Causes and Treatments of Failed Back Surgery Syndrome

Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

You are likely reading this article because you are looking for some answers to your diagnosis of failed back surgery syndrome. You have probably been told that many people have very successful surgeries, and that is very true, but failed back surgery complications are something that does happen and you need to move forward from here.

Moving forward may be difficult for you as your pain can be significant or bothersome and it is compromising your quality of life. Although your back pain may not be as severe as it was before the surgery, you, like many will continue to experience significant back pain after spinal surgery. Why? Because the back surgery involved removing supporting structures, such as a lamina, facet, or disc, weakening their spinal structures. As you will see in the research below, doctors are being told to inform patients of the substantial likelihood of re-operation following a lumbar spine operation. Later in this article, we will present non-surgical treatment options that may help you with your post-surgical back pain.

If you would like help from our staff on the assessment of your condition, please email us.

Companion information to this article:

Failed Back Surgery Syndrome treatment options: Article outline:


Part 1: A post-surgical pain that is worse than it should be:

  • A heightened sense of pain from an altered pain processing center that is not functioning correctly. Your back hurts more than it should.
  • What does this mean? The central nervous system is sending out disrupted or distorted pain sensations and the sensation of pain is now worse.

Part 2: Who is at greater risk for failed back surgery syndrome?

  • Failed back surgery syndrome is not completely understood.
  • Failed back surgery syndrome statistics: Patients who suffer from failed back surgery syndrome are showing up in the offices and clinics of physicians, surgeons, and pain specialists in overwhelming numbers.
  • Spinal instability at the L3-L4 segment above a previous L5-S1 fusion. The ground zero of new-onset pain after spinal surgery.
    Successful failure, failure of a successful surgery, which one are you?
  • Why are patients dissatisfied with their successful spinal surgery? Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% were classified as satisfied.

Part 3: Why does spinal surgery fail to relieve pain? Why do many have “disastrous results”

  • There are many types of spinal surgery, each with its own success and failure rates.
  • Lumbar Decompression Failure.
  • Discectomy Failure.
  • Endoscopic discectomy – the least invasive procedure – here are the patients it won’t work for.
  • What are the disastrous results in failed back surgery patients?
  • Recurrence of back or leg pain after surgery is a well-recognized problem with an incidence of up to 28%.
  • It doesn’t matter what type of spinal surgery you had, 1 in 5 people will have persistent pain after the surgery.

Part 4: What type of treatment is available for failed back surgery patients?

  • More surgery, spinal cord stimulation, epidural injection, exercise therapy, and psychotherapy . . . the evidence of the clinical outcome for each treatment has not been clearly determined.
  • Not only does the MRI confuse treatment options after spinal fusion failure – But it may have led directly to the failed surgery.
  • Adjacent Segment Disease
  • The problem of treatments leading to drug addiction in patients with failed back surgery syndrome.
  • Opioids
  • Treatments: Spinal Cord Stimulation or Opioids? Both?
  • “Higher Preimplantation Opioid Doses Associated With Long‐Term Spinal Cord Stimulation Failure “
  • The idea is Spinal Cord Stimulation is supposed to reduce opioid use – research gives varying opinions if this is true.
  • There is limited evidence for oral opioids in the treatment of chronic lower back pain; however, their routine use is widespread.
  • Limitations of Spinal Cord Stimulators – People still take opioids.
  • Spinal cord stimulation (SCS) has been considered an alternative therapy to reduce opioid requirements in certain chronic pain disorders.
  • “Spinal cord stimulators should be explored as the best option against further exposing patients to more failed procedures.”
  • Why the spinal cord stimulations have to be removed.
  • Failed Back Surgery Syndrome Treatment: Intrathecal drug delivery.
  • Failed Back Surgery Syndrome Treatment: Mind Over Body Pain Control.
  • Depression after failed back surgery . . . some researchers believe that being depressed after surgery is “understandable” and “unworthy of diagnosis or treatment.”.

Part 5: Adjacent segment disease and spinal instability – the key to treatment may be spinal ligaments

 


Part 1: A post-surgical pain that is worse than it should be:

Surgeons and doctors had no definitive way to conclude who would suffer from excessive pain caused by fear of surgery or recovery after surgery.


A heightened sense of pain from an altered pain processing center that is not functioning correctly. Your back hurts more than it should.

What does this mean? The central nervous system is sending out disrupted or distorted pain sensations and the sensation of pain is now worse.

In many failed back surgery patients, something, perhaps the surgery itself, has caused altered central pain processing. You feel more pain than is normal or that your tests and images suggest you should be feeling. In November 2022, doctors writing in the French journal Clinical Neurophysiology (1) investigated the presence of altered central pain processing in patients with failed back surgery syndrome.

In this study, there were three groups of patients.

  • 34 patients with failed back surgery syndrome
  • 102 patients post-lumbar surgery without low back pain, and
  • 102 healthy subjects who did not have surgery or back problems.

What did the researchers find?

  • Compared with both control groups, failed back surgery syndrome patients showed a reduction in both pressure pain threshold (they were more sensitive to pressure sensation and felt more muscle pain) and conditioned pain modulation (doctors replicate a pain sensation and repeat the stimulus to see if the same pain sensation will eventually cause more pain than it originally did.)

What caused this?

  • The doctors suggested that a condition of augmented central pain processing in patients with failed back surgery syndrome exists. Something is causing these people more pain than they should have and the same pain stimulus is making their pain worse. The doctors suggest that this may be caused by dysfunction of endogenous pain facilitation and inhibition. What does this mean? The central nervous system is sending out disrupted or distorted pain sensations and the sensation of pain is now worse. Treatment efforts, they suggest, “should take into account functional alterations in the central nervous system of failed back surgery patients patients.”

What caused this? Pre-surgical anxiety and depression factors are not conclusive as failure factors

In this study, the researchers examined previously published data on patients undergoing surgery for lumbar degenerative disease and the amount of fear-avoidance beliefs (i.e., pain-related fear, pain catastrophizing, pain anxiety) in relation to a surgical outcome measure (i.e., pain intensity, functional status and health-related quality of life). What they found was moderate evidence indicating that preoperative pain-related fear is not a significant predictor for postoperative pain and function following surgery for lumbar degenerative disease. Additionally, limited evidence was found for a lack of predictive value of preoperative pain catastrophizing for postoperative health-related quality of life.

Was it the surgery? Maybe it was.

  • Throughout this article, we have shown studies suggesting this may be a possible explanation. But also the researchers of this paper noted: “Patients with failed back surgery patients had a significantly higher prevalence of anxiety, depression, and pain catastrophizing thoughts than the patient controls.”

A September 2022 study from a team of European researchers published in the journal Pain Management (2) dispelled myths that this pain was “in the head” of many patients. The researchers of this paper suggested that after review, previously published research “showed moderate evidence indicating that preoperative pain-related fear is not a significant predictor for postoperative pain and function following surgery for lumbar degenerative disease.” (Many people did not go into surgery believing they would have more pain after the surgery). “Additionally, limited evidence was found for a lack of predictive value of preoperative pain catastrophizing for postoperative health-related quality of life.” (The surgeons and doctors had no definitive way to conclude who would suffer from excessive pain caused by fear of surgery or recovery after surgery).”


Part 2: Who is at greater risk for failed back surgery syndrome?


An August 2022 study in the Journal of Orthopaedic Surgery and Research (3) writes that: “The most common reasons for early reoperation and late operation were surgical site infection and adjacent segment diseases, respectively. Osteoporosis and diabetes were independent risk factors for early reoperation, and multilevel fusion was an independent risk factor for late reoperation. Surgeons should pay more attention to these patients, and future studies should consider the effects of follow-up periods on results.”

Failed back surgery syndrome is not completely understood

A September 2022 paper in the Journal of Clinical Neuroscience (4) comes from the Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California. In this paper, the researchers point out that because the cause of failed back surgery syndrome is not completely understood, the risk factors and evaluation of patients with failed back surgery syndrome remain challenging. To help their fellow clinicians assess risk factors for possible failed back surgery syndrome prior to surgery, the researchers set out to examine data from patients undergoing anterior lumbar fusion, posterior lumbar fusion, or decompression procedures from January 2010 to December 2017 from an insurance database. Rates of failed back surgery syndrome at six- and twelve-months post-surgery were determined for patients undergoing single/multilevel procedures according to a place of service, and approach/procedure type.

Results:

  • 102,047 patients underwent lumbar fusion or decompression surgery (54% decompression procedures, 36% posterior fusions, and 8.9% anterior fusions).
  • 5.4% of patients were diagnosed with failed back surgery syndrome within six months of the index (first) procedure, and 8.4% were diagnosed with failed back surgery syndrome within twelve months.
  • Failed back surgery syndrome was higher in the inpatient (6.0%) vs. outpatient (4.3%) groups.
  • High rates of failed back surgery syndrome occurred in the elderly (age group 70-74)
  • Among the surgical techniques, multi-level procedures had significantly higher rates of failed back surgery syndrome than single-level procedures, the highest being 10% in multi-level inpatient decompression procedures.

Failed back surgery syndrome statistics: Patients who suffer from failed back surgery syndrome are showing up in the offices and clinics of physicians, surgeons, and pain specialists in overwhelming numbers

The problem of failed back surgery syndrome is one that is decades long. In 2014, researchers from John Hopkins University issued these concerns (which continue to be concerns in 2023) to their fellow spinal surgeons. (5

  • Patients who suffer from failed back surgery syndrome are showing up in the offices and clinics of physicians, surgeons, and pain specialists in overwhelming numbers.
  • As lumbar spinal fusion surgery continues to grow in prevalence, so will the number of patients suffering from failed back surgery syndrome.
  • It is important for physicians treating these patients to expand their knowledge of what causes failed back surgery syndrome so they can adequately be prepared to manage these complex cases in the future.

Management of failed back surgery patients should, according to the Johns Hopkins team, begin with a systematic evaluation looking for:

Certain diagnoses may be confirmed with diagnostic procedures such as intra-articular injections, medial branch blocks, or transforaminal nerve root blocks. Once a cause is determined, a multidisciplinary approach to treatment is most effective.

  • This includes exercise or physical therapy,
  • psychological counseling,
  • medication,
  • and interventional procedures.

The most invasive treatment option, short of revision surgery, is spinal cord stimulation. This intervention has a number of studies demonstrating its efficacy and cost-effectiveness in this population. Finally, revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.

What are we seeing in this image? Spinal instability at the L3-L4 segment above a previous L5-S1 fusion. The ground zero of new-onset pain after spinal surgery.

  • In the first of the three panels starting at the left, we see the patient in the NEUTRAL, standing straight position. In this position, we see the L3 has slipped well forward above the L4 vertebrae. We also see space between the Neuroforamina.
  • In the center of the three panels, we see the FLEXION position. The patient is bending forward. We also see space between the Neuroforamina.
  • The third panel is an image of the spine in EXTENSION. This would be a position not only of bending backward but a position many athletes, tennis, golf, running, or sports or work with overhead arm motion required. In this position, there is a narrowing of the space between the Neuroforamina. This can cause Lumbar Radiculopathy or lumbar stenosis situation.
In patients we see, Prolotherapy injections would be recommended for appropriate candidates where a realistic expectation of 90% pain relief (curative) may be achieved. This is not attainable in all patients and is not typical. However, for appropriate candidates, significant pain relief can be achieved. Prolotherapy injections are explained below.

Successful failure, failure of a successful surgery, which one are you?

I would like to remind our readers that people have very successful spinal surgeries. These are the people that we do not see at our center, we see the people who do not. These simple stories go something like this:

Failed lumbar fusion at L5-S1

Dear Caring Medical, I have failed lumbar fusion at L5-S1. The fusion did not help alleviate my chronic pain which is sometimes severe and debilitating. I’m hoping to eliminate or manage the pain in my back to allow for normal daily functioning like sitting, driving, walking, and standing.

The surgery was a success, but I still have pain

“My surgeon said my L5-S1 fusion surgery was technically very successful. Unfortunately, scar tissue has developed and is pressing on my nerves.”

“My surgery was very successful, but I have spinal muscular atrophy as a result and weakness in my spine.”

“My surgery did not go well. I have had several surgeries since. I am on nerve blocks, pumps, pain meds.”

When people contact us, we have to have realistic expectations that we can help them. We cannot help everyone. If someone has a hardware failure, such as a broken screw, a crooked rod, or any other hardware malfunction, the hardware issues need to be addressed with their surgeons before a discussion of avoidance of further surgeries can be discussed.

The caption of the image below reads: Fusion surgeries put pressure on adjacent joints. This particular patient suffered from severe bilateral sacroiliac pain. As the image shows, the sacroiliac joints are right next to the area that was fused.

severe bilateral sacroiliac pain after spinal fusion

Why are patients dissatisfied with their successful spinal surgery? Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% were classified as satisfied.

In October 2020, research led by the Department of Neurological Surgery, at Vanderbilt University Medical Center asked: “Why are patients dissatisfied after spine surgery when improvements in disability and pain are clinically meaningful?” Their findings were published in The Spine Journal (6). Here are the highlights:

  • “Studies have found that most patients are satisfied after spine surgery, with rates ranging from 53% to 90%. Patient satisfaction appears to be closely related to achieving clinical improvement in pain and disability after surgery.” However the researchers noted, “there remains an important subpopulation of patients who have clinically relevant improvement but report being dissatisfied with surgery.” The question is then, why are they dissatisfied?

In this study, patients completed a pre-surgery and 12-month post-surgery assessment to evaluate disability, pain, and satisfaction. Clinical improvement was defined as patients who achieved a 30% or greater improvement in spine-related disability or extremity pain.

Results: Twenty-eight percent of patients were classified as dissatisfied with their spine surgery and 72% were classified as satisfied. For patients with clinical improvement in disability or extremity pain at 1-year, significant predictors of higher odds of dissatisfaction included:

  • Pre-surgery psychological distress
  • Counting of smoking
  • Workers compensation claim
  • Lower education
  • Higher ASA (American Society of Anesthesiologists) grade
    • ASA I – normal healthy patient.
    • ASA II – The patient suffers from mild systemic disease.
    • ASA III – The patient suffers from severe systemic disease.
    • ASA IV – The patient suffers from a systemic disease that is life-threatening
  • Lumbar versus cervical procedure
  • Increased axial pain
  • Major complications within 30 days, and
  • Revision surgery within 12 months.
  • The most important contributors to dissatisfaction were returning to work and returning to previous physical activity, with the odds of dissatisfaction being over 2 times and 4 times higher for these variables.

Part 3: Why does spinal surgery fail to relieve pain? Why do many have “disastrous results”


There are many types of spinal surgery, each with its own success and failure rates.

Lumbar Decompression Failure

In this article, we will only touch on some of the concerns expressed by doctors with lumbar decompression, for a more detailed discussion and analysis please refer to these three articles on our website:

An interesting study on cervical stenosis surgery causing lumbar stenosis complications

One example of how spinal surgery anywhere on the spine can cause problems in other areas of the spine was demonstrated by Korean and American doctors published in the publication Global Spine Journal. (7) They found that patients who underwent surgery for lumbar stenosis symptoms, often show radiologic evidence of cervical and thoracic spinal stenosis. However, the cervical and thoracic stenosis did not cause pain or other symptoms typical of stenosis.

When these patients were sent to lumbar decompression surgery, the prolonged surgical positioning during the lumbar decompression procedure caused the cervical and thoracic spine to become symptomatic in many patients.

This is a classic example of surgery fixing one problem and causing a worse problem in another area of the spine. Non-surgical treatments for spinal instability should be explored in these patients.

An August 2022 paper in the medical journal EFORT Open Reviews (7) describes tandem spinal stenosis. “Tandem spinal stenosis is defined as the concomitant occurrence of stenosis in at least two or more distinct regions (cervical, thoracic, or lumbar) of the spine and may present with a constellation of signs and symptoms. It has four subtypes, including cervico-lumbar, cervico-thoracic, thoraco-lumbar, and cervico-thoraco-lumbar tandem spinal stenosis. . . The diagnosis of tandem spinal stenosis is challenging. The clinical presentation of tandem spinal stenosis could be complex, concealed, or severe, and these features may be confusing to clinicians, resulting in an incomplete or delayed diagnosis. . . The optimal treatment option for tandem spinal stenosis is still under debate; areas of controversies include the choice of the decompression range, the choice between simultaneous or staged surgical patterns, and the order of the surgeries.”

Discectomy Failure

In a discectomy (removal of the disc), the surgeon must spread muscle and cut various ligaments in order to perform the surgery. The surgery itself can potentially lead to ligament laxity and spinal instability. Sometimes this leads to an “immediate failure,” of the back surgery.

German researchers writing in the medical journal Neurosurgical Review (8) noted:

Immediate failed back surgery syndrome following lumbar microdiscectomy is defined as persistence, deterioration or recurrence (during hospital stay) of radicular pain and/or sensorimotor deficits and/or sphincter dysfunction after microdiscectomy, which was uneventful from the surgeon’s perspective.

In some patients who revealed no clear reason to have immediately failed back surgery syndrome, a diagnosis of battered root syndrome (nerve root swelling due to excessive surgical manipulation) was made.

Further removal of a disc or fusion at one level can lead to disc herniation at the same level or at different levels in the future. It is very common for doctors to see a patient with “one level fixed,” while another segment of the spine is now unstable, degenerated, and causing pain as noted in the above study.

Another way surgery causes harm is that in a discectomy, a large portion of the disc remains behind. This is the portion that, if removed, will cause great risk to the patient. The remaining disc can be as much as 40% of the original disc and it can also re-herniate.

A September 2021 study (9) from doctors at the Hospital for Special Surgery, New York; the Icahn School of Medicine at Mount Sinai, New York; and the Weill Cornell Medical College, continued this line of research in trying to determine “the rate of early failures (readmission or reoperation for new or recurrent pain/neurological symptoms) within 30 days after lumbar discectomy and identify associated risk factors.”

In assessing the medical records of 62,690 patients :

  • The overall rate of readmission within 30 days was 3.3%, including 1.2% for pain or neurological symptoms.
  • Populations at increased risk of readmission were those with three or more levels of surgical treatment.
  • Increased risk for readmission was seen in patients over 70 years old age, class 3 obesity (morbid obesity), and in female patients.
  • The overall rate of reoperation within 30 days was 2.2%, including 1.2% for revision decompression or lumbar fusion surgery.

In March 2023 researchers writing in the Global Spine Journal (10) Potential risk factors were identified in the included studies that reported multivariate analysis results, including age, race, obesity, higher American Society of Anesthesiologists score, anemia, bleeding disorder, chronic pulmonary disease, heart failure, dependent status, depression, diabetes, frailty, malnutrition, chronic steroid use, surgeries with anterior approach, multilevel spinal surgeries, perioperative transfusion, presence of postoperative complications, prolonged operative time, and prolonged length of stay.

Endoscopic discectomy – the least invasive procedure – here are the patients it won’t work for.

Some consider endoscopic discectomy as the least invasive surgery for disc herniation. In this procedure, bones do not have to be removed, and muscles do not need to be moved out of the way. In January of 2020, a paper in the Journal of Spine Surgery (11) examined independent risk factors to assess their correlation to sub-optimal outcomes after endoscopic lumbar discectomy.

Study highlights:

  • Analysis of clinical outcomes of 55 consecutive patients treated with endoscopic discectomy between June 2018 and March 2019
  • Primary outcome measures were postoperative reductions of the visual analog score (VAS) graded on a scale of 1 to 10 for back and leg pain and modified MacNab criteria (A grading of (Excellent, Good, Fair, Poor) as well as time to narcotic independence.
  • Risk factors examined included smoking, facet disease, adjacent segments disc degeneration, obesity, alcohol abuse, and psychiatric illness.

Results:

  • Most patients suffered from contained herniations (49.1%) followed by extruded herniations (18.2%).
  • Follow-up ranged from 6-18 months.
  • The most common surgical levels were the L5-S1 level (30.9%), L4-S1 (29.1%), and L4-5 (25.5%).
  • The mean return to work was 24 – 26 weeks.
  • MacNab outcomes showed that
    • 47.3% (26/55) had excellent,
    • 36.4% good (20/55),
    • 12.7% fair (7/55), and
    • 3.6% had poor (2/55), respectively.
  • The VAS scores for the back (7.69 to 2.65) and leg (6.78 to 2.65) pain reduced significantly.

Non-surgical treatments for spinal instability should be explored. Please see our article on Post-laminectomy syndrome for a discussion on that topic.

What are the disastrous results in failed back surgery patients?

For patients, fixing one problem but causing the same problem to appear in another area of the spine can be seen as “disastrous results.” Disastrous result is a term used by doctors in Mexico who investigated patients diagnosed with Failed Back Surgery Syndrome.

In their research, they noted:

The majority of the cases in one group had a previous diagnosis of lumbar stenosis whereas disc herniation was the main diagnosis in the group number.

  • The main reason for failed back surgery in the stenosis group was a technical error during surgery (61.1%).
  • In group 2 the disc herniation group -misdiagnosis was highly prevalent (57.4%). (12)

Therefore disastrous results could be seen arising from “surgical error,” and MRI misinterpretation.

Research appearing in the journal, Seminars in Musculoskeletal Radiology, lists potential complications following spinal fusion which could confuse the interpretation of the MRI for doctors who are trying to see why the patient is suffering from post-surgical pain.

Radiologists are told to look for specific complications related to the use of spinal instrumentation (the hardware) that include incorrectly positioned instrumentation and failure of spinal fusion, leading to instrumentation loosening or breakage. This is in addition to leakage of cerebrospinal fluid, infection, and continued disc herniation. (13)

The problem is MRI cannot tell what is causing the patient’s pain anatomically, it now has to look for suspect hardware. What if there is no suspect hardware? Diagnosis Failed Back Surgery Syndrome.

Recurrence of back or leg pain after surgery is a well-recognized problem with an incidence of up to 28%

Doctors in the United Kingdom wrote in The Journal of Bone and Joint Surgery:(14)

“Recurrence of back or leg pain after discectomy is a well-recognized problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success….The debate around which procedure is the most effective for these patients remains controversial.”

  • Note that the above study cites a 28% rate of post-surgical pain.
  • The researchers also note that controversy exists over the best revision surgery for pain after surgery.
  • Their conclusion is that surgeons may as well choose the least invasive surgery since there’s no one revision surgery that is better than the other.

As mentioned above, surgery of any kind can cause harm to soft tissue, revision surgery is likely not the best answer. Non-surgical treatments for spinal instability should be explored.

It doesn’t matter what type of spinal surgery you had, 1 in 5 people will have persistent pain after the surgery

In an April 2020 study in the Journal of Orthopaedic Surgery and Research,(15) the investigators of this study suggested that there is a substantial risk of ongoing pain following spine surgery, with 1-in-5 patients experiencing persistent postoperative pain within 2 years of surgery, the underlying indications for surgical modality and related choice of surgical procedure do not, by itself, appear to be a driving factor.

Many people we see in our office tell us that they had one surgery or another based on the level of anticipated success that the surgery would have. For many people, the surgery does provide that success, but for many others not. Most notably people who get minimally invasive spinal surgeries believe that these surgeries offer less risk. Research tells us that this is not always the case. We also address this below.


Causes of Chronic Post-Surgical Spinal Pain and why another surgery is being recommended

Before we look at the latest findings on how to help patients understand their failed back surgery and what they can do about it, let’s have a brief summary introduction.

In this video, Ross Hauser, MD describes the 5 main reasons that back surgery failed to help the patient’s condition.

  1. The surgery did not address the actual cause of the patient’s pain. The diagnosis is wrong.  The main cause of ‘”missed” lower back pain is an injury to the Sacroiliac Joint. If your MRI showed disc degenerative disease and you had the discs operated on but the Sacroiliac Joint was not addressed, the pain will continue after the surgery.
  2. The surgery made the lower back MORE unstable. Foraminotomy, Laminectomy, Microdiscectomy, and disc surgery, all have to remove parts of the bone in the spine.
  3.  The “missed secondary problem.” The surgery may have successfully addressed what was considered your primary problem, but, you really had two problems. This could be a multi-segmental problem that was not discovered until after the first surgery.
  4. Too much sitting after surgery, possibly too much bed rest.
  5. Rarer, scar tissue pinches on the nerves. This is discussed at length below.

Generally speaking, spinal pain that occurs right after surgery is from sensitized nerves, while chronic post-surgical spinal pain is often from spinal instability, but, can have many different causes. Some of these problems can include:

  • The surgery caused arachnoiditis – a condition of acute inflammation of the arachnoid membrane that surrounds and protects the nerves of the spinal cord. Symptoms include intense burning or stinging pain and neurological problems.
  • Deconditioning – too much bed rest or as mentioned above, too much sitting
  • EnthesopathyThe enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone. The term enthesopathy typically refers to a degenerated enthesis; though when some doctors use this term, they typically mean enthesitis (inflammation of the enthesis).
  • Epidural fibrosis (scar tissue)
  • Failure of the fusion. This is the failure of the bone and hardware to graft
  • Neuralgia – Nerve pain – Neuritis – Nerve Inflammation – During surgery many superficial sensory nerves have to be cut in order to get down to the vertebrae, and sometimes these nerves get inflamed and/or compressed as they rebuild themselves. Generally, Lyftogt perineural injections and/ or Nerve Release and Regeneration Injection Therapy (NRRIT) may help to resolve this post-surgical neuritis. The treatment is done on or along with the surgery site as well as on any chronic compression injuries that are found on physical examination. Generally, post-surgical treatments are given once a week until the symptoms are resolved. Most likely, four to eight sessions will be needed.
  • Pain from adjacent structures. This subject is covered at length in the companion article to this piece. Surgery for degenerative disc disease? Researchers say many are unnecessary and make patients worse.
  • Spinal Instability
    • The surgery caused spinal instability by removing too much bone.
    • The surgery caused spinal instability by damaging the spinal ligaments.

Now let’s get to the research:

“(Surgeons) believe that the procedure [laminectomy] is done too frequently with improper indications, and with an astounding lack of appreciation of its effect on the mechanical function of the spine.”

In the image below we see a general concept of how open discectomy, endoscopic discectomy, laminectomy, and laminotomy are performed.

In this image below we see a general concept of how open discectomy, endoscopic discectomy, laminectomy and laminotomy are performed.

The above is a powerful statement. It was made forty years ago by two leading spinal surgeons Dr. Augustus  A.  White  III  and  Dr.  Manohar  M.  Panjabi, in their learning and teaching textbook Clinical Biomechanics of the Spine. In this publication, they stated simply: “We believe that the procedure [laminectomy] is done too frequently with improper indications, and with an astounding lack of appreciation of its effect on the mechanical function of the spine.”(16)

Over 40 years later, little has changed.

All spinal surgeries alter spinal mechanics, causing more force to be generated in the areas surrounding the spinal surgical site.

  • In spinal laminectomies and microdiscectomies, the surgical procedure may contribute to clinical instability through the removal of supporting structures of the spinal column. This will alter the spinal dynamic and make the patient more susceptible to new pain.
  • With spinal fusions, pain can be felt at the non-fused adjacent segments. The parts of the spine immediately above and below the surgery site.

Laminectomy in the lower back, thoracic region, or neck can cause or lead to spinal instability. The thoracic spine is especially vulnerable to clinical instability after a laminectomy because it normally has a physiologic kyphosis (a curvature). Because of this normal curvature, the posterior ligaments are not as strong as other ligaments since the stability of the thoracic spine is partially derived from the rib cage. When the lamina (the bony plate of the vertebrae) is taken out, anterior forces prevail, making the thoracic kyphosis (curvature) and instability worse.


Part 4: What type of treatment is available for failed back surgery patients?


More surgery, spinal cord stimulation, epidural injection, exercise therapy, and psychotherapy . . . the evidence of the clinical outcome for each treatment has not been clearly determined.

Often we will see patients with a history of multiple spinal surgeries. Sometimes a few years apart, sometimes many years apart. The progression will usually go from a partial laminectomy to a full decompressive laminectomy.

In the image’s caption are the technical aspects of the laminectomy and bilateral laminotomy procedures.

  • In the laminectomy, the lamina and the spinal process are removed. The ligamentum flavum and the supraspinous ligament are removed.
  • In laminoplasty, a trough or “open door” is drilled into the lamina to allow more room for the spinal cord. This is a decompression: surgery.

Failed Back Surgery Syndrome treatment options

A paper in the medical journal Pain Physician (17) makes it clear that there are not many traditional remedies for the patient who is worse off after back surgery. This is from the research as it appeared in the medical journal Pain Physician.  

“Failed back surgery syndrome is a frequently encountered disease entity following lumbar spinal surgery. Although many plausible reasons have been investigated, the exact pathophysiology remains unknown.”

“Various medications, reoperations, interventions such as spinal cord stimulation, epidural adhesiolysis or epidural injection, exercise therapy, and psychotherapy have been suggested treatment options (for back pain). However, the evidence of the clinical outcome for each treatment has not been clearly determined.”

Not being clearly determined is a non-committal way to say these treatments will not meet the patient’s expectations of pain relief. They do not work. Drug addiction for many is the next step.


Not only does the MRI confuse treatment options after spinal fusion failure – But it may have led directly to the failed surgery

MRI misinterpretations may can cause failed back surgery syndrome

If the MRI showed what was really causing the pain, the lumbar fusion would have worked!

Here is a remarkable finding from research on lumbar fusion success or non-success.

Writing in The Open Orthopaedics Journal, (18) Bo Nystrom of the Clinic of Spinal Surgery in Sweden wrote:

“Results following fusion for chronic low back pain are unpredictable and generally not very satisfying. The major reason is the absence of a detailed description of the symptoms of patients with pain, if present, in a motion segment of the spine.

Various radiological findings have been attributed to discogenic pain, but if these radiological signs were really true signs of such pain, fusion would have been very successful.

If discogenic pain exists, it should be possible to select these patients from all others within the chronic low back pain population. Even if this selection were 100% perfect, however, identification of the painful segment would remain, and at present, there is no reliable test for doing so.” 

We cover this subject at length in my article MRI causes failed back surgery.

Adjacent Segment Disease

Many people have great success with lumbar fusion surgery. These are the people we do not see in our clinic. The people seeking our help and the people we see at our center did not have such great success with their surgery. They developed more back pain, more spinal instability, and some radiating pain in their feet. The need for more fusion has been recommended to them as well because the adjacent segments below and above the fusion have now been comprised.

An August 2022 paper in the Journal of Orthopaedic Surgery and Research (19) wrote: “The most common reasons for early reoperation and late operation were surgical site infection and adjacent segment diseases, respectively. Osteoporosis and diabetes were independent risk factors for early reoperation, and multilevel fusion was an independent risk factor for late reoperation. Surgeons should pay more attention to these patients . . .”

A July 2023 study in the Journal of Neurosurgery Spine (20) examined 902 patients suffering from adjacent segment disease following spinal surgery. Forty-nine (5.4%) patients required reoperation for adjacent segment disease. A significantly higher BMI (Body Mass Index) value was observed in the adjacent segment disease group. Microdiscectomy and microdecompression procedures performed at the upper or lower level of an arthrodesis without fusion extension (more segmental fusion) have a statistically significant impact (causing greater risk) on the development of adjacent segment disease. Postoperative pelvic tilt in the adjacent segment disease group was higher than in the non-adjacent segment disease group. The researchers concluded: “Identifying risk factors for the development of adjacent-level syndrome allows the implementation of a prevention strategy in patients undergoing lumbar arthrodesis surgery. Age older than 65 years, high BMI, preexisting disc degeneration at the adjacent level, and high postoperative pelvic tilt are the most relevant factors. In addition, patients older than 65 years achieve higher levels of clinical improvement and postsurgical satisfaction than do younger patients.”

A team of surgeons from medical universities in Spain published an October 2021 paper in the Italian/English medical journal Minerva Anestesiologica (21) to remind their colleagues of the challenges of treating and preventing adjacent segment disease following spinal fusion.

“The adjacent segment syndrome is defined as the changes in the adjacent structures of an operated spinal level that produce symptoms of pain and disability, which worsen the quality of life of a patient. Pain management specialists must be aware of these biomechanical changes brought by spinal surgeries, as well as of the symptoms associated with pain after surgery, to reach an appropriate diagnosis and provide adequate treatment.

Specialized pain literature contains few reports on specific management of patients using the terms “adjacent segment syndrome, degeneration, or disease”; most of the literature comes from surgical journals.

It is necessary to perform studies with a population sample comprising patients with adjacent segment syndrome after spinal surgery since almost all treatments applied in this group are extrapolated from those used in patients with pain originating in the same area but who have not previously undergone spine surgery. Therefore, we consider it necessary for pain physicians to understand the underlying biomechanics, promote the diagnosis of this condition, and analyze possible treatments in patients with adjacent segment disease to alleviate their pain and improve their quality of life.”

What is being suggested is that there is not enough being done to prevent and properly treat failed back surgery syndrome as a result of adjacent segment disease.

The problem of treatments leading to drug addiction in patients with failed back surgery syndrome.

In March 2019, research led by the University of California, Berkeley published in the journal Cell Transplantation (22) offers this warning:

  • “Because of the increasing cases of spinal surgery, medical doctors are expecting to oversee the care of patients with Failed back surgery syndrome more frequently than before. It is challenging enough to manage back pain without falling into the grave of narcotic addiction.”
  • “According to our clinical studies, the abuse and overdose of narcotics are closely related to the psychological mode and/or state of patients. Consequently, patients who receive narcotics for more than 14 days are recommended for psychological evaluation and treatment, particularly for patients with chronic back pain. Narcotic usage should be strictly controlled by the official drug administration. There should also be a specific committee in hospitals to monitor narcotic usage for nonmalignant diseases.”
  • “(Patients with Failed back surgery syndrome) are likely to suffer from chronic pain despite multiple types of therapy. Narcotics are among the various medications these patients take for the alleviation of pain, and they often become addicted after long-term use. “

Opioids

Continued opioid use after surgery.

An April 2023 study (23) published in the Global Spine Journal evaluated the “factors associated with increased risk of prolonged post-operative opioid pain medication usage following spine surgery, as well as identify the risk of various post-operative complications that may be associated with pre-operative opioid usage.”

  • 553,509 patients who underwent spine surgery during a 10-year period
    • 34.9% of patients used opioids 1-3 months before surgery.
      • 25% patients were still using opioids at 6 weeks,
      • 17.3% at three months,
      • 12.7% at six months, and
      • 9.0% at 1 year after surgery.
    • Pre-operative opioid exposure was associated with increased likelihood of post-operative use at 6-12 weeks, 3-6 months, 6-12 months, and more than 12 months.

A January 2024 study published in the Clinical neurology and neurosurgery (24) from doctors at the Keck School of Medicine of University of Southern California investigated outcomes in long-term preoperative NSAID  and long-term preoperative Opioid use in patients with low back pain in the United States, and the resultant postoperative complications following lumbar fusion.

Methods: In this retrospective cohort study of patients with lumbar pathologies, multivariate population-based regression models were developed using the 2010-2017 National Readmission Database. Short-term complications (30-, 90-day) and long-term complications (180-, 300-day) were analyzed at readmission.

In this large-scale study of lumbar spinal fusion patients:

  • 22,975 patients used preoperative NSAID long-term and 11,213 were preoperative long-term opioid users.
  • Hospital readmission analysis showed that preoperative NSAID use had significantly lower odds of readmission compared to preoperative long-term opioid use.
  • Preoperative NSAID use had significantly higher odds of hardware failure within 300-days of receiving a lumbar fusion.

Preoperative opioid use before undergoing spinal surgery is associated with increased risk of postoperative chronic opioid therapy

An August 2023 study (25) wrote that the current medical research “has general consensus that preoperative opioid use leads to poorer outcomes following spinal surgery. (This study) highlights some common themes identified in this patient population. Namely, preoperative opioid exposure in patients undergoing spinal surgery is associated with increased risk of postoperative chronic opioid therapy, decreased return to work rates, increased length of hospitalization, and increased healthcare costs.”

A February 2023 paper published in the journal World neurosurgery (26) lead by Thomas Jefferson University and Jefferson Hospital for Neuroscience “compared the incidence of 2-year subsequent surgical procedures and postoperative adverse events in patients undergoing lumbar fusion with or without 90-day preoperative opioid use.” The thinking was “patients using preoperative opioids would have a higher incidence of subsequent surgery and adverse outcomes.”

  • In this study outcomes of 2112 patients who used opioids preoperatively were assessed.
  • There was a significantly higher incidence of infection in opioid users compared with nonusers.
  • There was no association between subsequent fusion surgery  and subsequent decompression surgery  between opioid users and nonusers.
  • Regarding postoperative infection risk, low-dose opioid users showed significantly higher incidence, but high-dose users did not show higher incidence than nonusers.

Treatments: Spinal Cord Stimulation or Opioids? Both?

Spinal Cord Stimulation explained

A July 2022 paper in the journal Neuromodulation (27) gives this assessment of Spinal Cord Stimulation. “Spinal Cord Stimulation showed beneficial effects on different domains of life (daily functioning, quality of life, treatment expectation, experiences, and satisfaction) in patients with failed back surgery syndrome. . .  Analysis suggests an overall improvement in most domains, although patients’ experiences show that limitations in daily life and living with the Spinal Cord Stimulation system persist. Multiple extensive preoperative counseling sessions and discussions with patients are deemed necessary to improve patient satisfaction and meet their expectations.”

What this paper is suggesting is that there can be good outcomes with Spinal Cord Stimulation, however, patient expectations are not often met. Why does this happen?

“Higher Preimplantation Opioid Doses Associated With Long‐Term Spinal Cord Stimulation Failure “

One reason that spinal cord stimulation may fail is a long history with opioids.

A January 2021 study in the medical journal Neuromodulation (28) comes to us from Finish doctors at Kuopio University Hospital, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland. Here is the data and recommendations they compiled:

While spinal cord stimulation is an effective treatment in failed back surgery syndrome, the effect of preimplantation opioid use on spinal cord stimulation outcome and the effect of spinal cord stimulation on opioid use during a two‐year follow‐up period was initiated in patients with persistent pain after spinal surgery.

Study highlights:

  • The study group included 211 consecutive failed back surgery syndrome patients who underwent spinal cord stimulation during a 17-year period concluding in 2014.
    • Study patients were divided into groups, which were as follows:
      • 1) spinal cord stimulation only (47 patients)
      • 2) successful spinal cord stimulation (implanted and in use throughout the two‐year follow‐up period, 131 patients), and
      • 3) unsuccessful spinal cord stimulation (implanted but later explanted or revised due to inadequate pain relief, 29 patients).
      • Patients who underwent explantation for other reasons (4 patients) were excluded.
      • Opioid use was also investigated in this group

Results:

  • Higher preimplantation opioid doses were associated with unsuccessful spinal cord stimulation only with 35 morphine milligram equivalents (MME)/day as the optimal cutoff value.
  • All opioids were discontinued in 23% of patients with successful spinal cord stimulation only but in none of the patients with unsuccessful spinal cord stimulation.
  • Strong opioids were discontinued in 39% of patients with successful spinal cord stimulation but in none of the patients with unsuccessful spinal cord stimulation.

Conclusions – detrimental dose escalation

  • Higher preimplantation opioid doses were associated with spinal cord stimulation failure, suggesting the need for opioid tapering before implantation. With continuous spinal cord stimulation therapy and no explanation or revision due to inadequate pain relief, 39% of FBSS patients discontinued strong opioids, and 23% discontinued all opioids. This indicates that spinal cord stimulation should be considered before detrimental dose escalation.

The idea is Spinal Cord Stimulation is supposed to reduce opioid use – research gives varying opinions if this is true

A January 2020 paper led by doctors at the Department of Neurosurgery, the University of Iowa Carver College of Medicine appeared in the journal Neuromodulation (29) discusses the realistic outlook of patients with failed back surgery syndrome, history of opioid use, and spinal cord stimulation.

“With only half of the chronic opioid users demonstrating meaningful opioid reduction after spinal cord stimulation implantation, (the researchers) demonstrate that current spinal cord stimulation technology does not reliably help a larger number of patients reduce opioid usage. Women, older age, and preoperative MED (pain medication usage) are predictive of meaningful opioid reduction but only one of these is modifiable. As not all patients saw benefit from their therapies, there is still much room for improvement in the treatment of refractory chronic pain that is associated with failed back surgery syndrome and chronic regional pain syndrome.”

An April 2021 paper in the journal Pain Medicine (30) however gives a more optimistic assessment showing: “that among patients who continued spinal cord stimulation therapy for at least 2 years, a significant proportion were able to reduce and/or discontinue systemic opioid use.”

What are we seeing in this image?

It is a pelvic x-ray showing a patient’s spinal cord stimulator and the spinal fusion screws. This is a graphic display of the complication and challenges of a failed back surgery. The patient to whom this x-ray belongs had a history of multiple spinal surgeries, cortisone injections, and the implantation of a spinal cord stimulator. The patient came in to see us because she was not getting pain relief. Following Prolotherapy treatments she had the SCS removed. Her story may not be typical of patient success with treatment. It is her story.

It is a pelvic x-ray showing a patient's spinal cord stimulator and the spinal fusion screws.

In this section, we will examine various treatments. For many people these treatments may work well long-term or short-term, for others, there are limits to treatments’ successful outcomes.

There is limited evidence for oral opioids in the treatment of chronic lower back pain; however, their routine use is widespread

Long-term Oxycodone – naloxone use?
Naloxone is given to counteract the long-term effects of narcotic use. In one case study published in 2015, Spanish researcher Dr. Borja Mugabure Bujedo recorded that a combination of  Oxycodone – naloxone can be a good alternative for the management of Failed Back Surgery Syndrome when other interventional or pharmacologic strategies have failed in a case report in the journal Anesthesiology and Pain Medicine. In this case report, higher doses than those recommended as a maximum daily ceiling (80/40 mg) were used in one selected patient with severe pain. (31)

  • Please see our article Painkillers Can Increase Chronic Pain for a further discussion on why doctors need to come up with a better plan of pain management rather than opioid dependence.

This is something the authors of the above-cited study acknowledge, “Failed Back Surgery Syndrome” obviously needs a multidimensional clinical approach. Therapy failure might result from psychosocial influences, structural abnormalities in the back, or a combination of both.”

The next sentence is much more telling. In it, Dr. Bujedo notes that despite success in this reported case history:

  • “Causes of back pain are largely unknown and correlations with diagnostic studies are uncertain. This lack of precise diagnosis is reflected in a multiplicity of nonspecific treatments, mostly of unproven value.  There is limited evidence for oral opioids in the treatment of chronic low back pain; however, their routine use is widespread.”

A 2018 study (32) published in the journal Clinical and Experimental Gastroenterology built on this research by suggesting that managing side effects, in this case, constipation would help the patient with their failed back problems. Here is what the researchers wrote: “Opioids are an effective treatment for moderate-to-severe pain. However, they are associated with a number of gastrointestinal side effects, most commonly constipation. Laxatives do not target the underlying mechanism of opioid-induced constipation, so many patients do not have their symptoms resolved. Fixed-dose prolonged-release oxycodone/naloxone tablets contain the opioid agonist oxycodone and the opioid antagonist naloxone. Naloxone blocks the action of oxycodone in the gut without compromising its analgesic effects.

Limitations of Spinal Cord Stimulators – People still take opioids

Spinal Cord Stimulators and opioids

For a more comprehensive understanding of how we can help people after failed spinal cord stimulation please see our article When Spinal Cord Stimulators are not helping.

Spinal cord stimulators can be very effective for many people. We typically do not see the people from whom spinal cord stimulators were effective at our center. We see the people for whom they were not.

Spinal cord stimulation is usually reserved as a last-chance effort at controlling back pain. Specifically, it is used for people who have pain after surgery, complex regional pain syndrome, or severe nerve pain and numbness. The procedure involves implanting a small pulse generator into the stomach and running coated wires to the spine to deliver electrical impulses to the spinal cord. These electrical impulses block pain signals traveling to the brain.

In most patients we see, the spinal cord stimulator does not replace the need for narcotic medication. Additionally, a foreign device is placed in the body, which is nearly never the best option. There are risks to implanting a foreign device in the body. Some of these risks include infection, scar tissue around the stimulator, headaches, breakage of electrical wire, and pain beyond the reach of the impulses.

Spinal cord stimulation (SCS) has been considered as an alternative therapy to reduce opioid requirements in certain chronic pain disorders

A February 2021 study in the Journal of Clinical Neuroscience (33) writes: “Spinal cord stimulation (SCS) has been considered as an alternative therapy to reduce opioid requirements in certain chronic pain disorders. However, information on long-term opioid consumption patterns and their impact on SCS device explanation (removed) is lacking. ”

In this study, 45 patients were followed following the removal of their spinal cord stimulation devices. Here is what happened to them:

  • Daily morphine equivalent dosage (MED) The number of pain medications they were taking:
    • Increased in 40% of patients
    • Decreased in 40% of patients
    • and remained the same in  20% of patients at 1-year follow-up,
  • Twelve (27%) patients had undergone explantation due to treatment failure at an average of 18 months after implantation.
  • Following explantation,
    • Reduction in the daily MED was seen in 92% of patients with dosages falling below the pre-operative baseline in nine.
    • Among the opioid naïve patients (not currently taking or had stopped taking opioids), 55% were on opioids at the last follow-up
  • (These results) indicate that daily opioid consumption does not decrease in most patients a year after SCS implantation.
  • Furthermore, postoperative evaluation beyond 1-year is necessary to assess the efficacy and durability of SCS therapy as well as its impact on the opioid requirement. Lastly, rigorous patient selection and pre-operative risk assessment for misuse and dependence are paramount to improving outcomes after SCS implantation.

“Spinal cord stimulators should be explored as the best option against further exposing patients to more failed procedures.”

In the July 2017 issue of the medical journal Spine(34) doctors explained that spinal cord stimulators should be explored as the best option against further exposing patients to more failed procedures: “Clinical evidence suggests that for patients with Failed Back Surgery Syndrome), repeated surgery will not likely offer relief. Additionally, evidence suggests long-term use of opioid pain medications is not effective in this population, likely presents additional complications, and requires strict management.

Why the spinal cord stimulations have to be removed 

Seventeen pain centers across the United States took part in a study to see why spinal cord stimulations had to be removed from patients.

In agreement with other studies, the pain centers found that clinically, spinal cord stimulation devices are cost-effective and improve function as well as the quality of life. However, despite the demonstrated benefits of spinal cord stimulation, some patients have the device removed. The researchers in this study wanted to know why.

The most common reason for device removal was:

  • lack or loss of pain relief, (43.9%)
  • followed by complications (20.2%)

This research appeared in the August 2017 edition of the medical journal Neuromodulation. (35)

Failed Back Surgery Syndrome Treatment: Intrathecal drug delivery

Similar to a spinal cord stimulator, spinal drug delivery (or intrathecal drug delivery) involves implanting a small pump in the stomach and running a catheter to the spine to deliver pain medication. It is used for people with chronic back pain who need large doses of narcotics to deal with the pain. Compared to oral medication, this “pain pump” requires a smaller dose of narcotics because the medication goes directly to the area of pain.

Research in the medical journal Neuromodulation (36) wrote of the benefits of intrathecal drug delivery. Researchers looked at patients who averaged 67 years of age, 68% were women, and 77% were Medicare beneficiaries.

  • Ninety-five percent of patients had low back pain, and 86% had limb pain.
  • The majority (81%) had pain for more than 5 years.
  • Failed treatments included:
    • epidural injections (74%),
    • lumbar spine surgery (46%),
    • spinal cord stimulation (14%),
    • and facet joint injections (11%),
    • with 84% also reporting significant systemic opioid side effects.

All patients taking long-acting opioids discontinued these within one month of the implant. Total systemic opioid elimination was accomplished by 68% of patients at one month post-implant, 84% at one year, and 92% at five years.

In October 2020 published in the medical journal Neuromodulation (37) examined patient satisfaction following intrathecal targeted drug delivery for chronic pain. The authors write: “Past studies have proven efficacy in pain relief and reduction in opioid use and cost-effectiveness in long-term pain management.” They also noted that “there are few studies investigating satisfaction among patients with implanted pain pumps that are managed with targeted intrathecal medications.”

In this study, four hundred and forty-three active targeted drug delivery patients were asked about their satisfaction with targeted drug delivery therapy.

  • The majority of patients reported improvement in pain, improvement of physical function, improvement in quality of life, and reduction in opioid use.
  • Complete discontinuation of oral opioid intake was reported in 38.9% of patients.
  • The majority of patients had a 40 cc reservoir implanted in an upper buttock pocket site and overall, 91% of patients were happy with the pump pocket location.

Conclusion: “Intrathecal TDD therapy can relieve pain and improve quality of life in patients with intractable pain and offers a reasonable alternative to long-term oral or skin patch opioid management. Patients utilizing targeted drug delivery therapy reported high degrees of satisfaction.”

A July 2023 study (38) from the University Hospitals Cleveland Medical Center assessed the effectiveness of a continuous intrathecal infusion of an admixture of bupivacaine and fentanyl in patients with chronic low back pain. In this study, patients with difficult-to-treat chronic low back pain in the setting of previous lumbar spine surgery (failed back surgery syndrome) and/or chronic vertebral compression fracture(s) were enrolled in a randomized double-blind cross-over study comparing saline infusion to infusion of a solution containing bupivacaine combined with low-dose fentanyl over a 14-18 hour period. The researchers found pain scores, at rest or with activity, decreased appreciably in both the saline infusion groups and the solution containing bupivacaine combined with low-dose fentanyl groups; however, significantly better improvements occurred in the fentanyl/bupivacaine group.

Failed Back Surgery Syndrome Treatment: Mind Over Body Pain Control

In a 2012 often-referenced article, doctors at the University of Duisburg-Essen in Germany wrote in the journal BMC Complementary and Alternative Medicine: “Mindfulness-based stress reduction (MBSR) is frequently used for pain conditions. While systematic reviews on MBSR for chronic pain have been conducted, there are no reviews for specific pain conditions. Therefore a systematic review of the effectiveness of MBSR in low back pain was performed….This review found inconclusive evidence of the effectiveness of MBSR in improving pain intensity or disability in chronic low back pain patients. However, there is limited evidence that MBSR can improve pain acceptance.”(39)

  • In other words, just live with the pain. Mental strength can help, but the reality is that there is an underlying cause of the pain that needs to be addressed. So what are other options for pain after back surgery?

In 2023, doctors at The University of South Australia and Southern Cross University followed the line of the 2012 study and performed an umbrella review (a review of research reviews) of 194 studies on Mindfulness-based interventions. (40) Although the researchers found “some promising evidence was identified for the use of Mindfulness-based interventions in Chronic musculoskeletal pain”, the generally low quality of research made it difficult to reach a definitive conclusion.”

Depression after failed back surgery . . . some researchers believe that being depressed after surgery is “understandable” and “unworthy of diagnosis or treatment.”

In the May 2017 edition of the Journal of Physical Therapy Science, researchers concluded that the surgery experience in patients with ongoing low-back pain makes their pain and depression worse. (41)

Here are the learning points from this research:

Doctors have long been aware that many patients experience some form of post-surgical depression in the six months following an invasive procedure. However, some researchers believe that being depressed after surgery is “understandable” and “unworthy of diagnosis or treatment.”

As most people with post-surgical depression emerge from depression after about six months, many doctors consider post-surgical depression either benign or even helpful as it keeps people inactive. Nevertheless, researchers have discovered that depressed patients are more likely to have other complications following back surgery.

They are less able to cooperate in their after-care, particularly in rehabilitative therapy. For people who have an existing history of depression and anxiety, recovery from post-surgical depression is neither guaranteed nor as straightforward as some surgeons expected.

Please see a further discussion in our article Chronic Back Pain, The Impact of Depression and Anxiety

Part 5: Adjacent segment disease and spinal instability – the key to treatment may be spinal ligaments

An October 2021 paper published in the European Federation of National Associations of Orthopaedics and Traumatology Open Review (EFORT) (42) examined who was at higher risk for developing adjacent segment degeneration following a spinal fusion. This is what they wrote: “Spinal fusion is the most widely accepted treatment for lumbar disc degenerative disease. However, it has been associated with adjacent segment degeneration as a potential long-term sequel, especially in those with preoperative risk factors, which may cause aberrant (unnatural and excessive) stress forces in these segments and lead to adjacent-level degeneration. Adjacent segment pathology can include adjacent segment degeneration and adjacent segment disease, although a clear and consensual definition of adjacent segment disease is missing. In most studies, adjacent segment degeneration is defined as radiographic changes in the intervertebral discs adjacent to the surgically treated levels, whereas adjacent segment disease is defined as the pathologic process associated with disc degeneration leading to clinical symptoms, such as radiculopathy, stenosis, and instability.”

Prolotherapy, as will also be explained in this article, is an injection therapy that seeks to stabilize the structures of the spine through healing soft tissue damage caused by the surgery or not fixed by the surgery. Prolotherapy is an injection technique that accelerates healing in soft tissue. Issues of hardware failure, bent or loose screws or plates, and faulty wiring are issues that need to be addressed by spinal surgeons first. This article will address issues of failed back surgery syndrome where hardware failure is not the issue.

We have taken you on a journey throughout this article to show the current options that are most commonly prescribed. We are now going to continue with the discussion of Prolotherapy.

New research, new hope on avoiding revision surgery with simple tissue regeneration injections

When chronic back pain continues after back surgery, some doctors are hopeful that they can help their patients with simple sugar or dextrose Prolotherapy injections. This concept will be discussed below with appropriate medical evidence.

In research from May 2019, researchers at the Gulhane Training and Research Hospital, Traditional and Complementary Medicine Practice Center, University of Health Sciences, Ankara, Turkey wrote in the European Spine Journal : (43)

  • “Patients with chronic low back pain, who do not respond to conservative treatment methods, generally undergo surgical revision operations, and sometimes an undesirable condition called failed back surgery syndrome (FBSS) may be inevitable. Hereby, dextrose (Prolotherapy injections) is one of the regenerative methods that has gained popularity in the treatment of many musculoskeletal problems, and we aimed to present and evaluate the outcomes of (Prolotherapy injections) for the treatment of FBSS.
  • A total of 79 patients with failed back surgery syndrome, who had a minimum of 6 months of symptoms and did not respond to 3 months of conservative methods between May 2014 and March 2016, participated in the study.”

What did the researchers find?

  • Prolotherapy injections provided significant pain relief and improvement in disability scores.

The conclusion of this research? The doctors said:

  • These results may be the first step giving a lead to an undiscovered field (of pain relief and spinal stability). This treatment method should be kept in mind for FBSS patients before giving a decision on revision surgery.”

What this research suggests is that if you inject a simple sugar (dextrose) into the supportive soft tissue structures of the spine, that is the spinal ligaments, tendon-bone attachments, and fascia, there is a good chance that the patient with pain following failed back surgery syndrome can get relief and a strengthen spine.

Because you have likely been suffering for some time, and because you have probably heard other researchers say the same thing about other treatments, we are going to provide you with comprehensive information on the various options you have.

Comprehensive Prolotherapy is a treatment designed to strengthen weakened soft tissue in the spine and bring stability to the area through injections, not surgery. More stability, less unnatural movement, less pain. We recommend a consultation for those on narcotics and those with spinal cord stimulators. In the case of spinal stimulators, we ask patients to bring in their X-rays showing exactly where the spinal cord stimulator is placed. As long as we can see where the stimulator electrodes are located we can safely do Prolotherapy.

  • Patients and doctors should realize there is obviously a reason why the spinal fusion didn’t work. In the fusion, the surgery fused the lumbar vertebrae, but the fusion surgery did not address where the cause of the pain was coming from. If pain persists after the surgery, the surgery does not address the cause or create more damage itself.
  • At 0:45 of the video, Dr. Hauser demonstrates how this happens.
  • Often when you have failed back surgery syndrome, the pain source can be traced to coming from your sacroiliac joint. If this is the case this is where we inject Prolotherapy.

Prolotherapy attacks the problems of a damaged spine instead of suppressing the symptoms. It offers a fix when all else fails. While Prolotherapy is an alternative to disc surgery, it can also help when disc surgery has already occurred yet failed to address the root issue.

When the surgery itself causes new post-surgical pain, can we treat that with Prolotherapy?

When you fuse two or three spinal segments together, mobility is lost. Spinal twisting and torque movement, however, have to come from somewhere. Where? The spinal segments above and below the fusion. These vertebral segments now have to move “excessively” to compensate. Ultimately, this extra movement and strain will cause accelerated degeneration of the disc, ligaments, and joints of these segments, thus making the person more prone to pain in these areas. This is most likely the explanation for the increased pain a few years down the road and the “need” for more operations later.

In research from Harold Wilkinson MD, published in the medical journal Pain Physician,(44), Dr. Wilkinson looked at difficult back pain cases: “Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery,” to see is simple dextrose Prolotherapy would be of benefit.

Here are some learning points:

  • Thirty of the 35 patients in this study had been referred to a neurosurgeon because of persistent pain and disability despite prior low back surgery and were referred for consideration for possible additional surgery.
  • After inclusion in this study, only four patients subsequently underwent additional surgery, though 29 patients requested repeat injections.
  • This suggests that painful enthesopathy can be a major pain generator for some patients and that diagnosing their condition as being due to a focal problem and treating those sites with prolotherapy can be an effective and “minimally invasive” treatment alternative. (The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone.)

In 2022 our research team published in the Journal of Back and Musculoskeletal Rehabilitation (45) of our findings into Prolotherapy treatments for low back pain. We cited the above research and noted the conclusion: “Prolotherapy injections to painful enthesopathies provide substantial relief from axial pain and tenderness along with functional improvement, even in cases of “failed back [surgery] syndrome”. In the full text of that paper, dozens of references for Prolotherapy are given.

The Spinal ligament repair injection treatment option Prolotherapy

Prolotherapy failed back surgery syndrome treatment

  • Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.

Failed Back Surgery Syndrome Treatment: Platelet Rich Plasma Therapy in combination with Prolotherapy

  • For patients with back pain, PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into the areas of the spine where damaged ligaments may be present.
  • Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
  • The procedure and preparation of therapeutic doses of growth factors consist of autologous blood collection (blood from the patient), plasma separation (blood is centrifuged), and application of the plasma rich in growth factors (injecting the plasma into the area.) In our office, patients are generally seen every 4-6 weeks. Typically three to six visits are necessary per area.

Some doctors may recommend the use of Platelet Rich Plasma to help patients with failed back surgery syndrome. The concentrated blood platelets bring healing and regenerating growth factors to the areas possibly damaged or affected by surgery. There is not much by way of published research to address PRP as a sole treatment for failed back surgery.

A 2016 study says that  Platelet-rich plasma (PRP) represents an additional approach, as it has shown some promise in bone regeneration, and should be explored for its potential role in limiting spinal fusion surgery failures. (46)

However, most research is focused on the use of PRP as an adjunct therapy to help prevent spinal fusion failure. Research has been mixed on these outcomes. A March 2022 paper in the Global Spine Journal (47) examined previously published research and found that “the effectiveness of PRP as a biological agent in augmenting spinal fusion is limited. Current evidence does not support the use of PRP as an adjuvant to enhance spinal fusion.”

In our practice, PRP is used in conjunction with dextrose Prolotherapy to stimulate the healing of the ligament and tendon attachments of the spine that cause pain, muscle spasms, degenerative discs, and other conditions.

For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.

Summary and contact us. Can we help you?

Many people only become aware of Prolotherapy after they have undergone a surgical procedure for back pain. Although the pain may not be as severe as it was before the surgery, most people continue to experience significant back pain after surgery. Why? Because the back surgery involved removing supporting structures, such as a lamina, facet, or disc, thus weakening surrounding segments.

Except in a life-threatening situation or impending neurologic injury, surgery should always be a last resort and performed only after all conservative treatments have been exhausted. Pain is not a life-threatening situation, although it can be very anxiety-provoking, life-demeaning, and aggravating. Pain should not be an automatic indication that surgery is necessary.

It is not uncommon for patients to say that surgery has been recommended to resolve their painful back conditions. Reasons for surgery may be herniated discs, compressed nerves, spinal stenosis, severe arthritis, and intractable pain. Such conditions may have nothing to do with the problem causing the pain. As previously discussed abnormalities noted on an MRI scan, such as a pinched nerve or herniated disc, rarely are the reasons we find for someone’s chronic back pain. We find at Caring Medical that spinal instability due to ligament weakness is the number one reason for chronic low back pain, and this diagnosis is not made by an MRI.

Prolotherapy injections to the weakened segments in the lumbar vertebrae often result in definitive pain relief in post-surgery pain syndromes.  Back pain is commonly due to several factors and surgery may have eliminated only one. It is possible, for example, to have back pain from a lumbar herniated disc and a sacroiliac joint problem. Surgery may address the herniated disc problem but not the sacroiliac problem. In this example, Prolotherapy injections to the sacroiliac joint can significantly help the chronic pain problem. Prolotherapy can help many people who have failed back surgery by addressing spinal instability and repairing loose, lax, damaged ligaments. The key to successful treatment is identifying the right candidates. These treatments will not help everyone.

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your back problems and spinal instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References

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