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Failed back surgery syndrome (FBSS) is a nonspecific term that has probably outlived its usefulness as we learned more about the problem, but the phrase remains embedded in the vernacular of the pain and spine worlds. One useful definition of FBSS is that the outcome of surgery did not meet the expectations of both the patient and the surgeon.1-4 This implies that the patient and surgeon had the same reasonable expectations for the outcome of surgery. It does not and should not mean the patient failed to get total pain relief or return to full function.

The structural cause of FBSS might have been present prior to surgery and not recognized or recognized but inadequately treated. On the other hand, the problem could have arisen after the surgery as a consequence of the surgery or might have nothing to do with the surgery itself.

The evaluation of the patient with FBSS must include the same careful history and physical examination that would be performed in any patient with chronic low back pain (CLBP). The history, which is most important, will help generate the likely differential diagnosis and form the basis for the subsequent diagnostic testing. As with all patients with CLBP, it is necessary to know the location of the pain, its intensity, and the effect on function. The response of the pain with changes in body position and basic functions such as standing, walking, and sitting provide clues to the diagnosis.5-10 In addition to patients with no surgery and CLBP, there are other important pain-related facts that are specific to those patients with FBSS.1,2 It is important to note whether the pain ever improved after surgery and, if so, for how long. It is necessary to know if the pain location, quality, and referral patterns are the same or different compared to before surgery. Needless to say, it is important to review past imaging studies, the operative report, and the preoperative notes to know the actual goals of the surgeon. Finally, it is important to consider that patients with FBSS can have an extraspinal source of pain that was overlooked prior to surgery or arose afterward.11-16

There are many causes of FBSS, but it is useful to keep in mind that “common things occur commonly.” The physician who is very familiar with the most common causes of FBSS will be able to arrive at the proper diagnoses for most patients.

There are many treatment options for patients with FBSS. We assume that the best patient outcomes will be obtained when the treatment is the one most appropriate for the patient's structural disorder. In order to arrive at the proper diagnosis, physicians must know the common structural causes of FBSS.



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