Etiology and evaluation of the failed back surgery syndrome

The term “failed back surgery syndrome” (FBSS) designates persistent or recurrent complaints of low back and/or leg pain in patients who have undergone operative procedures intended to relieve those complaints. The genesis of FBSS is multifactorial. It commonly occurs as a consequence of improper patient selection, including failure to recognize psychological abnormalities that adversely affect outcomes. It may result from inadequate operations, operative complications, progression of degenerative processes, or onset of new pathology. The temporal relationships between patients’ initial operations and recurrence of symptoms provide substantial clues about the etiology of recurrent symptoms. Evaluation should be individualized and is based upon the history and physical examination. Radiographic studies should be performed selectively to confirm a clinical diagnosis. Plain radiographs, CT scanning, discography, and nuclear medicine scans have roles in the evaluation of FBSS patients, but magnetic resonance imaging is usually the imaging modality of choice. Psychologic evaluation is essential in many instances. FBSS patients should not be denied reoperation simply because of previous failure, but reoperation is appropriate only if radiographic studies demonstrate a surgically correctable lesion that unequivocally correlates with the patient’s clinical presentation. Physicians should be challenged, not deterred, by the term “failed back surgery syndrome.”