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It is a classic condition of low back pain that persists after the back surgery. The term of failed back syndrome is broadly used to refer to the pain that is not alleviated after the back surgery. Patients will repeat same pain after the back surgery or new symptoms of pain in new location. There are many reasons for failed back surgery including bony abnormality, bony arthritis, pseudo-arthritis joint problem, facet arthritis, neural disorders like persistent nerve root impingement, reherniation, and arachnoiditis i.e. scar tissue in or around the nerves.
A complete history with work and home environment evaluation to rule out psycho-social factors that may be contributing to patient symptoms. A detailed physical examination to evaluate a facet disease, sacroiliitis and sciatica. MRI scan and CT myelogram to evaluate for persistent nerve compression, reherniation, arachnoiditis, i.e. scarring around the nerve, infection or tumor around the spine.
After a careful evaluative, diagnosis individual cause has to be addressed. A multidisciplinary approach with pain physician, physical therapist, and psychotherapist is usually helpful. Patient may need a combination of medications including analgesics, NSAID, anti-depressants, and anti-seizure medication for neuropathic pain. Facet arthritis may need facet injection followed by facet rhizotomy. Nerve root compression may benefit from selective sleeve root injection. Long-term oral opiates may be warranted in selected group of patients, only if patient fails above-mentioned modalities. In selected group of patients, last resort may be neurostimulation or intrathecal morphine implanted pump. Repeat back surgery may rarely be required if definite diagnosis is not established. Unfortunately, failure rate goes up with each successive back surgery.