What is Failed Back Surgery Syndrome?

Failed Back Surgery Syndrome (FBSS) refers to persistent and/or recurrent pain following spinal surgery. Many aspects of this syndrome have led to the conclusion that the term is inadequate. It simplistically groups a wide spectrum of post-surgical clinical scenarios attributable to an equally broad range of possible and concomitant causes, among which one possible, but by no means unique, cause is the failure of spinal surgery.

 

Recognizing Signs and Symptoms of FBSS

Pain is the primary symptom reported by patients. It may be localized exclusively to the lumbar region or radiate to the lower extremities, with varying intensity among patients. Clinical examination is crucial to establish the presence of neurological disorders, primarily deficits in muscle strength, in addition to the preoperative assessment.

 

Causes of Failed Back Surgery Syndrome

Medical Factors

Medical factors recognized as predictors of an unsatisfactory surgical outcome include:

• Chronic Pain Syndromes: Chronic pain triggers a phenomenon initiated by a physical or emotional event (in this case, chronic pain falls into both categories) leading to increasing inactivity and apathy;
• Inappropriate surgical indication, inadequate performance of the surgical procedure. Clinical examination, radiological examinations, and their correlation constitute the cardinal presupposition justifying the need for surgery. When this prerequisite is lacking, the probability of therapeutic failure is very high. Variability in surgical skills among operators is a factor to consider when calculating the therapeutic success of a surgical procedure;
• Number of Surgeries: The probability of a good outcome decreases as the number of surgeries performed increases;
• Invasive/Destructive Nature of Surgery: The more invasive and/or destructive the surgical procedure, the higher the probability of postoperative pain syndromes;

Psychosocial Factors

Psychosocial factors explaining the high prevalence of patients complaining of post-surgical spinal pain syndrome include:

• Low level of education on the rules of preventing degenerative diseases of the spine. Absence of prevention programs and identification of risk factors for the development of back problems in the home and professional environment. Poor quality of conservative therapy for problems related to low back pain. Misinformation about diseases that cause pain and so-called iatrogenic diseases;
• Negative psychological factors (e.g., recent bereavement, job loss and/or professional difficulties, etc.). Pre-existing chronic pain syndromes. Psychological disorders (e.g., hysteria or hypochondria). If present, these factors predict an unsatisfactory postoperative outcome and, if surgery is still indicated, require a multidisciplinary approach in terms of psychological pain management;
• Smoking and obesity are considered moderate predictors of poor surgical outcome;

The development of scar tissue that, over time, exerts mechanical traction on the nerve elements contained in the spinal canal is considered one of the most frequently implicated mechanisms in the onset and/or persistence of pain present before surgery.

 

Diagnosis of Failed Back Surgery Syndrome

The diagnosis of FBSS is essentially clinical. Magnetic resonance imaging, possibly integrated with tomographic studies, allows, with anamnestic data and clinical examination, the rapid recognition of a postoperative complication. For example, migration and/or dislocation of the synthesis support, inadequate surgical decompression of the involved nerve elements, recurrence of the underlying pathology, or a complication of another nature such as spondylodiscitis can be observed.

If symptoms are not associated with radiological images suggestive of serious postoperative complications, a multidisciplinary therapeutic procedure needs to be planned with the help of specialized professionals who can complement. In some cases, therapy leads to replacing the skills of the neurosurgeon, for example, with those of the pain therapist, psychologist or psychotherapist, and physiotherapist.

 

Treatment of Post-Spinal Surgery Pain

Treatment of pain after spinal surgery is established based on the appropriate choice of analgesic and anti-inflammatory drugs, both in terms of molecules and dosage. There are techniques for administering pain medication (pharmacological blocks) or performing pulsed radiofrequency stimulation directly on the structures responsible for the painful symptoms. Epiduroscopy is an interesting therapeutic option. It is a minimally invasive procedure that allows "dissolution" of the scar adhesions of the spinal canal with the sac and spinal roots and administration of analgesic and anti-inflammatory drugs directly to the nerve structures causing the symptoms. Pulsed ganglion radiofrequency can also be combined with this procedure. It can be associated with epiduroscopy when there is predominantly radicular pain with neuropathic characteristics. The technique consists of bringing a fine catheter through the same epidural access, onto the ganglion of the nerve root and to the area by pulsed ganglion radiofrequency delivered under the direct control of the operator. It is not possible to provide a precise expectation of healing for patients suffering from chronic pain syndromes. The results of the procedures and pharmacological treatment adopted vary from patient to patient and depend on a wide range of factors, purely medical, psychosocial, specific to each patient.