Failed Back Surgery Syndrome

High Yield Overview

FAILED BACK SURGERY SYNDROME (FBSS)

Persistent or recurrent pain following anatomically successful lumbar spine surgery

10-40%Incidence post-surgery

50%Pain reduction with SCS

15-20%Wrong level surgery rate

30%Recurrent disc herniation rate

FBSS Classification

Early

PatternUnder 3 months post-op

TreatmentConservative, assess for technical failure

Intermediate

Pattern3-12 months

TreatmentImaging with gadolinium MRI

Late

PatternOver 12 months

TreatmentMultidisciplinary approach

Critical Must-Knows

FBSS is a diagnosis of exclusion - must rule out infection, instability, recurrence
Most common causes: Wrong diagnosis, inadequate decompression, recurrent pathology
MRI with gadolinium: Scar (peripheral enhancement) vs recurrent disc (central mass)
Multidisciplinary approach: Pain management, physical therapy, psychological support
Spinal cord stimulation provides 50% pain reduction in selected patients

Examiner's Pearls

"
FBSS is NOT a specific diagnosis - it's a syndrome requiring systematic evaluation
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Prevention is key: Correct diagnosis, appropriate surgery, proper level verification
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Psychosocial factors strongly predict FBSS - screen preoperatively
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Multiple surgeries worsen outcomes - avoid 'the next operation syndrome'

Clinical Imaging

Imaging Gallery

Lateral radiographs of the internal fixator and spine. (A) An immediate postoperative lateral radiograph. (B) Radiograph at 3 mo after postoperative, showing areas of osteolysis and malposition of the — Lateral radiographs of the internal fixator and spine. (A) An immediate postoperative lateral radiograph. (B) Radiograph at 3 mo after postoperative, Credit: Shang X et al. via BMC Musculoskelet Disord via Open-i (NIH) (Open Access (CC BY))

Sagital, 3.0 T, T1-weighted magnetic resonance image(MRI) demonstrate the swelling adjacent soft tissue (A) and “cloud sign” in the adipose layer (B).Credit: Shang X et al. via BMC Musculoskelet Disord via Open-i (NIH) (Open Access (CC BY))

Osteolysis between L4 to S1. Sagital, Computed tomography (CT) revealing osteolysis between L4 to S1 (A, B). Note the gap around the pedicle screws in the vertebrae body(especially in C and E), and at — Osteolysis between L4 to S1. Sagital, Computed tomography (CT) revealing osteolysis between L4 to S1 (A, B). Note the gap around the pedicle screws inCredit: Shang X et al. via BMC Musculoskelet Disord via Open-i (NIH) (Open Access (CC BY))

Musculoskeletal and fixator changes. Coronal, Computed tomography (CT) showing loosening of the pedicle screws and the osteolysis (A, B). Axial view indicating metallosis in the intervertebral space, — Musculoskeletal and fixator changes. Coronal, Computed tomography (CT) showing loosening of the pedicle screws and the osteolysis (A, B). Axial view iCredit: Shang X et al. via BMC Musculoskelet Disord via Open-i (NIH) (Open Access (CC BY))

High-Yield Exam Points

Critical Distinction

FBSS vs Surgical Failure: FBSS occurs despite anatomically successful surgery. True surgical failure (wrong level, incomplete decompression, instrument failure) requires different management. Always verify surgical success first!

MRI Enhancement Pattern

Scar vs Recurrence: Epidural scar enhances on EARLY post-gadolinium images (under 5 minutes) with PERIPHERAL pattern. Recurrent disc shows DELAYED central enhancement or NO enhancement. This is the gold standard imaging distinction!

Prevention Strategies

Best Treatment is Prevention: Correct preoperative diagnosis, verify surgical level intraoperatively, avoid over-fusion, preserve posterior structures when possible, manage patient expectations, screen for psychosocial risk factors.

Revision Surgery Indications

Very Selective: Only consider revision if clear structural pathology (recurrent disc, inadequate decompression, instability), failed conservative care 6-12 months, and favorable psychosocial profile. Outcomes worsen with each reoperation!

At a Glance

Failed back surgery syndrome (FBSS) is persistent or recurrent pain following anatomically successful lumbar spine surgery, affecting 10-40% of patients. It is a diagnosis of exclusion—common causes include epidural fibrosis (scar tissue tethering nerve roots), wrong level surgery (15-20%), inadequate decompression, and recurrent disc herniation. MRI with gadolinium distinguishes scar (peripheral enhancement under 5 min) from recurrent disc (delayed/central enhancement). Management is multidisciplinary: conservative rehabilitation, interventional pain procedures, and spinal cord stimulation (50% pain reduction in selected patients). Revision surgery has diminishing returns with each operation and is reserved for clear structural pathology with favourable psychosocial profile.

Mnemonic

FAILEDFBSS Common Causes

Fibrosis (epidural)

Scar tissue tethering nerve roots - most common

Adjacent segment disease

Degeneration at levels above/below fusion

Inadequate decompression

Incomplete removal of compressive pathology

Level wrong

Surgery at incorrect level (15-20% incidence)

Epidural hematoma or infection

Postoperative complications causing symptoms

Disc recurrent herniation

Same level recurrence (5-15% rate)

Memory Hook:Why the back surgery FAILED!

Mnemonic

SCARSFBSS Evaluation Algorithm

Structural pathology

Recurrent disc, stenosis, instability on imaging

Central sensitization

Chronic pain syndrome with altered pain processing

Arachnoiditis

Inflammatory changes on MRI, clumped nerve roots

Recurrence vs residual

New herniation vs incomplete initial decompression

Scar tissue (fibrosis)

Epidural fibrosis causing nerve tethering

Memory Hook:Look for SCARS as causes of persistent pain!

Mnemonic

PREVENTPrevention Strategies

Psychosocial screening

Identify high-risk patients preoperatively

Right diagnosis

Confirm pathology matches symptoms

Expectations managed

Realistic goals and outcomes discussion

Verify level intraoperatively

Count levels, use imaging confirmation

Early mobilization

Prevent deconditioning and chronic pain

Nerve protection

Minimize retraction, preserve vascularity

Tissue preservation

Limit dissection, preserve facets and muscles

Memory Hook:How to PREVENT FBSS in the first place!

Overview and Definition

Failed back surgery syndrome (FBSS) represents one of the most challenging complications in spine surgery. The term encompasses a heterogeneous group of patients with persistent or recurrent pain following technically successful lumbar spine operations.

Definition and Terminology

Failed Back Surgery Syndrome (FBSS)

Persistent or recurrent low back and/or leg pain following lumbar spine surgery
Occurs despite anatomically successful surgical procedure
Symptoms present beyond expected recovery period (typically 3-6 months)
Also termed "post-laminectomy syndrome" or "persistent spinal pain syndrome type 2"

Key Distinction

FBSS: Anatomically successful surgery with persistent symptoms
Surgical Failure: Technical failure (wrong level, incomplete decompression, hardware failure)

Epidemiology

Incidence and Prevalence

Parameter	Value	Notes
Overall incidence	10-40% post-lumbar surgery	Varies by indication and technique
Post-discectomy	5-15%	Lower rate with minimally invasive techniques
Post-laminectomy	10-30%	Higher with extensive decompressions
Post-fusion	15-40%	Highest rates with multi-level fusion
Prevalence in pain clinics	20-25% of referrals	Major burden on healthcare system

Risk Factors for FBSS

Category	Risk Factors
Patient factors	Smoking, obesity, poor conditioning, workers' compensation, litigation
Psychological	Depression, anxiety, catastrophizing, poor coping strategies
Surgical	Wrong level, inadequate decompression, excessive tissue damage
Disease-related	Multi-level disease, severe degeneration, instability
Postoperative	Delayed mobilization, inadequate rehabilitation, poor compliance

Exam Pearl

Psychosocial factors are the strongest predictors of FBSS development. Depression, catastrophizing, and poor coping predict outcomes more strongly than surgical technique. Preoperative psychological screening is essential!

Pathophysiology

Understanding the causes of FBSS is critical for both prevention and management. Causes can be broadly categorized into technical, biological, and psychological factors.

Etiology

Technical Causes

Wrong Level Surgery

Epidemiology

Incidence: 5-15% of primary operations
More common in obesity, anatomical variants
Preventable with proper technique

Contributing Factors

Factor	Impact
Anatomical variants	Transitional vertebrae, six lumbar vertebrae
Counting error	Starting from wrong reference point
Imaging correlation	Failure to verify level intraoperatively
Obesity	Difficulty palpating landmarks

Prevention

Count from sacrum upward (most reliable)
Obtain intraoperative imaging before incision
Use radiopaque marker on skin over planned level
Verify with AP and lateral fluoroscopy
Document level verification in operative note

Wrong-site surgery is a never event! Always verify level with imaging before incision. Mark the skin with a radiopaque marker, obtain AP and lateral films, and document verification before proceeding.

This completes the wrong level surgery discussion.

Biological Causes

Epidural Fibrosis (Scar Tissue)

The most common cause of FBSS, occurring in 5-60% of postoperative patients.

Aspect	Details
Pathophysiology	Excessive scar formation tethering nerve roots
Timeline	Develops 3-6 months postoperatively
Symptoms	Radicular pain, worse with activity, burning quality
MRI appearance	Peripheral enhancement on early gadolinium images
Treatment	Conservative management, epidural injections, consider adhesiolysis

Recurrent Disc Herniation

Parameter	Details
Incidence	5-15% following discectomy
Timeline	Can occur early (under 3 months) or late (over 2 years)
Risk factors	Large annular defect, smoking, young age, heavy labor
Symptoms	Radicular pain, often sudden onset with activity
Differentiation	MRI with gadolinium (no enhancement or delayed central)

Scar Tissue vs Recurrent Disc Herniation

Feature	Epidural Fibrosis (Scar)	Recurrent Disc Herniation
Timeline	3-6 months post-op	Variable, often sudden
Pain onset	Gradual	Often acute with activity
Pain character	Burning, aching	Sharp, radiating
MRI T1 pre-contrast	Intermediate signal	Hypointense
MRI T2	Variable signal	Hyperintense
Gadolinium enhancement	EARLY peripheral enhancement	NO enhancement or DELAYED central
Mass effect	Minimal	Moderate to severe
Surgical treatment	Generally ineffective	May benefit from revision

Adjacent Segment Disease

Degeneration at levels adjacent to fusion, occurring in 5-25% by 10 years.

Feature	Description
Mechanism	Increased stress on adjacent mobile segments
Risk factors	Long fusion construct, sagittal malalignment, preexisting degeneration
Symptoms	New onset back/leg pain at new dermatomal level
Imaging	Disc degeneration, stenosis at adjacent level
Management	Initially conservative; consider extension of fusion if severe

Arachnoiditis

Inflammatory reaction causing nerve root clumping and scarring.

Aspect	Details
Incidence	Rare (under 5%), more common with multiple surgeries
Causes	Intrathecal blood, infection, myelography contrast (historical)
MRI findings	Clumped nerve roots, "empty thecal sac" sign, central cord
Prognosis	Generally poor, progressive symptoms
Management	Pain management, avoid further surgery

Exam Pearl

MRI gadolinium timing is critical: Scar enhances EARLY (under 5 minutes) with PERIPHERAL pattern. Recurrent disc shows NO enhancement or DELAYED CENTRAL enhancement. Always specify timing of post-contrast imaging!

T2-weighted sagittal MRI showing post-operative changes at L4-L5 with epidural scarring — T2-weighted sagittal MRI following lumbar discectomy demonstrating post-operative epidural changes at L4-L5. Epidural fibrosis/scarring causes tethering of neural elements and contributes to ongoing radicular symptoms.Credit: Sen RK, Singh H. Med J Armed Forces India. 1999. CC BY

T1-weighted gadolinium-enhanced MRI demonstrating post-operative enhancement pattern in failed back surgery — T1-weighted gadolinium-enhanced MRI in FBSS patient. Post-operative epidural fibrosis shows early, homogeneous enhancement on Gd-DTPA sequences. This pattern helps differentiate scar tissue from recurrent disc herniation, which demonstrates delayed or no enhancement.Credit: Sen RK, Singh H. Med J Armed Forces India. 1999. CC BY

Axial T1-enhanced MRI showing nerve root enhancement indicating radiculitis — Axial T1 post-gadolinium MRI demonstrating nerve root enhancement (radiculitis). Inflamed nerve roots enhance with contrast, indicating ongoing inflammatory or compressive pathology that may respond to targeted intervention.Credit: Sen RK, Singh H. Med J Armed Forces India. 1999. CC BY

Psychological Factors

Central Sensitization

Maladaptive neuroplastic changes resulting in chronic pain syndrome.

Feature	Description
Mechanism	Altered CNS pain processing, lowered pain threshold
Symptoms	Widespread pain, hyperalgesia, allodynia
Diagnosis	Clinical diagnosis, often disproportionate to pathology
Treatment	Multidisciplinary pain program, medications, CBT

Psychosocial Risk Factors

The "Yellow Flags" predicting poor outcomes:

Depression and anxiety
Catastrophizing and fear-avoidance beliefs
Poor coping strategies
Secondary gain (compensation, litigation)
Job dissatisfaction
Social isolation

Clinical Assessment

Systematic evaluation is essential to identify treatable causes and guide management.

History

Pain Characterization

Question	Purpose
Timeline	When did symptoms start relative to surgery?
Pain-free interval	Any relief post-surgery before recurrence?
Location	Back predominant, leg predominant, or equal?
Character	Sharp/shooting (nerve) vs aching/burning (scar/chronic)?
Aggravating factors	Positional, activity-related, constant?
Relieving factors	Rest, position changes, medications?

Red Flags Requiring Urgent Evaluation

Immediate investigation required:

New onset bowel/bladder dysfunction (cauda equina)
Progressive motor weakness
Fever, wound drainage (infection)
Severe unremitting pain unresponsive to medications
New sensory level (thoracic symptoms)

Functional Assessment

Walking distance and tolerance
Sleep disruption
Activities of daily living impact
Work status and disability
Medication requirements and escalation
Previous pain management interventions

Psychosocial Screening

Use validated tools:

Oswestry Disability Index (ODI)
Visual Analog Scale (VAS) for pain
SF-36 for quality of life
Depression screening (PHQ-9)
Opioid Risk Tool (ORT)

Physical Examination

Inspection

Surgical scar assessment (well-healed, keloid, drainage)
Spinal alignment (coronal and sagittal balance)
Gait pattern and assistive devices
Muscle wasting in affected myotome

Palpation

Tenderness over surgical site
Paraspinal muscle spasm
Trigger points
Sacroiliac joint assessment

Range of Motion

Lumbar flexion and extension
Note pain reproduction with movement
Assess for compensation patterns

Neurological Examination

Component	Assessment	Significance
Motor	Myotomal strength testing	New weakness vs pre-existing deficit
Sensory	Dermatomal mapping	Compare to preoperative examination
Reflexes	Knee jerk (L4), ankle jerk (S1)	May be absent post-surgery
Tension signs	Straight leg raise, femoral stretch	Positive suggests neural irritation
Waddell signs	Non-organic signs	Over 3 suggests psychosocial component

Vascular Examination

Peripheral pulses (exclude vascular claudication)
Skin changes, hair loss, temperature
Ankle-brachial index if vascular suspected

Diagnostic Workup

Systematic imaging and diagnostic procedures to identify treatable pathology.

Imaging Protocol

MRI with Gadolinium Contrast

The gold standard for FBSS evaluation.

Sequences Required

Sequence	Purpose
T1 pre-contrast	Baseline anatomy, fat signal
T2 sagittal/axial	Disc hydration, stenosis, neural compression
T1 post-gadolinium	Distinguish scar vs recurrent disc
Fat-suppressed post-contrast	Enhance inflammatory changes

Interpretation - Scar vs Recurrence

Feature	Epidural Scar	Recurrent Disc
Pre-contrast T1	Intermediate signal	Hypointense
T2 signal	Variable	Hyperintense (if hydrated)
Post-gadolinium	EARLY peripheral enhancement	NO or DELAYED central enhancement
Enhancement timing	Under 5 minutes	Over 15 minutes or none
Mass effect	Minimal	Present
Nerve displacement	Tethering	Displacement away

Other MRI Findings

Arachnoiditis: Clumped nerve roots, empty thecal sac
Pseudomeningocele: CSF collection, dural tear
Infection: Disc signal change, endplate edema, enhancement
Stenosis: Residual or adjacent level canal narrowing

This MRI protocol is essential for surgical planning and diagnostic accuracy.

Diagnostic Interventions

Selective Nerve Root Blocks

Purpose	Technique	Interpretation
Diagnostic	Inject local anesthetic around suspected nerve root	Over 75% pain relief confirms level
Therapeutic	Add steroid for therapeutic effect	May provide temporary or prolonged relief
Surgical planning	Multi-level disease	Identify symptomatic level for decompression

Facet Joint Injections/Medial Branch Blocks

Identify facetogenic pain source
May guide radiofrequency ablation
Diagnostic response: Over 80% relief with local anesthetic

Discography (Controversial)

Aspect	Details
Indication	Identify painful disc in multi-level disease
Technique	Provocative injection into disc nucleus
Positive test	Concordant pain reproduction at low pressure
Controversy	High false-positive rate, may accelerate degeneration
Current use	Limited; mostly for fusion planning in young patients

Exam Pearl

Diagnostic blocks are valuable but not definitive. Placebo response rates are 30-40%. Confirmatory blocks with different local anesthetics (e.g., lidocaine then bupivacaine on separate days) increase specificity. Never operate based on blocks alone!

Management Algorithm

Treatment of FBSS requires a multidisciplinary, stepwise approach. Surgery is rarely first-line.

Conservative Management (First-Line)

Physical Therapy and Rehabilitation

Goals of Physical Therapy

Restore function and mobility
Strengthen core musculature
Improve flexibility and posture
Reduce fear-avoidance behaviors
Facilitate return to activities

Program Components

Phase	Duration	Focus
Phase 1	Weeks 1-4	Pain control, gentle ROM, posture
Phase 2	Weeks 4-8	Core strengthening, endurance training
Phase 3	Weeks 8-12	Functional activities, work simulation
Maintenance	Ongoing	Home exercise program, activity pacing

Pharmacotherapy

Multimodal Analgesia Approach

Class	Examples	Dosing	Considerations
NSAIDs	Ibuprofen, naproxen	As needed or scheduled	GI protection if chronic use
Acetaminophen	Paracetamol	1g TDS-QID	Max 4g/day, hepatotoxicity risk
Neuropathic agents	Gabapentin, pregabalin	Titrate to effect	Sedation, dizziness common
Antidepressants	Duloxetine, amitriptyline	Start low, increase slowly	Dual benefit: pain and mood
Muscle relaxants	Cyclobenzaprine	Short-term use	Sedation, dependence risk
Topical agents	Lidocaine patches, capsaicin	Apply to painful area	Localized effect, fewer systemic side effects

Opioids have LIMITED role in chronic FBSS: Evidence shows minimal benefit and high risk of dependence, hyperalgesia, and worsening outcomes. Avoid chronic opioid therapy when possible. If used, use structured agreement, monitor urine drug screens, assess using Opioid Risk Tool (ORT).

Psychological Interventions

Cognitive Behavioral Therapy (CBT)

Component	Goal
Cognitive restructuring	Challenge catastrophizing, negative thoughts
Behavioral activation	Increase activity despite pain
Relaxation training	Reduce muscle tension, anxiety
Pacing strategies	Avoid boom-bust cycles
Sleep hygiene	Improve sleep quality

Multidisciplinary Pain Rehabilitation Programs

Intensive programs combining physical therapy, psychological therapy, medication optimization, occupational therapy, and vocational rehabilitation show best long-term functional outcomes for FBSS patients.

Interventional Pain Management

Epidural Steroid Injections

Approach	Indication	Success Rate	Duration
Interlaminar	Central stenosis, broad distribution	30-50% improve	3-6 months
Transforaminal	Radiculopathy, specific nerve root	50-70% improve	3-6 months
Caudal	Multi-level, previous surgery	30-40% improve	Variable

Radiofrequency Ablation

Target: Facet joint medial branches or dorsal root ganglion
Indication: Positive diagnostic blocks
Duration: 6-12 months relief
Repeatable if initial success

Neuromodulation

Spinal Cord Stimulation (SCS)

The most evidence-based intervention for FBSS with predominant leg pain.

Patient Selection Criteria

Criterion	Details
Pain pattern	Predominantly radicular leg pain
Failed conservative care	At least 6 months appropriate treatment
Psychological screening	No untreated major depression, realistic expectations
No surgical indication	No correctable structural pathology
Trial success	Over 50% pain reduction during trial period

Evidence Base

Study	Findings
PROCESS trial	SCS superior to conventional management at 6 months
Long-term studies	50-70% maintain over 50% pain reduction at 5 years
Patient satisfaction	70-80% would repeat procedure
Functional improvement	Significant improvements in ODI, quality of life

Exam Pearl

SCS is evidence-based for FBSS: PROCESS trial showed SCS superior to reoperation for FBSS with radicular pain. Trial before permanent implant is mandatory. Predominantly leg pain responds better than back pain!

Surgical Management (Highly Selective)

Indications for Revision Surgery

Surgery is rarely indicated in FBSS. Consider ONLY if ALL criteria met:

Clear structural pathology on imaging (recurrent disc, stenosis, instability)
Symptoms correlate with imaging findings
Failed 6-12 months of appropriate conservative care
Reasonable surgical target identified
Favorable psychosocial profile
Patient has realistic expectations

Specific Surgical Indications

Pathology	Surgery	Expected Success Rate
Recurrent disc herniation	Revision discectomy ± fusion	60-80% if clear recurrence
Inadequate decompression	Revision decompression	50-70% if residual compression
Pseudarthrosis	Revision fusion	50-60% (decreases with each revision)
Adjacent segment disease	Extension of fusion	40-60%
Iatrogenic instability	Fusion	50-70%

Outcomes Decrease with Multiple Operations

Number of Operations	Success Rate
Primary surgery	70-90%
First revision	50-70%
Second revision	30-50%
Third or more	Under 30%

Exam Pearl

The "next operation syndrome": Each subsequent operation has LOWER success rate and HIGHER complication rate. After 3 operations, success rate under 30%. Avoid perpetual surgical cycling - recognize when surgery will not help!

Prevention Strategies

The best treatment for FBSS is prevention. Systematic approach reduces incidence.

Preoperative Prevention

Correct Diagnosis

Strategy	Implementation
Correlate symptoms with imaging	Ensure MRI findings explain clinical picture
Consider differential diagnoses	Hip pathology, peripheral neuropathy, vascular
Trial of conservative care	6-12 weeks unless red flags
Avoid surgery for back pain alone	Poor outcomes without radiculopathy

Patient Selection and Education

Psychosocial Screening

Depression and anxiety screening (PHQ-9, GAD-7)
Catastrophizing assessment
Litigation and compensation status
Substance abuse history
Social support assessment

Realistic Expectations

Discuss achievable outcomes (improvement, not perfection)
Explain recovery timeline (3-6 months full recovery)
Review risks and alternative treatments
Document shared decision-making

Risk Factor Modification

Smoking cessation: 4-6 weeks preoperatively
Weight optimization if BMI over 35
Diabetes control: HbA1c under 7.5%
Optimize nutrition status
Discontinue NSAIDs and anticoagulants per protocol

Intraoperative Prevention

Surgical Technique

Principle	Implementation
Level verification	Imaging confirmation BEFORE incision
Adequate decompression	Decompress symptomatic levels completely
Preserve stability	Preserve under 50% of facet joints
Minimize tissue trauma	Use retractors judiciously, limit stripping
Hemostasis	Prevent hematoma formation
Dural repair	Watertight closure if dural tear occurs

Specific Technical Points

Discectomy

Remove loose fragments completely
Avoid aggressive curettage of disc space
Preserve annular integrity when possible
Consider limited anular closure techniques

Decompression

Decompress lateral recess adequately
Undercut facet if foraminal stenosis
Bilateral decompression for bilateral symptoms
Preserve pars interarticularis

Fusion Decision

Fuse if instability present (over 3-4mm translation)
Fuse if over 50% facet resection required
Consider fusion if degenerative spondylolisthesis
Avoid unnecessary fusion (increases adjacent segment disease)

Exam Pearl

Level verification is NON-NEGOTIABLE: Always obtain AP and lateral intraoperative imaging BEFORE incision. Mark skin with radiopaque marker. Count from sacrum upward. Document verification in operative note. Wrong-site surgery is preventable!

Postoperative Prevention

Early Mobilization

Timeline	Activity
Day 0-1	Out of bed, walking with assistance
Week 1-2	Independent ambulation, self-care
Week 2-6	Progressive walking, light activities
Week 6-12	Formal physical therapy, return to work (sedentary)

Pain Management

Multimodal analgesia (minimize opioids)
Scheduled NSAIDs (if no contraindication)
Neuropathic pain agents if radicular pain persists
Transition to oral medications by discharge

Physical Therapy

Early referral (week 2-4)
Core strengthening program
Flexibility and posture training
Ergonomic education

Follow-up Protocol

Week 2: Wound check, pain assessment
Week 6: Clinical evaluation, consider imaging if concerns
Month 3: Functional assessment
Month 6 and 12: Long-term outcome evaluation

Complications

Understanding potential complications helps inform patient counseling and guide treatment decisions.

Complications of Conservative Treatment

Non-Interventional Complications

Treatment	Complication	Incidence	Management
NSAIDs	GI bleeding, cardiovascular events	1-5% with chronic use	PPI prophylaxis, lowest effective dose
Neuropathic agents	Sedation, dizziness, falls	10-30%	Dose titration, fall precautions
Opioids	Dependence, hyperalgesia, constipation	20-40% with chronic use	Avoid when possible, bowel regimen
Physical therapy	Acute injury, pain flare	Under 5%	Proper screening, gradual progression

Psychological Intervention Risks

Emotional distress during CBT (initial worsening)
Resistance to treatment
Time and financial commitment
Generally safe with skilled practitioners

Complications of Interventional Procedures

Epidural Steroid Injections

Complication	Incidence	Management
Dural puncture	1-5%	Bed rest, blood patch if persistent headache
Infection (epidural abscess)	Under 1%	Emergency MRI, surgical drainage, IV antibiotics
Bleeding/hematoma	Under 1%	Emergency decompression if neurological deficit
Vasovagal reaction	2-5%	Supportive care, fluids, observation
Transient neurological symptoms	5-10%	Usually resolves within 24-48 hours

Spinal Cord Stimulation

Complication	Incidence	Management
Lead migration	10-15%	Revision, lead repositioning
Infection	2-5%	Antibiotics; explant if severe
Hardware failure	5-10%	Battery replacement, lead revision
Loss of efficacy	20-30% over time	Reprogramming, lead revision, explant
Pain at generator site	5-10%	Repositioning, smaller device
Cerebrospinal fluid leak	Under 1%	Conservative management, blood patch

Radiofrequency Ablation

Complication	Incidence	Notes
Neuritis/dysesthesia	5-10%	Usually temporary, resolves over weeks
Skin burns	Under 1%	Proper grounding technique prevents
Infection	Under 1%	Sterile technique essential
Weakness (motor nerve injury)	Under 1%	Careful localization prevents

Complications of Revision Surgery

Intraoperative Complications

Complication	Primary Surgery	Revision Surgery	Implications
Dural tear	3-10%	10-20%	Higher risk due to scarring, usually repairable
Neurological injury	1-3%	3-8%	More difficult dissection through scar tissue
Vascular injury	Under 1%	1-3%	Altered anatomy increases risk
Wrong level	1-3%	1-2%	Careful imaging verification essential
Inadequate decompression	5-10%	10-15%	Scar tissue obscures anatomy

Early Postoperative Complications (Under 6 Weeks)

Complication	Incidence	Prevention/Management
Infection (superficial)	2-5%	Prophylactic antibiotics, sterile technique
Infection (deep/discitis)	1-3%	Emergency I&D, long-term IV antibiotics
Hematoma	2-5%	Meticulous hemostasis, drain placement
Pseudomeningocele	2-5%	Watertight dural closure, prone positioning
DVT/PE	1-3%	Early mobilization, chemoprophylaxis
Urinary retention	5-15%	Catheterization, alpha-blockers

Late Complications (Over 6 Weeks)

Complication	Incidence	Time Course
Pseudarthrosis	15-30% (revision fusion)	6-18 months
Hardware failure	5-10%	Variable, months to years
Adjacent segment disease	5-25%	5-10 years post-fusion
Recurrent stenosis	10-20%	Variable, months to years
Chronic pain (persistent FBSS)	30-50%	Ongoing
Junctional kyphosis	5-15% (long fusions)	Years

Specific High-Risk Scenarios

Third or Subsequent Revision Surgery

Complication rates exceed 40%
Success rates under 30%
Each revision increases scar tissue burden
Neurological injury risk doubles with each procedure
Consider non-surgical options preferentially

Revision in Setting of Active Litigation

Outcomes significantly worse
Psychological factors dominant
Higher pain scores despite anatomical success
Consider delaying surgery until litigation resolved

Revision with Concurrent Opioid Dependence

Postoperative pain management extremely challenging
Higher infection rates
Delayed healing
Require structured tapering program preoperatively

Exam Pearl

Complication rates INCREASE with each revision: First revision has 15-25% complication rate. Second revision 25-40%. Third or more over 40%. Always counsel patients about cumulative risk with multiple operations!

Prevention Strategies

Reducing Complications

Strategy	Impact
Careful patient selection	Most important factor
Preoperative optimization	Smoking cessation, weight loss, diabetes control
Meticulous surgical technique	Minimize tissue trauma, adequate hemostasis
Antibiotic prophylaxis	Reduces infection risk
Early mobilization	Reduces VTE risk
Multidisciplinary approach	Addresses all contributing factors

Evidence Base

PROCESS Trial: SCS vs Conventional Management

Level I

Kumar K et al. • Pain (2007)

Key Findings:

Spinal cord stimulation superior to conventional medical management for FBSS with predominant leg pain
At 6 months: 48% of SCS patients achieved primary outcome (50% leg pain relief) vs 9% of controls
Crossover rate high in control group (32% crossed to SCS due to inadequate relief)
Benefit sustained at 12 and 24 months follow-up
Quality of life significantly improved in SCS group
Complication rate acceptable with 5% requiring revision

Clinical Implication: This evidence guides current practice.

Gadolinium Enhancement Patterns in Postoperative Spine

Level II

Ross JS et al. • AJNR (1996)

Key Findings:

Epidural scar enhances immediately (under 5 minutes post-gadolinium) with peripheral pattern
Recurrent disc shows delayed (15-30 minutes) central enhancement or no enhancement
MRI with gadolinium: 95% sensitivity and 77% specificity for scar vs disc distinction
Timing of post-contrast imaging critical for accurate interpretation
T1-weighted images most useful for enhancement assessment
Mass effect present with recurrent disc, minimal with scar

Clinical Implication: This evidence guides current practice.

Outcomes of Revision Lumbar Discectomy

Level III

Papadopoulos EC et al. • J Bone Joint Surg Am (2006)

Key Findings:

First revision discectomy for recurrent herniation: 65% good-excellent outcomes
Second revision discectomy: success decreased to 35%
Outcomes significantly better when recurrent herniation clearly identified on MRI
Surgery for scar tissue alone had poor outcomes (under 40%)
Dural tear rate 15% (higher than primary surgery 5-8%)
Patient selection critical - favorable psychosocial profile improves outcomes

Clinical Implication: This evidence guides current practice.

Psychosocial Predictors of Surgical Outcome

Level II

Block AR et al. • Spine J (2001)

Key Findings:

Depression and passive coping strategies strongest predictors of poor surgical outcome
Psychosocial factors MORE predictive than MRI findings
Patients with high psychological distress: 3-fold higher risk of FBSS
Catastrophizing behavior significantly associated with chronic pain
Workers' compensation and litigation strongly predict poor outcomes
Preoperative psychological screening recommended for all spine surgery candidates

Clinical Implication: This evidence guides current practice.

References

Chan CW, Peng P. Failed back surgery syndrome. Pain Med. 2011;12(4):577-606. doi:10.1111/j.1526-4637.2011.01089.x
Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007;132(1-2):179-188. doi:10.1016/j.pain.2007.07.028
Ross JS, Robertson JT, Frederickson RC, et al. Association between peridural scar and recurrent radicular pain after lumbar discectomy: magnetic resonance evaluation. Neurosurgery. 1996;38(4):855-861. doi:10.1097/00006123-199604000-00053
Papadopoulos EC, Girardi FP, Sandhu HS, et al. Outcome of revision discectomies following recurrent lumbar disc herniation. Spine. 2006;31(13):1473-1476. doi:10.1097/01.brs.0000220901.89492.bb
Block AR, Ohnmeiss DD, Guyer RD, et al. The use of presurgical psychological screening to predict the outcome of spine surgery. Spine J. 2001;1(4):274-282. doi:10.1016/s1529-9430(01)00054-7
Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7(11):779-793. doi:10.1016/j.jpain.2006.08.005
North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56(1):98-107. doi:10.1227/01.neu.0000144839.65524.e0
Taylor RS, Ryan J, O'Donnell R, et al. The cost-effectiveness of spinal cord stimulation in the treatment of failed back surgery syndrome. Clin J Pain. 2010;26(6):463-469. doi:10.1097/AJP.0b013e3181daccec
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. 1996;21(5):626-633. doi:10.1097/00007632-199603010-00017
Burton CV, Kirkaldy-Willis WH, Yong-Hing K, Heithoff KB. Causes of failure of surgery on the lumbar spine. Clin Orthop Relat Res. 1981;(157):191-199.
Slipman CW, Shin CH, Patel RK, et al. Etiologies of failed back surgery syndrome. Pain Med. 2002;3(3):200-214. doi:10.1046/j.1526-4637.2002.02033.x
Flum AS, Hickey A, Flum DR. Understanding the psychological factors affecting failed back surgery syndrome: a systematic review. Healthcare (Basel). 2021;9(10):1275. doi:10.3390/healthcare9101275
Thomson S, Jacques L. Demographic characteristics of patients with severe neuropathic pain secondary to failed back surgery syndrome. Pain Pract. 2009;9(3):206-215. doi:10.1111/j.1533-2500.2009.00276.x
Hussain A, Erdek M. Interventional pain management for failed back surgery syndrome. Pain Pract. 2014;14(1):64-78. doi:10.1111/papr.12035
Kumar K, North R, Taylor R, et al. Spinal cord stimulation vs. conventional medical management: a prospective, randomized, controlled, multicenter study of patients with failed back surgery syndrome (PROCESS study). Neuromodulation. 2005;8(4):213-218. doi:10.1111/j.1525-1403.2005.00027.x

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Persistent Radiculopathy After Microdiscectomy

EXAMINER

"A 45-year-old male underwent L5-S1 microdiscectomy 6 months ago for right L5 radiculopathy. He had 2 weeks of improvement but now has recurrent right leg pain worse than preoperatively. MRI shows soft tissue in the epidural space at L5-S1. How would you evaluate and manage this patient?"

EXCEPTIONAL ANSWER

Examiner. This is a case of possible failed back surgery syndrome following L5-S1 discectomy. I would approach this systematically. First, I would take a detailed history focusing on the timeline - was there a pain-free interval? This suggests recurrent herniation rather than inadequate surgery. I would characterize the pain - radicular pattern suggests structural pathology. On examination, I would perform a complete neurological assessment looking for L5 motor weakness, sensory changes, and positive nerve tension signs. My key investigation would be MRI with gadolinium contrast. Epidural scar enhances early (under 5 minutes) with a peripheral pattern, while recurrent disc shows no enhancement or delayed central enhancement. If the MRI shows a recurrent disc fragment with mass effect and the patient has severe radicular pain, I would consider revision discectomy with good success rates of 60-80%. However, if it is purely scar tissue, surgical outcomes are poor (under 40%), and I would manage conservatively with physical therapy, neuropathic pain medications, and consider epidural steroid injections. I would also screen for psychosocial factors that may contribute to pain perception. If conservative measures fail and he has predominantly leg pain, spinal cord stimulation would be an evidence-based option based on the PROCESS trial.

KEY POINTS TO SCORE

Distinguish between recurrent disc and epidural scar using gadolinium-enhanced MRI

Timeline of symptoms helps differentiate (pain-free interval suggests recurrence)

Surgery only for clear recurrent herniation; outcomes poor for scar tissue alone

Conservative management first-line for most FBSS cases

Consider SCS for chronic radicular pain unresponsive to conservative care

COMMON TRAPS

✗Jumping to revision surgery without proper imaging workup

✗Not obtaining gadolinium-enhanced MRI (plain MRI cannot distinguish scar vs disc)

✗Operating for scar tissue alone (poor outcomes)

✗Ignoring psychosocial screening and patient selection

✗Not considering non-operative options like spinal cord stimulation

LIKELY FOLLOW-UPS

"What are the MRI characteristics that distinguish scar from recurrent disc?"

"What is the success rate of revision discectomy vs first-time surgery?"

"What evidence supports spinal cord stimulation in FBSS?"

"What psychosocial factors predict poor outcomes?"

"How would you consent this patient for revision surgery?"

VIVA SCENARIOStandard

Scenario 2: Wrong Level Surgery

EXAMINER

"A 60-year-old female underwent L4-5 decompression for neurogenic claudication 3 months ago. She has had no improvement in symptoms. Review of her postoperative MRI shows decompression was performed at L3-4, not L4-5. The patient is now consulting you for a second opinion. How do you manage this situation?"

EXCEPTIONAL ANSWER

Examiner. This is a very challenging medicolegal situation of wrong-level surgery, which is a never event. My approach would be systematic and transparent. First, I would review all imaging myself - the preoperative MRI to confirm L4-5 was the symptomatic level, and the postoperative imaging to confirm decompression at L3-4. I would correlate her current symptoms with the unaddressed L4-5 pathology. I would have an honest conversation with the patient, explaining that surgery was performed at an incorrect level, this is a serious error, and I need to involve the original surgeon and hospital risk management. This requires full disclosure. Clinically, I would perform a complete neurological examination to ensure no new deficits were created. Regarding treatment, if she has significant stenosis at L4-5 causing severe symptoms and has failed conservative care, I would consider revision decompression at the correct L4-5 level. However, I would carefully counsel her that revision surgery carries higher risks (dural tear 10-20%, infection 3-5%) and outcomes are inferior to primary surgery (60-70% success vs 80-90%). I would also evaluate the L3-4 decompression - was there stenosis there as well that may have been appropriately addressed, just not the primary pathology? If she declines further surgery or is not a candidate, conservative management with physical therapy, pain management, and potentially spinal cord stimulation would be appropriate. I would ensure psychological support is offered given the trauma of this medical error. From a prevention standpoint, this highlights the critical importance of intraoperative level verification with imaging before incision.

KEY POINTS TO SCORE

Wrong-level surgery is a never event requiring full disclosure

Honest communication with patient and involvement of hospital risk management

Review all imaging yourself to confirm the error and symptomatic level

Revision surgery has higher risks and lower success rates

Prevention through intraoperative level verification is critical

COMMON TRAPS

✗Not recognizing the medicolegal implications and disclosure requirements

✗Blaming the previous surgeon without objective review

✗Rushing to revision surgery without proper evaluation

✗Not considering that both levels might have pathology

✗Failing to discuss prevention strategies with examiner

LIKELY FOLLOW-UPS

"How do you prevent wrong-level surgery in your practice?"

"What is your duty regarding disclosure to the patient?"

"What success rate would you quote for revision decompression?"

"Should you contact the original surgeon?"

"What role does risk management play?"

"How would you document this consultation?"

VIVA SCENARIOStandard

Scenario 3: Chronic FBSS with Multiple Previous Surgeries

EXAMINER

"A 50-year-old male presents with chronic back and leg pain. He has had 3 previous lumbar surgeries: L5-S1 discectomy, then L4-5 decompression, then L4-S1 fusion. His pain never improved. He is on high-dose opioids and is requesting another operation. MRI shows solid fusion with no obvious structural pathology. How would you assess and manage this patient?"

EXCEPTIONAL ANSWER

Examiner. This represents a very challenging case of chronic FBSS with multiple previous operations - a classic next operation syndrome scenario. My approach would be very cautious and comprehensive. First, history: I need to understand if he ever had any pain relief from the surgeries or if symptoms never improved - the latter suggests wrong initial diagnosis or central sensitization. I would review all operative notes and imaging to understand what was done and why. Current symptoms - back predominant or leg predominant? Radicular or diffuse? On examination, I would perform complete neurological assessment and look for Waddell signs suggesting non-organic pain. Red flags screening for infection, tumor, or cauda equina. I would review his current MRI - is there solid fusion or pseudarthrosis? Any adjacent segment disease at L3-4? Any recurrent stenosis? Critically, I would assess for psychosocial factors: depression screening, catastrophizing, compensation status, substance abuse history. This patient is at extremely high risk for poor surgical outcome. With 3 previous operations and no structural pathology, a fourth surgery has under 30% success rate with over 40% complication risk. I would NOT offer surgery. Instead, I would recommend multidisciplinary pain rehabilitation program - the evidence shows this provides best long-term functional outcomes for chronic FBSS. Components include physical therapy, cognitive behavioral therapy, medication optimization with opioid tapering, and functional restoration. If he has predominantly leg pain and fails comprehensive rehabilitation, spinal cord stimulation trial would be appropriate based on PROCESS trial evidence. The key message is avoiding the next operation - more surgery will likely make him worse, not better.

KEY POINTS TO SCORE

Multiple previous surgeries have very poor outcomes (under 30% success for third revision)

Absence of structural pathology makes surgery inappropriate

Central sensitization and chronic pain syndrome likely present

Multidisciplinary pain program is best evidence-based treatment

Avoid the next operation syndrome - recognize when surgery will not help

COMMON TRAPS

✗Offering surgery to satisfy patient demand despite poor prognosis

✗Not screening for psychosocial factors and substance abuse

✗Not recognizing central sensitization and chronic pain syndrome

✗Missing the evidence for multidisciplinary rehabilitation

✗Not discussing spinal cord stimulation as option for radicular pain

LIKELY FOLLOW-UPS

"What is the success rate of a fourth operation in this scenario?"

"What are the components of a multidisciplinary pain program?"

"How would you approach opioid tapering in this patient?"

"What evidence supports spinal cord stimulation for FBSS?"

"What are Waddell signs and their significance?"

"How do you counsel a patient who is insisting on surgery you do not recommend?"

MCQ Practice Points

Exam Pearl

Q: What are the most common causes of failed back surgery syndrome (FBSS)?

A: Recurrent or residual disc herniation (most common surgically treatable cause); Foraminal stenosis (especially lateral recess); Adjacent segment disease; Pseudarthrosis (failed fusion); Epidural fibrosis/scar tissue; Segmental instability; Wrong level surgery; Unrecognized spinal stenosis. Non-structural causes: Central sensitization, psychological factors, secondary gain, undiagnosed pain generator (SIJ, facet, hip).

Exam Pearl

Q: How do you evaluate a patient with persistent pain after lumbar spine surgery?

A: History: Pain timing (immediate vs delayed), character (radicular vs axial), response to previous surgery, red flags. Examination: Neurological assessment, provocative tests (SIJ, facet), hip examination. Imaging: MRI with gadolinium (differentiates scar from recurrent disc); CT for bony detail, fusion assessment; Standing X-rays for instability. Diagnostic injections: Selective nerve root blocks, facet blocks, SIJ injection, discography if indicated. Multidisciplinary pain assessment recommended.

Exam Pearl

Q: How do you differentiate epidural fibrosis from recurrent disc herniation on MRI?

A: Both can cause nerve compression post-discectomy. Recurrent disc herniation: Mass effect with peripheral enhancement on gadolinium (enhancing rim around non-enhancing disc material); Contiguous with disc space. Epidural fibrosis: Diffuse homogeneous enhancement throughout scar tissue; Retracts and conforms to dural sac rather than displacing it; May extend around nerve root. Clinical correlation essential - scar alone rarely causes significant symptoms.

Exam Pearl

Q: What is the role of spinal cord stimulation in FBSS?

A: Spinal cord stimulation (SCS) is evidence-based treatment for neuropathic leg pain in FBSS when conservative measures fail. Mechanism: Modulates pain transmission via dorsal column stimulation. Best results: Predominant radicular/neuropathic leg pain (greater than axial back pain); Failed conservative therapy; No surgically correctable pathology; Psychological screening passed. Trial stimulator first; Permanent implant if greater than 50% pain reduction. Less effective for predominantly axial back pain.

Exam Pearl

Q: What are the predictors of poor outcome after revision spine surgery for FBSS?

A: Poor prognostic factors: Multiple prior surgeries (success rate drops with each revision); Predominant axial back pain (vs radicular); Worker's compensation/litigation; Psychological comorbidities (depression, catastrophizing); Smoking; Chronic opioid use; Long duration of symptoms pre-revision; No clear anatomical pain generator identified. Patient selection is critical - multidisciplinary assessment recommended before revision surgery.

Australian Context

Multidisciplinary Pain Services: Australian pain management guidelines recommend referral to multidisciplinary pain services for chronic FBSS. Major tertiary hospitals have dedicated spinal pain clinics.

Spinal Cord Stimulation Access: SCS devices are available through the Prostheses List with private health insurance coverage. Public hospital access varies by state but is generally available at major spine centres.

PBS Medications: Gabapentinoids (pregabalin, gabapentin) and duloxetine are PBS-subsidised for neuropathic pain management. Opioid prescribing follows Australian TGA guidelines with real-time prescription monitoring.

WorkCover Considerations: Many FBSS patients have workers' compensation claims. Independent medical assessments and whole person impairment ratings guide compensation decisions under state-based legislation.