Post-laminectomy pain syndrome is also known as failed back surgery syndrome (FBSS). This term can be seen as pejorative, ethically ambiguous, and placing the onus of the “failure” on the patient.1 With the recommendation of the International Association for the Study of Pain (IASP) and the implementation of International Classification of Disease (ICD-11) on January 1st, 2022, this diagnosis was changed to “chronic pain after spinal surgery (CPSS)”. However, the ICD-11 has yet to be widely adopted. The terms “post-laminectomy pain” and “FBSS” will be used throughout this document for continuity and to improve search engine optimization for this topic, but readers should be aware of the new terminology for future reference. The term “persistent spinal pain syndrome (PSPS)” with two subtypes (T1 – no spine surgery performed and T2 – post-spine surgery) has also been proposed to address some ambiguity with CPSS but has not yet been added to the ICD-11.1,2
Post-laminectomy pain is defined by the IASP as “lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location”.3 There may be many causes for this chronic pain creating a complex pathophysiology.
Predictive risk factors include preoperative (patient) factors, intraoperative factors, and postoperative factors.4,5,6,7,8
- Preoperative: this can be divided into patient-specific and surgery-specific factors. Depression, anxiety, hypochondriasis, obesity, smoking, worker’s compensation or ongoing litigation, and radiographic findings such as disc herniation, stenosis, and fibrosis increase the risk of FBSS.9,10 Psychosocial factors are strongly linked to developing disability from low back pain (LBP).11 However, this does not exclude an organic problem, and these factors should be optimized before the surgery.12 Earlier surgery in patients with poor psychometrics and lumbar disc disease may actually improve pain outcome, as prolonged pain and distress can reduce the efficacy of the surgery.13 Selecting an inappropriate patient for surgical treatment (e.g., isolated axial back pain for microdiscectomy or multiple revision surgeries) or an inappropriate surgical approach (e.g., inadequate decompression) can increase the risk of developing FBSS.6 Patients with previous back surgeries have a lower chance of pain relief following surgery and a higher chance of developing FBSS.8
- Surgical: operating at the wrong vertebral level or operating at a single vertebral level when the pain generators are multiple levels can lead to poor pain relief.6,8 Lumbarization of the sacral vertebra or sacralization of the lumbar vertebra can lead to operating at the incorrect level. Poor surgical technique is also significant factor in the development of FBSS, especially if there is inadequate decompression at the lateral recess or neural foramina.14,15 Conversely, spine instability may occur if > 33% of the bilateral articular or 100% unilateral articular surfaces are removed.14 Minimally invasive techniques with limited exposure can increase the likelihood of incorrect surgery.6 With consecutive reoperations of spinal fusions, success rates decline and spinal instability increases.16,17 Reoperation after lumbar microdiscectomy may have a higher success rate.
- Postoperative: long-term complications following surgery can cause FBSS in some patients, which can be divided into disease-related and surgery-related factors. Disc herniation can occur at the same or adjacent level to the surgical site.18,19 Adjacent segment disease is a known complication of lumbar fusion, and is a risk factor for reoperation following microendoscopic discectomy.19 Sagittal plane imbalance following lumbar spinal fusion also predisposes to adjacent segment disease.20 Mismatch between pelvic incidence and lumbar lordosis following lumbar spinal fusion is another risk factor.21 Nerve root irritation can be another factor contributing to FBSS, such as nerve root entrapment due to epidural fibrosis or “battered root syndrome” due to excessive bleeding or excessive nerve root retraction causing radicular pain.6
Epidemiology including risk factors and primary prevention
Most adults will experience chronic low back point in their lives, with estimates ranging from 51-60% to 80-84%.22 The incidence is increased with age and in females.23 The aging population also increases the incidence of surgery for lower back pain.4 FBSS is not precisely defined and has heterogeneous etiologies, so estimates range from 10% to 40% incidence following lumbar laminectomy with or without fusion.5,7 The incidence of FBSS increases with more complex surgery; the failure rates of lumbar fusion range from 30-46% and 19-25% for microdiscectomy. Decompressive surgery seems to be the most beneficial for low back pain with a success rate between 65% and 75%.24
As discussed above, preoperative risk factors include anxiety, depression, hypochondriasis, obesity, smoking, worker’s compensation or ongoing litigation, and radiographic findings such as disc herniation, stenosis, and fibrosis can increase the risk of FBSS. Psychosocial factors do not exclude an organic etiology but require special consideration. Inappropriate surgical candidates or surgical approaches also predispose to FBSS. Identification of which risk factors can be modified can help in primary prevention of FBSS.
The pathophysiology of FBSS is multifactorial. Lateral foraminal stenosis is the most common structural abnormality in patients that develop FBSS.7 Disc degeneration, disc herniation, neuropathic pain, and pseudoarthrosis are other factors that can cause FBSS.25 Epidural fibrosis and spinal instability following surgery can also predispose to FBSS7Neuropathic pain may result from incomplete decompression, migration of pedicle screws, compression from scar tissue, local arachnoiditis, or centralization of pain unrelated to neural impingement. Myofascial pain can also be a pain generator, which may result from intraoperative insult to the muscles, compounded by postural changes in the postoperative period.26
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Persistent symptoms immediately after surgery might suggest technical issues, psychosocial overlay, severe nerve damage not alleviated by decompression, improper presurgical diagnosis, incomplete decompression or recurrent herniation. Early recurrence of symptoms occurring in the first one to five days should prompt imaging to evaluate for hematoma. If the patient expresses relief initially, but pain returns in one or two weeks, an infection should be ruled out. When symptoms present months after surgery, recurrent disc herniation, spinal nerve trauma, or post-operative fibrosis should be considered. Pain that presents more than a year after surgical intervention might be caused by the development of adjacent segmental instability or stenosis.27
Specific secondary or associated conditions and complications
Patients might develop progressive pain and dysfunction. Success rates decrease for each surgical re-intervention, falling from 50% after the first repeat surgery, to 30% after the second, 15% after the third, and 5% after the fourth.28
Essentials of Assessment
The evaluation of a patient with post-laminectomy pain should include a detailed history assessment and should compare the preoperative symptomatology with the recent one. Initial evaluation should include the location of pain, low back (axial), vs. the leg (radicular), as this can help to differentiate etiology. The following assessment should focus on duration of pain, which can be categorized as new, persistent, or recurrent.29 If the pain is of an early onset or is the same as described preoperatively, an intraoperative or postoperative etiology may be suspected.30 Next, evaluation should include circumstances, positions, quality, pattern, and movements that improve or exacerbate the symptoms.29 History should also assess red and yellow flags. Red flags are considered organic signs and symptoms (nocturnal pain, weight loss, trauma, infection, saddle anesthesia, acute bladder and/or bowel incontinence or retention).7 Yellow flags are considered psychological stressors (fear-avoidance behavior and reduced activity, back pain-related negative attitude stating that it is harmful or potentially severely disabling, an expectation that passive, rather than active, treatment will be beneficial, tendency toward depression, low morale, and social withdrawal, social or financial problems).7 Prior pain treatments (pharmacological and non-pharmacological), along with their efficacy, should be established. Validated low back pain scales, like the Pain Catastrophizing Scale, can be useful to quantify pain experiences.31
Initial examination should include observation of the surgical site condition, posture, spinal alignment, range of motion, balance, and gait. Vital signs and examination of abdominal, pelvic and vascular systems may be important. A complete motor and sensory neurologic examination should be included. Evaluation of the sacroiliac joints (SIJ), hips, and knees should complement the examination. Special tests to assess for nerve root tension signs must be performed (seated/straight-leg-raising test, femoral nerve stretch test). Assessment of Waddell signs, which include non-organic findings that deviate from anatomic patterns of injury pathology, should also be addressed. Some of the signs include disproportionate pain behavior, regional weakness, or altered sensation (whole-leg weakness or sensory loss), change in straight-leg-raise-test result after distraction, superficial or non-anatomic tenderness, and pain while simulating examination tests such as axial pressure in the skull. Presence of two or more signs may be indicative of psychological distress and is associated with poor outcome after surgery.32
If presence of significant yellow flags including co-existent mood disorder or signs of chronic pain syndrome, consider psychological consultation including a detailed neuropsychological assessment battery to ensure accurate diagnosis and help with subsequent treatment planning.
Pain might result in functional limitations such as diminished walking tolerance. Change in biomechanics and resultant mobility restriction may lead to an inability to perform daily activities, depression, or anxiety which impairs quality of life. The generic WHOQOL-BREF questionnaire can be used to evaluate quality of life, which studies have found to be directly related to postoperative recovery in FBSS patients.
Laboratory studies will be guided by the history and physical examination. If infection is suspected, white blood cell count, erythrocyte sedimentation rate, or C-reactive protein are indicated. If abscess is suspected, open or percutaneous drain placement may be indicated. Blood cultures should be drawn to find causative organism, with most common microbe being Staphylococcus aureus.33
Imaging studies should be guided by the reported symptoms. Plain radiographs with flexion-extension films and whole spine-anteroposterior and lateral views should be ordered to evaluate surgical site, spinal alignment, or segmental instability.7 Plain radiographs with flexion-extension films and whole spine-anteroposterior and lateral views should be ordered to evaluate surgical site, spinal alignment, or segmental instability.7 Magnetic resonance imaging (MRI) should be performed to evaluate discogenic pathology or foraminal encroachment. Nerve root enhancement, nerve root thickening, and extensive epidural fibrosis are all findings related to recurrent or residual symptoms.6Contrast enhancement is necessary if the patient history is worrisome for infection in the intervertebral discs or vertebral bodies, and also helps to differentiate post-operative epidural fibrosis from recurrent disc herniation. Nuclear imaging also has a role in the evaluation for a possible infectious etiology as a cause of recurrent symptoms.34
Supplemental assessment tools
Electromyography and nerve conduction tests can help differentiate a more distal peripheral neuropathy from a radicular process. Selective nerve root blocks (SNRBs) may be useful in some patients for both diagnostic and therapeutic purposes, targeting particular nerve roots to identify a potential pain generator. If the pain is suspected to be coming from the zygopophyseal joint, a medial branch block may be performed. The SIJ may be susceptible to altered biomechanics following L5-S1 fusion surgery. If suspected, an SIJ block may be performed as another diagnostic and therapeutic tool.6,35 In recent years, accelerometers have been proposed as a tool to objectively evaluate functional recovery and document outcomes through activity.36
Early predictions of outcomes
One of the most important factors to consider in the prediction of outcomes is adequate patient selection for surgery, which includes psychological status. One common cause for poor surgical outcome is incorrect preoperative diagnosis. Patients with psychological disturbances, workers compensation or disability claims, abnormal pain behavior, depression and/or anxiety have poorer results after lumbar spine surgery.6,26,28,32 Awareness is growing on the concept of central sensitization, which accounts for chronic ‘unexplained’ low back pain. Hyperexcitable spinal neurons show reduced pain thresholds36 and may result in poor surgical outcomes. Identification and diagnosis may be difficult but extremely important for the creation of an adequate and specific treatment plan in the preoperative and postoperative phases37. Elective spinal surgery may need to be deferred till the underlying psychological issues are appropriately assessed and addressed.
Back pain is a common cause of work-related disability and accounts for some of the highest medical expenses for employers. The cost of treatment for the subset of patients that undergo surgical intervention is considerable. Spinal fusion surgery costs alone were estimated at 16 billion dollars in 20046. This figure does not take into consideration other factors such as home or work-environment adaptations.
Social role and social support system
Considering the role that psychosocial factors play in the development of this and other chronic pain syndromes, it is important to determine if the patient has adequate social support, as social stressors may perpetuate depression or anxiety.
Communication with the surgeon, understanding the type of surgery performed, post-operative precautions, and early implementation of post-operative rehabilitation are important considerations in treatment planning. Since failure to meet patient expectations partly defines this syndrome, adequate preoperative discussion and goal setting (stabilizing the spine vs. pain relief) is of paramount importance.
Rehabilitation Management and Treatments
Treatment for failed back surgery syndrome can be broadly divided into conservative (e.g., rehabilitation or medication) or aggressive (e.g., interventional or surgical) treatments. In the absence of emergency or “red flag” symptoms such as bowel/bladder incontinence, motor weakness, or focal neural deficit, conservative treatments should be attempted first.5, 8 Additionally, the presence of new pain or re-exacerbation of ongoing pain warrants re-evaluation including re-imaging and evaluation for surgical spine evaluation.38
Available or current treatment guidelines
There are no definitive guidelines for treatment of FBSS, although various treatment pathways or algorithms have been developed. Gatzinsky et al. describe 6 algorithms for treatment of FBSS; however, they focus on one treatment or subgroup of FBSS and do not involve a multidisciplinary team (MDT) with expert consensus focusing on a variety of evaluation and treatment options for patients with FBSS.
Gatzinsky et al. provide a treatment algorithm incorporating MDT recommendations, summarized in Figure 1, aspects of which will be further discussed in this article. The authors propose four levels of increasingly invasive treatment of FBSS, with ongoing physical therapy, rehabilitation, and psychosocial support throughout.
Figure 1: An FBSS care pathway using an MDT consensus
The proposed standardized multidisciplinary team’s failed back surgery syndrome care pathway, as recommended by the Chronic Back and Leg Pain Network. FBSS, failed back surgery syndrome; IDD, intrathecal drug delivery; MDT, multidisciplinary team; SCS, spinal cord stimulation; SIJ, sacroiliac joint; TENS, transcutaneous electrical nerve stimulation; WHO, World Health Organization. Note. In cases of new pain and/or exacerbation of original pain at any stage of this flow, reimaging and spine expertise is required.1 Best practice is for the psychosocial evaluation to be performed by a psychologist or psychiatrist with specific experience in the field of pain. Assessments may include the relevant tests and questionnaires aiming to identify patients with major psychological or psychiatric contraindications.2 Best practice is to avoid long-term use of WHO Step III analgesics and review ineffective long-term use of antineuropathic pain medication.3 There is limited evidence supporting a prolonged effect of epidural injections, selective nerve root blocks, and radiofrequency denervation in an FBSS population. Despite this lack of clinical evidence, these therapies may be tried/reserved for the management of acute exacerbation in pain.
Copyright © 2019 Kliment Gatzinsky et al.
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Adapted from Gatzinsky et al.38
At different disease stages
Initial treatments, or Level One treatments, should focus on optimizing nonmedical and conservative medical treatments. This includes physical therapy, rehabilitation, and management of psychosocial factors. An approach that combines pain education with behavioral therapy and patient-centered exercises to improve pain-limited function seems to be more effective than traditional rehabilitation.
Pharmacotherapy at this stage includes the World Health Organization (WHO) Step I and Step II analgesics. Step I analgesics include nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen for treatment of nociceptive pain. Adjuvant therapy with a short course of Step II analgesics (i.e., weak opioids) such as tramadol or a combination of acetaminophen and codeine can be considered. Step III analgesics, strong opioids, should be avoided due to lack of evidence of long-term effectiveness and the known risks of prolonged opioid therapy.
Treatment of FBSS with neuropathic radicular pain is based on the use of gabapentinoids (gabapentin and pregabalin) and antidepressants (amitriptyline and duloxetine). Combination of two drugs for treatment of neuropathic pain may be effective, however there is a risk of gabapentin dependency and abuse with prolonged use, and combinations of gabapentinoids and opioids can increase the risk of opioid-related death; the UK government recently re-classified gabapentinoids as Class C controlled drugs. Prolonged gabapentinoids use should be carefully monitored.
A 30% improvement in pain, following at least six weeks of first-line therapy to determine side effects, warrants continued first-line therapy use until it is no longer effective. A second first-line treatment should be tried for six weeks before moving to second-line treatments. Other treatment modalities such as acupuncture, manual therapy, functional restoration, and cognitive behavioral therapy and relaxation techniques can be integrated into the management of pain, however they have moderate evidence for management of chronic back pain Transcutaneous electrical nerve stimulation (TENS) is another complementary therapy to medication, but with limited evidence in patients with FBSS. Level Two treatments include minimally invasive therapies and diagnostic procedures. Evidence-based guidelines and systematic reviews exist for interventional treatment of chronic spinal pain, including FBSS. Patients should be re-assessed before considering interventional treatments. Nociceptive pain generators that are thought to be contributing factors should be thoroughly evaluated, including provocative tests with known likelihood ratios, to identify the most significant cause of FBSS. For example, if the sacroiliac joint (SIJ) or lumbar facets are thought to be pain generators, provocative physical exam maneuvers and possibly radiographic imaging should be used to identify which component would most benefit from an interventional treatment. This should ideally be confirmed with anesthetic blocks, before using steroid injections or radiofrequency ablations in these areas.
Selective nerve root block injections can also be used to treat neuropathic pain in patients with FBSS. Pulse radiofrequency (PRF) or spinal cord stimulation (SCS) can then be considered in these patients for a sustained effect. However, both practitioners and patients should be aware of the limited evidence for long-term benefit in both repeated spinal injections and PRF.
If epidural or perineural fibrosis is thought to be the pain generator in FBSS, percutaneous epidural adhesiolysis can be an effective treatment, demonstrating up to 24 months of sustained pain relief, and should be used when other second-line interventional treatments have been ineffective.
Level Three treatments include interventional electrical neurostimulation that target the neuropathic component of FBSS. An MDT should assess these patients before third-line interventional treatment. SCS has shown to be safe and effective for many years for treatment of neuropathic pain, with improvements in quality of life and sleep, and reduction of medication use. Axial back pain is not as reliably treated with SCS, and recent innovations such as multicolumnar leads with an algorithmic program, peripheral nerve stimulation, high frequency stimulation, burst stimulation, and closed loop stimulation have shown varying benefit for this type of pain.
Level Four treatments are controversial as it involves WHO Step III analgesia with strong opioid medications and monitoring the patient until intolerable drug-related adverse events or tolerance develops. In addition to a lack of evidence of long-term efficacy of opioids in FBSS, adverse effects of opioids include dependance, development of tolerance, abuse, addiction, and death by overdose. High-potency opioid use should be limited in treatment of chronic pain.
Intrathecal drug delivery (IDD) with morphine or ziconotide can be considered in patients who responded to high-dose opioids but were limited by its side effects; however, no protocols exist for the use of IDD in treatment of FBSS and there are no randomized controlled trials (RCTs) evaluating its long-term efficacy.
If Level Four treatments are unsuccessful, there should be a final MDT assessment to inform the patient of their prognosis, emphasize avoiding further interventional treatments, and reviewing and promoting all noninvasive options.
Surgical revision for FBSS is associated with significant morbidity and decreased likelihood of success with every revision, and should be reserved for patients with a documented anatomic or pathologic cause for their FBSS.7 Recurrent disc herniation and postoperative sagittal imbalance are indications for surgical revision.
Recurrent disc herniation may occur at the operative or adjacent level, usually with a radicular component, and there is no consensus whether further decompression or decompression with fusion is the best option.7 Sebaaly et al. believe the algorithm by Assaker et al. offers the best compromise, with the first recurrent herniation treated with microdiscectomy and the second recurrence with a more aggressive solution, posterior fusion with anterior grafting.
Spinal balance plays a key role in postoperative pain relief in spinal instrumentation and fusion. Coronal balance (i.e. with the C7 vertical axis lying < 4 cm from the central sacral vertical line), pelvic tilt, lumbar lordosis, and sagittal vertical axis are all factors that can affect postoperative pain.7Spinal imbalance can increase the risk of adjacent segment deterioration, distal junctional pathology, proximal junctional kyphosis and failure.7
Coordination of care
An interdisciplinary team composed of physiatrists, therapists, spine surgeons and behavioral health experts intervening at different stages in treatment will provide the patient with the best chance at functional improvement.38
Patient & family education
The patient, family members, and caregivers should be oriented to the different factors that might affect clinical outcome. This might include early identification of psychological pathology, complications of surgery, adequate rehabilitation and surgical follow-up, along with harmful and beneficial behavioral modifications.
At this time there are no studies that evaluate the use of regenerative medicine on post laminectomy pain patients. However, even though future research is warranted, regenerative medicine may have an indication to address adjacent segment disease or other possible pain generators like discogenic pain disease. Intradiscal Platelet Rich Plasma is a potential effective management option for discogenic low back pain.25 Evaluation and measurement should be individualized and relies on self-reporting. Although not validated for FBSS, various tools are widely used for chronic low back pain. The Oswestry Low Back Pain Disability Questionnaire, Short-Form Health Survey (SF) 12 or 36, Visual Analog Scale, and the International Physical Activity Questionnaire could be used as tools to evaluate the efficacy of different treatment strategies, including a baseline measure prior to surgical intervention.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
- Adequate patient selection prior to surgery is important in the prevention of FBSS.
- Appropriate diagnosis and management of underlying psychological issues is of critical importance in optimizing patient outcomes. Elective spinal surgery may need to be deferred till the underlying psychological issues are appropriately assessed and addressed
- FBSS is not a single entity, but a plethora of multiple potential etiologies. Causes may include surgical factors, mechanical factors, or central sensitization. Therefore, identifying the specific pain generator, keeping in mind the time frame when symptoms develop, is helpful in achieving early and successful pain management.
- It is important to implement a treatment plan through an interdisciplinary team approach, which should focus on achievable functional goals.
Cutting Edge/Emerging and Unique Concepts and Practice
Cutting edge concepts and practice
New treatment strategies are currently being studied, such as using peripheral nerve field stimulation (PNfS) in conjunction with spinal cord stimulation (SCS)40, along with the incorporation of regenerative techniques for spine care. The link between symptomatic spinal stenosis and multifidi atrophy without correlation to the extent of muscle denervation would suggest that strengthening of the paraspinal muscles would make atrophy reversible and possibly alleviate axial pain.41 For patients with post-laminectomy pain refractory to SCS, salvage therapies such as alternative waveforms of SCS (burst, high frequency, or multiple waveform) or dorsal root ganglion (DRG) stimulation have been studied. DRG stimulation is an emerging option for salvage therapy and was shown to be non-inferior and superior to t-SCS in treating lower extremity neuropathic pain for CRPS in the ACCURATE study 1. Assessment of brain remodeling and plasticity in patients with chronic pain by using functional MRI (fMRI), along with evaluation of individual genetic differences in endogenous pain modulation, could provide new tools in guiding therapy or tailoring different individualized treatment strategies.42
Another exciting avenue of research is the incorporation of machine learning to provide unique insights into the components of FBSS pain. Instead of examining a single variable such as pain intensity or the Visual Analog Scale, a Multi-dimensional Clinical Response Index (MCRI) was created by Rigoard et al. to also include functional capacity, anxiety-depression, quality of life and quantitative pain mapping as factors involved in FBSS. Machine learning was used for instantaneous assessment of these variables, which can be used to help predict effective areas of treatment and monitor for improvement in pain in patients with FBSS.
Gaps in the Evidence-Based Knowledge
Gaps in the evidence-based knowledge
- The use of opiates for chronic pain remains controversial. It is important to balance the risk for side effects, cost and abuse, with the benefit of achieving clear functional goals by providing proper analgesia.38
- The benefits of initial or repeated surgery, versus interventional pain management techniques, continues to be debated. Further research is required to determine which approach is more cost-effective and provides greater functional improvement.
- Because FBSS lacks a precise pathophysiology and has a complex clinical presentation, there is no gold standard in the treatment of FBSS. Gatzinsky et al. recommended an MDT approach to FBSS patients to prevent them from becoming “siloed” in a certain discipline, which can limit them to specialty-specific treatments, and patients do not explore the full array of multidisciplinary treatments available to them.
- As discussed previously, FBSS is a heterogeneous entity with different etiologies. This complicates evaluation of treatments for FBSS, as they may be targeting different components of pain. With the change in terminology to the better-defined CPSS in ICD-11, as well as the use of PSPS Type 1 and Type 2, future studies may be better suited to evaluate the effect of specific treatments on specific components of FBSS.
- Petersen EA, Schatman ME, Sayed D, Deer T. Persistent Spinal Pain Syndrome: New Terminology for a New Era. J Pain Res 2021;14: 1627-30.
- Christelis N, Simpson B, Russo M, Stanton-Hicks M, Barolat G, Thomson S, Schug S, Baron R, Buchser E, Carr DB, Deer TR, Dones I, Eldabe S, Gallagher R, Huygen F, Kloth D, Levy R, North R, Perruchoud C, Petersen E, Rigoard P, Slavin K, Turk D, Wetzel T, Loeser J. Persistent Spinal Pain Syndrome: A Proposal for Failed Back Surgery Syndrome and ICD-11. Pain Med 2021;22(4): 807-18.
- Merskey H, Bogduk N. Lumbar Spinal or Radicular Pain after Failed Spinal Surgery (XXVI-10). Classification of Chronic Pain, Second Edition (Revised): 8-9.
- Baber Z, Erdek MA. Failed back surgery syndrome: current perspectives. J Pain Res 2016;9: 979-87.
- Orhurhu VJ, Chu R, Gill J. Failed Back Surgery Syndrome. StatPearls. Treasure Island (FL); 2022.
- Chan CW, Peng P. Failed back surgery syndrome. Pain Med 2011;12(4): 577-606.
- Sebaaly A, Lahoud MJ, Rizkallah M, Kreichati G, Kharrat K. Etiology, Evaluation, and Treatment of Failed Back Surgery Syndrome. Asian Spine J 2018;12(3): 574-85.
- Daniell JR, Osti OL. Failed Back Surgery Syndrome: A Review Article. Asian Spine J 2018;12(2): 372-79.
- Slipman CW, Shin CH, Patel RK, Isaac Z, Huston CW, Lipetz JS, Lenrow DA, Braverman DL, Vresilovic EJ, Jr. Etiologies of failed back surgery syndrome. Pain Med 2002;3(3): 200-14; discussion 14-7.
- Clancy C, Quinn A, Wilson F. The aetiologies of Failed Back Surgery Syndrome: A systematic review. J Back Musculoskelet Rehabil 2017;30(3): 395-402.
- Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J 2005;5(1): 24-35.
- Voorhies RM, Jiang X, Thomas N. Predicting outcome in the surgical treatment of lumbar radiculopathy using the Pain Drawing Score, McGill Short Form Pain Questionnaire, and risk factors including psychosocial issues and axial joint pain. Spine J 2007;7(5): 516-24.
- Carrafiello G, Fontana F, Cotta E, Petulla M, Brunese L, Mangini M, Fugazzola C. Ultrasound-guided thermal radiofrequency ablation (RFA) as an adjunct to systemic chemotherapy for breast cancer liver metastases. Radiol Med 2011;116(7): 1059-66.
- Phillips FM, Cunningham B. Managing chronic pain of spinal origin after lumbar surgery: the role of decompressive surgery. Spine (Phila Pa 1976) 2002;27(22): 2547-53; discussion 54.
- Slipman C. Posterior joints of the lumbar spine as a potential cause of low back pain. Pain Med 2004;5(3): 287-8.
- Nachemson AL. Evaluation of results in lumbar spine surgery. Acta Orthop Scand Suppl 1993;251: 130-3.
- Fritsch EW, Heisel J, Rupp S. The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments. Spine (Phila Pa 1976) 1996;21(5): 626-33.
- Parker SL, Mendenhall SK, Godil SS, Sivasubramanian P, Cahill K, Ziewacz J, McGirt MJ. Incidence of Low Back Pain After Lumbar Discectomy for Herniated Disc and Its Effect on Patient-reported Outcomes. Clin Orthop Relat Res 2015;473(6): 1988-99.
- Hong X, Liu L, Bao J, Shi R, Fan Y, Wu X. Characterization and Risk Factor Analysis for Reoperation After Microendoscopic Diskectomy. Orthopedics 2015;38(6): e490-6.
- Kumar MN, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 2001;10(4): 314-9.
- Rothenfluh DA, Mueller DA, Rothenfluh E, Min K. Pelvic incidence-lumbar lordosis mismatch predisposes to adjacent segment disease after lumbar spinal fusion. Eur Spine J 2015;24(6): 1251-8.
- Henschke N, Kamper SJ, Maher CG. The epidemiology and economic consequences of pain. Mayo Clin Proc 2015;90(1): 139-47.
- Shmagel A, Foley R, Ibrahim H. Epidemiology of Chronic Low Back Pain in US Adults: Data From the 2009-2010 National Health and Nutrition Examination Survey. Arthritis Care Res (Hoboken) 2016;68(11): 1688-94.
- Pearson A, Lurie J, Tosteson T, Zhao W, Abdu W, Weinstein JN. Who should have surgery for spinal stenosis? Treatment effect predictors in SPORT. Spine (Phila Pa 1976) 2012;37(21): 1791-802.
- Schofferman J, Reynolds J, Herzog R, Covington E, Dreyfuss P, O’Neill C. Failed back surgery: etiology and diagnostic evaluation. Spine J 2003;3(5): 400-3.
- Waguespack A, Schofferman J, Slosar P, Reynolds J. Etiology of long-term failures of lumbar spine surgery. Pain Med 2002;3(1): 18-22.
- Devlin VJ. REVISION SPINE SURGERY. Spine Secrets E-Book 2020: 323-32.
- Bagnall D. Failed back surgery syndrome. Musculoskeletal, Sports, and Occupational Medicine New York, NY: Demos Pub 2011: 25-27.
- Rigoard P, Gatzinsky K, Deneuville JP, Duyvendak W, Naiditch N, Van Buyten JP, Eldabe S. Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Consensus Statement on Definition and Outlines for Patient Assessment. Pain Res Manag 2019;2019: 3126464.
- Kallewaard JW, Nijhuis H, Huygen F, Wille F, Zuidema X, van de Minkelis J, Raza A. Prospective Cohort Analysis of DRG Stimulation for Failed Back Surgery Syndrome Pain Following Lumbar Discectomy. Pain Pract 2019;19(2): 204-10.
- Adams VJ, Walker B, Jepson D, Cooper C, Tyler J, Clewley D, Rozenfeld S, Nitsch KP. Measurement Characteristics and Clinical Utility of the Pain Catastrophizing Scale in Individuals Experiencing Low Back Pain. Archives of Physical Medicine and Rehabilitation 2017;98(11): 2350-51.
- Kim Y, Boden SD. Update on the History and Physical Evaluation of a Failed Back Surgery Syndrome. 2008;20(4): 236-39.
- Parchi PD, Evangelisti G, Andreani L, Girardi F, Darren L, Sama A, Lisanti M. Postoperative Spine Infections. Orthop Rev (Pavia) 2015;7(3): 5900.
- Love C, Palestro CJ. Nuclear medicine imaging of bone infections. Clin Radiol 2016;71(7): 632-46.
- Datta S, Everett CR, Trescot AM, Schultz DM, Adlaka R, Abdi S, Atluri SL, Smith HS, Shah RV. An updated systematic review of the diagnostic utility of selective nerve root blocks. Pain Physician 2007;10(1): 113-28.
- Baron R, Hans G, Dickenson AH. Peripheral input and its importance for central sensitization. Ann Neurol 2013;74(5): 630-6.
- Nijs J, Meeus M, Van Oosterwijck J, Roussel N, De Kooning M, Ickmans K, Matic M. Treatment of central sensitization in patients with ‘unexplained’ chronic pain: what options do we have? Expert Opin Pharmacother 2011;12(7): 1087-98.
- Gatzinsky K, Eldabe S, Deneuville JP, Duyvendak W, Naiditch N, Van Buyten JP, Rigoard P. Optimizing the Management and Outcomes of Failed Back Surgery Syndrome: A Proposal of a Standardized Multidisciplinary Team Care Pathway. Pain Res Manag 2019;2019: 8184592.
- Assaker R, Zairi F. Failed back surgery syndrome: to re-operate or not to re-operate? A retrospective review of patient selection and failures. Neuro-Chirurgie 2015;61 Suppl 1: S77-82.
- Reverberi C, Dario A, Barolat G. Spinal cord stimulation (SCS) in conjunction with peripheral nerve field stimulation (PNfS) for the treatment of complex pain in failed back surgery syndrome (FBSS). Neuromodulation 2013;16(1): 78-82; discussion 83.
- Yarjanian JA, Fetzer A, Yamakawa KS, Tong HC, Smuck M, Haig A. Correlation of paraspinal atrophy and denervation in back pain and spinal stenosis relative to asymptomatic controls. PM R 2013;5(1): 39-44.
- Henry DE, Chiodo AE, Yang W. Central nervous system reorganization in a variety of chronic pain states: a review. PM R 2011;3(12): 1116-25.
- Rigoard P, Ounajim A, Goudman L, Louis PY, Slaoui Y, Roulaud M, Naiditch N, Bouche B, Page P, Lorgeoux B, Baron S, Charrier E, Poupin L, Rannou D, de Montgazon GB, Roy-Moreau B, Grimaud N, Adjali N, Nivole K, Many M, David R, Wood C, Rigoard R, Moens M, Billot M. A Novel Multi-Dimensional Clinical Response Index Dedicated to Improving Global Assessment of Pain in Patients with Persistent Spinal Pain Syndrome after Spinal Surgery, Based on a Real-Life Prospective Multicentric Study (PREDIBACK) and Machine Learning Techniques. J Clin Med 2021;10(21).
- Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162(4): 276-86.
- Connolly J, 3rd, Javed Z, Raji MA, Chan W, Kuo YF, Baillargeon J. Predictors of Long-term Opioid Use Following Lumbar Fusion Surgery. Spine (Phila Pa 1976) 2017;42(18): 1405-11.
- Durand G, Girodon J, Debiais F. Medical management of failed back surgery syndrome in Europe: evaluation modalities and treatment proposals. Neuro-Chirurgie 2015;61 Suppl 1: S57-65.
- Dworkin RH, O’Connor AB, Kent J, Mackey SC, Raja SN, Stacey BR, Levy RM, Backonja M, Baron R, Harke H, Loeser JD, Treede RD, Turk DC, Wells CD. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain 2013;154(11): 2249-61.
- Van Boxem K, Cheng J, Patijn J, van Kleef M, Lataster A, Mekhail N, Van Zundert J. 11. Lumbosacral radicular pain. Pain Pract 2010;10(4): 339-58.
Original Version of the Topic
William F. Micheo, MD, Fernando L. Sepúlveda, MD, Roxanna Amill, MD. Post-laminectomy pain. 8/30/2013
Previous Revision(s) of the Topic
William F. Micheo, MD, Fernando L. Sepúlveda, MD, Roxanna Amill, MD. Post-laminectomy pain. 2/21/2018
Benjamin Seidel, DO
Nothing to Disclose
Rohini Singh, DO
Nothing to Disclose
Mohammad Zaidi, MD
Nothing to Disclose