When Back Surgery Fails

Laminectomy, discectomy, spinal fusion...

These are just a few of the procedures that can alleviate debilitating pain so you can return to your daily activities.

But like most things in life, there is no guarantee.

And in some cases, back surgeries don't always provide relief.

When they do work, these procedures can eliminate nerve compression, make the spine more stable, and help patients overcome dependence on pain medication.

When back surgeries don't work, you can feel like you're back at square one.

Failed back surgery syndrome (FBSS) is an issue many people have to deal with after having one or more procedures.

The condition shines a light on a crucial fact in medicine...

Surgical procedures don't always work.

What is Failed Back Surgery Syndrome (FBSS)?

Low back pain is one of the main factors leading to the loss of health.⁶ With aging comes degeneration of the spine—especially in the lumbar (low back) area.

As time goes on, damage to the intervertebral discs can lead to arthritic changes that alter the way the spine moves.

These changes can cause structures like bone spurs and discs to put pressure on nerves, leading to muscle weakness, tingling, loss of sensation, and pain.

According to the International Association for the Study of Pain, FBSS is low-back pain that persists after surgical intervention. This also includes pain that starts after someone undergoes a spinal surgical procedures.¹

Surgery can sometimes make pain symptoms worse, further contributing to stress, anger, and frustration.

You might become afraid to move, fearing that every tiny twinge is going to turn into shooting pain down the legs or a "pulled" back.

And as we know, the less we move, the worse our health becomes.

Some people with FBSS can isolate themselves from others. And the inability to keep up with others during physical activities can cause shame.

We often think of pain as having only physical effects. In fact, it can be a source of mental and emotional stress as well.

So What Causes Failed Back Surgery Syndrome (FBSS)?

The causes of failed back surgery syndrome (FBSS) include physical, psychological, and lifestyle factors. But they also include factors beyond your control.

For example, choosing an inappropriate candidate for surgery, or the wrong surgical approach, can cause persistent pain after surgery. Also, if you've had multiple surgeries in the past, you're more likely to develop FBSS.¹

Psychological factors like depression and anxiety have been correlated with FBSS. Smoking can also play a role.¹

More egregious cases of failed back surgery syndrome are the result of surgical errors, such as operating at the wrong site, failing to address multiple levels of the spine, or using improper technique.¹

Complications related to surgery can also contribute to chronic back pain after spinal surgery, such as infections and injury to the nerves.

But changes to spinal function after surgery can result in pain and other symptoms, which can create stress that further damages tissues.

Fusing two or more spinal segments requires the segments above and/or below to allow for more movement. And the more movement in a joint, the less stable it is. This increased instability can further damage joint tissues.

This "transition syndrome" has been reported in 36% of patients after a lumbar spinal fusion.³

Spinal stenosis, the narrowing of the openings through which nerve roots pass, can also be a factor in post-surgery symptoms. This narrowing can be a result of arthritic changes and instability.

Finally, disc degeneration and herniation can also play a role in FBSS, as can the formation of scar tissue that adheres to nerve roots after back surgery.⁹

How Common is Failed Back Surgery Syndrome (FBSS)?

Between 10 and 40 percent of back-surgery recipients experience FBSS. The number of surgeries and the level of complexity of the procedures can influence whether or not they experience FBSS.¹

After a second surgery, 30 percent of patients experience a successful outcome. That number decreases to 15 percent after the third procedure, and 5 percent after the fourth.³

A microdiscectomy is less complex than a lumbar spinal fusion. So, the risk of developing FBSS after a discectomy is lower (19 to 25 percent) than the risk for someone undergoing a spinal fusion (30 to 46 percent).²

Common Symptoms of Failed Back Surgery Syndrome (FBSS)

Common symptoms associated with failed back surgery syndrome (FBSS) include persistent pain in the legs and back, numbness, or burning sensations.

The symptoms of FBSS can affect your daily living and prevent you from sleeping through the night. You may be unable to return to full mobility or recovery from surgery.

All of this can lead to feelings of depression and anxiety, as well as contributing to long-term use of pain medication.¹⁰

The Impact of Failed Back Surgery Syndrome on Wellbeing

How Chronic Pain Affects Function

Someone struggling with FBSS is likely to experience a lower quality of life (more pain, disability, unemployment, and drug use) when compared to those with other painful conditions like rheumatoid arthritis and fibromyalgia.¹

As a Medical Exercise professional, I've worked with clients who are constantly tired, frustrated, and overwhelmed by persistent pain and other symptoms.

In one case, exercise provided some relief. The client reported a greater awareness of his posture and of making sure he was engaging the right muscles during certain activities.

And although we made progress with his ability to perform functional movements, the stiffness and pain symptoms continued. This was one of those cases where the client needed be referred to an appropriate medical professional for further evaluation.

Psychological Effects of Persistent Pain After Back Surgery

In addition to depression, anxiety, and poor sleep, post-surgery patients may develop PTSD, panic disorders, ADHD, and suicidality.⁷

The need for additional medical interventions can further add to psychological and financial stress.

This highlights the importance of addressing mental/emotional challenges related to physical health issues—something that often gets overlooked when discussing pain.

More Surgeries May Not Be the Answer

As you'd probably guess, failed back surgery syndrome commonly leads to recommendations for additional surgeries.

One example is when pain becomes worse after surgery. Another is when the initial surgery simply did not result in the intended outcome.

The failure rates of surgical procedures are one of the many things you need to consider when deciding on which path to take.

Putting off surgery may be a choice you make once you learn about failure rates and the risk of persistent pain. That's why it's important to evaluate all your available options.

You may explore more conservative approaches before choosing to undergo back surgery. But at the end of the day, chronic pain can be so severe that surgery is the best option.

What Can You Do When You're Still in Pain After Back Surgery

The first step to take if you're experiencing persistent pain and other symptoms after back surgery is to get an evaluation from a licensed medical professional.

You need to consider your entire health history along with the details related to your surgery. The more information your doctor has, the more likely they are to provide an accurate diagnosis.

The type of pain can shed light on some possible causes. Leg pain, for example, can be a result of nerve root compression from a herniated disc or spinal stenosis.

If the pain is in the low-back area, it might be related to a dysfunctional sacroiliac (SI) joint or damage to the cartilage of the facet joints of the spine.

Pain can also be a result of dysfunction in the muscle tissues.

Your doctor should take into account any mental health factors, such as anxiety and depression, as these have a high comorbidity with failed back surgery syndrome.¹

A psychological evaluation that identifies things like your emotional state, beliefs about your pain, and other factors should be part of the evaluation.

X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI), help uncover the cause of chronic back or leg pain after back surgery.

The MRI test can help identify disc herniations and the formation of scar tissue.¹

There's evidence showing that people with FBSS can benefit from the use of spinal cord stimulation. And this is typically the treatment of choice after other measures have already been taken.¹

Keep in mind that your physician may be of many people on your healthcare team. You may also need to refer to pain specialists, physical therapists, and other practitioners in an effort to manage FBSS.

How Can Exercise Help With Persistent Pain After Back Surgery?

Regular exercise can restore function, strength, and mobility after a laminectomy, discectomy, spinal fusion, and other surgeries.

Strengthening core muscles improves stability of the trunk, allowing you to lift, push, pull, and carry safely with minimal or no pain.

The right stretching program can keep muscles flexible and joints mobile. It can counter the stiffness many people experience after back surgery, especially when waking up first thing in the morning.

Combining exercise with other modalities such as functional decompression, treadmill training, and vibration therapy have been shown to effectively manage FBSS.⁵

Just keep in mind that these modalities may require different health professionals, as they may be outside the scope of practice of Medical Exercise Specialists, personal trainers, and other exercise professionals.

When it comes to physical activity, you'll need to obtain medical clearance from your physician and/or surgeon. They can determine if you are ready to start an exercise program and establish guidelines to make sure you exercise safely.

Exercise Criteria: Are You Ready for Physical Activity After Back Surgery?

There are specific things I look for when working with clients after they've had back surgery:

1. Radiating Pain

You should have no radiating pain. If you experience pain shooting down the leg, either ongoing or during certain movements, you need to refer to your physician before starting an exercise program.

2. Full Range of Motion in the Low Back

If you're unable to move your lumbar spine in all directions comfortably and within a normal range, you may not be ready for exercise.

Your physician can help you determine if you can start exercising and provide your exercise professional with the information they need to select the right exercise (and avoid the wrong ones).

3. Full Lower-Body Control

You must be able to move and control your legs and feet. This means a level of strength and coordination that allows you to perform common exercises that strengthen the lower body, which is essential for pelvic and spinal stability.

Exercise goals after back surgery include strengthening the trunk and lower extremities as well as improving the level of function in the low back.

Improving cardiovascular endurance and flexibility is also important. Tight muscles and stiff joints can make pain worse and limit range of motion.

Aerobic exercise should be low-impact, such as cycling or aquatic exercise.

Some Signs to Watch Out For

If you start an exercise program, there are some red flags to be aware of. These let you know when you need to go back to your physician or physical therapist.

If pain, numbness, weakness, or tingling symptoms get worse, you should get evaluated by your doctor.

Bladder or bowel problems can indicate neurological issues that need to be addressed by a licensed medical professional prior to continuing an exercise program.

If you experience sudden or unexplained weight loss, there could be an underlying health problem that needs to be evaluated by your doctor.

Finally, if you struggle with anxiety, depression, or other mental and emotional symptoms, these factors can affect your ability to maintain an exercise program.

The exercises, stretches, and other activities you choose depend on your specific condition, medical history, and needs.

The goal is to help you develop an exercise routine you can do on your own. Establishing independence benefits both physical and psychological wellbeing.

Managing Back Pain in the Long Term

There's one hard truth about failed back surgery syndrome (FBSS).

And it's this...

If you're struggling with FBSS, there's a chance that you may never completely eliminate your symptoms.

And the chances of developing FBSS increase with each additional back surgery.

Nerve damage and structural changes to the spine may cause pain to continue. And more involved surgeries bring their own set of risks.

In this case, the focus should be on managing back pain over time.

Thankfully, there are steps you can take to manage pain and other symptoms.

Strong core muscles improve spinal stability and reduce some of the wear and tear that can occur with aging.

Working with a Medical Exercise professional can help you identify your spinal "neutral". Meaning, the spinal position where you feel less pain. Improving your ability to maintain this position while performing your daily activities is key to preventing pain symptoms and the risk of injury.

Proper breathing can help restore function of the abdominal muscles and reduce the stress on muscles of the shoulders and neck when we breathe incorrectly.

Reducing stress, a healthy diet, and other lifestyle changes can also help you manage persistent back pain after surgery.

With the help of your physician, physical therapist, and exercise professional, you can safely return to function and do the things you love doing with minimal pain.

The goal should be to improve your quality of life. And although that may not equate to pain-free living, it can reduce the impact that failed back surgery syndrome can have on your life.

Key Takeaways

Failed back surgery syndrome can wreak havoc on your sense of wellbeing and your ability to perform at work, home, and in your hobbies.

There are many factors that can contribute to pain, numbness, weakness, and other symptoms that continue after back surgery.

The inability to resolve these issues through one or more surgical procedures can cause frustration, depression, and other mental/emotional challenges alongside physical ones.

More surgeries may or may not be the answer.

But either way, getting a thorough evaluation by a medical professional is the first step to relief.

Exercise can play a major role in addressing residual muscle weakness or dysfunctions that contribute to the symptoms of FBSS.

There are criteria for determining if exercise is appropriate for your needs, and there are specific goals and red flags to keep in mind.

Taking a multidisciplinary approach (with the help of your primary care physician, surgeon, physical therapist, and exercise professional) will yield the best results.

And knowing that managing pain and other symptoms often becomes the priority (as opposed to eliminating them completely), lets you set the right expectations.

With the knowledge, tools, and resources you need to restore function after back surgery, you can make lasting changes to your physical, mental, and emotional health.¹

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Darwin Ruiz helps clients restore function, strength, and endurance after spinal surgery or injury. If you'd like to learn more about Medical Exercises and find out if exercise is appropriate for your situation, click here to schedule a complimentary consultation.

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References:

1. Orhurhu VJ, Chu R, Gill J. Failed Back Surgery Syndrome. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539777/
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7. Stanton E, Fresquez Z, Muehlbauer EJ, Wang JC, Buser Z. Onset of mental disorders in patients who developed failed back surgery syndrome. Eur Spine J. 2022 Oct;31(10):2612-2618. doi: 10.1007/s00586-022-07334-4. Epub 2022 Aug 9. PMID: 35941391. https://pubmed.ncbi.nlm.nih.gov/35941391/
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9. Mohi Eldin, M. M., & Abdel Razek, N. M. (2015). Epidural fibrosis after lumbar disc surgery: Prevention and outcome evaluation. Asian Spine Journal, 9(3), 370. https://doi.org/10.4184/asj.2015.9.3.370
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