"FBSS (Failed Back Surgery Syndrome)" — What You Should Know
Persistent pain after surgery has a name — and it has treatments.
Last week, we discussed the causes and management of pain that remains after surgery. This week, we'll focus specifically on the condition known as persistent post-surgical spinal pain — its medical name, and the treatments available.
FBSS / PSPS: What Do These Mean?
Why Naming It Matters
Persistent pain after spine surgery has a recognized medical name.
- FBSS: Failed Back Surgery Syndrome
- PSPS: Persistent Spinal Pain Syndrome (the more modern and preferred term)
Don't Be Misled by the Word "Failed"
The word "Failed" in FBSS is a major source of misunderstanding.
FBSS does not mean your surgery failed.
This name was coined over 50 years ago and no longer reflects our modern understanding. That's precisely why the newer term PSPS (Persistent Spinal Pain Syndrome) is now recommended.
FBSS is simply an umbrella term for "pain that persists after spinal surgery." Even when the surgery itself was performed correctly, pain can remain for a variety of reasons.
How Common Is It?
The percentage of patients diagnosed with FBSS/PSPS after lumbar surgery:
- Approximately 5-27% of surgical patients (the range varies depending on how it's defined and studied)
- Studies suggest roughly 10-20% is a reasonable estimate
What Causes FBSS?
FBSS rarely has a single cause. Multiple factors usually overlap.
Structural Causes
| Cause | Explanation |
|---|---|
| Incomplete decompression | Nerve compression wasn't fully relieved |
| Re-stenosis | The surgical site has narrowed again |
| Adjacent segment disease | New problems at levels above or below a fusion |
| Scar tissue (epidural fibrosis) | Post-surgical scarring affects the nerves |
| Hardware issues | Screws loosening, shifting position |
Neurological Causes
| Cause | Explanation |
|---|---|
| Irreversible nerve damage | Long-term compression left the nerve itself damaged |
| Central sensitization | The brain and spinal cord's pain processing system has become hypersensitive |
| Peripheral nerve degeneration | Co-existing conditions such as diabetic neuropathy |
Psychosocial Factors
| Factor | Explanation |
|---|---|
| Depression and anxiety | Chronic pain triggers depression, and depression amplifies pain |
| Catastrophizing | A thought pattern that perceives pain as an overwhelming threat |
| Social isolation | Pain limits activity, reducing social connections |
| Sleep disturbance | Pain disrupts sleep --> fatigue --> lower pain threshold |
These psychological factors are not "all in your head." As a function of the brain, your mental state directly influences how you experience pain.
Treatment Options for FBSS
Treating FBSS requires a multifaceted approach tailored to the underlying causes.
1. Medication
| Medication Type | Purpose |
|---|---|
| Pregabalin (Lyrica) | First-line treatment for neuropathic pain |
| Mirogabalin (Tarlige) | Same class as pregabalin; developed in Japan |
| Duloxetine (Cymbalta) | An antidepressant that also suppresses pain signals |
| Tramadol | Moderate-strength analgesic, used carefully |
Combining multiple medications can sometimes produce better results than any single drug. "One medication didn't work" doesn't mean nothing will.
2. Rehabilitation
- Even with pain, staying active within your ability is essential
- Breaking the cycle of "pain --> inactivity --> muscle loss --> more pain"
- Gradual progression under the guidance of a physical therapist
3. Psychological Support
- Cognitive behavioral therapy (CBT): Changes thought patterns and behaviors around pain
- Mindfulness: Changes how you relate to pain
- Collaboration with psychiatry or psychology services
- This isn't about dismissing the pain as "mental" — it's a scientifically proven treatment approach
4. Nerve Blocks
- Identifying and treating the specific source of remaining pain
- Options include epidural blocks, nerve root blocks, sacroiliac joint blocks, and others
5. Neuromodulation
When conventional treatments aren't enough:
- Spinal Cord Stimulation (SCS): Delivers mild electrical signals to the spinal cord to reduce pain
- Works through a completely different mechanism than medications or injections
- Includes a trial period — you can test its effectiveness before committing to permanent implantation
--> We'll cover SCS in detail in Week 22.
6. Revision Surgery
- Appropriate when a clear structural problem exists (re-stenosis, hardware malposition, etc.)
- However, outcomes from revision surgery tend to be less favorable than the initial operation — careful judgment is needed
- Indications for reoperation are limited
The Most Important Thing: Don't Carry This Alone
The single most important principle in FBSS treatment is not suffering in silence.
- "I've already had surgery — I can't complain about still being in pain" --> Yes, you can. Please do.
- "I'd feel bad telling my surgeon" --> Telling them about your pain helps them help you
- "There's probably nothing left to try" --> There are still options
Your First Step
- Be honest with your surgeon about your current pain
- Ask for a referral to a pain clinic if needed
- Start keeping a pain diary (when, where, how much it hurts)
Summary
- FBSS/PSPS: An umbrella term for persistent pain after spinal surgery. It does not mean "surgery failed"
- Affects 5-27% of surgical patients
- Causes are typically a combination of structural, neurological, and psychosocial factors
- Treatment is multifaceted: medication, rehabilitation, psychological support, nerve blocks, SCS, revision surgery
- Don't carry the burden alone --> talk to your surgeon first
- Pain clinics staffed by specialists are available to help