Failed back surgery syndrome: a suggested algorithm of care

Abstract

Failed back surgery syndrome (FBSS) is a complex condition which can be very difficult to treat. In this article, we propose a pragmatic algorithm for the management of the syndrome. The management of this condition should include a comprehensive initial assessment to rule out treatable cause, pharmacological optimisation, psychological techniques and neuromodulation. There is good evidence to support early application of conventional spinal cord stimulation for FBSS patients suffering from predominant buttock and leg pain. Emerging techniques in neuromodulation such as high-frequency spinal cord stimulation, peripheral nerve field stimulation and dorsal root ganglion stimulation hold promise for the future, but long-term outcome regarding efficacy and safety is not yet established. Intrathecal drug delivery systems should also be considered in those who are unsuitable or unresponsive to neuromodulation and still warrant further treatment. However, the long-term outcome may not be as good as with other treatments mentioned above.

Keywords

Failed back surgery syndrome treatment algorithm pharmacotherapy pain management programme multidisciplinary team neuromodulation spinal cord stimulation intrathecal pump

Get full access to this article

View all access options for this article.

References

Wilkinson

. The failed back syndrome: aetiology and therapy. 2nd ed. Philadelphia: Harper & Row, 1991.

North

Campbell

James

. Failed back surgery syndrome: 5-year follow-up in 102 patients undergoing repeated operation. Neurosurgery 1991; 28: 685–691.

Stojanovic

. Stimulation methods for neuropathic pain control. Curr Pain Headache Rep 2001; 54: 130–137.

Leveque

Villavicencio

Bulsara

. Spinal cord stimulation for failed back surgery syndrome. Neuromodulation 2001; 4: 1–9.

Law

Lehman

Kirsch

. Reoperation after lumbar intervertebral disc surgery. J Neurosurg 1978; 48: 259–263.

Lehmann

LaRocca

. Repeat lumbar surgery: A review of patients with failure from previous lumbar surgery treated by spinal canal exploration and lumbar spinal fusion. Spine 1981; 6: 615–619.

Long

Filtzer

Bendebba

. Clinical features of the failed-back syndrome. Neurosurgery 1988; 69: 61–71.

Krämer

. The discectomy syndrome. Z Orthop 1987; 125: 622–625.

North

Kidd

Shipley

. Spinal cord stimulation versus reoperation for failed back surgery syndrome: a cost effectiveness and cost utility analysis based on a randomized, controlled trial. Neurosurgery 2007; 61: 361–369.

10.

Chan

Peng

. Failed back surgery syndrome. Pain Medicine 2011; 12: 577–606.

11.

Van Buyten

Linderoth

. ‘The failed back surgery syndrome’: Definition and therapeutic algorithms – an update. Eur J Pain Supplements 2010; 4(S4): 273–286.

12.

Anderson

. A rationale for the treatment algorithm of failed back surgery syndrome. Curr Pain Headache Rep 2000; 4(5): 395–406

13.

Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin. NICE Technology Appraisal Guidance, http://publications.nice.org.uk/spinal-cord-stimulation-for-chronic-pain-of-neuropathic-or-ischaemic-origin-ta159 (2008, accessed 27 November 2012).

14.

British Pain Society. Spinal cord stimulation for the management of pain: Recommendations for best clinical practice, www.britishpainsociety.org/book_scs_main.pdf (2009, accessed 27 November 2012).

15.

Dominic

. Spinal cord stimulation: The clinical application of new technology. Anesthesiology Research and Practice, article ID 375691, www.hindawi.com/journals/arp/2012/375691/ (2012, accessed 27 November 2012).

16.

Kumar

Hunter

Demeria

. Spinal cord stimulation in treatment of chronic benign pain: Challenges in treatment planning and present status, a 22-year experience. Neurosurgery 2006; 58(3): 481–496.

17.

Thompson

. Spinal cord stimulation for neuropathic pain, www.neuromodulation.com/spinal-cord-stimulation-for-neuropathic-pain (1996, accessed 27 November 2012).

18.

Block

Vanharanta

Ohnmeiss

. Discographic pain report: Influence of psychological factors. Spine 1996; 21(3): 334–338.

19.

Schofferman

Anderson

Hines

. Childhood psychological trauma and chronic refractory low-back pain. Clin J Pain 1993; 9(4): 360–365.

20.

Ross

. MR imaging of the postoperative lumbar spine. Magnetic Resonance Imaging Clin N Am 1999; 7(3): 513–524.

21.

Grane

. The postoperative lumbar spine: A radiological investigation of the lumbar spine after discectomy using MR imaging and CT. Acta Radiol Suppl 1998; 414: 1–23.

22.

Van Goethem

Parizel

van den Hauwe

. Imaging findings in patients with failed back surgery syndrome. J Belge Radiol 1997; 80(2): 81–84.

23.

North

Kidd

Farrokhi

. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: A randomised controlled trial. Neurosurgery 2005; 56(1): 98–107.

24.

Braverman

Slipman

Lenrow

. Using gabapentin to treat failed back surgery syndrome caused by epidural fibrosis: A report of 2 cases. Arch Phys Med Rehab 2001; 82(5): 691–693.

25.

Baron

Freynhagen

Tölle

. The efficacy and safety of pregabalin in the treatment of neuropathic pain associated with chronic lumbosacral radiculopathy. Pain 2010; 150(3): 420–427.

26.

Duthie

Nimmo

. Adverse effects of opioid analgesic drugs. Br J Anaesth 1987; 59: 61–77.

27.

Katz

Mazer

. The impact of opioids on the endocrine system. Clin J Pain 2009; 25: 170–175.

28.

Daniell

. Hypogonadism in men taking sustained action oral opioids. J Pain 2002; 3: 377–384.

29.

Turk

Wilson

Cahana

. Treatment of chronic non-cancer pain. The Lancet 2011; 377 (9784): 2226–2235.

30.

Dworkin

O’Connor

Backonja

. Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain 2007; 132(3): 237–251.

31.

Hazard

. Failed back surgery syndrome: Surgical and non-surgical approaches. Clinical Orthop Relat Res. 2006; 443: 228–232.

32.

Devulder

. Transforaminal nerve root sleeve injection with corticosteroids, hyaluronidase, and local anesthetic in the failed back surgery syndrome. J Spinal Disord 1998; 11(2): 151–154.

33.

Ragab

DeShazo

. Management of back pain in patients with previous back surgery. Am J Med 2008; 121(4): 272–278.

34.

Manchikanti

Singh

Cash

. Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 3 – post surgery syndrome. Pain Physician 2008; 11: 817–831.

35.

Oakley

Prager

. Spinal cord stimulation: Mechanisms of action. Spine 2002; 27(22): 2574–2583.

36.

Linderoth

Foreman

. Physiology of spinal cord stimulation: Review and update. Neuromodulation: Technology at the Neural Interface 2002; 2(3): 150–164.

37.

Kumar

Taylor

Jacques

. 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.

38.

Manca

Eldabe

Buscher

. Relationship between health-related quality of life, pain, and functional disability in neuropathic pain patients with failed back surgery syndrome. Value in Health 2010; 13(1): 95–102.

39.

Burchiel

K J

Anderson

Wilson

. Prognostic factors of spinal cord stimulation for chronic back and leg pain. Neurosurgery 1995; 36(6): 1101–1111.

40.

Hildebrandt

Pfingsten

Saur

. Prediction of success from a multidisciplinary treatment program for chronic low back pain. Spine 1997; 22: 990–1001.

41.

Lechnyr

. Pre-implant psychological evaluations: A follow-up study of patients who have undergone a pain management device. Prac Pain Manag 2009; 9(1): 25–28.

42.

Block

Kremer

Gaylor

. Behavioural treatment of chronic pain: Variables affecting treatment efficacy. Pain 1980; 8(3): 367–375.

43.

North

Kidd

Wimberly

. Prognostic value of psychological testing in patients undergoing spinal cord stimulation: A prospective study. Neurosurgery 1996; 39(2): 301–310.

44.

Kumar

Abbas

Rizvi

. The use of spinal cord stimulation in pain management. Pain Management 2012; 2: 125–134.

45.

Esmer

Blum

Rulf

. Mindfulness-based stress reduction for failed back surgery syndrome: A randomized controlled trial. J Am Osteopath Assoc 2010; 110(11): 646–652.

46.

Burchiel

Anderson

Brown

. Prospective, multicenter study of spinal cord stimulation for relief of chronic back and extremity pain. Spine 1996; 21(23): 2786–2794.

47.

Smet

VanBuyten

Al-Kaisy

. Successful treatment of low back pain with a novel neuromodulation device. In: Proceedings of the 14th North American Neuromodulation Society Annual Meeting, Las Vegas, Nevada, USA, 2010.

48.

Liem

. Personal communication (unpublished data), 2012.

49.

Huygen

. Personal communication (unpublished data), 2012.

50.

Mironer

Hutcheson

Satterthwaite

. Prospective, two-part study of the interaction between spinal cord stimulation and peripheral nerve field stimulation in patients with low back pain: development of a new spinal-peripheral neurostimulation method. Neuromodulation: Technology at the Neural Interface 2011; 14(2): 151–155.

51.

Paice

Penn

Shott

. Intraspinal morphine for chronic pain: A retrospective multicenter study. J Pain Symptom Manage 1996; 11: 71–80.

52.

Winkelmuller

. Long-term effects of continuous intrathecal opioid treatment in chronic pain of non-malignant aetiology. J Neurosurg 1996; 85: 458–467.

53.

Anderson

Burchiel

. A prospective study of long term intrathecal morphine in the management of chronic non-malignant pain. Neurosurgery 1999; 44: 289–300.

54.

Raphael

Southall

Gnanadurai

. Long-term experience with implanted intrathecal drug administration systems for failed back syndrome and chronic mechanical low back pain. BMC Musculoskeletal Disorders 2002, 3: 17.

55.

Levy

. The failed and future promise of intraspinal drug administration for neurologic disorders. Neuromodulation 2012; 15(3): 165–170.

56.

Deer

Krames

Hassenbusch

. Polyanalgesic Consensus Conference 2007: Recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation: Technology at the Neural Interface 2007; 10(4): 300–328.

57.

Smith

Coyne

. Implantable drug delivery systems (IDDS) after failure of comprehensive medical management (CMM) can palliate symptoms in the most refractory cancer pain patients. J Palliat Med 2005; 8(4): 736–742.