Failed Back Surgery Syndrome (FBSS)
Failed back surgery syndrome (FBSS) is a term used to describe persistent or recurrent pain in the back or legs following spinal surgery, when the surgical outcome has not met the patient's and surgeon's expectations.
What is Failed Back Surgery Syndrome?
Failed back surgery syndrome (FBSS) is a term used to describe persistent or recurrent pain in the back or legs following spinal surgery, when the surgical outcome has not met the patient's and surgeon's expectations. FBSS is not a single diagnosis but rather an umbrella term covering a range of causes of unsatisfactory post-operative outcomes after lumbar spine surgery.
Importantly, FBSS does not mean that the surgery itself was performed incorrectly or that the surgeon made an error. It reflects the complex, multifactorial nature of spinal pain and the inherent limitations of surgery as a treatment for conditions that often involve not just structural pathology but also nerve sensitisation, psychological factors, and muscular dysfunction.
FBSS is more common than many patients expect — studies suggest that 10–40% of patients undergoing lumbar spinal surgery experience some degree of persistent or recurrent pain. At One Brain and Spine, our Melbourne neurosurgeons approach FBSS with a thorough, systematic assessment to identify reversible causes and develop an individualised management plan.
What Causes Failed Back Surgery Syndrome?
The causes of persistent pain after spinal surgery are multiple and often coexist:
Structural Causes (Potentially Reversible)
- Recurrent disc herniation — re-herniation at the operated level, occurring in 5–10% of microdiscectomy patients
- Residual or inadequate decompression — insufficient removal of compressing pathology at the original surgery
- Adjacent segment disease — degeneration at levels above or below a spinal fusion, producing new symptomatic stenosis or disc herniation
- Pseudarthrosis — failed fusion where the vertebrae have not united, causing ongoing instability and pain
- Spinal instability — excessive decompression at the original surgery may have destabilised the spine
- Epidural fibrosis — scar tissue forming around the nerve roots following surgery, causing tethering and recurrent pain
- Hardware complications — loose, broken, or malpositioned implants from previous fusion surgery
Non-Structural Causes
- Central sensitisation — chronic pain processing changes in the nervous system that persist even after structural problems are corrected
- Psychological factors — anxiety, depression, and pain catastrophising significantly influence chronic post-operative pain outcomes
- Wrong-level surgery — rare; surgery performed at a level that was not the true pain generator
- Muscle deconditioning — persistent paraspinal muscle weakness and deconditioning following surgery
Symptoms of Failed Back Surgery Syndrome
Symptoms of FBSS vary depending on the underlying cause but typically include:
- Persistent or recurrent lower back pain — often similar to or continuous with pre-operative pain
- Persistent or new leg pain (sciatica) — radicular pain in the same or different distribution as the original symptoms
- Neurological symptoms — persistent numbness, tingling, or weakness
- Reduced functional capacity — inability to return to work or previous activity levels
- Psychological distress — depression, anxiety, and sleep disturbance are common accompanying features of chronic post-surgical pain
How is FBSS Assessed?
Accurate assessment of FBSS requires a thorough review of the patient's history, original surgical indication, procedure performed, post-operative course, and current symptom profile. At One Brain and Spine, our Melbourne neurosurgeons conduct a comprehensive evaluation:
Clinical Review
Understanding the original diagnosis, the surgical procedure, the immediate post-operative outcome, and the nature and timing of symptom recurrence is essential. This guides the selection of appropriate investigations.
Imaging
- MRI with and without contrast — the key investigation; contrast (gadolinium) helps distinguish epidural fibrosis from recurrent disc herniation
- CT scan — assesses fusion status (pseudarthrosis), hardware integrity, and bony anatomy
- CT myelogram — used when MRI is limited by spinal instrumentation artefact
- Dynamic X-rays — assess for adjacent segment instability or pseudarthrosis
- SPECT CT — identifies metabolically active pain generators including active disc degeneration and facet joint arthritis
Treatments
Non-Surgical Treatment Options
The majority of patients with FBSS are managed non-surgically. A multidisciplinary, multimodal approach is essential:
- Comprehensive pain management — specialist pain management programmes addressing physical, psychological, and social dimensions of chronic pain
- Physiotherapy and rehabilitation — targeted core strengthening, functional rehabilitation, and graded return to activity
- Psychological support — CBT, acceptance and commitment therapy (ACT), and pain neuroscience education for central sensitisation
- Epidural steroid injections — can provide relief when residual or recurrent nerve root compression is identified
- Spinal cord stimulation (neuromodulation) — a highly effective treatment for FBSS with persistent neuropathic leg pain. A small electrode is placed in the epidural space and connected to an implantable pulse generator that modifies pain signal transmission. Strong evidence supports spinal cord stimulation for FBSS in appropriately selected patients.
When is Revision Surgery Required?
Revision spinal surgery for FBSS should be approached with great care and only after thorough assessment has identified a clearly correctable structural cause. Reoperation for FBSS without a clear anatomical explanation for failure carries a high risk of further unsatisfactory outcomes. Indications for revision surgery include:
- Confirmed recurrent disc herniation at the operated level causing significant radiculopathy
- Confirmed pseudarthrosis with persistent pain and instability
- Adjacent segment disease causing new neurological compromise or severe refractory symptoms
- Significant hardware complications
- Progressive neurological deficit
Frequently Asked Questions — Failed Back Surgery Syndrome Melbourne
Does FBSS mean my surgery was done incorrectly?
Not necessarily. Failed back surgery syndrome reflects the complex, multifactorial nature of spinal pain. Even technically perfect surgery may not resolve pain when central sensitisation, psychological factors, or non-structural contributors are present. It is important to have a thorough reassessment to identify any correctable causes.
Will more surgery help my FBSS?
Revision surgery is helpful only when a clearly correctable structural cause — such as recurrent disc herniation or failed fusion — has been identified. Reoperation without a clear indication is unlikely to improve outcomes and carries significant risk. At One Brain and Spine, our neurosurgeons will conduct a thorough assessment to determine whether revision surgery is appropriate.
What is spinal cord stimulation and how does it help FBSS?
Spinal cord stimulation is a form of neuromodulation where a small electrode delivers electrical impulses to the spinal cord, modifying pain signal transmission. It is one of the most effective treatments for persistent neuropathic leg pain in FBSS patients. It does not treat structural pathology but can dramatically reduce pain perception and improve quality of life.
Can I get spinal cord stimulation in Melbourne?
Yes. Spinal cord stimulation is available in Melbourne through our specialist neurosurgical and pain management practices at One Brain and Spine. Our team can assess your suitability and provide a referral to appropriate services.
Why Choose One Brain and Spine for Failed Back Surgery Syndrome in Melbourne?
One Brain and Spine is a specialist neurosurgical group practice in Melbourne, formed by three experienced neurosurgeons committed to the highest standard of spinal care. We offer the full spectrum of evidence-based treatments from conservative management through to the most advanced minimally invasive and endoscopic surgical techniques available in Australia.
- Specialist neurosurgeons — all fellowship-trained with subspecialty expertise in spinal surgery
- Latest surgical technology — robotic-assisted navigation, endoscopic techniques, and microsurgery
- Conservative-first approach — surgery recommended only when clearly indicated
- Multidisciplinary care — working with physiotherapists, pain specialists, and radiologists across Melbourne
- Transparent, patient-centred consultations — your diagnosis and all options explained clearly
- Privately insured patients welcome — all major health funds accepted