Ethics in Medicine

Failed Back Surgery Syndrome: A Review Article

Kristen Sparrow • August 13, 2020

Failed Back Surgery Syndrome: A Review Article

San Francisco Acupuncture for Back PainBackground research for my writing project.  Back surgery is one of the most expensive surgeries that have a troubled past and current state of affairs.  It is one of those “biologically plausible” procedures that can wreak havoc.

. 2018 Apr; 12(2): 372–379.
Published online 2018 Apr 16. doi: 10.4184/asj.2018.12.2.372
PMCID: PMC5913031
PMID: 29713421

Failed Back Surgery Syndrome: A Review Article


Postsurgical spine syndrome is becoming an increasingly common challenge for clinicians who deal with spinal disorders owing to the expanding indications for spinal surgery and the aging world population. A multidisciplinary approach is most appropriate for patients who are unlikely to benefit from further formal surgical intervention. Anticonvulsant medications are effective in managing neuropathic pain after surgery, whereas opioids are rarely beneficial. Neuromodulation via a surgically implanted dorsal column neurostimulator is gaining popularity owing to its substantial superiority over conventional medical management and/or further surgical intervention. However, considering that prevention is always better than cure, spinal surgeons need to be well aware of the many poor prognostic indicators for spinal surgery, particularly psychosocial overlay.

Keywords: Postsurgical spine syndrome, Failed back surgery syndrome, Repeat spinal surgery, Chronic pain management, Neuromodulation, Spinal cord stimulation


Low back pain (LBP) has been estimated to have a lifetime prevalence of 60%–80% among the global population, making it one of the most common health complaints []. Approximately 10% of individuals suffering from LBP have symptoms that persist for longer than 3 months []. As a consequence of the large number of patients with LBP who have sought treatment, a substantial increase in those undergoing surgery has been observed over the past two decades.

Failed back surgery syndrome (FBSS) is a term used to describe a clinical entity that has been acknowledged since the advent of spinal surgery. It was perhaps best described by Follett and Dirks [] as the “surgical end stage after one or several interventions on the lumbar neuroaxis indicated to relieve lower back pain, radicular pain or the combination of both, without effect”. A more functional definition is “when the outcome of lumbar spinal surgery does not meet the pre-surgical expectations of the patient and surgeon” [].

The term FBSS has been criticized for being a clinical misnomer for both patients and surgeons alike []. The qualifier “failed” does little to elucidate the entity, and it is perhaps most appropriate to abandon this term entirely. The diagnostic term “postsurgical spine syndrome” perhaps more accurately describes the aforementioned clinical entity [].

Between 1998 and 2008, the yearly number of lumbar fusion surgeries performed in the United States increased from 77,682 to 210,407, with the total number of spinal operations exceeding one million in 2002 [,]. The direct yearly cost of spinal fusion surgery in the United States was over US$ 16 billion in 2004 [], whereas the overall failure rate of lumbar spine surgery was estimated to be 10%–46% []. Given that these rates have not changed substantially over the years despite advances in technology and surgical technique, the number of patients developing FBSS can be expected to continually increase [].

The potential widespread occurrence of this condition necessitates accurate assessment of this challenging patient population to best address their symptoms and deliver the most effective treatment.

The Problem

Repeat spinal surgery is a treatment option with diminishing returns. Although more than 50% of primary spinal surgeries are successful, no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries, respectively []. The prevalence and incidence of patients with FBSS are comparable with those of patients with rheumatoid arthritis. However, patients with FBSS and neuropathic pain experience higher levels of pain and a poorer quality of life and physical function compared with those with osteoarthritis, rheumatoid arthritis, complex regional pain syndrome, and fibromyalgia [].

Factors Leading to Failed Back Surgery Syndrome

1. Patient factors

A number of patient-related factors may be associated with higher rates of FBSS and should be considered when discussing treatment options. A patient’s psychosocial wellbeing has a significant effect on his/her treatment outcome and pain experience such that Carragee et al. [] found poor psychosocial wellbeing to be the strongest predictor of LBP disability in a study comparing morphological and social risk factors. This is also true when predicting poor outcomes after spinal surgery []. A large number of patients assessed for spinal surgery comprise those claiming workers’ compensation or receiving disability support pension. Both of these groups have been found to be significantly more likely to have poorer outcomes after spinal surgery, with those claiming workers’ compensation having the poorest outcomes. The figures become even more alarming after considering preexisting depression [].