Failed back surgery syndrome: To re-operate or not to re-operate? A retrospective review of patient selection and failures

Introduction. - Persisting pain after spine surgery remains a challenge for the patient and the pain physician. The etiology depends on age, pathology and the interval between the first and the revision surgery. In young patients who underwent initially to discectomy, the etiology of failed back surgery syndrome (FBSS) is commonly a recurrence of herniation whereas in the elderly population, who has previously undergone a spinal fusion, persisting pain might be due to secondary sagittal unbalance associated, as a consequence, to adjacent disc disease or pseudarthrosis. Objective. - To review the etiology of failed back surgery syndrome and to discuss the radiological work-up and the treatment strategies. Methods. - Retrospective analysis of 39 consecutive patients diagnosed with FBSS. For all cases, the following parameters were reviewed: original diagnosis and initial surgery, interval between the last surgery and the revision procedure, final diagnosis after revision. Treatment options were discussed. Results. - Twelve patients have undergone decompressive procedures and 27 had one or multilevel fusion for various back and/or leg pain. In group 1 (decompressive surgery), the mean age of patients who had a disc herniation was 42.2 years and 69 years for patients who had laminectomies for lumbar stenosis. In group 2 (fusion), the mean age was 63.3. Loss of lumbar lordosis in elderly after one or several laminectomy(ies) was found to be a cause of failure because of sagittal kyphosis and consecutive back pain. In the fused group, suboptimal correction of lumbar lordosis could generate a pseudarthrosis, proximal junctional lcyphosis and persisting pain. Conclusion. - Dealing with FBSS patients is far from simple but it corresponds to daily practice for spine surgeons. Clinical and radiological assessments should include a full diagnostic work-up focusing on sagittal balance. Surgical treatment and re-operation might be an option if a consistent source of pain is detected. (C) 2015 Published by Elsevier Masson SAS.