Failed Back Surgery Syndrome treatment options
Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.
You are likely reading this article because you are looking for some answers to your diagnosis of failed back surgery syndrome. You have probably been told that many people have very successful surgeries, and that is very true, but failed back surgery complications are something that does happen and that you need to move forward from here. Moving forward may be difficult for you as your pain can be significant or bothersome and it is compromising your quality of life. Although your back pain may not be as severe as it was before the surgery, you like many will continue to experience significant back pain after spinal surgery. Why? Because the back surgery involved removing supporting structures, such as a lamina, facet, or disc, weakening their spinal structures. As you will see in the research below, doctors are being told to inform patients of the substantial likelihood of re-operation following a lumbar spine operation. Later in this article, we will present non-surgical treatment options to help you with your back pain.
If you would like help from our staff on the assessment of your condition, please email us.
- Successful back surgery failure? Failure of a successful surgery?
- Failed lumbar fusion at L5-S1.
- The surgery was a success, I still have pain.
- Causes of chronic post-surgical spinal pain and why another surgery is being recommended.
- Surgeons believe that laminectomy is done too frequently with improper indications, and with an astounding lack of appreciation of its effect on the mechanical function of the spine.
- What type of treatment is available for failed back surgery patients?
- More surgery, spinal cord stimulation, epidural injection, exercise therapy, and psychotherapy?
- “Returning to the operating room is a complex and challenging decision.”
- The problem of treatments leading to drug addiction in patients with failed back surgery syndrome.
- Failed back surgery syndrome statistics: Patients who suffer from failed back surgery syndrome are showing up in the offices and clinics of physicians, surgeons, and pain specialists in overwhelming numbers
- It doesn’t matter what type of spinal surgery you had, 1 in 5 people will have persistent pain after the surgery.
- Why does spinal surgery fail to relieve pain? Why do many have “disastrous results.”
- There are many types of spinal surgery, each with its own success and failure rates.
- Lumbar Decompression.
- Endoscopic discectomy – the least invasive procedure – here are the patients it won’t work for.
- What are the disastrous results in failed back surgery patients?
- Recurrence of back or leg pain after surgery is a well-recognized problem with an incidence of up to 28%.
- Not only does the MRI confuse treatment options after spinal fusion failure – It may have led directly to the failed surgery.
- Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial.
- Adjacent Segment Disease
- “Higher Preimplantation Opioid Doses Associated With Long‐Term Spinal Cord Stimulation Failure ”
- The idea is Spinal Cord Stimulation is supposed to reduce opioid use – the concept is not working that well
- There is limited evidence for oral opioids in the treatment of chronic low back pain; however, their routine use is widespread
- Limitations of Spinal Cord Stimulators – People still take opioids.
- Why the spinal cord stimulations have to be removed.
- Intrathecal drug delivery.
- Mind over body pain control.
- Depression after failed back surgery.
- Adjacent segment disease and spinal instability – the key to treatment may be spinal ligaments.
- New research, new hope on avoiding revision surgery with simple tissue regeneration injections.
- When the surgery itself causes new post-surgical pain, can we treat that with Prolotherapy?
- Platelet Rich Plasma Therapy in combination with Prolotherapy.
What are we seeing in this image?
Spinal instability at the L3-L4 segment above a previous L5-S1 fusion.
- In the first of the three panels starting at the left, we see the patient in the NEUTRAL, standing straight position. In this position, we see the L3 has slipped well forward above the L4 vertebrae. We also see space between the Neuroforamina.
- In the center of the three panels, we see the FLEXION position. The patient is bending forward. We also see space between the Neuroforamina.
- The third panel is an image of the spine in EXTENSION. This would be a position not only of bending backward but a position many athletes, tennis, golf, running or sports or work with overhead arm motion required. In this position, there is a narrowing of the space between the Neuroforamina. This can cause Lumbar Radiculopathy or lumbar stenosis situation.
Successful failure, failure of a successful surgery, which one are you?
We would like to remind our readers that people have very successful spinal surgeries. These are the people that we do not see at our center, we see the people who did not. These simple stories go something like this:
Failed lumbar fusion at L5-S1
Dear Caring Medical, I have failed lumbar fusion at L5-S1. The fusion did not help alleviate my chronic pain which is sometimes severe and debilitating. I’m hoping to eliminate or manage the pain in my back to allow for normal daily functioning like sitting, driving, walking, and standing.
The surgery was a success, I still have pain
“My surgeon said my L5-S1 fusion surgery was technically very successful. Unfortunately, scar tissue has developed and is pressing on my nerves.”
“My surgery was very successful, but I have spinal muscular atrophy as a result and weakness in my spine.”
“My surgery did not go well. I have had several surgeries since. I am on nerve blocks, pumps, pain meds.”
When people contact us, we have to have a realistic expectation that we can help them. If someone had a broken screw, a crooked rod, or any other hardware failure, the hardware issues need to be addressed with their surgeons before a discussion of avoidance of further surgeries can be discussed.
Causes of Chronic Post-Surgical Spinal Pain and why another surgery is being recommended
Before we look at the latest findings on how to help patients understand their failed back surgery and what they can do about it, let’s have Ross Hauser, MD present a brief summary introduction.
In this video, Ross Hauser, MD describes the 5 main reasons that back surgery failed to help the patient’s condition.
- The surgery did not address the actual cause of the patient’s pain. The diagnosis is wrong. The main cause of ‘”missed” low back pain is an injury to the Sacroiliac Joint. If your MRI showed disc degenerative disease and you had the discs operated on but the Sacroiliac Joint was not addressed, the pain will continue after the surgery.
- The surgery made the lower back MORE unstable. Foraminotomy, Laminectomy, Microdiscectomy, disc surgery, all have to remove parts of the bone in the spine.
- The “missed secondary problem.” The surgery may have successfully addressed what was considered your primary problem, but, you really had two problems. This could be a multi-segmental problem that was not discovered until after the first surgery.
- Too much sitting after surgery, possibly too much bed rest.
- Rarer, scar tissue pinches on the nerves. This is discussed at length below.
Generally speaking, spinal pain that occurs right after surgery is from sensitized nerves, while chronic post-surgical spinal pain is often from spinal instability, but, can have many different causes. Some of these problems can include:
- The surgery caused arachnoiditis – a condition of acute inflammation of the arachnoid membrane that surrounds and protects the nerves of the spinal cord. Symptoms include intense burning or stinging pain and neurological problems.
- Deconditioning – too much bed rest or as mentioned above, too much sitting
- Enthesopathy – The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone. The term enthesopathy typically refers to a degenerated enthesis; though when some doctors use this term, they typically mean enthesitis (inflammation of the enthesis).
- Epidural fibrosis (scar tissue)
- Failure of the fusion. This is the failure of the bone and hardware to graft
- Neuralgia – Nerve pain – Neuritis – Nerve Inflammation – During surgery many superficial sensory nerves have to be cut in order to get down to the vertebrae, and sometimes these nerves get inflamed and/or compressed as they rebuild themselves. Generally, Lyftogt perineural injections and/ or Nerve Release and Regeneration Injection Therapy (NRRIT) may help to resolve this post-surgical neuritis. The treatment is done on or along with the surgery site as well as on any chronic compression injuries that are found on physical examination. Generally, post-surgical treatments are given once/week until the symptoms are resolved. Most likely, four to eight sessions will be needed.
- Pain from adjacent structures. This subject is covered at length in the companion article to this piece. Surgery for degenerative disc disease? Researchers say many are unnecessary and make patients worse.
- Spinal Instability
- The surgery caused spinal instability by removing too much bone.
- The surgery caused spinal instability by damaging the spinal ligaments.
Now let’s get to the research:
“(Surgeons) believe that the procedure [laminectomy] is done too frequently with improper indications, and with an astounding lack of appreciation of its effect on the mechanical function of the spine.”
The above is a powerful statement. It was made forty years ago by two leading spinal surgeons Dr. Augustus A. White III and Dr. Manohar M. Panjabi, in their learning and teaching textbook Clinical Biomechanics of the Spine. In this publication, they stated simply: “We believe that the procedure [laminectomy] is done too frequently with improper indications, and with an astounding lack of appreciation of its effect on the mechanical function of the spine.”(1)
Over 40 years later, little has changed.
All spinal surgeries alter spinal mechanics, causing more force to be generated at the areas surrounding the spinal surgical site.
- In spinal laminectomies and microdiscectomies, the surgical procedure may contribute to clinical instability through the removal of supporting structures of the spinal column. This will alter the spinal dynamic and make the patient more susceptible to new pain.
- With spinal fusions, pain can be felt at the non-fused adjacent segments. The parts of the spine immediately above and below the surgery site.
Laminectomy in the lower back, thoracic region, or neck can cause or lead to spinal instability. The thoracic spine is especially vulnerable to clinical instability after a laminectomy because it normally has a physiologic kyphosis (a curvature). Because of this normal curvature, the posterior ligaments are not as strong as other ligaments since the stability of the thoracic spine is partially derived from the rib cage. When the lamina (the bony plate of the vertebrae) is taken out, anterior forces prevail, making the thoracic kyphosis (curvature) and instability worse.
What type of treatment is available for failed back surgery patients? More surgery, spinal cord stimulation, epidural injection, exercise therapy, and psychotherapy . . . the evidence of the clinical outcome for each treatment has not been clearly determined.
Later in this article, we will present research and information on a few treatments that we have seen help many patients. First, we will explore the traditional options that you may already be on.
A paper in the medical journal Pain Physician (2) makes it clear that there are not many traditional remedies for the patient who is worse off after back surgery. This is from the research as it appeared in the medical journal Pain Physician.
“Failed back surgery syndrome is a frequently encountered disease entity following lumbar spinal surgery. Although many plausible reasons have been investigated, the exact pathophysiology remains unknown.”
“Various medications, reoperations, interventions such as spinal cord stimulation, epidural adhesiolysis or epidural injection, exercise therapy, and psychotherapy have been suggested treatment options (for back pain). However, the evidence of the clinical outcome for each treatment has not been clearly determined.”
Not being clearly determined is a non-committal way to say these treatments will not meet the patient’s expectations of pain relief. They do not work. Drug addiction for many is the next step.
“Returning to the operating room is a complex and challenging decision”
April 2019 in the European Spine Journal (3) cited this research in addressing the likelihood of persistent postoperative pain following reoperation after lumbar surgery. In this paper neuro and spinal surgeons advised their fellow surgeons the following: “High rates of persistent postoperative pain (following secondary or revision spinal surgery) and associated healthcare costs suggest that returning to the operating room is a complex and challenging decision. Spinal surgeons should review whether the potential benefits of additional surgery are justified when other approaches to managing and relieving chronic pain have demonstrated superior outcomes.” (Other methods are listed below).
The problem of treatments leading to drug addiction in patients with failed back surgery syndrome
In March 2019, research led by the University of California, Berkeley published in the journal Cell Transplantation (4) offers this warning:
- “Because of the increasing cases of spinal surgery, medical doctors are expecting to oversee the care of patients with Failed back surgery syndrome more frequently than before. It is challenging enough to manage back pain without falling into the grave of narcotic addiction.”
- “According to our clinical studies, the abuse and overdose of narcotics are closely related to the psychological mode and/or state of patients. Consequently, patients who receive narcotics for more than 14 days are recommended for psychological evaluation and treatment, particularly for patients with chronic back pain. Narcotic usage should be strictly controlled by the official drug administration. There should also be a specific committee in hospitals to monitor narcotic usage for nonmalignant diseases.”
- “(Patients with Failed back surgery syndrome) are likely to suffer from chronic pain despite multiple types of therapy. Narcotics are among the various medications these patients take for the alleviation of pain, and they often become addicted after long-term use. “
Failed back surgery syndrome statistics: Patients who suffer from failed back surgery syndrome are showing up in the offices and clinics of physicians, surgeons, and pain specialists in overwhelming numbers
Recently, researchers from John Hopkins University issued these concerns to their fellow spinal surgeons:(5)
- Patients who suffer from failed back surgery syndrome are showing up in the offices and clinics of physicians, surgeons, and pain specialists in overwhelming numbers.
- As lumbar spinal fusion surgery continues to grow in prevalence, so will the number of patients suffering from failed back surgery syndrome.
- It is important for physicians treating these patients to expand their knowledge of what causes failed back surgery syndrome so they can adequately be prepared to manage these complex cases in the future.
Management of failed back surgery patients should, according to the John Hopkins team, begin with a systematic evaluation looking for:
- new-onset stenosis,
- recurrent herniated discs
- epidural fibrosis (scar tissue in the spine),
- pseudarthrosis (a bone fracture that can only be repaired by medical intervention).
Certain diagnoses may be confirmed with diagnostic procedures such as intra-articular injections, medial branch blocks, or transforaminal nerve root blocks. Once a cause is determined, a multidisciplinary approach to treatment is most effective.
- This includes exercise or physical therapy,
- psychological counseling,
- and interventional procedures.
The most invasive treatment option, short of revision surgery, is spinal cord stimulation. This intervention has a number of studies demonstrating its efficacy and cost-effectiveness in this population. Finally, revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.
It doesn’t matter what type of spinal surgery you had, 1 in 5 people will have persistent pain after the surgery
In an April 2020 study in the Journal of Orthopaedic Surgery and Research,(6) the investigators of this study suggested that there is a substantial risk of ongoing pain following spine surgery, with 1-in-5 patients experiencing persistent postoperative pain within 2 years of surgery, the underlying indications for surgical modality and related choice of surgical procedure do not, by itself, appear to be a driving factor.
Many people we see in our office tell us that they had one surgery or another based on the level of anticipated success that the surgery would have. For many people, the surgery does provide that success, for many others not. Most notably are people who get minimally invasive spinal surgeries believing that these surgeries offer less risk. Research tells us that this is not always the case. We also address this below.
Why does spinal surgery fail to relieve pain? Why do many have “disastrous results”
There are many types of spinal surgery, each with its own success and failure rates.
Lumbar Decompression Failure
In this article we will only touch on some of the concerns expressed by doctors with lumbar decompression, for more detailed discussion and analysis please refer to these three articles on our website:
- Sacroiliac Joint Dysfunction Treatment – What treatments will help you, what treatments may fail you
- Lumbar spinal stenosis surgery alternatives
- Prolotherapy and non-surgical treatment of lumbar radiculopathy
An interesting study on cervical stenosis surgery causing lumbar stenosis complications
One example of how spinal surgery anywhere on the spine can cause problems in other areas of the spine was demonstrated by Korean and American doctors publishing in the publication Global Spine Journal. (7) They found that patients who underwent surgery for lumbar stenosis symptoms, often show radiologic evidence of cervical and thoracic spinal stenosis. However, the cervical and thoracic stenosis did not cause pain or other symptoms typical of stenosis.
When these patients were sent to lumbar decompression surgery, the prolonged surgical positioning during the lumbar decompression procedure caused the cervical and thoracic spine to become symptomatic in many patients.
This is a classic example of surgery fixing one problem and causing a worse problem in another area of the spine. Non-surgical treatments for spinal instability should be explored in these patients.
In a discectomy (removal of the disc), the surgeon must spread muscle and cut various ligaments in order to perform the surgery. The surgery itself can potentially lead to ligament laxity and spinal instability. Sometimes this leads to an “immediate failure,” of the back surgery.
German researchers writing in the medical journal Neurosurgical Review (8) noted:
“Immediate failed back surgery syndrome following lumbar microdiscectomy is defined as persistence, deterioration or recurrence (during hospital stay) of radicular pain and/or sensorimotor deficits and/or sphincter dysfunction after microdiscectomy, which was uneventful from the surgeon’s perspective.
In some patients who revealed no clear reason to have immediately failed back surgery syndrome, diagnosis of battered root syndrome (nerve root swelling due to excessive surgical manipulation) was made.
Further removal of a disc or fusion at one level can lead to disc herniation at the same level or at different levels in the future. It is very common for doctors to see a patient with “one level fixed,” while another segment of the spine is now unstable, degenerated, and causing pain as noted in the above study.
Another way surgery causes harm is that in a discectomy, a large portion of the disc remains behind. This is the portion that, if removed, will cause great risk to the patient. The remaining disc can be as much as 40% of the original disc and it can also re-herniate.
Endoscopic discectomy – the least invasive procedure – here are the patients it won’t work for
Some consider endoscopic discectomy as the least invasive surgery for disc herniation. In this procedure bones do not have to be removed, muscles do not need to be moved out of the way. In January of 2020, a paper in the Journal of Spine Surgery (9) examined independent risk factors to assess their correlation to sub-optimal outcomes after endoscopic lumbar discectomy.
- Analysis of clinical outcomes of 55 consecutive patients treated with endoscopic discectomy between June 2018 and March 2019
- Primary outcome measures were postoperative reductions of the visual analog score (VAS) graded on a scale of 1 to 10 for back and leg pain and modified MacNab criteria (A grading of (Excellent, Good, Fair, Poor) as well as time to narcotic independence.
- Risk factors examined included smoking, facet disease, adjacent segments disc degeneration, obesity, alcohol abuse, and psychiatric illness.
- Most patients suffered from contained herniations (49.1%) followed by extruded herniations (18.2%).
- Follow-up ranged from 6-18 months.
- The most common surgical levels were the L5-S1 level (30.9%), L4-S1 (29.1%), and L4-5 (25.5%).
- The mean return to work was 24 – 26 weeks.
- MacNab outcomes showed that
- 47.3% (26/55) had excellent,
- 36.4% good (20/55),
- 12.7% fair (7/55), and
- 3.6% had poor (2/55), respectively.
- The VAS scores for the back (7.69 to 2.65) and leg (6.78 to 2.65) pain reduced significantly.
Non-surgical treatments for spinal instability should be explored. Please see our article on Post-laminectomy syndrome for a discussion on that topic.
What are the disastrous results in failed back surgery patients?
For patients, fixing one problem but causing the same problem to appear in another area of the spine can be seen as “disastrous results.” This is a term used by doctors in Mexico who investigated patients diagnosed with Failed Back Surgery Syndrome.
In their research they noted:
The majority of the cases in one group had a previous diagnosis of lumbar stenosis whereas disc herniation was the main diagnosis in the group number.
- The main reason for failed back surgery in the stenosis group was a technical error during surgery (61.1%).
- In group 2 the disc herniation group -misdiagnosis was highly prevalent (57.4%). (10)
Therefore the disastrous results could be seen arising from “surgical error,” and MRI misinterpretation.
Research appearing in the journal, Seminars in Musculoskeletal Radiology, lists potential complications following spinal fusion which could confuse the interpretation of the MRI for doctors who are trying to see why the patient is suffering from post-surgical pain.
Radiologists are told to look for specific complications related to the use of spinal instrumentation (the hardware) that include incorrectly positioned instrumentation and failure of spinal fusion, leading to instrumentation loosening or breakage. This is in addition to leakage of cerebrospinal fluid, infection, continued disc herniation. (11)
The problem is MRI cannot tell what is causing the patient’s pain anatomically, it now has to look for suspect hardware. What if there is no suspect hardware? Diagnosis Failed Back Surgery Syndrome.
Recurrence of back or leg pain after surgery is a well-recognized problem with an incidence of up to 28%
Doctors in the United Kingdom wrote in The Journal of Bone and Joint Surgery:(12)
“Recurrence of back or leg pain after discectomy is a well-recognized problem with an incidence of up to 28%. Once conservative measures have failed, several surgical options are available and have been tried with varying degrees of success….The debate around which procedure is the most effective for these patients remains controversial.”
- Note that the above study cites a 28% rate of post-surgical pain.
- The researchers also note that controversy exists over the best revision surgery for pain after surgery.
- Their conclusion is that surgeons may as well choose the least invasive surgery since there’s no one revision surgery that is better than the other.
As mentioned above, surgery of any kind interferes can cause harm to soft tissue, revision surgery is likely not the best answer. Non-surgical treatments for spinal instability should be explored.
Not only does the MRI confuse treatment options after spinal fusion failure – It may have led directly to the failed surgery
If the MRI showed what was really causing the pain, the lumbar fusion would have worked!
Here is a remarkable finding from research on lumbar fusion success or non-success.
Writing in The Open Orthopaedics Journal, (13) Bo Nystrom of the Clinic of Spinal Surgery in Sweden wrote:
“Results following fusion for chronic low back pain are unpredictable and generally not very satisfying. The major reason is the absence of a detailed description of the symptoms of patients with pain, if present, in a motion segment of the spine.
Various radiological findings have been attributed to discogenic pain, but if these radiological signs were really true signs of such pain, fusion would have been very successful.
If discogenic pain exists, it should be possible to select these patients from all others within the chronic low back pain population. Even if this selection were 100% perfect, however, identification of the painful segment would remain, and at present, there is no reliable test for doing so.”
We cover this subject at length in my article MRI causes failed back surgery.
Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial.
Revision surgery is a popular treatment option. In 2007, doctors at the University of Washington published a heavily cited paper that has been referenced in more than 230 medical studies and countless articles, including this one.
The most stunning line from the study’s conclusion is this one:
“Patients should be informed that the likelihood of reoperation following a lumbar spine operation is substantial.”(14)
Most recently this research was cited in a July 2017 study from Rush University medical center doctor published in the journal Clinical Spine Surgery (15) which examined the “unfortunate” circumstance of revision lumbar surgery.
Here are the learning points of the 2017 study:
- The need for revision of a lumbar fusion is an unfortunate occurrence, and there is little known about specific risk factors for morbidity and readmission after this procedure.
- The purpose of this study is to use a large, national sample to identify patient and operative factors that may contribute to the development of these adverse outcomes.
- In the paper’s conclusion, patients who had:
- severe symptomatic disease such as insulin-dependent diabetes.
- An operation of more than 5 hours and 10 minutes
- Three or more levels of fusion were at greater risk of the need for revision surgery
- The research sums up with: “In general, longer, more extensive procedures on sicker patients were associated with increased risk of postoperative complications and readmission.”
One more note on the 2007 study, in 2011 the same research team published a remarkable study in The Journal of Bone and Joint Surgery on a segment population of patients who experienced a DECLINE in revision surgeries. This is what the research said:
“The likelihood of repeat surgery for spinal stenosis declined with increasing age and comorbidity (worsen health problems), perhaps because of concern for greater risks.”(16)
Adjacent Segment Disease
Many people have great success with lumbar fusion surgery. These are the people we do not see in our clinic. The people seeking our help and the people we see at our center did not have such great success with their surgery. They developed more back pain, more spinal instability, and for some radiating pain into their feet. The need for more fusion has been recommended to them as well because the adjacent segments below and above the fusion have now been comprised.
A team of surgeons from medical universities in Spain published an October 2021 paper in the Italian/English medical journal Minerva Anestesiologica (17) to remind their colleagues of the challenges of treating and preventing adjacent segment disease following spinal fusion.
“The adjacent segment syndrome is defined as the changes in the adjacent structures of an operated spinal level that produce symptoms of pain and disability, which worsen the quality of life of a patient. Pain management specialists must be aware of these biomechanical changes brought by spinal surgeries, as well as of the symptoms associated with pain after surgery, to reach an appropriate diagnosis and provide adequate treatment.
Specialized pain literature contains few reports on specific management of patients using the terms “adjacent segment syndrome, degeneration or disease”; most of the literature comes from surgical journals.
It is necessary to perform studies with a population sample comprising patients with adjacent segment syndrome after spinal surgery, since almost all treatments applied in this group are extrapolated from those used in patients with pain originating in the same area but who have not previously undergone spine surgery. Therefore, we consider it necessary for pain physicians to understand the underlying biomechanics, promote the diagnosis of this condition, and analyze possible treatments in patients with adjacent segment disease to alleviate their pain and improve their quality of life.”
What is being suggested is that there is not enough being done to prevent and properly treat failed back surgery syndrome as a result of adjacent segment disease.
“Higher Preimplantation Opioid Doses Associated With Long‐Term Spinal Cord Stimulation Failure “
A January 2021 study in the medical journal Neuromodulation (18) comes to us from Finish doctors at Kuopio University Hospital, School of Medicine, Institute of Clinical Medicine, University of Eastern Finland. Here is the data and recommendations they compiled:
While spinal cord stimulation is an effective treatment in failed back surgery syndrome, the effect of preimplantation opioid use on spinal cord stimulation outcome and the effect of spinal cord stimulation on opioid use during a two‐year follow‐up period was initiated in patients with persistent pain after spinal surgery.
- The study group included 211 consecutive failed back surgery syndrome patients who underwent spinal cord stimulation during a 17 year period concluding in 2014.
- Study patients were divided into groups, which were as follows:
- 1) spinal cord stimulation only (47 patients)
- 2) successful spinal cord stimulation (implanted and in use throughout the two‐year follow‐up period, 131 patients), and
- 3) unsuccessful spinal cord stimulation (implanted but later explanted or revised due to inadequate pain relief, 29 patients).
- Patients who underwent explantation for other reasons (4 patients) were excluded.
- Opioid use was also investigated among this group
- Study patients were divided into groups, which were as follows:
- Higher preimplantation opioid doses associated with unsuccessful spinal cord stimulation only with 35 morphine milligram equivalents (MME)/day as the optimal cutoff value.
- All opioids were discontinued in 23% of patients with successful spinal cord stimulation only but in none of the patients with unsuccessful spinal cord stimulation only.
- Strong opioids were discontinued in 39% of patients with successful spinal cord stimulation but in none of the patients with unsuccessful spinal cord stimulation.
Conclusions – detrimental dose escalation
- Higher preimplantation opioid doses were associated with spinal cord stimulation failure, suggesting the need for opioid tapering before implantation. With continuous spinal cord stimulation therapy and no explantation or revision due to inadequate pain relief, 39% of FBSS patients discontinued strong opioids, and 23% discontinued all opioids. This indicates that spinal cord stimulation should be considered before detrimental dose escalation.
What are we seeing in this image?
It is a pelvic x-ray showing a patient’s spinal cord stimulator and the spinal fusion screws. This is a graphic display of the complication and challenges of a failed back surgery. The patient to whom this x-ray belongs had a history of multiple spinal surgeries, cortisone injections, and the implantation of a spinal cord stimulator. The patient came in to see us because she was not getting pain relief. Following Prolotherapy treatments she had the SCS removed. Her story may not be typical of patient success with treatment. It is her story.
In this section, we will examine various treatments. For many people these treatments may work well long-term or short-term, for others, there are limits to treatments’ successful outcomes.
The idea is Spinal Cord Stimulation is supposed to reduce opioid use – the concept is not working that well
A January 2020 paper led by doctors at the Department of Neurosurgery, University of Iowa Carver College of Medicine appeared in the journal Neuromodulation (19) discuss the realistic outlook of patients with failed back surgery syndrome, history of opioid use, and spinal cord stimulation.
“With only half of the chronic opioid users demonstrating meaningful opioid reduction after spinal cord stimulation implantation, (the researchers) demonstrate that current spinal cord stimulation technology does not reliably help a larger number of patients reduce opioid usage. Women, older age, and preoperative MED (pain medication usage) are predictive of meaningful opioid reduction but only one of these are modifiable. As not all patients saw benefit from their therapies, there is still much room for improvement in the treatment of refractory chronic pain that is associated with failed back surgery syndrome and chronic regional pain syndrome.”
There is limited evidence for oral opioids in the treatment of chronic low back pain; however, their routine use is widespread
- Steroids are only effective in a minority of patients with failed back surgery syndrome
- Research shows effective treatment options for failed back surgery syndrome beyond secondary revision procedures, narcotic medications, spinal cord stimulators.
Long-term Oxycodone – naloxone use?
Naloxone is given to counteract the long-term effects of narcotic use. In one case study, Spanish research Dr. Borja Mugabure Bujedo recorded that a combination of Oxycodone – naloxone can be a good alternative for the management of Failed Back Surgery Syndrome when other interventional or pharmacologic strategies have failed in a case report in the journal Anesthesiology and Pain Medicine. In this case report, higher doses than those recommended as a maximum daily ceiling (80/40 mg) were used in one selected patient with severe pain. (20)
- Please see our article Painkillers can increase chronic pain for a further discussion on why doctors need to come up with a better plan of pain management rather than opioid dependence.
This is something the authors of the above-cited study acknowledge, “Failed Back Surgery Syndrome” obviously needs a multidimensional clinical approach. Therapy failure might result from psychosocial influences, structural abnormalities in the back, or a combination of both.”
The next sentence is much more telling. In it, Dr. Bujedo notes that despite success in this reported case history:
- “causes of back pain are largely unknown and correlations with diagnostic studies are uncertain. This lack of precise diagnosis is reflected in a multiplicity of nonspecific treatments, mostly of unproven value. There is limited evidence for oral opioids in the treatment of chronic low back pain; however, their routine use is widespread.”
A 2018 study (21) published in the journal Clinical and Experimental Gastroenterology built on this research by suggesting that managing side-effects, in this case, constipation would help the patient with their failed back problems. Here is what the researchers wrote: “Opioids are an effective treatment for moderate-to-severe pain. However, they are associated with a number of gastrointestinal side effects, most commonly constipation. Laxatives do not target the underlying mechanism of opioid-induced constipation, so many patients do not have their symptoms resolved. Fixed-dose prolonged-release oxycodone/naloxone tablets contain the opioid agonist oxycodone and the opioid antagonist naloxone. Naloxone blocks the action of oxycodone in the gut without compromising its analgesic effects.
Limitations of Spinal Cord Stimulators – People still take opioids
For a more comprehensive understanding of how we can help people after failed spinal cord stimulation please see our article When Spinal Cord Stimulators are not helping.
Spinal cord stimulators can be very effective for many people. We typically do not see the people from whom spinal cord stimulators were effective at our center. We see the people for whom they were not.
Spinal cord stimulation is usually reserved as a last-chance effort at controlling back pain. Specifically, it is used for people who have pain after surgery, complex regional pain syndrome, or severe nerve pain and numbness. The procedure involves implanting a small pulse generator into the stomach and running coated wires to the spine to deliver electrical impulses to the spinal cord. These electrical impulses block pain signals traveling to the brain.
In most patients we see, the spinal cord stimulator does not replace the need for narcotic medication. Additionally, a foreign device is placed in the body, which is nearly never the best option. There are risks to implanting a foreign device in the body. Some of these risks include infection, scar tissue around the stimulator, headaches, breakage of electrical wire, and pain beyond the reach of the impulses.
A February 2021 study in the Journal of Clinical Neuroscience (22) writes: “Spinal cord stimulation (SCS) has been considered as an alternative therapy to reduce opioid requirements in certain chronic pain disorders. However, information on long-term opioid consumption patterns and their impact on SCS device explanation (removed) is lacking. ”
In this study, 45 patients were followed following the removal of their spinal cord stimulation devices. Here is what happened to them:
- Daily morphine equivalent dosage (MED) The number of pain medications they were taking:
- Increased in 40% of patients
- Decreased in 40% of patients
- and remained the same in 20% of patients at 1-year follow-up,
- Twelve (27%) patients had they underwent explantation due to treatment failure at an average of 18 months after implantation.
- Following explantation,
- Reduction in the daily MED was seen in 92% of patients with dosages falling below pre-operative baseline in nine.
- Among the opioid naïve patients (not currently taken or had stopped taking opioids), 55% were on opioids at the last follow-up
- (These results) indicate that daily opioid consumption does not decrease in most patients year after SCS implantation.
- Furthermore, post-operative evaluation beyond 1-year is necessary to assess the efficacy and durability of SCS therapy as well as its impact on the opioid requirement. Lastly, rigorous patient selection and pre-operative risk assessment for misuse and dependence are paramount to improving outcomes after SCS implantation.
Research shows the good and the bad
A heavily referenced paper in The Korean Journal of Pain praised spinal cord stimulation as a widely used and efficient alternative for the management of difficult to treat chronic pain, unresponsive to conservative therapies. Technological improvements have been considerable and the current neuromodulation devices are both extremely sophisticated and reliable in obtaining good results for various clinical situations of chronic pain, such as failed back surgery syndrome, complex regional pain syndrome, ischemic and coronary artery disease. (23)
In the July 2017 issue of the medical journal Spine, doctors explained that spinal cord stimulators should be explored as the best option against further exposing patients to more failed procedures: “Clinical evidence suggests that for patients with Failed Back Surgery Syndrome), repeated surgery will not likely offer relief. Additionally, evidence suggests long-term use of opioid pain medications is not effective in this population, likely presents additional complications, and requires strict management. (24)
In a December 2017 study, doctors in Spain writing in the medical journal Pain Medicine acknowledge that:
- Spinal cord stimulation for patients with failed back surgery syndrome show variable results and limited to moderate evidence.
- In the last years, the stimulation of high frequency has been considered as a better alternative in this pathology for its supposed benefits compared to the stimulation with conventional frequency.
So they performed a study on 55 patients comparing the high frequency and standard frequency stimulators. The result:
The evolutionary pattern of the different parameters studied in our patients with failed back surgery syndrome does not differ according to their treatment by spinal stimulation, with conventional or high frequency, in a one-year follow-up. (25)
One did not work better than the other.
Why the spinal cord stimulations have to be removed
Seventeen pain centers across the United States took part in a study to see why spinal cord stimulations had to be removed from patients.
In agreement with other studies, the pain centers found that clinically, spinal cord stimulation devices are cost-effective and improve function as well as the quality of life. However, despite the demonstrated benefits of spinal cord stimulation, some patients have the device removed. The researchers in this study wanted to know why.
The most common reason for device removal was:
- lack or loss of pain relief, (43.9%)
- followed by complications (20.2%)
This research appeared in the August 2017 edition of the medical journal Neuromodulation. (26)
Failed Back Surgery Syndrome treatment: Intrathecal drug delivery
Similar to a spinal cord stimulator, spinal drug delivery (or intrathecal drug delivery) involves implanting a small pump in the stomach and running a catheter to the spine to deliver pain medication. It is used for people with chronic back pain who need large doses of narcotics to deal with the pain. Compared to oral medication, this “pain pump” requires a smaller dose of narcotics because the medication goes directly to the area of pain.
Research in the medical journal Neuromodulation wrote of the benefits of intrathecal drug delivery. Researchers looked at patients who were averaged 67 years of age, was 68% women, and 77% were Medicare beneficiaries.
- Ninety-five percent of patients had low back pain, and 86% had limb pain.
- The majority (81%) had pain for more than 5 years.
- Failed treatments included:
- epidural injections (74%),
- lumbar spine surgery (46%),
- spinal cord stimulation (14%),
- and facet joint injections (11%),
- with 84% also reporting significant systemic opioid side-effects.
All patients taking long-acting opioids discontinued these within one month of the implant. Total systemic opioid elimination was accomplished by 68% of patients at one-month post-implant, 84% at one year, and 92% at five years. (27)
However, doctors in Germany noted in the journal Pain Physician that the assessment of the functionality of intrathecal drug delivery systems remains difficult and time-consuming. Catheter-related problems are still very common, and sometimes difficult to diagnose. (28)
Failed Back Surgery Syndrome treatment: Mind over body pain control
In an often referenced article, doctors at the University of Duisburg-Essen in Germany wrote in the journal BMC Complementary and Alternative Medicine:
“Mindfulness-based stress reduction (MBSR) is frequently used for pain conditions. While systematic reviews on MBSR for chronic pain have been conducted, there are no reviews for specific pain conditions. Therefore a systematic review of the effectiveness of MBSR in low back pain was performed….This review found inconclusive evidence of the effectiveness of MBSR in improving pain intensity or disability in chronic low back pain patients. However, there is limited evidence that MBSR can improve pain acceptance.”(29)
- In other words, just live with the pain. Mental strength can help, but the reality is that there is an underlying cause of the pain that needs to be addressed. So what are other options for pain after back surgery?
Depression after failed back surgery
In the May 2017 edition of the Journal of Physical Therapy Science, researchers concluded that the surgery experience in patients with ongoing low-back pain makes their pain and depression worse. (30)
Here are the learning points from this research:
Doctors have long been aware that many patients experience some form of post-surgical depression in the six months following an invasive procedure. However, some researchers believe that being depressed after surgery is “understandable” and “unworthy of diagnosis or treatment.”
As most people with post-surgical depression emerge from depression after about six months, many doctors consider post-surgical depression either benign or even helpful as it keeps people inactive. Nevertheless, researchers have discovered that depressed patients are more likely to have other complications following back surgery.
They are less able to cooperate in their after-care, particularly in rehabilitative therapy. For people who have an existing history of depression and anxiety, recovery from post-surgical depression is neither guaranteed nor as straightforward as some surgeons expected.
Please see a further discussion at our article Chronic back pain the impact of depression and anxiety
Adjacent segment disease and spinal instability – the key to treatment may be spinal ligaments
An October 2021 paper published in the European Federation of National Associations of Orthopaedics and Traumatology Open Review (EFORT) (31) examined who was at higher risk for developing adjacent segment degeneration following a spinal fusion. This is what they wrote: “Spinal fusion is the most widely accepted treatment for lumbar disc degenerative disease. However, it has been associated with adjacent segment degeneration as a potential long-term sequel especially in those with preoperative risk factors, which may cause aberrant (unnatural and excessive) stress forces in these segments and lead to adjacent level degeneration. Adjacent segment pathology can include adjacent segment degeneration and adjacent segment disease, although a clear and consensual definition of adjacent segment disease is missing. In most studies, adjacent segment degeneration is defined as radiographic changes in the intervertebral discs adjacent to the surgically treated levels, whereas adjacent segment disease is defined as the pathologic process associated with disc degeneration leading to clinical symptoms, such as radiculopathy, stenosis, and instability.”
Prolotherapy, as will also be explained in this article, it is an injection therapy that seeks to stabilize the structures of the spine through healing soft tissue damage caused by the surgery or not fixed by the surgery. Prolotherapy is an injection technique that accelerates healing in soft tissue. Issues of hardware failure, bent or loose screws or plates, faulty wiring are issues that need to be addressed by spinal surgeons first. This article will address issues of failed back surgery syndrome where hardware failure is not the issue.
We have taken you on a journey throughout this article to show the current options that are most commonly prescribed. We are now going to continue with the discussion of Prolotherapy.
New research, new hope on avoiding revision surgery with simple tissue regeneration injections
When chronic back pain continues after back surgery, some doctors are hopeful that they can help their patients with simple sugar or dextrose Prolotherapy injections. This concept will be discussed below with appropriate medical evidence.
In research from May 2019, researchers at the Gulhane Training and Research Hospital, Traditional and Complementary Medicine Practice Center, University of Health Sciences, Ankara, Turkey wrote in the European Spine Journal : (32)
- “Patients with chronic low back pain, who do not respond to conservative treatment methods, generally undergo surgical revision operations, and sometimes an undesirable condition called failed back surgery syndrome (FBSS) may be inevitable. Hereby, dextrose (Prolotherapy injections) is one of the regenerative methods that has gained popularity in the treatment of many musculoskeletal problems, and we aimed to present and evaluate the outcomes of (Prolotherapy injections) for the treatment of FBSS.
- A total of 79 patients with failed back surgery syndrome, who had minimum 6 months of symptoms and did not respond to 3 months of conservative methods between May 2014 and March 2016, participated in the study.”
What did the researchers find?
- Prolotherapy injections provided significant pain relief and improvement in disability scores.
The conclusion of this research? The doctors said:
- “These results may be the first step giving a lead to an undiscovered field (of pain relief and spinal stability). This treatment method should be kept in mind for FBSS patients before giving a decision of revision surgery.”
What this research is suggesting is that if you inject a simple sugar (dextrose) into the supportive soft tissue structures of the spine, that is the spinal ligaments, tendon-bone attachments, and fascia, there is a good chance that the patient with pain following failed back surgery syndrome can get relief and a strengthen spine.
Because you have likely been suffering for some time, and because you have probably heard other researchers say the same thing about other treatments, we are going to provide you with comprehensive information on the various options you have.
Comprehensive Prolotherapy is a treatment designed to strengthen weakened soft tissue in the spine and bring stability to the area through injections, not surgery. More stability, less unnatural movement, less pain. We recommend a consultation for those on narcotics and those with spinal cord stimulators. In the case of spinal stimulators, we ask patients to bring in their X-rays showing exactly where the spinal cord stimulator is placed. As long as we can see where the stimulator electrodes are located we can safely do Prolotherapy.
- Patients and doctors should realize there is obviously a reason why the spinal fusion didn’t work. In the fusion, the surgery fused the lumbar vertebrae, but the fusion surgery did not address where the cause of the pain was coming from. If pain persists after the surgery, the surgery did not address the cause or create more damage itself.
- At 0:45 of the video, Dr. Hauser demonstrates how this happens.
- Often when you have failed back surgery syndrome, the pain source can be traced to coming from your sacroiliac joint. If this is the case this is where we inject Prolotherapy.
Prolotherapy attacks the problems of a damaged spine instead of suppressing the symptoms. It offers a fix when all else fails. While Prolotherapy is an alternative to disc surgery, it can also help when disc surgery has already occurred yet failed to address the root issue.
When the surgery itself causes new post-surgical pain, can we treat that with Prolotherapy?
When you fuse two or three spinal segments together, mobility is lost. Spinal twisting and torque movement, however, have to come from somewhere. Where? The spinal segments above and below the fusion. These vertebral segments now have to move “excessively” to compensate. Ultimately, this extra movement and strain will cause accelerated degeneration of the disc, ligaments, and joints of these segments, thus making the person more prone to pain in these areas. This is most likely the explanation for the increased pain a few years down the road and the “need” for more operations later.
In research from Harold Wilkinson MD, published in the medical journal Pain Physician,(33), Dr. Wilkinson looked at difficult back pain cases: “Of the patients studied, 86% of patients had undergone prior lumbar spine surgery and all were referred for neurosurgical evaluation for possible surgery,” to see is simple dextrose Prolotherapy would be of benefit.
Here are some learning points:
- Thirty of the 35 patients in this study had been referred to a neurosurgeon because of persistent pain and disability despite prior low back surgery and were referred for consideration for possible additional surgery.
- After inclusion in this study, only four patients subsequently underwent additional surgery, though 29 patients requested repeat injections.
- This suggests that painful enthesopathy can be a major pain generator for some patients and that diagnosing their condition as being due to a focal problem and treating those sites with prolotherapy can be an effective and “minimally invasive” treatment alternative. (The enthesis is the point at which the connective tissue structures, such as a joint capsule, fascia, ligament, tendon, or muscle attach to the bone.)
Other Prolotherapy research (34, 35, 36) has shown Prolotherapy can stabilize the areas that are painful. For most cases, three to eight visits of Prolotherapy, given once per month is all that is needed. Remember getting one spinal fusion operation may end up leading to another. Perhaps, a second opinion by a Prolotherapy doctor before getting a spinal fusion operation is needed? It may help you avoid surgery. Please refer to for more discussion Cervical pain Adjacent segment disease following neck surgery.
Failed Back Surgery Syndrome treatment: Platelet Rich Plasma Therapy in combination with Prolotherapy
Some doctors may recommend the use of Platelet Rich Plasma to help patients with failed back surgery syndrome. Platelet Rich Plasma is an injection of your concentrated blood platelets into the area of pain. The concentrated blood platelets bring healing and regenerating growth factors to the areas possibly damaged or affected by surgery.
Recent research says that Platelet-rich plasma (PRP) represents an additional approach, as it has shown some promise in bone regeneration, and should be explored for its potential role in limiting spinal fusion surgery failures. (37)
In other research PRP injections into atrophied lumbar multifidus muscle were found to be a safe, effective method for relieving chronic low back pain and disability with long-term patient satisfaction and a success rate of 71.2%. (38)
In our practice, PRP is used in conjunction with dextrose Prolotherapy to stimulate healing of the ligament and tendon attachments of the spine that cause pain, muscle spasms, and degenerative disc, and other conditions.
For more information on the combined use of PRP and Prolotherapy please see Prolotherapy treatments for lumbar instability and low back pain.
Summary and contact us. Can we help you?
Many people only become aware of Prolotherapy after they have undergone a surgical procedure for back pain. Although the pain may not be as severe as it was before the surgery, most people continue to experience significant back pain after surgery. Why? Because the back surgery involved removing supporting structures, such as a lamina, facet, or disc, thus weakening surrounding segments.
Except in a life-threatening situation or impending neurologic injury, surgery should always be a last resort and performed only after all conservative treatments have been exhausted. Pain is not a life-threatening situation, although it can be very anxiety-provoking, life-demeaning, and aggravating. Pain should not be an automatic indication that surgery is necessary.
It is not uncommon for patients to say that surgery has been recommended to resolve their painful back conditions. Reasons for surgery may be herniated discs, compressed nerves, spinal stenosis, severe arthritis, and intractable pain. Such conditions may have nothing to do with the problem causing the pain. As previously discussed abnormalities noted on an MRI scan, such as a pinched nerve or herniated disc, rarely are the reasons we find for someone’s chronic back pain. We find at Caring Medical that spinal instability due to ligament weakness is the number one reason for chronic low back pain, and this diagnosis is not made by an MRI.
Prolotherapy injections to the weakened segments in the lumbar vertebrae often result in definitive pain relief in post-surgery pain syndromes. Back pain is commonly due to several factors and surgery may have eliminated only one. It is possible, for example, to have back pain from a lumbar herniated disc and a sacroiliac joint problem. Surgery may address the herniated disc problem but not the sacroiliac problem. In this example, Prolotherapy injections to the sacroiliac joint can significantly help the chronic pain problem. Prolotherapy can help many people who have failed back surgery by addressing spinal instability and repairing loose, lax, damaged ligaments. The key to successful treatment is identifying the right candidates. These treatments will not help everyone.
We hope you found this article informative and it helped answer many of the questions you may have surrounding your back problems and spinal instability. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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