FAILED BACK SURGERY SYNDROME

Facts:

1. Persistent or recurrent low back and/or radicular pain occurs following disc surgery in 10-20% of patients.
   
2. The outcome of any kind of treatment (including consecutive surgical intervention) is worse once surgery has taken place.
   
3. The most common reason for reintervention is recurrent disc herniation.
   
4. With a second intervention the rate of epidural fibrosis and instability increases to greater than 60%.

Symptoms:

1. Central low back pain with or without radicular pain.
   
2. Pain worse in evenings than in the mornings.
   
3. Pain may radiate into the hip and buttock areas (pseudoradicular pain or somatic referred pain).
   
4. Pain may radiate below the knee (radicular pain).
   
5. Pain may be worse in the sacral area mimicking sacro-iliac joint pain, especially following back fusions.

Diagnosis:

1. MRI scans can be helpful when findings agree with symptoms.
   
2. Facet nerve blocks may be helpful in diagnosing axial back pain.
   
3. Provocation discography may be needed to diagnose discogenic pain.
   
4. Selective nerve root blocks can help delineate painful nerve roots.

Treatment:

1. Precision epidural blocks with fluoroscopy (transforaminal usually).
   
2. Fluoroscopically guided caudal blocks with guidable catheter for lysis of epidural adhesions.
   
3. Pulsed radiofrequency treatment of painful nerve roots.
   
4. Spinal cord stimulation.
   
5. Pain Pump implants.