There are many reasons why patients may continue to have pain. Low back pain is often from more than one source. For example, there may be pain coming from a herniated disc as well as from arthritis in the small joints, known as facet joints. Even if one problem is surgically corrected, pain may persist from the other.
There can be a problem related to the surgery itself, such as a complication from the surgical hardware that was implanted or an infection. Pain may also be caused by continued degeneration of the discs and joints of the spine. This may be especially prevalent at the areas above and below the surgical site. Scar tissue formation (known as epidural fibrosis) and inflammation around the nerves (known as arachnoiditis) may also cause pain.
The best treatment for FBSS is prevention. Non-operative therapy should be the first step in treating low back pain, unless there is a clear anatomical problem that requires more urgent surgical intervention. Conservative treatment often includes physical therapy and medications, including anti-inflammatory medications and muscle relaxers. Certain types of spinal injections are also very helpful in reducing pain. If an adequate trial of conservative therapy fails to significantly improve symptoms then surgical treatment may be explored.
 Patients should be aware that even with a skilled surgeon, there is no guarantee of complete pain resolution from a low back surgery.
If a person develops FBSS, it is important to apply a multi-disciplinary approach to treatment of this complex problem.
First, the spine surgeon should evaluate for problems related to the surgery or for new anatomical problems that may require treatment. If there are no problems requiring surgical intervention, then multi-disciplinary care involving physical therapy, medications and spinal injections should be pursued. Physical therapy should include not only treatments for pain, like deep heat, but also muscular training exercises and instruction on how to do daily activities in a less painful manner.
There are two main types of pain called nociceptive (pain due to tissue injury) and neuropathic (nerve-related) pain. Different classes of medications are used to treat these different types of pain. FBSS includes both nociceptive and neuropathic pain; therefore, many classes of medications have been used to treat the pain associated with FBSS. With FBSS pain in the legs is often nerve-related and some antidepressants, as well as some anti-epileptic medications, have shown benefit for neuropathic pain.
Opiate pain medications may be used; however, their long-term use is controversial. In recent years, much has been learned and more information is available on the serious side-effects of opiate medications. Although opiate medications may be beneficial, their use has significant risks and should be limited if possible.
Treatment of FBSS pain may also include spinal injections, which would include injections around the nerves, discs or small joints in the back. Epidural steroid injections are the most commonly performed. These injections are performed to reduce inflammation around the nerves as they leave the spine to reduce pain. There are several other spinal injections that may be beneficial, such as sacroiliac joint injections or facet joint injections. These injections not only are helpful in treating pain, but also help facilitate diagnosis of the exact pain generator.
 There are some patients that do not respond to less invasive techniques, but they may benefit from more intensive treatments, like spinal cord stimulation.
Spinal cord stimulation is frequently used for the leg pain associated with FBSS. A small lead is placed in the epidural space around the spinal cord. This lead is attached to a generator which produces a tapping or tingling sensation. The goal of spinal cord stimulation is to replace the pain sensation with the more pleasurable tapping or tingling sensation. Before having the device implanted, a screening trial is performed where the patient has a temporary lead placed and is able to test their response to the device. Once the device is implanted the patient can turn the device on and off as well as make some adjustments to the stimulation they receive. Spinal cord stimulation is highly effective for the nerve pain associated with FBSS.
In summary, we are not sure why some patients develop Failed Back Surgery Syndrome and others do not. Fortunately, we can diagnose the disorder and are able to offer treatments to relieve pain, restore function and get folks back to their daily activities of life.
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