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Failed Back Surgery Syndrome: When The Pain Comes Back After Surgery

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doctor looking at patient's back

From a constant, dull ache to a stabbing or shooting sensation, back pain can show up like an out-of-town relative — sometimes it’s just annoying; other times it’s unbearable.

Back pain can also hurt more than just your body. Your daily activities or just going to work can become difficult. You often now may RSVP no, because you don’t want to deal with the discomfort.

Nearly one in 10 people experience lower back pain, causing more disability than any other condition in the world. And for some, surgery may be the only option for relief. Sometimes, though, surgery doesn’t bring that relief. Up to 40% of patients have experienced continued pain after surgery, which is often referred to as Failed Back Surgery Syndrome (FBSS).

Andrew H. Milby, MD, a Penn Medicine orthopaedic spine surgeon and Assistant Professor of Orthopaedic Surgery at the Penn Presbyterian Medical Center and the Veteran's Administration Medical Center, gives his insight on FBSS and what you should know about your recurring back pain.

What is Failed Back Surgery Syndrome? Is it really a result of a “failed” procedure?

Dr. Milby: The general definition of Failed Back Surgery Syndrome is persistent or recurrent symptoms in anybody who has had previous spinal surgery.

Patients might feel like they got better for a little while, but then started to get worse again. Or they might feel like their symptoms never got better — or perhaps even got worse than before. Their symptoms might have gone from back pain to leg pain or from leg pain to back pain, or both

Dr. Milby FBSS  

What are some of the underlying causes of recurrent back or leg pain after surgery?

Dr Milby: One of the biggest categories of patients that I see is called non-union or pseudoarthrosis — when a solid spinal fusion fails to form after surgery. When a patient who has undergone a spinal fusion wakes up from surgery, the spine is not actually fused — they’re stabilized. And gradually over time, just like they’re healing a broken bone, they become fused. There is a small percentage of people that simply do not complete this healing process for a variety of reasons, and this can cause them to feel worse many months, or even years, after their previous surgery. If the bone doesn’t actually knit together, the screws and rods will predictably work themselves loose over time, or even break. Once this happens, patients may develop either new back pain or recurrent leg symptoms.

The other big category is that of continued degeneration at a level next to a previous surgery. This is not really a failure as much as a continuation of the same disease. Because the spine has many different levels, patients very often can have a successful surgery at one level of the spine, but then continue to have wear and tear above or below. This often causes similar symptoms to recur, usually many years after an otherwise-successful surgery.

When a patient comes to you and is experiencing recurring back or leg pain, how do you determine what treatment they’ll need?

Dr. Milby: It’s strictly a matter of what the right surgery is for that particular patient. Sometimes having had a previous surgery can muddy the waters a little bit, but it doesn’t necessarily change things that much.

The patients who’ve had surgery and know what it has to offer, but then feel worse again — those are patients who we really shouldn’t be giving up on because it obviously helped them at some point.

The question becomes whether their pain has something to do with the surgery itself wearing out or whether something is happening at another level of their spine either above or below where they had their previous surgery.

Some patients can have surgery and feel good for 5 or 10 years — and then the next level up or down the spine can develop the same problem. That new problem can require undergoing a similar procedure, or starting over again with more conservative options — like physical therapy, medications, and injections — before considering surgery.

What’s important for your patients to understand when it comes to understanding recurrent back or leg pain?

Dr. Milby: It’s always a matter of trying to a get a diagnosis, regardless of whether somebody has had surgery or not. You have to figure out what the underlying cause is.

Penn has access to all of the various tools we need to get a specific diagnosis. You can have special imaging studies; consultations with specialists who work with patients who have specific conditions, such as pseudoarthrosis; metabolism work-ups to assess calcium and vitamin D levels, thyroid function, and nutrition. These are all a part of our multidisciplinary approach.

We also have the ability from the anesthesiology standpoint to take care of anybody — no matter what kind of shape their lungs, heart, or kidneys are in. Whatever medical problems they have, we can keep them safe if they need a complex surgery.

But the bottom line is, despite having all the latest technology and testing available to us, the most important way we sort out a patient’s symptoms is by talking to them. There’s no substitute for them sitting face-to-face with a surgeon and telling us what they feel.

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