory deficit should be determined by comparing with contralateral dermatomes. Both light and deep sensation should be checked.

The differential diagnosis of FBSS include other causes of back pain, for example, rheumatoid arthritis, ankylosing spondylitis, osteoarthritis of the hip, pelvic tumors, retroperitoneal tumors, and aortic aneurysm. Also pertinent are the psychological factors that need to be identified. Waddell's signs[48] should be looked for. These include signs of superficial or nonanatomic pain on palpation, the report of pain during painless-designed evaluation, and an overreaction to stimuli. Presence of two or more Waddell's sign is associated with poorer outcome irrespective of spine pathology.[48],[49] It is worth noting the ability of physical examination to identify the variable source of pain.[48]


  Investigation Top


The investigation of choice in FBSS depends on the findings from history and examination. Current radiological investigations are able to identify the cause of FBSS in 94%–95% of patients.[16],[34]

Plain whole spine X-ray, anterior–posterior and lateral view, erect standing, in flexion and extension, may show evidence of instability, pars defect, deformity, sagittal balance, and degenerative changes.[21],[50],[51] The main drawback of X-ray is its inability to show soft tissue abnormality such as epidural fibrosis, disc protrusion, and neural impingement.

Magnetic resonance imaging (MRI) provides a good image of the soft tissues, and thus it is able to provide the most suitable information on the source of pain. It is performed best with gadolinium enhancement to help differentiate epidural fibrosis which enhances compared to recurrent disc herniation which does not appear enhanced.[52],[53] Also, conditions such as nerve root thickening, lateral recess and neural foraminal stenosis, discitis, and pseudomeningocele can be detected with gadolinium-enhanced MRI.[53],[54] Three-dimensional MRI has been shown to be better than conventional MRI in detecting intra- and extra-foraminal stenosis.[55] Contrast-enhanced MRI with fat saturation is the investigation of choice when infection is suspected because it allows for the evaluation of bone edema and discitis earlier than other modalities.[56]

Computed tomography (CT) is used in assessing hardware position, fusion mass, and bone quality. CT-myelography is used to show compression of neural elements when MRI is contraindicated.[56],[57] Provocative discography is a diagnostic aid that helps in isolating a specific intervertebral disc as a source of back or leg pain.[46] Its utility is doubtful, as up to 40% of asymptomatic individuals may experience pain after disc injection, which is indistinguishable from symptomatic patient.[58] Interventional diagnostic injections are helpful in ruling in/out a specific nerve root or joint as a cause of pain.[7],[36] For example, lumbar medial branch blocks, sacroiliac joint blocks, and selective nerve root block. An anesthetic block is considered positive when there is 75% or more relief of the targeted pain for several hours according to the duration of the local anesthesia used.[31]

Electrodiagnostic evaluation may be useful especially if pre- and postoperative results are compared. A change in compound motor action potential and increase in peripheral membrane irritability may reflect worsening postoperative neuropathy.[6]

Other investigations such as complete blood count, erythrocyte sedimentation rate, and C-reactive protein are done especially when infection is being considered.


  Treatment Top


The goal of treatment of FBSS is to identify and rectify the source of pain and to improve the quality of life and reverse the progression of debility. Unfortunately, achieving these goals may not always be possible because of the myriad causes of low back pain. A multidisciplinary approach is the best way of addressing FBSS.

The treatment modalities used are (1) conservative, (2) interventional, and (3) surgical. Conservative include pharmacological, physical therapy, and psychological.

Pharmacological

It is multimodal and increasingly controversial.[26] The mechanism of action, presumed modification of specific symptom complexes, and side effect should be put into consideration when prescriptions are made.[6] Drugs used include nonsteroidal anti-inflammatory drugs (NSAIDs), opiods, muscle relaxant, steroids, and antidepressant such as gabapentinoids.[7],[10],[30],[32] These drugs are given to reduce pain and facilitate improvement in function.

The safety and efficacy of NSAID, opiods, and antidepressant in the treatment of chronic low back pain have been reviewed.[59] NSAIDs are efficacious but have higher side effects such as gastrointestinal bleeding, renal impairment, and stroke. While opiods have fewer efficacies compared with the NSAIDs, they have a high tendency for dependence, paradoxical hyperalgesia, androgen deficiency, and insomnia.[6],[30],[32],[60] Antidepressants such as gabapentinoids are best used for neuropathic pain even though their efficacy has not been fully accepted.[7],[30],[61],[62]

Physical therapy

The aim of physical therapy is to decrease pain, improve posture, stabilize the hypermobile segments, improve fitness, and reduce mechanical stress on the spinal structures.[63] The efficacy of physical therapy and exercise has been studied extensively. The general consensus is that physical therapy is efficacious in the management of FBSS.[63],[64]

Interventional pain procedure

This is indicated as a therapeutic and diagnostic modality. Various formulations of steroid, local anesthetic agents, and hyaluronidase are available. The main aim is to achieve pain relief and delay the need for surgery in pathologies such as herniated disc, postoperative adhesion, thickened ligamentum flavum, and facet joint arthropathy.[2],[6] Injections are given as epidural interlamina, epidural transforamina, sacroiliac joint blockade, facet medial branch blocks, and rhizotomy. However, it has not been clearly established that pain relief from postoperative radiculopathy following epidural steroid injection is actually due to the corticosteroid.[65],[66],[67] In addition, the alteration of surgery on the soft tissues and presence of implant may increase the difficulty in depositing the steroids in the required site thereby increasing the risk of dural puncture.[36],[68]

Fluoroscopic transforaminal route is an alternative. However, it has been reported to be associated with higher risk of spinal infarction.[32]

Percutaneous adhesiolysis may be done when adhesion is the cause of FBSS.[69] Hyaluronidase as a single agent or in combination with steroid is used to achieve theoretical lyses of adhesion.[70]

Radiofrequency ablation

Specific nerves are targeted and subjected to radiofrequency ablation (RFA). It helps achieve prolonged and sustained pain relief that a diagnostic block or therapeutic injection cannot.[26] Usually, a medial branch block is done to identify the response. Subsequently, a RFA is done corresponding to the medial branch block. This can provide pain relief for 6 months to 2 years.[70],[71]

Transcutaneous electrical nerve stimulation, spinal manipulation, and acupuncture

While these treatment modalities have reasonable role in the management of chronic low back pain, their role in pain relive of FBSS is not well established. They achieve a very short time pain relieve in FBSS.[7],[32],[72],[73],[74]

Intrathecal pump and spinal cord stimulators

Intrathecal analgesics are used to augment interventional procedures. They help achieve systemic pain control and improve the quality of life. About 88%–92% of the patients have reported satisfactory pain relieve with intrathecal analgesia.[15],[75] However, because of its formidable side effects such as constipation, urinary retention, constipation, equipment malfunction, and catheter tip granuloma,[7] intrathecal analgesics are recommended only when all other viable options have failed.[7]

Spinal cord stimulator (SCS) involves use of a subcutaneously buried pulse generator that is connected to electrodes placed in the epidural space over the dorsal columns and the location, frequency, and intensity of the electrical stimulation are adjusted to provide coverage to the painful areas.[3],[7],[76] The benefits of SCS to patients with neuropathic pain from FBSS have been demonstrated in several studies.[77],[78],[79]

Psychotherapy/cognitive behavioral therapy

Psychotherapy/cognitive behavioral therapy has been defined as intervention that applies psychological principles to change the overt behavior, thoughts, or feelings of persons with chronic pain to help them experience less distress and enjoy more satisfying and productive daily lives.[80] Psychotherapy has been found to be useful in patients with chronic back pain.[32],[81],[82]

Cognitive therapy consists of reformulation of fears and erroneous believe, while behavioral therapy involves limiting kinesiophobia and muscle reconditioning by teaching relaxation and stress management.[32]

Revision surgery

Reoperation following FBSS is usually discouraged especially when the precise cause of pain has not been identified. With every repeated surgery, the success rate decreases.[83] In addition, the morbidity and mortality increases. However, some clinical conditions [Table 2] have been identified as indications for revision surgery.[83]
Table 2: Indication for reoperation in FBSS

Click here to view


Proper patient selection, correct diagnosis, and indicated surgical procedure targeted at pain generators are essential. Successful outcome as measured by >50% pain reduction and reduction in Oswestry Disability Questionnaire score in the range of 90%[14] have been demonstrated; however, most studies did not agree to this.[9],[12]


  Conclusion Top


The number of FBSS is rising due to the increase in the number of back surgeries done. Management of FBSS is multidisciplinary and challenging. Efforts should be made to match pain generators with symptoms. This can only be achieved by proper patient selection, using history physical examination, and investigations. Most patients will do well with conservative management such as medication, physiotherapy, and interventional procedures. SCS has increasingly been shown to provide prolonged pain relief. Few patients with progressive neurological symptoms, instabilities, or proven hardware issues may require reoperation. However, the benefit must outweigh the potential risk of increased morbidity. It is pertinent for physician to individualize patient management and to identify potential treatment pitfalls which may be glairing if the psychological state of the patient is examined.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2]


This article has been cited by
1 Failed Back Surgery Syndrome: No Longer a Surgeon’s Defeat—A Narrative Review
Grzegorz Miekisiak
Medicina. 2023; 59(7): 1255
[Pubmed] | [DOI]



 

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Abstract
Introduction
Etiology of Fbss
Clinical Assessment
Physical Examination
Investigation
Treatment
Conclusion
References
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