Failed back syndrome (

abbreviated An abbreviation () is a shortened form of a word or phrase, by any method including shortening, contraction, initialism (which includes acronym), or crasis. An abbreviation may be a shortened form of a word, usually ended with a trailing per ...

as FBS) is a condition characterized by

chronic pain Chronic pain is pain that persists or recurs for longer than 3 months.https://icd.who.int/browse/2025-01/mms/en#1581976053 It is also known as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is in cont ...

following back surgeries. The term "post-laminectomy syndrome" is sometimes used by doctors to indicate the same condition as failed back syndrome. Many factors can contribute to the onset or development of FBS, including residual or recurrent

spinal disc herniation A disc herniation or spinal disc herniation is an injury to the intervertebral disc between two vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, ...

, persistent post-operative pressure on a

spinal nerve A spinal nerve is a mixed nerve, which carries Motor neuron, motor, Sensory neuron, sensory, and Autonomic nervous system, autonomic signals between the spinal cord and the body. In the human body there are 31 pairs of spinal nerves, one on each s ...

, altered joint mobility,

joint hypermobility Hypermobility, also known as double-jointedness, describes joints that stretch farther than normal. For example, some hypermobile people can bend their thumbs backwards to their wrists, bend their knee joints backwards, put their leg behind the ...

with instability, scar tissue (

fibrosis Fibrosis, also known as fibrotic scarring, is the development of fibrous connective tissue in response to an injury. Fibrosis can be a normal connective tissue deposition or excessive tissue deposition caused by a disease. Repeated injuries, ch ...

), depression,

anxiety Anxiety is an emotion characterised by an unpleasant state of inner wikt:turmoil, turmoil and includes feelings of dread over Anticipation, anticipated events. Anxiety is different from fear in that fear is defined as the emotional response ...

sleeplessness Insomnia, also known as sleeplessness, is a sleep disorder where people have difficulty sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low ene ...

, spinal muscular

deconditioning Deconditioning is the adaptation of an organism to a less demanding environment, or, alternatively, the decrease of physiological adaptation to normal conditions. Deconditioning can result from decreased physical activity, prescribed bed rest, or ...

and ''

Cutibacterium acnes ''Cutibacterium acnes'' (''Propionibacterium acnes'') is the relatively slow-growing, typically aerotolerant anaerobic, gram-positive bacterium (rod) linked to the skin condition of acne; it can also cause chronic blepharitis and endophthalmitis ...

'' infection. An individual may be predisposed to the development of FBS due to systemic disorders such as

diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...

autoimmune disease An autoimmune disease is a condition that results from an anomalous response of the adaptive immune system, wherein it mistakenly targets and attacks healthy, functioning parts of the body as if they were foreign organisms. It is estimated tha ...

and

peripheral vascular disease Peripheral artery disease (PAD) is a vascular disorder that causes abnormal narrowing of arteries other than those that supply the heart or brain. PAD can happen in any blood vessel, but it is more common in the legs than the arms. When narro ...

Signs and symptoms

Common symptoms of failed back syndrome include diffuse, dull, and aching pain in the back or legs, often accompanied by abnormal sensations such as sharp, pricking, or stabbing pain in the extremities. Patients may also experience pain at a different level from the location originally treated, along with an inability to fully recuperate and restricted mobility. Sharp, stabbing pain in the back, numbness, back spasms, or pain radiating from the lower back into the legs are frequently reported. In addition to physical discomfort, FBS can lead to psychological symptoms such as anxiety, depression, and

insomnia Insomnia, also known as sleeplessness, is a sleep disorder where people have difficulty sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low ene ...

. Some individuals may develop a dependence on pain medication due to

Cause

The number of spinal surgeries varies around the world. The

United States The United States of America (USA), also known as the United States (U.S.) or America, is a country primarily located in North America. It is a federal republic of 50 U.S. state, states and a federal capital district, Washington, D.C. The 48 ...

and the

Netherlands , Terminology of the Low Countries, informally Holland, is a country in Northwestern Europe, with Caribbean Netherlands, overseas territories in the Caribbean. It is the largest of the four constituent countries of the Kingdom of the Nether ...

report the highest number of spinal surgeries, while the

United Kingdom The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Northwestern Europe, off the coast of European mainland, the continental mainland. It comprises England, Scotlan ...

and

Sweden Sweden, formally the Kingdom of Sweden, is a Nordic countries, Nordic country located on the Scandinavian Peninsula in Northern Europe. It borders Norway to the west and north, and Finland to the east. At , Sweden is the largest Nordic count ...

report the fewest. Recently, there have been calls for more aggressive surgical treatment in

Europe Europe is a continent located entirely in the Northern Hemisphere and mostly in the Eastern Hemisphere. It is bordered by the Arctic Ocean to the north, the Atlantic Ocean to the west, the Mediterranean Sea to the south, and Asia to the east ...

. Success rates of spinal surgery vary for many reasons. Patients who have undergone one or more operations on the

lumbar spine The lumbar vertebrae are located between the thoracic vertebrae and pelvis. They form the lower part of the back in humans, and the tail end of the back in quadrupeds. In humans, there are five lumbar vertebrae. The term is used to describe t ...

and continue to experience pain afterwards can be divided into two groups. * The first group comprise those in whom

surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

was not actually indicated or the surgery performed was not likely to achieve the desired result, and those in whom surgery was indicated but which technically did not achieve the intended result. Patients whose pain complaints are of a

sciatic The sciatic nerve, also called the ischiadic nerve, is a large nerve in humans and other vertebrate animals. It is the largest branch of the sacral plexus and runs alongside the hip joint and down the right lower limb. It is the longest and widest ...

, radicular nature have a better chance for a good outcome than those whose pain complaints are limited to pain in the back. * The second group includes patients who had incomplete or inadequate operations. Lumbar

spinal stenosis Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in ...

may be overlooked, especially when it is associated with disc protrusion or

herniation A hernia (: hernias or herniae, from Latin, meaning 'rupture') is the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides. The term is also used for the normal development of the in ...

. Removal of a disc, while not addressing the underlying presence of

stenosis Stenosis () is the abnormal narrowing of a blood vessel or other tubular organ or structure such as foramina and canals. It is also sometimes called a stricture (as in urethral stricture). ''Stricture'' as a term is usually used when narrowing ...

, can lead to disappointing results. Occasionally operating on the wrong level occurs, as does failure to recognize an extruded or sequestered disc fragment. Inadequate or inappropriate surgical exposure can lead to other problems in not getting to the underlying

pathology Pathology is the study of disease. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatme ...

. Hakelius reported a 3% incidence of serious

nerve root A nerve root () is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as: * Cranial nerve roots: the initial or proximal segment of one of the twelve pairs of cranial nerves leaving the central nervous s ...

damage. In 1992, Turner ''et al.'' published a survey of 74 journal articles which reported the results after decompression for

. Good to excellent results were on average reported by 64% of the patients. There was, however, a wide variation in outcomes reported. There was a better result in patients who had a degenerative

spondylolisthesis Spondylolisthesis is when one spinal vertebra slips out of place compared to another. While some medical dictionaries define spondylolisthesis specifically as the forward or anterior displacement of a vertebra over the vertebra inferior to it (o ...

. A similarly designed study by Mardjekto et al. found that a concomitant spinal

arthrodesis Arthrodesis, also known as artificial ankylosis or syndesis, is the artificial induction of joint ossification between two bones by surgery. This is done to relieve intractable pain in a joint which cannot be managed by pain medication, splin ...

(fusion) had a greater success rate. Herron and Trippi evaluated 24 patients, all with degenerative

treated with

laminectomy A laminectomy is a surgical procedure that removes a portion of a vertebra called the Lamina of the vertebral arch, lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postla ...

alone. At follow-up varying between 18 and 71 months after surgery, 20 out of the 24 patients reported a good result. Epstein reported on 290 patients treated over a 25-year period. Excellent results were obtained in 69% and good results in 13%. These optimistic reports do not correlate with "return to competitive employment" rates, which for the most part are dismal in most spinal surgery series. In the past two decades there has been a dramatic increase in fusion surgery in the U.S.: in 2001 over 122,000 lumbar fusions were performed, a 22% increase from 1990 in fusions per 100,000 population, increasing to an estimate of 250,000 in 2003, and 500,000 in 2006. In 2003, the national bill for the hardware for fusion alone was estimated to have soared to $2.5 billion a year. For patients with continued pain after surgery which is not due to the above complications or conditions, interventional pain physicians speak of the need to identify the "pain generator" i.e. the anatomical structure responsible for the patient's pain. To be effective, the surgeon must operate on the correct anatomic structure, but is often not possible to determine the source of the pain. The reason for this is that many patients with

often have disc bulges at multiple spinal levels and the physical examination and imaging studies are unable to pinpoint the source of pain. In addition,

spinal fusion Spinal fusion, also called spondylodesis or spondylosyndesis, is a surgery performed by Orthopedic surgery#Practice, orthopaedic surgeons or neurosurgeons that joins two or more vertebrae. This procedure can be performed at any level in the spine ...

itself, particularly if more than one spinal level is operated on, may result in "adjacent segment degeneration". This is thought to occur because the fused segments may result in increased

torsional In the field of solid mechanics, torsion is the twisting of an object due to an applied torque. Torsion could be defined as strain or angular deformation, and is measured by the angle a chosen section is rotated from its equilibrium position. Th ...

and stress forces being transmitted to the

intervertebral discs An intervertebral disc (British English), also spelled intervertebral disk (American English), lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the ver ...

located above and below the fused

vertebrae Each vertebra (: vertebrae) is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spinal ...

. This pathology is one reason behind the development of artificial discs as a possible alternative to fusion surgery. But fusion surgeons argue that

is more time-tested, and artificial discs contain metal hardware that is unlikely to last as long as biological material without shattering and leaving metal fragments in the spinal canal. These represent different

schools of thought A school of thought, or intellectual tradition, is the perspective of a group of people who share common characteristics of opinion or outlook of a philosophy, discipline, belief, social movement, economics, cultural movement, or art movement. ...

. (See discussion on disc replacement infra.) Another highly relevant consideration is the increasing recognition of the importance of " chemical radiculitis" in the generation of

back pain Back pain (Latin: ''dorsalgia'') is pain felt in the back. It may be classified as neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia (tailbone or sacral pain) based on the segment affected. The lumbar area ...

. A primary focus of surgery is to remove "pressure" or reduce mechanical compression on a

neural In biology, the nervous system is the highly complex part of an animal that coordinates its actions and sensory information by transmitting signals to and from different parts of its body. The nervous system detects environmental changes t ...

element: either the

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...

, or a

. But it is increasingly recognized that

, rather than being solely due to compression, may instead entirely be due to chemical inflammation of the nerve root. It has been known for several decades that disc herniations result in a massive inflammation of the associated nerve root. In the past five years increasing evidence has pointed to a specific inflammatory mediator of this pain. This inflammatory molecule, called

tumor necrosis factor-alpha Tumor necrosis factor (TNF), formerly known as TNF-α, is a chemical messenger produced by the immune system that induces inflammation. TNF is produced primarily by activated macrophages, and induces inflammation by binding to its receptors o ...

(TNF), is released not only by the herniated or protruding disc, but also in cases of disc tear (annular tear), by facet joints, and in

. In addition to causing pain and inflammation, TNF may also contribute to disc degeneration. If the cause of the pain is not compression, but rather is inflammation mediated by TNF, then this may well explain why surgery might not relieve the pain, and might even exacerbate it, resulting in FBS.

Role of
sacroiliac joint The sacroiliac joint or SI joint (SIJ) is the joint between the sacrum and the ilium bones of the pelvis, which are connected by strong ligaments. In humans, the sacrum supports the spine and is supported in turn by an ilium on each side. The ...
(SIJ) in
lower back pain Low back pain or wiktionary:lumbago#Etymology, lumbago is a common musculoskeletal disorders, disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can var ...
(LBP)

A 2005 review by Cohen concluded, 'The SI joint is a real yet underappreciated pain generator in an estimated 15% to 25% of patients with axial LBP'. Studies by Ha, et al., show that the incidence of SI joint degeneration in post-lumbar fusion surgery is 75% at 5 years post-surgery, based on imaging. Studies by DePalma and Liliang, et al., demonstrate that 40–61% of post-lumbar fusion patients were symptomatic for SI joint dysfunction based on diagnostic blocks.

Smoking

Recent studies have shown that cigarette smokers will routinely fail all spinal surgery, if the goal of that surgery is the decrease of pain and impairment. Many surgeons consider smoking to be an absolute

contraindication In medicine, a contraindication is a condition (a situation or factor) that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a rea ...

to spinal surgery.

Nicotine Nicotine is a natural product, naturally produced alkaloid in the nightshade family of plants (most predominantly in tobacco and ''Duboisia hopwoodii'') and is widely used recreational drug use, recreationally as a stimulant and anxiolytic. As ...

appears to interfere with bone metabolism through induced

calcitonin Calcitonin is a 32 amino acid peptide hormone secreted by parafollicular cells (also known as C cells) of the thyroid (or endostyle) in humans and other chordates in the ultimopharyngeal body. It acts to reduce blood calcium (Ca2+), opposing the ...

resistance and decreased

osteoblastic Osteoblasts (from the Greek combining forms for "bone", ὀστέο-, ''osteo-'' and βλαστάνω, ''blastanō'' "germinate") are cells with a single nucleus that synthesize bone. However, in the process of bone formation, osteoblasts function ...

function. It may also restrict small blood vessel diameter leading to increased scar formation. There is an association between

cigarette smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or released from the mouth, as is generally done with pipes and cigars. The practice is believed to hav ...

and chronic pain syndromes of all types. In a report of 426 spinal surgery patients in

Denmark Denmark is a Nordic countries, Nordic country in Northern Europe. It is the metropole and most populous constituent of the Kingdom of Denmark,, . also known as the Danish Realm, a constitutionally unitary state that includes the Autonomous a ...

, smoking was shown to have a negative effect on fusion and overall patient satisfaction, but no measurable influence on the functional outcome. There is a validation of the hypothetical assumption that postoperative

smoking cessation Smoking cessation, usually called quitting smoking or stopping smoking, is the process of discontinuing tobacco smoking. Tobacco smoke contains nicotine, which is Addiction, addictive and can cause Substance dependence, dependence. As a resu ...

helps to reverse the impact of cigarette smoking on outcome after spinal fusion. If patients cease cigarette smoking in the immediate post operative period, there is a positive impact on success. Regular smoking in adolescence was associated with low back pain in young adults. Pack-years of smoking showed an exposure-response relationship among girls. A recent study suggested that cigarette smoking adversely affects serum

hydrocodone Hydrocodone, also known as dihydrocodeinone, is a semi-synthetic opioid used to treat pain and as a cough suppressant. It is taken by mouth. Typically, it is dispensed as the combination acetaminophen/hydrocodone or ibuprofen/hydrocodone fo ...

levels. Prescribing physicians should be aware that in some cigarette smokers, serum hydrocodone levels might not be detectable. In a study from Denmark reviewing many reports in the literature, it was concluded that smoking should be considered a weak risk indicator and not a cause of low back pain. In a multitude of epidemiologic studies, an association between smoking and low back pain has been reported, but variations in approach and study results make this literature difficult to reconcile. In a massive study of 3482 patients undergoing lumbar spine surgery from the National Spine Network, co-morbidities of (1) smoking, (2) compensation, (3) self reported poor overall health and (4) pre-existing psychological factors were predictive in a high risk of failure. Followup was carried out at 3 months and one year after surgery. Pre-operative depressive disorders tended not to do well. Smoking has been shown to increase the incidence of post operative infection as well as decrease fusion rates. One study showed 90% of post operative infections occurred in smokers, as well as

myonecrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who i ...

(muscle destruction) around the

wound A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying diseas ...

Pathology

Before the advent of CT scanning, the pathology in failed back syndrome was difficult to understand.

Computerized tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

in conjunction with

metrizamide Metrizamide is a non-ionic iodine-based radiocontrast agent. It is also a density gradient medium for the centrifugation of biological particles. Historically metrizamide replaced iofendylate (trade names: Pantopaque, Myodil) as the contrast age ...

myelography Myelography is a type of radiographic examination that uses a contrast medium (e.g. iodised oil) to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors. Historically the procedure involved the inj ...

in the late 1960s and 1970s allowed direct observation of the mechanisms involved in post operative failures. Six distinct pathological conditions were identified: * Recurrent or persistent disc

. *

Spinal stenosis Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in ...

. * Post operative infection. * Epidural post-operative

. * Adhesive

arachnoiditis Arachnoiditis is an inflammatory condition of the arachnoid mater or 'arachnoid', one of the membranes known as meninges that surround and protect the central nervous system. The outermost layer of the meninges is the dura mater (Latin for hard ...

. *

Nerve injury Nerve injury is an injury to a nerve. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Herbert Seddon introduced a classification of nerve injuries based on three main types of nerve ...

Recurrent or persistent disc herniation

Removal of a disc at one level can lead to

disc herniation A disc herniation or spinal disc herniation is an injury to the intervertebral disc between two vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, ...

at a different level at a later time. Even the most complete

surgical excision Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery ...

of the disc still leaves 30–40% of the disc, which cannot be safely removed. This retained disc can re-herniate sometime after surgery. Virtually every major structure in the abdomen and the posterior

retroperitoneal space The retroperitoneal space (retroperitoneum) is the spatium, anatomical space (sometimes a potential space) behind (''retro'') the peritoneum. It has no specific delineating anatomical structures. Organs are retroperitoneal if they have peritoneum ...

has been injured, at some point, by removing discs using posterior

discectomy A discectomy (also called open discectomy, if done through a 1/2 inch or larger skin opening) is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an int ...

surgical procedures. The most prominent of these is a laceration of the left internal iliac vein, which lies in close proximity to the anterior portion of the disc. In some studies, recurrent pain in the same radicular pattern or a different pattern can be as high as 50% after disc surgery. Many observers have noted that the most common cause of a failed back syndrome (FBS) is caused from recurrent disc herniation at the same level originally operated. A rapid removal in a second surgery can be curative. The clinical picture of a recurrent disc herniation usually involves a significant pain-free interval. However, physical findings may be lacking, and a good history is necessary. The time period for the emergence of new symptoms can be short or long. Diagnostic signs such as the straight leg raise test may be negative even if real

is present. The presence of a positive myelogram may represent a new disc herniation, but can also be indicative of a post operative scarring situation simply mimicking a new disc. Newer

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...

imaging techniques have clarified this dilemma somewhat. Conversely, a recurrent disc can be difficult to detect in the presence of post op scarring.

Myelography Myelography is a type of radiographic examination that uses a contrast medium (e.g. iodised oil) to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors. Historically the procedure involved the inj ...

is inadequate to completely evaluate the patient for recurrent disc disease, and CT or MRI scanning is necessary. Measurement of tissue density can be helpful. Even though the complications of

for disc herniation can be significant, a recent series of studies involving thousands of patients published under auspices of

Dartmouth Medical School The Geisel School of Medicine is the medical school of Dartmouth College located in Hanover, New Hampshire. The fourth oldest medical school in the United States, it was founded in 1797 by New England physician Nathan Smith. It is one of the sev ...

concluded at four-year follow-up that those who underwent surgery for a lumbar disc herniation achieved greater improvement than nonoperatively treated patients in all primary and secondary outcomes except work status.

Spinal stenosis

can be a late complication after

for disc herniation or when surgery was performed for the primary pathological condition of

. In the Maine Study, among patients with

lumbar spinal stenosis Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...

completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or non-surgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. A large study of

from Finland found the prognostic factors for ability to work after surgery were ability to work before surgery, age under 50 years, and no prior back surgery. The very long-term outcome (mean follow-up time of 12.4 years) was excellent-to-good in 68% of patients (59% women and 73% men). Furthermore, in the longitudinal follow-up, the result improved between 1985 and 1991. No special complications were manifested during this very long-term follow-up time. The patients with total or subtotal block in preoperative

achieved the best result. Furthermore, patients with block stenosis improved their result significantly in the longitudinal follow-up. The postoperative stenosis seen in

computed tomography A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

(CT) scans was observed in 65% of 90 patients, and it was severe in 23 patients (25%). However, this successful or unsuccessful

surgical decompression In medicine, decompression refers to the removal or repositioning of any structure compressing any other structure. Common examples include decompressive craniectomy (removal of part of the skull to relieve pressure on the brain), a spinal decompre ...

did not correlate with patients' subjective

disability Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be Cognitive disability, cognitive, Developmental disability, d ...

, walking capacity or severity of pain. Previous back surgery had a strong worsening effect on surgical results. This effect was very clear in patients with total block in the preoperative

. The surgical result of a patient with previous back surgery was similar to that of a patient without previous back surgery when the time interval between the last two operations was more than 18 months. Post-operative MRI findings of

are probably of limited value compared to symptoms experienced by patients. Patients' perception of improvement had a much stronger correlation with long-term surgical outcome than structural findings seen on post-operation

magnetic resonance imaging Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and ...

. Degenerative findings had a greater effect on patients' walking capacity than stenotic findings. Postoperative radiologic stenosis was very common in patients operated on for

, but this did not correlate with

clinical outcome Clinical endpoints or clinical outcomes are outcome measures referring to occurrence of disease, symptom, sign or laboratory abnormality constituting a target outcome in clinical research trials. The term may also refer to any disease or sign th ...

. The clinician must be cautious when reconciling clinical symptoms and signs with postoperative

findings in patients operated on for lumbar spinal stenosis. A study from

Georgetown University Georgetown University is a private university, private Jesuit research university in Washington, D.C., United States. Founded by Bishop John Carroll (archbishop of Baltimore), John Carroll in 1789, it is the oldest Catholic higher education, Ca ...

reported on one-hundred patients who had undergone decompressive surgery for lumbar stenosis between 1980 and 1985. Four patients with post-fusion stenosis were included. A 5-year follow-up period was achieved in 88 patients. The mean age was 67 years, and 80% were over 60 years of age. There was a high incidence of coexisting medical diseases, but the principal disability was lumbar stenosis with neurological involvement. Initially there was a high incidence of success, but recurrence of neurological involvement and persistence of low-back pain led to an increasing number of failures. By 5 years this number had reached 27% of the available population pool, suggesting that the failure rate could reach 50% within the projected life expectancies of most patients. Of the 26 failures, 16 were secondary to renewed neurological involvement, which occurred at new levels of stenosis in eight and recurrence of stenosis at operative levels in eight. Reoperation was successful in 12 of these 16 patients, but two required a third operation. The incidence of

at 5 years was higher in the surgical failures (12 of 26 patients) than in the surgical successes (16 of 64). Spondylolisthetic

tended to recur within a few years following decompression. Because of age and associated illnesses, fusion may be difficult to achieve in this group.

Post-operative infection

A small minority of lumbar surgical patients will develop a post operative infection. In most cases, this is a bad complication and does not bode well for eventual improvement or future employability. Reports from the surgical literature indicate an infection rate anywhere from 0% to almost 12%. The incidence of infection tends to increase as the complexity of the procedure and operating time increase. Usage of metal implants (instrumentation) tends to increase the risk of infection. Factors associated with an increased infection include

diabetes mellitus Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained hyperglycemia, high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or th ...

obesity Obesity is a medical condition, considered by multiple organizations to be a disease, in which excess Adipose tissue, body fat has accumulated to such an extent that it can potentially have negative effects on health. People are classifi ...

malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...

smoking Smoking is a practice in which a substance is combusted, and the resulting smoke is typically inhaled to be tasted and absorbed into the bloodstream of a person. Most commonly, the substance used is the dried leaves of the tobacco plant, whi ...

, previous infection,

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

, and

immunodeficiency Immunodeficiency, also known as immunocompromise, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that aff ...

. Previous wound infection should be considered as a contraindication to any further spinal surgery, since the likelihood of improving such patients with more surgery is small.

Antimicrobial prophylaxis Antibiotic prophylaxis refers to, for humans, the prevention of infection complications using antimicrobial therapy (most commonly antibiotics). Antibiotic prophylaxis in domestic animal feed mixes has been employed in America since at least 1970 ...

reduces the rate of surgical site infection in lumbar spine surgery, but a great deal of variation exists regarding its use. In a Japanese study, utilizing the

Centers for Disease Control The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency under the Department of Health and Human Services (HHS), and is headquartered in Atlanta, ...

recommendations for antibiotic prophylaxis, an overall rate of 0.7% infection was noted, with a single dose antibiotic group having 0.4% infection rate and multiple dosage antibiotic infection rate of 0.8%. The authors had previously used prophylactic antibiotics for 5 to 7 postoperative days. Based on the

Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) is the National public health institutes, national public health agency of the United States. It is a Federal agencies of the United States, United States federal agency under the United S ...

(CDC) guideline, their antibiotic prophylaxis was changed to the day of surgery only. It was concluded there was no statistical difference in the rate of infection between the two different antibiotic protocols. Based on the

CDC The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency under the Department of Health and Human Services (HHS), and is headquartered in Atlanta, ...

guideline, a single dose of prophylactic antibiotic was proven to be efficacious for the prevention of infection in

surgeries.

Epidural post-operative fibrosis

Epidural scarring following a

for disc excision is a common feature when re-operating for recurrent

sciatica Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities such as heavy lifting, though gradual onset may also occur. The pain is often desc ...

radiculopathy Radiculopathy (; ), also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). Radiculopathy can result in pain (radicular pain), weakness, altered se ...

. When the scarring is associated with a

and/or recurrent

, it is relatively common, occurring in more than 60% of cases. For a time, it was theorized that placing a fat graft over the dural could prevent post operative scarring. However, initial enthusiasm has waned in recent years. In an extensive

involving 2 or more

vertebra Each vertebra (: vertebrae) is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spina ...

, post operative scarring is the norm. It is most often seen around the L5 and S1 nerve roots.

Adhesive arachnoiditis

Fibrous scarring can also be a complication within the

subarachnoid In anatomy, the meninges (; meninx ; ) are the three membranes that envelop the brain and spinal cord. In mammals, the meninges are the dura mater, the arachnoid mater, and the pia mater. Cerebrospinal fluid is located in the subarachnoid sp ...

space. It is notoriously difficult to detect and evaluate. Prior to the development of

, the only way to ascertain the presence of

was by opening the dura. In the days of CT scanning and Pantopaque and later,

Metrizamide Metrizamide is a non-ionic iodine-based radiocontrast agent. It is also a density gradient medium for the centrifugation of biological particles. Historically metrizamide replaced iofendylate (trade names: Pantopaque, Myodil) as the contrast age ...

, the presence of

could be speculated based on

radiographic Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical ("diagnostic" radiography and "therapeu ...

findings. Often,

prior to the introduction of

was the cause of

. It can also be caused by the long term pressure brought about with either a severe

. The presence of both epidural scarring and

in the same patient are probably quite common.

Arachnoiditis Arachnoiditis is an inflammatory condition of the arachnoid mater or 'arachnoid', one of the membranes known as meninges that surround and protect the central nervous system. The outermost layer of the meninges is the dura mater (Latin for hard ...

is a broad term denoting inflammation of the meninges and

space. A variety of causes exist, including infectious, inflammatory, and

neoplastic A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

processes. Infectious causes include

bacterial Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria were among the ...

, viral,

fungal A fungus (: fungi , , , or ; or funguses) is any member of the group of eukaryotic organisms that includes microorganisms such as yeasts and molds, as well as the more familiar mushrooms. These organisms are classified as one of the tradit ...

, and

parasitic Parasitism is a close relationship between species, where one organism, the parasite, lives (at least some of the time) on or inside another organism, the host, causing it some harm, and is adapted structurally to this way of life. The ent ...

agents. Noninfectious inflammatory processes include surgery, intrathecal hemorrhage, and the administration of

intrathecal Intrathecal administration is a route of administration for drugs via an injection into the spinal canal, or into the subarachnoid space (sin. ''intrathecal space'') so that it reaches the cerebrospinal fluid (CSF). It is useful in several applic ...

(inside the dural canal) agents such as myelographic contrast media,

anesthetics An anesthetic (American English) or anaesthetic (British English; see spelling differences) is a drug used to induce anesthesia ⁠— ⁠in other words, to result in a temporary loss of sensation or awareness. They may be divided into tw ...

(e.g. chloroprocaine), and

steroids A steroid is an organic compound with four fused rings (designated A, B, C, and D) arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter mem ...

(e.g. Depo-Medrol, Kenalog). Lately iatrogenic arachnoiditis has been attributed to misplaced Epidural Steroid Injection therapy when accidentally administered intrathecally. The preservatives and suspension agents found in all steroid injectates, which aren't indicated for epidural administration by the U.S. Food & Drug Administration (FDA) due to reports of severe adverse events including

paralysis Paralysis (: paralyses; also known as plegia) is a loss of Motor skill, motor function in one or more Skeletal muscle, muscles. Paralysis can also be accompanied by a loss of feeling (sensory loss) in the affected area if there is sensory d ...

and

death Death is the end of life; the irreversible cessation of all biological functions that sustain a living organism. Death eventually and inevitably occurs in all organisms. The remains of a former organism normally begin to decompose sh ...

, have now been directly linked to the onset of the disease following the initial stage of chemical meningitis.

Neoplasia A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

includes the hematogenous spread of systemic tumors, such as

breast The breasts are two prominences located on the upper ventral region of the torso among humans and other primates. Both sexes develop breasts from the same embryology, embryological tissues. The relative size and development of the breasts is ...

and lung carcinoma,

melanoma Melanoma is the most dangerous type of skin cancer; it develops from the melanin-producing cells known as melanocytes. It typically occurs in the skin, but may rarely occur in the mouth, intestines, or eye (uveal melanoma). In very rare case ...

, and

non-Hodgkin lymphoma Non-Hodgkin lymphoma (NHL), also known as non-Hodgkin's lymphoma, is a group of blood cancers that includes all types of lymphomas except Hodgkin lymphomas. Symptoms include enlarged lymph nodes, fever, night sweats, weight loss, and tiredn ...

. Neoplasia also includes direct seeding of the

cerebrospinal fluid Cerebrospinal fluid (CSF) is a clear, colorless Extracellular fluid#Transcellular fluid, transcellular body fluid found within the meninges, meningeal tissue that surrounds the vertebrate brain and spinal cord, and in the ventricular system, ven ...

(CSF) from primary central nervous system (CNS) tumors such as

glioblastoma multiforme Glioblastoma, previously known as glioblastoma multiforme (GBM), is the most aggressive and most common type of cancer that originates in the brain, and has a very poor prognosis for survival. Initial signs and symptoms of glioblastoma are nons ...

medulloblastoma Medulloblastoma is a common type of primary brain cancer in children. It originates in the part of the brain that is towards the back and the bottom, on the floor of the skull, in the cerebellum, or posterior fossa. The brain is divided into two ...

ependymoma An ependymoma is a tumor that arises from the ependyma, a tissue of the central nervous system. Usually, in pediatric cases the location is intracranial, while in adults it is spinal. The common location of intracranial ependymomas is the floor ...

, and choroid plexus carcinoma. Strictly speaking, the most common cause of

in failed back syndrome is not infectious or from cancer. It is due to non-specific scarring secondary to the surgery or the underlying pathology.

Nerve injury

Laceration A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma (mechanical, thermal, chemical), or can develop slowly over time due to underlying diseas ...

of a

, or damage from cautery or traction can lead to

, however this can be difficult to determine. Chronic compression of the nerve root by a persistent agent such as disc, bone (

osteophyte Osteophytes are Exostosis, exostoses (bony projections) that form along joint margins. They are distinct from enthesophytes, which are bone, bony projections that form at the attachment of a tendon or ligament. Osteophytes are not always distingui ...

) or

scarring A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a nat ...

can also permanently damage the nerve root. Epidural scarring caused by the initial

or occurring after the surgery can also contribute to

nerve damage Nerve injury is an injury to a nerve. There is no single classification system that can describe all the many variations of nerve injuries. In 1941, Herbert Seddon introduced a classification of nerve injuries based on three main types of nerve ...

. In one study of failed back patients, the presence of pathology was noted to be at the same site as the level of surgery performed in 57% of cases. The remaining cases developed pathology at a different level, or on the opposite side, but at the same level as the surgery was performed. In theory, all failed back patients have some sort of nerve injury or damage which leads to a persistence of symptoms after a reasonable healing time.

Diagnosis

Management/Treatment

Failed back syndrome is a well-recognized complication of surgery of the lumbar spine. It can result in chronic pain and disability, often with disastrous emotional and financial consequences to the patient. Many patients have traditionally been classified as "spinal cripples" and are consigned to a life of long-term narcotic treatment with little chance of recovery. Despite extensive work in recent years, FBS remains a challenging and costly disorder. The treatments of post-laminectomy syndrome include

physical therapy Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease preventio ...

microcurrent electrical neuromuscular stimulator A microcurrent electrical neuromuscular stimulator or MENS (also microamperage electrical neuromuscular stimulator) is a device used to send weak electrical signals into the body. Such devices apply extremely small microamp �Aelectrical currents ...

, minor nerve blocks,

transcutaneous electrical nerve stimulation A transcutaneous electrical nerve stimulation (TENS or TNS) is a device that produces mild electric current to stimulate the nerves for therapeutic purposes. TENS, by definition, covers the complete range of transcutaneously applied currents u ...

behavioral medicine Behavioral medicine is concerned with the integration of knowledge in the biological, behavioral, psychological, and social sciences relevant to health and illness. These sciences include epidemiology, anthropology, sociology, psychology, physio ...

, non-steroidal anti-inflammatory medications, membrane stabilizers,

antidepressants Antidepressants are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction. Common side effects of antidepressants include dry mouth, weight gain, dizziness, headaches, akathisia, sexu ...

, spinal cord stimulation, and

morphine Morphine, formerly also called morphia, is an opiate that is found naturally in opium, a dark brown resin produced by drying the latex of opium poppies (''Papaver somniferum''). It is mainly used as an analgesic (pain medication). There are ...

pump A pump is a device that moves fluids (liquids or gases), or sometimes Slurry, slurries, by mechanical action, typically converted from electrical energy into hydraulic or pneumatic energy. Mechanical pumps serve in a wide range of application ...

. Use of epidural steroid injections may be minimally helpful in some cases. The targeted

anatomic Anatomy () is the branch of Morphology (biology), morphology concerned with the study of the internal structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things ...

use of a potent anti-inflammatory anti-TNF

therapeutics A therapy or medical treatment is the attempted remediation of a health problem, usually following a medical diagnosis. Both words, ''treatment'' and ''therapy'', are often abbreviated tx, Tx, or Tx. As a rule, each therapy has indications an ...

is being investigated.

Opioids

A study of chronic pain patients from the

University of Wisconsin A university () is an institution of tertiary education and research which awards academic degrees in several academic disciplines. ''University'' is derived from the Latin phrase , which roughly means "community of teachers and scholars". Uni ...

found that

methadone Methadone, sold under the brand names Dolophine and Methadose among others, is a synthetic opioid used medically to treat chronic pain and opioid use disorder. Prescribed for daily use, the medicine relieves cravings and opioid withdrawal sym ...

is most widely known for its use in the treatment of

opioid Opioids are a class of Drug, drugs that derive from, or mimic, natural substances found in the Papaver somniferum, opium poppy plant. Opioids work on opioid receptors in the brain and other organs to produce a variety of morphine-like effects, ...

dependence, but

also provides effective

analgesia Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals ...

. Patients who experience inadequate pain relief or intolerable side effects with other opioids or who suffer from neuropathic pain may benefit from a transition to methadone as their

analgesic An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in s ...

agent. Adverse effects, particularly respiratory depression and death, make a fundamental knowledge of

's pharmacological properties essential to the provider considering

therapy for a patient with chronic pain.

Patient selection

Patients who have

pain (pain in the back, radiating down the buttock to the leg) and clear clinical findings of an identifiable radicular nerve loss caused by a herniated disc will have a better post operative course than those who simply have low back pain. If a specific disc herniation causing pressure on a nerve root cannot be identified, the results of surgery are likely to be disappointing. Patients involved in worker's compensation, tort litigation or other compensation systems tend to fare more poorly after surgery. Surgery for spinal stenosis usually has a good outcome, if the surgery is done in an extensive manner, and done within the first year or so of the appearance of symptoms. Oaklander and North define failed back syndrome as chronic pain after one or more surgical procedure to the spine. They delineated these characteristics of the relation between the patient and the surgeon: # The patient makes increasing demands on the surgeon for

pain relief Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals ...

. The surgeon may feel a strong responsibility to provide a remedy when the surgery has not achieved the desired goals. # The patient grows increasingly angry at the failure and may become litigious. # There is an escalation of

narcotic The term narcotic (, from ancient Greek ναρκῶ ''narkō'', "I make numb") originally referred medically to any psychoactive compound with numbing or paralyzing properties. In the United States, it has since become associated with opiates ...

pain medication An analgesic drug, also called simply an analgesic, antalgic, pain reliever, or painkiller, is any member of the group of drugs used for pain management. Analgesics are conceptually distinct from anesthetics, which temporarily reduce, and in so ...

which can be habituating or addictive. # In the face of expensive conservative treatments which are likely to fail, the surgeon is persuaded to attempt further surgery, even though this is likely to fail as well. # The probability of returning to gainful employment decreases with increasing length of disability. # The financial incentives to remain

disabled Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be cognitive, developmental, intellectual, mental, physica ...

may be perceived as outweighing the incentive to recover. In the absence of a financial source for disability or worker's compensation, other psychological features may limit the ability of the patient to recover from surgery. Some patients are simply unfortunate, and fall into the category of "chronic pain" despite their desire to recover and the best efforts of the physicians involved in their care. Even less invasive forms of surgery are not uniformly successful; approximately 30,000-40,000

patients obtain either no relief of symptomatology or a recurrence of symptoms. Another less invasive form of spinal surgery, percutaneous disc surgery, has reported revision rates as high as 65%. It is no surprise, therefore, that FBS is a significant medical concern which merits further research and attention by the medical and surgical communities.

Total disc replacement

Lumbar In tetrapod anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm (anatomy), diaphragm and the sacrum. Naming and location The lumbar region is sometimes referred to as the lowe ...

total disc replacement was originally designed to be an alternative to lumbar

(fusion). The procedure was met with great excitement and heightened expectations both in the United States and Europe. In late 2004, the first lumbar total disc replacement received approval from the

U.S. Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food ...

. More experience existed in Europe. Since then, the initial excitement has given way to skepticism and concern. Various failure rates and strategies for revision of total disc replacement have been reported. The role of artificial or total disc replacement in the treatment of spinal disorders remains ill-defined and unclear. Evaluation of any new technique is difficult or impossible because physician experience may be minimal or lacking. Patient expectations may be distorted. It has been difficult to establish clear cut indications for artificial disc replacement. It may not be a replacement procedure or alternative to fusion, since recent studies have shown that 100% of fusion patients had one or more contraindications to disc replacement. The role of disc replacement must come from new indications not defined in today's literature or a relaxation of current contraindications. A study by Regan found the result of replacement was the same at L4-5 and L5-S1 with the CHARITE disc. However, the ProDisc II had more favorable results at L4-5 compared with L5-S1. A younger age was predictive of a better outcome in several studies. In others it has been found to be a negative predictor or of no predictive value. Older patients may have more complications. Prior spinal surgery has mixed effects on disc replacement. It has been reported to be negative in several studies. It has been reported to have no effect in other studies. Many studies are simply inconclusive. Existing evidence does not allow drawing definite conclusions about the status of disc replacement at present.

Electrical stimulation

Many failed back syndrome patients are significantly impaired by chronic pain in the back and legs. Many of these will be treated with some form of electrical stimulation. This can be either a

device placed on the skin over the back or a nerve stimulator implanted into the back with electrical probes which directly touch the spinal cord. Also, some chronic pain patients utilize

fentanyl Fentanyl is a highly potent synthetic piperidine opioid primarily used as an analgesic (pain medication). It is 30 to 50 times more Potency (pharmacology), potent than heroin and 50 to 100 times more potent than morphine. Its primary Medici ...

or narcotic patches. These patients are generally severely impaired and it is unrealistic to conclude that application of

neurostimulation Neurostimulation is the purposeful modulation of the nervous system's activity using invasive (e.g. microelectrodes) or Non-invasive procedure, non-invasive means (e.g. transcranial magnetic stimulation, transcranial electric stimulation such as ...

will reduce that impairment. For example, it is doubtful that

will improve the patient enough to return to competitive employment.

Neurostimulation Neurostimulation is the purposeful modulation of the nervous system's activity using invasive (e.g. microelectrodes) or Non-invasive procedure, non-invasive means (e.g. transcranial magnetic stimulation, transcranial electric stimulation such as ...

palliative Palliative care (from Latin root "to cloak") is an interdisciplinary medical care-giving approach aimed at optimizing quality of life and mitigating or reducing suffering among people with serious, complex, and often terminal illnesses. Man ...

. Transcutaneous electrical nerve stimulator units work by blocking

neurotransmission Neurotransmission (Latin: ''transmissio'' "passage, crossing" from ''transmittere'' "send, let through") is the process by which signaling molecules called neurotransmitters are released by the axon terminal of a neuron (the presynaptic neuron ...

as described by the pain theory of Melzack and Wall. Success rates for implanted

has been reported to be 25% to 55%. Success is defined as a relative decrease in pain.

Chiropractic

Limited case series have shown improvement for patients with failed back surgery who were managed with chiropractic care.

Alternate procedures

Smaller procedures that do not remove

bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...

(such as endoscopic transforaminal lumbar discectomy and reconfiguration) do not cause post

laminotomy A laminotomy is an orthopaedic neurosurgery, neurosurgical procedure that removes part of the lamina of the vertebral arch, lamina of a vertebral arch in order to relieve pressure in the vertebral canal. A laminotomy is less invasive than conve ...

syndrome.

Prognosis

Under rules promulgated by Titles II and XVI of the United States

Social Security Act The Social Security Act of 1935 is a law enacted by the 74th United States Congress and signed into law by U.S. President Franklin D. Roosevelt on August 14, 1935. The law created the Social Security (United States), Social Security program as ...

, chronic

and spinal stenosis are recognized as disabling conditions under Listing 1.04 A (

), 1.04 B (

) and 1.04 C (

Return to work

In a groundbreaking

Canadian Canadians () are people identified with the country of Canada. This connection may be residential, legal, historical or cultural. For most Canadians, many (or all) of these connections exist and are collectively the source of their being ''C ...

study, Waddell ''et al.'' reported on the value of repeat surgery and the return to work in worker's compensation cases. They concluded that workers who undergo spinal surgery take longer to return to their jobs. Once two spinal surgeries are performed, few if any ever return to gainful employment of any kind. After two spinal surgeries, most people in the worker's comp system will not be made better by more surgery. Most will be worse after a third surgery. Episodes of back pain associated with on the job injuries in the worker's compensation setting are usually of short duration. About 10% of such episodes will not be simple, and will degenerate into chronic and disabling back pain conditions, even if surgery is not performed. It has been hypothesized that job dissatisfaction and individual perception of physical demands are associated with an increased time of recovery or an increased risk of no recovery at all. Individual psychological and social work factors, as well as worker-employer relations are also likely to be associated with time and rates of recovery. A Finnish study of return to work in patients with

treated by surgery found that: # None of the patients who had

retired Retirement is the withdrawal from one's position or occupation or from one's active working life. A person may also semi-retire by reducing work hours or workload. Many people choose to retire when they are elderly or incapable of doing their j ...

before the operation returned to work afterward. # The variables that predicted postoperative ability to work for women were: being fit to work at the time of operation, age < 50 years at the time of operation, and duration of lumbar spinal stenosis symptoms < 2 years. # For men, these variables were: being fit to work at the time of operation, age < 50 years at the time of operation, no prior surgery, and the extent of the surgical procedure equal to or less than one

. In fact, women's and men's working capacity do not differ after

operation. If the aim is to maximize working capacity, then, when a lumbar spinal stenosis operation is indicated, it should be performed without delay. In lumbar spinal stenosis patients who are older than 50 years old and on sick leave, it is unrealistic to expect that they will return to work. Therefore, after such an extensive surgical procedure, re-education of patients for lighter jobs could improve the chances of these patients returning to work. In a related Finnish study, a total of 439 patients operated on for lumbar spinal stenosis during the period 1974–1987 was re-examined and evaluated for working and functional capacity approximately 4 years after the decompressive surgery. The ability to work before or after the operation and a history of no prior back surgery were variables predictive of a good outcome. Before the operation 86 patients were working, 223 patients were on sick leave, and 130 patients were retired. After the operation 52 of the employed patients and 70 of the unemployed patients returned to work. None of the retired patients returned to work. Ability to work preoperatively, age under 50 years at the time of operation and the absence of prior back surgery predicted a postoperative ability to work. A report from Belgium noted that patients reportedly return to work an average of 12 to 16 weeks after surgery for lumbar disc herniation. However, there are studies that lend credence to the value of an earlier stimulation for return to work and performance of normal activities after a limited

. At follow-up assessment, it was found that no patient had changed employment because of back or leg pain. The sooner the recommendation is made to return to work and perform normal activities, the more likely the patient is to comply. Patients with ongoing disabling back conditions have a low priority for return to work. The probability of return to work decreases as time off work increases. This is especially true in Belgium, where 20% of individuals did not resume work activities after surgery for a disc herniation of the lumbar spine. In Belgium, the medical advisers of sickness funds have an important role legally in the assessment of working capacity and medical rehabilitation measures for employees whose fitness for work is jeopardized or diminished for health reasons. The measures are laid down in the sickness and invalidity legislation. They are in accordance with the principle of preventing long-term disability. It is apparent from the authors' experience that these measures are not adapted consistently in medical practice. Most of the medical advisers are focusing purely on evaluation of corporal damage, leaving little or no time for rehabilitation efforts. In many other countries, the evaluation of work capacity is done by social security doctors with a comparable task. In a comprehensive set of studies carried out by the

University of Washington School of Medicine The University of Washington School of Medicine is the medical school of the University of Washington, a public research university in Seattle, Washington. According to ''U.S. News & World Report''s 2022 Best Graduate School rankings, University ...

, it was determined that the outcome of lumbar fusion performed on injured workers was worse than reported in most published case series. They found 68% of lumbar fusion patients still unable to return to work two years after surgery. This was in stark contrast to reports of 68% post-op satisfaction in many series. In a follow-up study it was found that the use of intervertebral fusion devices rose rapidly after their introduction in 1996. This increase in metal usage was associated with a greater risk of complication without improving disability or re-operation rates.

Research

The identification of

as a central cause of inflammatory spinal pain now suggests the possibility of an entirely new approach to selected patients with FBS. Specific and potent inhibitors of TNF became available in the U.S. in 1998, and were demonstrated to be potentially effective for treating

in experimental models beginning in 2001. Targeted anatomic administration of one of these anti-TNF agents,

etanercept Etanercept, sold under the brand name Enbrel among others, is a biologic medical product that is used to treat autoimmune diseases by interfering with tumor necrosis factor (TNF), a soluble inflammatory cytokine, by acting as a TNF inhibitor. ...

, a patented treatment method, has been suggested in published pilot studies to be effective for treating selected patients with chronic disc-related pain and FBS. The scientific basis for pain relief in these patients is supported by the many current review articles. In the future new imaging methods may allow non-invasive identification of sites of neuronal inflammation, thereby enabling more accurate localization of the pain generators responsible for symptom production. These treatments are still experimental. If chronic pain in FBS has a chemical component producing inflammatory pain, then prior to additional surgery it may make sense to use an anti-inflammatory approach. Often this is first attempted with non-steroidal anti-inflammatory medications, but the long-term use of

non-steroidal anti-inflammatory drug Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...

s for patients with persistent back pain is complicated by their possible cardiovascular and gastrointestinal toxicity; and NSAIDs have limited value to intervene in TNF-mediated processes. An alternative often employed is the injection of

cortisone Cortisone is a pregnene (21-carbon) steroid hormone. It is a naturally-occurring corticosteroid metabolite that is also used as a pharmaceutical prodrug. Cortisol is converted by the action of the enzyme corticosteroid 11-beta-dehydrogenase ...

into the spine adjacent to the suspected pain generator, a technique known as epidural steroid injection. Although this technique began more than a decade ago for FBS, the efficacy of epidural steroid injections is now generally thought to be limited to short term pain relief in selected patients only. In addition, epidural steroid injections, in certain settings, may result in serious complications. Fortunately, there are now emerging new methods that directly target TNF. These TNF-targeted methods represent a highly promising new approach for patients with chronic severe spinal pain, such as those with FBS. Ancillary approaches, such as rehabilitation,

anti-depressants Antidepressants are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction. Common side effects of antidepressants include dry mouth, weight gain, dizziness, headaches, akathisia, sex ...

, and, in particular, graduated exercise programs, may all be useful adjuncts to anti-inflammatory approaches. In addition, more invasive modalities, such as spinal cord stimulation, may offer relief for certain patients with FBS, but these modalities, although often referred to as "minimally invasive", require additional surgery, and have complications of their own.

Worldwide perspective

A report from

Spain Spain, or the Kingdom of Spain, is a country in Southern Europe, Southern and Western Europe with territories in North Africa. Featuring the Punta de Tarifa, southernmost point of continental Europe, it is the largest country in Southern Eur ...

noted that the investigation and development of new techniques for instrumented

of the

spine Spine or spinal may refer to: Science Biology * Spinal column, also known as the backbone * Dendritic spine, a small membranous protrusion from a neuron's dendrite * Thorns, spines, and prickles, needle-like structures in plants * Spine (zoology), ...

is not free from

conflicts of interest A conflict of interest (COI) is a situation in which a person or organization is involved in multiple interests, financial or otherwise, and serving one interest could involve working against another. Typically, this relates to situations in whi ...

. The influence of financial forces in the development of new technologies and its immediate application to spine surgery shows the relationship between the published results and the industry support. Authors who have developed and defended fusion techniques have also published new articles praising new spinal technologies. The author calls spinal surgery the "American Stock and Exchange" and "the bubble of spine surgery". The scientific literature doesn't show clear evidence in the cost-benefit studies of most instrumented surgical interventions of the spine compared with the conservative treatments. It has not been yet demonstrated that fusion surgery and disc replacement are better options than conservative treatment. It is necessary to point out that at present "there are relationships between the industry and back pain, and there is also an industry of the back pain". Nonetheless, the "market of the spine surgery" is growing because patients are demanding solutions for their back problems. The tide of scientific evidence seems to go against the spinal fusions in the degenerative disc disease, discogenic pain and in specific back pain. After decades of advances in this field, the results of spinal fusions are mediocre. New epidemiological studies show that "spinal fusion must be accepted as a non proved or experimental method for the treatment of back pain". The surgical literature on

published in the last 20 years establishes that instrumentation seems to slightly increase the fusion rate and that instrumentation doesn't improve the clinical results in general. We still are in need of randomized studies to compare the surgical results with the natural history of the disease, the placebo effect, or conservative treatment. The European guidelines for lumbar chronic pain management show "strong evidence" indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper posterolateral fusion without instrumentation. Recently, the literature published in this field is sending a message to use "minimally invasive techniques"; – the abandonment of transpedicular fusions. Surgery in general, and usage of metal fixation should be discarded in most cases. In

, the national registry of lumbar spine surgery reported in the year 2000 that 15% of patients with spinal stenosis surgery underwent a concomitant fusion. Despite the traditionally conservative approach to spinal surgery in Sweden, there have been calls for a more aggressive approach to lumbar procedures in recent years. Finally, Cherkin et al. evaluated worldwide surgical attitudes. There were twice the number of surgeons per capita in the

compared to the

. Numbers were similar to

. Despite having very few spinal surgeons, the

proved to be quite aggressive in surgery. Sweden, despite having a large number of surgeons, was conservative and produced relatively few surgeries. The most surgeries were done in the United States. In the UK, more than a third of non-urgent patients waited over a year to see a spinal surgeon. In

Wales Wales ( ) is a Countries of the United Kingdom, country that is part of the United Kingdom. It is bordered by the Irish Sea to the north and west, England to the England–Wales border, east, the Bristol Channel to the south, and the Celtic ...

, more than half waited over three months for consult. Lower rates of referrals in the United Kingdom was found to discourage surgery in general. Fee for service and easy access to care was thought to encourage spinal surgery in the United States, whereas salaried position and a conservative philosophy led to less surgery in the United Kingdom. There were more spinal surgeons in Sweden than in the United States. However, it was speculated that the Swedish surgeons being limited to compensation of 40–48 hours a week might lead to a conservative philosophy. There have been calls for a more aggressive approach to lumbar surgery in both the United Kingdom and Sweden in recent years.

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{{Medical resources , DiseasesDB = , ICD10 = {{ICD10, M96.1 , ICD9 = , ICDO = , OMIM = , MedlinePlus = , MeSH = , GeneReviewsNBK = , GeneReviewsName = , Orphanet = Chronic pain syndromes Neurosurgery Orthopedic problems