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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.
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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.
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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.
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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 ...