Failed Back Surgery Syndrome

Epidural fibrosis. Scar tissue forms after any epidural intervention. Where it tethers a nerve root, the nerve loses its normal ability to glide as you move, and becomes symptomatic with position and activity. This is the most common finding in leg pain that returns some months after otherwise successful decompression.

Adjacent segment change. A fused segment does not move, so the segments above and below absorb more load. Over years this accelerates degeneration at those levels, and pain returns at a location adjacent to the original surgery rather than at it.

The facet joints. Frequently the original pain was facet-mediated and the disc finding on imaging was incidental. Decompressing a disc that was never the generator leaves the actual source untouched.

The sacroiliac joint. Commonly missed, and more likely after lumbar fusion because load transfers to the pelvis. It refers pain to the buttock and posterior thigh in a pattern easily mistaken for recurrent radiculopathy.

Central sensitization. After a long period of unrelieved pain the nervous system amplifies signaling independent of the original injury. This is real and treatable, but it is a different problem requiring different treatment.

Imaging after spine surgery is genuinely difficult to interpret. Hardware creates artefact, post-surgical change looks abnormal in everyone, and scar is hard to distinguish from recurrent disc on a static image. Reading a post-operative MRI in isolation and treating what looks worst is how patients end up with a second operation that does not help either.

We rely more heavily on two things. Electrodiagnostic testing establishes objectively whether a nerve root is functionally affected and at which level, independent of what the images show. And diagnostic blocks answer the question directly: numb a specific structure, see whether the pain changes.

A facet block, an SI joint injection or a selective nerve root block each tests a specific hypothesis. The answers accumulate into a diagnosis.

Where scar tissue is tethering a nerve — epiduroplasty uses a catheter under fluoroscopic guidance to break up adhesions and deliver medication directly to the affected nerve, restoring some of its ability to move freely.

Where the facet joints are confirmed — radiofrequency ablation of the medial branch nerves gives longer relief than repeated injection.

Where neuropathic pain is established and diffuse — spinal cord stimulation has its strongest evidence base in precisely this population. The landmark randomized comparison, Kumar and colleagues in Pain in 2007, studied stimulation against conventional medical management in failed back surgery syndrome specifically.

Where central sensitization dominates — the work is different: ketamine for refractory nerve pain, counseling, and metabolic and inflammatory treatment.

We will not manage this with escalating medication alone. Our approach is interventional-first, set out plainly in our opioid stewardship protocol, and long-term opioid therapy without interventional support is not something we offer.

We also will not promise that a diagnosis is always findable. Sometimes several generators contribute and no single one dominates. In that case we say so, and the goal shifts honestly from cure to function — which is a legitimate goal, but it should be arrived at after the diagnostic work, not instead of it.