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Failed back surgery syndrome (FBSS) was defined by North and Campbell in 1991 as persistent or recurring low back pain, with or without sciatica, following one or more lumbar spine operations.1 Van Goethem and colleagues describe it as a syndrome characterized by intractable pain and various degrees of functional incapacitation, following spine surgery.2 Rowlingson uses the term failed back surgery syndrome for patients with chronic debilitating low back pain occurring in a patient after back surgery of a variety of types, such as discectomy, laminectomy, and lumbosacral fusion, that was unsuccessful in relieving the patient’s symptoms.3 Fiume and colleagues consider FBSS to be a severe, long-lasting, disabling, and relatively frequent (5%–10%) complication of lumbosacral spine surgery.4 Although disability and chronic pain are commonly seen in the lumbosacral region and the lower extremity, similar mechanisms, pathophysiology, diagnostic dilemmas, and management options can be seen and extrapolated to the cervicothoracic region and the upper extremity.


In 1934, Mixter and Barr demonstrated that a herniated disc could cause nerve root encroachment, ultimately producing back pain.5 In 1951, Barr determined that a patient might have persistent low back pain, sciatica, or both, despite surgical intervention.6 In 1979, Finneson and Cooper made a statement that, “No matter how severe or intractable the pain, it can always be made worse by surgery.”7 The cause of FBSS has been recognized to be multifactorial over the past decade.


Population studies indicate that of all patients with acute back and leg pain, only 1% to 2% actually suffer from disc herniation and require surgery.8 Nearly 300,000 spinal surgeries are performed each year in the United States.9 Approximately 85% of these procedures involve laminectomy and discectomy and 15% are spinal fusions.10 The success rate in most surgical series ranged from 80% to 98%.11–17 Nachemson17 has pointed out that the success rate drops in a dramatic fashion after the first operation. The success rate drops to about 30% after the second operation, 15% after the third, and 5% after the fourth. The difference in patient populations and evaluation criteria make it difficult to compare the various series published to date. Principally, the results are variable, because of the different procedures being grouped as one.


In a retrospective study by Dvorak and colleagues, 371 post–disc surgery patients were interviewed 4 to 17 years later by neurologists.18 As many as 70% had residual low back pain; 23% had severe, permanent low back pain; 45% had residual nerve root pain; 35% patients were undertreated; 14% received disability benefits; and 17.2% patients received repeat surgery. Fritch and colleagues conducted a retrospective study on 182 revisions with FBSS from 1965 to 1990, to identify the cause of failure of primary discectomy, the outcome of revisions, and factors that influenced these outcomes.19 The rate of revision surgery ranged from 5% to 33%. In 80% of patients, the results were satisfactory ...

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