"FBSS (Failed Back Surgery Syndrome)" — What You Should Know
Persistent pain after surgery has a name, and it can be treated.
Last week, we discussed the causes and management of pain that remains after surgery. This week covers 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 newer, preferred term)
Don't Be Misled by the Word "Failed"
The word "Failed" in FBSS causes a lot of misunderstanding.
FBSS does not mean your surgery failed.
The name was coined over 50 years ago and no longer fits what we now know. That is why the newer term PSPS (Persistent Spinal Pain Syndrome) is now recommended.
FBSS is an umbrella term for "pain that persists after spinal surgery." Even when the surgery itself was done correctly, pain can remain for many reasons.
How Common Is It?
The percentage of patients diagnosed with FBSS/PSPS after lumbar surgery:
- Approximately 5-27% of surgical patients (the range depends on how it is defined and studied)
- Studies suggest roughly 10-20% is a reasonable estimate
What Causes FBSS?
FBSS rarely has a single cause. Several 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) | Scarring after surgery affects the nerves |
| Hardware issues | Screws loosening or shifting position |
Neurological Causes
| Cause | Explanation |
|---|---|
| Irreversible nerve damage | Long-term compression left the nerve itself damaged |
| Central sensitization | The pain processing system in the brain and spinal cord has become oversensitive |
| Peripheral nerve degeneration | Other 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 sees 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." Pain is processed by the brain, so your mental state directly affects how you feel pain.
Treatment Options for FBSS
Treating FBSS calls for several approaches, matched 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 pain reliever, used carefully |
Combining medications sometimes works better than any single drug. If one medication didn't work, that doesn't mean nothing will.
2. Rehabilitation
- Even with pain, staying active within your ability is essential
- This breaks the cycle of "pain --> inactivity --> muscle loss --> more pain"
- Activity is increased step by step with a physical therapist
3. Psychological Support
- Cognitive behavioral therapy (CBT): Changes thought patterns and behaviors around pain
- Mindfulness: Changes how you relate to pain
- Working with psychiatry or psychology services
- This does not dismiss the pain as "mental"; it is a scientifically proven treatment approach
4. Nerve Blocks
- Finding and treating the specific source of remaining pain
- Options include epidural blocks, nerve root blocks, sacroiliac joint blocks, and others
5. Neuromodulation
When standard treatments aren't enough:
- Spinal Cord Stimulation (SCS): Sends mild electrical signals to the spinal cord to reduce pain
- Works in a completely different way from medications or injections
- Reversible: if it does not suit you, the device can be removed
--> We'll cover SCS in detail in Week 22.
6. Revision Surgery
- Appropriate when there is a clear structural problem (re-stenosis, hardware malposition, etc.)
- Results of revision surgery tend to be less favorable than those of the first operation, so careful judgment is needed
- Reasons to operate again are limited
The Most Important Thing: Don't Carry This Alone
The most important principle in FBSS treatment is not suffering in silence.
- "I've already had surgery, so 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 usually a combination of structural, neurological, and psychosocial factors
- Treatment combines several approaches: 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