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 Table of Contents  
Year : 2018  |  Volume : 8  |  Issue : 2  |  Page : 47-53

Management of Failed Back Surgery Syndrome (FBSS)

Spine Team, Orthopaedic Unit, Department of Surgery, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria

Date of Web Publication30-May-2019

Correspondence Address:
Dr. Mohammed K Abubakar
Spine Team, Orthopaedic Unit, Department of Surgery, Aminu Kano Teaching Hospital/Bayero University, Kano
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ais.ais_38_18

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This article aims to highlight the current management of failed back surgery syndrome (FBSS) based on a systematic review of current literature. Literatures reviewed were from the Internet medical search engine such as PubMed, MEDLINE, and Embase. The search was narrowed down to the topic under review. In all, 1,345 articles were initially obtained. These were subsequently narrowed to 83 reviews so as to meet the objective of the review which describes persistent or recurring low back pain with or without sciatica following one or more spine surgeries. The increase in the number of patients undergoing back surgery has led to a corresponding increase in patients whose expectations are not met. Poor outcome following back surgery ranges from 10% to 40%. Outcome worsens with increase in the number of reoperation. Evaluation of this patient should be by detailed history, physical examination, and investigation. The treatment approach should be holistic and all encompassing. Patients psychological state and expectations should be assessed. Etiology of FBSS may include wrong diagnosis, failure to address the primary pathology, and intraoperative surgical errors. Treatment of FBSS is multidisciplinary. The treatment modalities include pharmacological, physical, interventional, spinal cord stimulation, psychological, and surgical.

Keywords: Failed back surgery syndrome, etiology, management

How to cite this article:
Abubakar MK, Mohammad S. Management of Failed Back Surgery Syndrome (FBSS). Arch Int Surg 2018;8:47-53

How to cite this URL:
Abubakar MK, Mohammad S. Management of Failed Back Surgery Syndrome (FBSS). Arch Int Surg [serial online] 2018 [cited 2021 Jan 17];8:47-53. Available from:

  Introduction Top

About 40%–80% of people will have back pain at least once in their life time.[1],[2],[3] A number of patients who have surgery for their back pathologies will come back with the same, new, or exacerbated symptom. These patients are said to have developed failed back surgery syndrome (FBSS). FBSS is defined using various parameters.[4],[5],[6],[7],[8] From the spine surgeon point of view, it is defined as a condition that describes persistent or recurring low back pain with or without sciatica following one or more spine surgeries.[9] The rising prevalence of spine surgery globally[10],[11],[12] and the increase in medical tourism in developing country like Nigeria[13] have led to rise in the number of patients with FBSS. It is imperative for physicians and other health workers to apply a holistic approach in the management of FBSS.

  Etiology of Fbss Top

Poor outcome following back surgery ranges from 10% to 40%.[5],[14],[15] More so the success of spine surgery decreases with the number of reoperations.[16],[17],[18],[19],[20] The etiology of FBSS has traditionally been categorized into preoperative, operative, and postoperative.[21] However, it has also been approached from the point of diagnostic error, surgical indication error, technical error, and others.[22]

The preoperative risk factors reported include the following: (1) prior lumbosacral surgery that predisposed to spinal instability.[5],[6],[7],[18],[23] Prevalence of spinal instability following single to multiple spine surgeries ranges from 12% to 50%.[6],[7],[24],[25] (2) Poor patient selection by the surgeon.[6],[7],[22],[26],[27],[28] Poor selection of patient may lead to wrong procedure due to wrong diagnosis.[6],[7],[29] Microdiscectomy done for axial pain[7] will definitely not solve the patient's problem. (3) Failure to recognize nonsurgical causes of radiculopathy and neuropathy such as diabetes mellitus, vascular disease, infection, plexopathies from tumor or trauma in patient selection.[6],[29]

Patient psychological state is crucial in determining the outcome of surgery. Presence of psychiatric disorder, social issues, occupational disharmony, and litigations have all been shown to affect surgical outcome.[6],[7],[21],[30],[31]

Intraoperative risk factors include several factors that have been described in the literature that predispose to FBSS. Pertinent among them are intact pain generators due to inadequate decompression, spinal instability from aggressive decompression, vertical stenosis from loss of disc height, unrecognized pathology such as disc fragment, kinking of nerve root, nerve root compression, and conjoint nerve root.[6],[7],[21],[26],[30] Also implicated is the battered root syndrome, which may follow excessive traction or bleeding[7],[30] and hardware mishap such as improper screw placement.[7],[30]

Postoperative risk factors: FBSS can be caused as a result of surgery-related problem and progression of disease. A summary of postoperative causes of FBSS is given in [Table 1].
Table 1: Postoperative causes of FBSS

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  Clinical Assessment Top

Clinical evaluation in FBSS should aim at identifying the nature of back pain in relation to pre- and postoperative states; whether the pain is persistent, worse, or new. The history should also elucidate whether the pain is predominantly axial pain or radicular.

Persistent pain may suggest poor patient selection, due to wrong diagnosis, wrong site, or wrong choice of surgery. It may be difficult to localize pathologic processes responsible for postoperative pain. As a guide, when back pain is more than leg pain or radiculopathy, then this may suggest discogenic pain at the site of surgery or adjacent levels, facet pain, sacroiliac joint, instability, or pseudoarthrosis.[6],[26],[31] When leg pain predominates, conditions such as foraminal stenosis, residual or recurrent disc herniation, and neuropathic pain should be considered.[31] When the pain is new, or where there is neurological impairment like urinary incontinence, foot drop, paraesthesia, or numbness, then diagnosis to consider should include misplaced screw, dislodge cage, bone fragment, and battered root.[26],[31]

Chronic neuronal pain is usually diffuse and not well localized. It may be described as cramming, aching, and thigh sensation.[6] Thus, it may resemble myofacial pain. Presence of fever in the immediate postoperative period may suggest infection or hematoma. The initial pre- and postoperative diagnoses should be thoroughly reviewed. Comorbidities and treatments, if any, should be reviewed.

Presence of “yellow flags” or psychological stressors as described by Kendall should be assessed.[47] These include fear avoidance behavior, back pain negative attitude, an expectation that passive rather than active treatment will be beneficial, tendency toward depression, addiction, and financial problems.[47]

  Physical Examination Top

In FBSS, the physical examination principally aims to identify the possible location of pathology and the neurological deficit. The musculoskeletal examinations should include limb length discrepancy, straight leg raising test, Lasegue test, femoral stretch test, a complete hip examination, and knee and ankle examination. The spine should be examined for deformity, tenderness, stepping, seated, and standing range of motion. Also, the sacroiliac joint and trochanter should be palpated for tenderness.[6],[7]

A full neurological examination should be carried out. The patient should be examined for tone, bulk, muscle wasting, reflexes, clonus, and Babinski reflex. Also, sensory deficit should be determined by comparing with contralateral dermatomes. Both light and deep sensation should be checked.

The differential diagnosis of FBSS include other causes of back pain, for example, rheumatoid arthritis, ankylosing spondylitis, osteoarthritis of the hip, pelvic tumors, retroperitoneal tumors, and aortic aneurysm. Also pertinent are the psychological factors that need to be identified. Waddell's signs[48] should be looked for. These include signs of superficial or nonanatomic pain on palpation, the report of pain during painless-designed evaluation, and an overreaction to stimuli. Presence of two or more Waddell's sign is associated with poorer outcome irrespective of spine pathology.[48],[49] It is worth noting the ability of physical examination to identify the variable source of pain.[48]

  Investigation Top

The investigation of choice in FBSS depends on the findings from history and examination. Current radiological investigations are able to identify the cause of FBSS in 94%–95% of patients.[16],[34]

Plain whole spine X-ray, anterior–posterior and lateral view, erect standing, in flexion and extension, may show evidence of instability, pars defect, deformity, sagittal balance, and degenerative changes.[21],[50],[51] The main drawback of X-ray is its inability to show soft tissue abnormality such as epidural fibrosis, disc protrusion, and neural impingement.

Magnetic resonance imaging (MRI) provides a good image of the soft tissues, and thus it is able to provide the most suitable information on the source of pain. It is performed best with gadolinium enhancement to help differentiate epidural fibrosis which enhances compared to recurrent disc herniation which does not appear enhanced.[52],[53] Also, conditions such as nerve root thickening, lateral recess and neural foraminal stenosis, discitis, and pseudomeningocele can be detected with gadolinium-enhanced MRI.[53],[54] Three-dimensional MRI has been shown to be better than conventional MRI in detecting intra- and extra-foraminal stenosis.[55] Contrast-enhanced MRI with fat saturation is the investigation of choice when infection is suspected because it allows for the evaluation of bone edema and discitis earlier than other modalities.[56]

Computed tomography (CT) is used in assessing hardware position, fusion mass, and bone quality. CT-myelography is used to show compression of neural elements when MRI is contraindicated.[56],[57] Provocative discography is a diagnostic aid that helps in isolating a specific intervertebral disc as a source of back or leg pain.[46] Its utility is doubtful, as up to 40% of asymptomatic individuals may experience pain after disc injection, which is indistinguishable from symptomatic patient.[58] Interventional diagnostic injections are helpful in ruling in/out a specific nerve root or joint as a cause of pain.[7],[36] For example, lumbar medial branch blocks, sacroiliac joint blocks, and selective nerve root block. An anesthetic block is considered positive when there is 75% or more relief of the targeted pain for several hours according to the duration of the local anesthesia used.[31]

Electrodiagnostic evaluation may be useful especially if pre- and postoperative results are compared. A change in compound motor action potential and increase in peripheral membrane irritability may reflect worsening postoperative neuropathy.[6]

Other investigations such as complete blood count, erythrocyte sedimentation rate, and C-reactive protein are done especially when infection is being considered.

  Treatment Top

The goal of treatment of FBSS is to identify and rectify the source of pain and to improve the quality of life and reverse the progression of debility. Unfortunately, achieving these goals may not always be possible because of the myriad causes of low back pain. A multidisciplinary approach is the best way of addressing FBSS.

The treatment modalities used are (1) conservative, (2) interventional, and (3) surgical. Conservative include pharmacological, physical therapy, and psychological.


It is multimodal and increasingly controversial.[26] The mechanism of action, presumed modification of specific symptom complexes, and side effect should be put into consideration when prescriptions are made.[6] Drugs used include nonsteroidal anti-inflammatory drugs (NSAIDs), opiods, muscle relaxant, steroids, and antidepressant such as gabapentinoids.[7],[10],[30],[32] These drugs are given to reduce pain and facilitate improvement in function.

The safety and efficacy of NSAID, opiods, and antidepressant in the treatment of chronic low back pain have been reviewed.[59] NSAIDs are efficacious but have higher side effects such as gastrointestinal bleeding, renal impairment, and stroke. While opiods have fewer efficacies compared with the NSAIDs, they have a high tendency for dependence, paradoxical hyperalgesia, androgen deficiency, and insomnia.[6],[30],[32],[60] Antidepressants such as gabapentinoids are best used for neuropathic pain even though their efficacy has not been fully accepted.[7],[30],[61],[62]

Physical therapy

The aim of physical therapy is to decrease pain, improve posture, stabilize the hypermobile segments, improve fitness, and reduce mechanical stress on the spinal structures.[63] The efficacy of physical therapy and exercise has been studied extensively. The general consensus is that physical therapy is efficacious in the management of FBSS.[63],[64]

Interventional pain procedure

This is indicated as a therapeutic and diagnostic modality. Various formulations of steroid, local anesthetic agents, and hyaluronidase are available. The main aim is to achieve pain relief and delay the need for surgery in pathologies such as herniated disc, postoperative adhesion, thickened ligamentum flavum, and facet joint arthropathy.[2],[6] Injections are given as epidural interlamina, epidural transforamina, sacroiliac joint blockade, facet medial branch blocks, and rhizotomy. However, it has not been clearly established that pain relief from postoperative radiculopathy following epidural steroid injection is actually due to the corticosteroid.[65],[66],[67] In addition, the alteration of surgery on the soft tissues and presence of implant may increase the difficulty in depositing the steroids in the required site thereby increasing the risk of dural puncture.[36],[68]

Fluoroscopic transforaminal route is an alternative. However, it has been reported to be associated with higher risk of spinal infarction.[32]

Percutaneous adhesiolysis may be done when adhesion is the cause of FBSS.[69] Hyaluronidase as a single agent or in combination with steroid is used to achieve theoretical lyses of adhesion.[70]

Radiofrequency ablation

Specific nerves are targeted and subjected to radiofrequency ablation (RFA). It helps achieve prolonged and sustained pain relief that a diagnostic block or therapeutic injection cannot.[26] Usually, a medial branch block is done to identify the response. Subsequently, a RFA is done corresponding to the medial branch block. This can provide pain relief for 6 months to 2 years.[70],[71]

Transcutaneous electrical nerve stimulation, spinal manipulation, and acupuncture

While these treatment modalities have reasonable role in the management of chronic low back pain, their role in pain relive of FBSS is not well established. They achieve a very short time pain relieve in FBSS.[7],[32],[72],[73],[74]

Intrathecal pump and spinal cord stimulators

Intrathecal analgesics are used to augment interventional procedures. They help achieve systemic pain control and improve the quality of life. About 88%–92% of the patients have reported satisfactory pain relieve with intrathecal analgesia.[15],[75] However, because of its formidable side effects such as constipation, urinary retention, constipation, equipment malfunction, and catheter tip granuloma,[7] intrathecal analgesics are recommended only when all other viable options have failed.[7]

Spinal cord stimulator (SCS) involves use of a subcutaneously buried pulse generator that is connected to electrodes placed in the epidural space over the dorsal columns and the location, frequency, and intensity of the electrical stimulation are adjusted to provide coverage to the painful areas.[3],[7],[76] The benefits of SCS to patients with neuropathic pain from FBSS have been demonstrated in several studies.[77],[78],[79]

Psychotherapy/cognitive behavioral therapy

Psychotherapy/cognitive behavioral therapy has been defined as intervention that applies psychological principles to change the overt behavior, thoughts, or feelings of persons with chronic pain to help them experience less distress and enjoy more satisfying and productive daily lives.[80] Psychotherapy has been found to be useful in patients with chronic back pain.[32],[81],[82]

Cognitive therapy consists of reformulation of fears and erroneous believe, while behavioral therapy involves limiting kinesiophobia and muscle reconditioning by teaching relaxation and stress management.[32]

Revision surgery

Reoperation following FBSS is usually discouraged especially when the precise cause of pain has not been identified. With every repeated surgery, the success rate decreases.[83] In addition, the morbidity and mortality increases. However, some clinical conditions [Table 2] have been identified as indications for revision surgery.[83]
Table 2: Indication for reoperation in FBSS

Click here to view

Proper patient selection, correct diagnosis, and indicated surgical procedure targeted at pain generators are essential. Successful outcome as measured by >50% pain reduction and reduction in Oswestry Disability Questionnaire score in the range of 90%[14] have been demonstrated; however, most studies did not agree to this.[9],[12]

  Conclusion Top

The number of FBSS is rising due to the increase in the number of back surgeries done. Management of FBSS is multidisciplinary and challenging. Efforts should be made to match pain generators with symptoms. This can only be achieved by proper patient selection, using history physical examination, and investigations. Most patients will do well with conservative management such as medication, physiotherapy, and interventional procedures. SCS has increasingly been shown to provide prolonged pain relief. Few patients with progressive neurological symptoms, instabilities, or proven hardware issues may require reoperation. However, the benefit must outweigh the potential risk of increased morbidity. It is pertinent for physician to individualize patient management and to identify potential treatment pitfalls which may be glairing if the psychological state of the patient is examined.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Who certified (Internet). Kelly E. WHO Patient Safety Program (cited October 2013). Available from: [Last accessed on 2018 Oct 17].  Back to cited text no. 1
CDC certified (Internet). Joanna G, Duc BN. Medical Tourism. Centre for Disease Control and Prevention. Travelers Health: Chapter 2 (cited April 2 2014). Available from: [Last accessed on 2018 Oct 17].  Back to cited text no. 2
Hanefeld J, Smith R, Horsfall, D, Lunt L. What do we know about Med Tourism? A review of literature. Travel Med 2014;21:410-7.  Back to cited text no. 3
Assaker R, Zairi F. Failed back surgery syndrome: To re-operate or not tore-operate? A retrospective review of patient selection and failures. Neurochirurgie 2015;61(Suppl. 1):S77-82.  Back to cited text no. 4
Slipman CW, Shin CH, Patel RK, Isaac Z, Huston CW, Lipetz JS, et al. Etiologies of failed back surgery syndrome. Pain Med 2002;3:200-14.  Back to cited text no. 5
Shapiro CM. The failed back surgery syndrome: Pitfalls surrounding evaluation and treatment. Phys Med Rehabil Clin N Am 2014;25:319-40.  Back to cited text no. 6
Chan CW, Peng P. Failed back surgery syndrome. Pain Med 2011;12:577-606.  Back to cited text no. 7
Clancy C, Quinn A, Wilson F. The aetiologies of failed back surgery syndrome: A systematic review. J Back Musculoskelet Rehabil 2017;30:395-402.  Back to cited text no. 8
Leong JC, Lu WW, Zheng Y, Zhu Q, Zhong S. Comparison of the strengths of lumbosacral fixation achieved with techniques using one and two triangulated sacral screws. Spine (Phila Pa 1976) 2006;31:303-8.  Back to cited text no. 9
Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C. Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976) 1998;23:2289-94.  Back to cited text no. 10
Gray DT, Deyo RA, Kreuter W, Mirza SK, Heagerty PJ, Comstock BA, et al. Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine 2006;31:1957-63.  Back to cited text no. 11
Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. US trends in lumbar fusion surgery for degenerative conditions. Spine 2005;30:1441-5.  Back to cited text no. 12
Abubakar, M, Basiru S, Oluyemi J, Abdulateef R, Atolagbe E. Medical tourism in Nigeria: Challenges and remedies to health care system development. Int J Dev Manage Rev (INJODEMAR) 2018;13.  Back to cited text no. 13
Pappas CT, Harrington T, Sonntag VK. Outcome analysis in 654 surgically treated lumbar disc herniations. Neurosurgery 1992;30:862-6.  Back to cited text no. 14
Barrios C, Ahmed M, Arrotegui JI, Bhornsson A. Clinical factors predicting outcome after surgeryfor herniated lumbar disc: An epidemiological multivariate analysis. J Spinal Disord 1990;3:205-9.  Back to cited text no. 15
Waguespack A, Schofferman J, Slosar P, Reynolds J. Etiology of long-term failures of lumbar spine surgery. Pain Med 2002;3:18-22.  Back to cited text no. 16
Mark VH. Instrumented fusions: A need for guidelines and research. Surg Neurol 2004;61:318-9.  Back to cited text no. 17
Nachemson A. Evaluation of results in lumbar spine surgery. Acta Orthop Scand 1993;251:130-3.  Back to cited text no. 18
Talbot L. Failed back surgery syndrome. BMJ 2003;327:985-7.  Back to cited text no. 19
Deyo RA. Back surgery—Who needs it? N Engl J Med 2007;356:2239-43.  Back to cited text no. 20
Sebaaly A, Lahoud MJ, Rizkallah M, Kreichati G, Kharrat K. Etiology, evaluation, and treatment of failed back surgery syndrome. Asian Spine J 2018;12:574-85.  Back to cited text no. 21
Romero-Vargas S, Obil-Chavarria C, Zárate-Kalfopolus B, Rosales-Olivares LM, Alpizar-Aguirre A, Reyes-Sánchez AA. Profile of the patient with failed back surgery syndrome in the National Institute of Rehabilitation. Comparative analysis. Cir Cir 2015;83:117-23.  Back to cited text no. 22
Harimaya K, Mishiro T, Lenke LG, Bridwell KH, Koester LA, Sides BA. Etiology and revision surgical strategies in failed lumbosacral fixation of adult spinal deformity constructs. Spine (Phila Pa 1976) 2011;36:1701-10.  Back to cited text no. 23
Fokter SK, Yerby SA. Patient based outcomes for the operative treatment of degenerative lumbar spinal stenosis. Eur Spine J 2006;15:1661-9.  Back to cited text no. 24
Skaf G, Bouclaous C, Alaraj A, Chamoun R. Clinical outcome of surgical treatment of failed back surgery syndrome. Surg Neurol 2005;64:483-8, discussion 488-9.  Back to cited text no. 25
Baber Z, Erdek MA. Failed back surgery syndrome: Current perspectives. J Pain Res 2016;9:979-87.  Back to cited text no. 26
Burton CV, Kirkaldy-Willis WH, Yong-Hing K, Heithoff KB. Causes of failure of surgery on the lumbar spine. Clin Orthop Relat Res 1981;157:191-9.  Back to cited text no. 27
Kuniya H, Aota Y, Kawai T, Kaneko K, Konno T, Saito T. Prospective study of superior cluneal nerve disorder as a potential cause of low back pain and leg symptoms. J Orthop Surg Res 2014;9:1.  Back to cited text no. 28
Teixeira MJ, Yeng LT, Garcia OG, Fonoff ET, Paiva WS, Araujo JO. Failed back surgery pain syndrome: Therapeutic approach descriptive study in 56 patients. Rev Assoc Med Bras (1992) 2011;57:282-7.  Back to cited text no. 29
Hussain A, Erdek M. Interventional pain management for failed back surgery syndrome. Pain Pract 2014;14:64-78.  Back to cited text no. 30
Schofferman J, Reynolds J, Herzog R, Covington E, Dreyfuss P, O'Neill C. Failed back surgery: Etiology and diagnostic evaluation. Spine J 2003;3:400-3.  Back to cited text no. 31
Durand G, Girodon J, Debiais F. Medical management of failed back surgery syndrome in Europe: Evaluation modalities and treatment proposals. Neurochirurgie 2015;61(Suppl. 1):S57-65.  Back to cited text no. 32
Burton CV, Kirkaldy-Willis WH, Yong-Hing K, Heithoff KB. Causes of failure of surgery on the lumbar spine. Clin Orthop Relat Res 1981;157:191-9.  Back to cited text no. 33
Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976) 2005;30:1441-5.  Back to cited text no. 34
Schaeren S, Broger I, Jeanneret B. Minimum four year follow-up of spinal stenosis with degenerative spondylolisthesis treated with decompression and dynamic stabilization. Spine 2008;33:E636-42.  Back to cited text no. 35
Ragab A, Deshazo RD. Management of back pain in patients with previous back surgery. Am J Med 2008;121:272-8.  Back to cited text no. 36
Kumar MN, Baklanov A, Chopin D. Correlation between sagittal plane changes and adjacent segmental degeneration following lumbar spine fusion. Eur Spine J 2001;10:314-9.  Back to cited text no. 37
Burton CV, Kirkaldy-Willis WH, Yong-Hing K, Heithoff KB. Causes of failure of surgery on the lumbar spine. Clin Orthop Relat Res 1981;157:191-9.  Back to cited text no. 38
Carroll SE, Wiesel SW. Neurological complications and lumbar laminectomy. A standardized approach to the multiply-operated lumbar spine. Clin Orthop Relat Res 1992;284:14-23.  Back to cited text no. 39
Fritsch EW, Heisel J, Rupp S. The failed back surgery syndrome-reasons, intraoperative findings, and long-term results: A report of 182 operative treatments. Spine (Phil Pa 1976) 1996;21:626-33.  Back to cited text no. 40
Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J 2008;8:8-20.  Back to cited text no. 41
Carney AI. Failed back surgery syndrome: Foreword. Neurochirurgie 2015;61:s1-4.  Back to cited text no. 42
D'Andrea F, Maiuri F, Corriero G, Gambardella A, La Tessa G, Gangemi M. Postoperative lumbar arachnoidal diverticula. Surg Neurol 1985;23:287-90.  Back to cited text no. 43
Kahanovitz N, Viola K, Gallagher M. Long-term strength assessment of postoperative discectomy patients. Spine (Phila Pa 1976) 1989;14:402-3.  Back to cited text no. 44
Scott Meyer R, Garfin SR. Recurrent lumbar disc herniation. In: Albert TJ, Vaccaro AR, editors. Mastercases: Spine Surgery. New York: Thieme; 2001. p. 143-7.  Back to cited text no. 45
Kahanovitz N, Viola K, Gallagher M. Long-term strength assessment of postoperative Discectomy patients. Spine 1989;14:402-3.  Back to cited text no. 46
Crawford C, Ryan K, Shipton E. Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain. N Z Med J 2007;120:U2536.  Back to cited text no. 47
Waddell G, McCulloch JA, Kummel E, Venner RM. Nonorganic physical signs in low-back pain. Spine (Phila Pa 1976) 1980;5:117-25.  Back to cited text no. 48
Carleton RN, Kachur SS, Abrams MP, Asmundson GJ. Waddell's symptoms as indicators of psychological distress, perceived disability, and treatment outcome. J Occup Rehabil 2009;19:41-8.  Back to cited text no. 49
Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007;16:1539-50.  Back to cited text no. 50
Kizilkilic O, Yalchin O, Sen O, Aydin MV, Yildirim T, Hurcan C. The role of standing flexion-extension radiographs for spondylolisthesis following single level disc surgery. Neurol Res 2007;29:540-3.  Back to cited text no. 51
Lee YS, Choi ES, Song CJ. Symptomatic nerve root changes on contrast-enhanced MR imaging after surgery for lumbar disk herniation. AJNR Am J Neuroradiol 2009;30:1062-7.  Back to cited text no. 52
van Goethem JWM, Parizel PM, Jinkins JR. Review article: MRI of the postoperative, lumbar spine. Neuroradiology 2002;44:723-39.  Back to cited text no. 53
Phillips FM, Cunningham B. Managing chronic pain of spinal origin after lumbar surgery. The role of decompressive surgery. Spine 2002;27:2547-53.  Back to cited text no. 54
Yamada H, Terada M, Iwasaki H, Endo T, Okada M, Nakao S, et al. Improved accuracy of diagnosis of lumbar intra and/or extraforaminal stenosis by use of three-dimensional MR imaging: Comparison with conventional MR imaging. J Orthop Sci 2015;20:287-94.  Back to cited text no. 55
Herrera Herrera I, Moreno de la Presa R, González Gutiérrez R, Bárcena Ruiz E, García Benassi JM. Evaluacion de la columna lumbar posquirurgica. [Evaluation of the postoperative lumbar spine]. Radiologia 2013;55:12-23.  Back to cited text no. 56
Guyer RD, Patterson M, Ohnmeiss DD. Failed back surgery syndrome: Diagnostic evaluation. J Am Acad Orthop Surg 2006;14:534-43.  Back to cited text no. 57
Carragee EJ, Chen Y, Tanner CM, Truong T, Lau E, Brito JL. Provocative discography in patients after limited lumbar discectomy: A controlled, randomized study of pain response in symptomatic and asymptomatic subjects. Spine (Phila Pa 1976) 2000;25:3065-71.  Back to cited text no. 58
White AP, Arnold PM, Norvell DC, Ecker E, Fehlings MG. Pharmacologic management of chronic low back pain: Synthesis of the evidence. Spine (Phila Pa 1976) 2011;36 (Suppl):S131-43.  Back to cited text no. 59
Rathmell JP, Jamison RN. Opioid therapy for chronic noncancer pain. Curr Opin Anesthesiol 1996;9:436-42.  Back to cited text no. 60
Braverman DL, Slipman CW, Lenrow DA. Using gabapentin to treat failed back surgery syndrome caused by epidural fibrosis: A report of 2 cases. Arch Phys Med Rehabil 2001;82:691-3.  Back to cited text no. 61
Dworkin RH, O'Connor AB, Audette J, et al. Recommendations for the pharmacological management of neuropathic pain: An overview and literature update. Mayo Clin Proc 2010;85(Suppl):S3-14.  Back to cited text no. 62
Jackson CP, Brown MD. Is there a role for exercise in the treatment of patients with low back pain? Clin Orthop Relat Res 1983;179:39-45.  Back to cited text no. 63
Kahanovitz N, Viola K, Gallagher M. Long-term strength assessment of postoperative discectomy patients. Spine 1989;14:402-3.  Back to cited text no. 64
Dworkin RH, O'Connor AB, Backonja M, Farrar JT, Finnerup NB, Jensen TS, et al. Pharmacologic management of neuropathic pain: Evidence-based recommendations. Pain 2007;132:237-51.  Back to cited text no. 65
Valat JP, Giraudeau B, Rozenberg S, Goupille P, Bourgeois P, Micheau-Beaugendre V, et al. Epidural corticosteroid injections for sciatica: A randomised, double-blind, controlled clinical trial. Ann Rheum Dis 2003;62:639-43.  Back to cited text no. 66
Klenerman L, Greenwood R, Davenport HT, White DC, Peskett S. Lumbar epidural injections in the treatment of sciatica. Br J Rheumatol 1984;23:35-8.  Back to cited text no. 67
Fredman B, Nun M, Zohar E, Iraqi G. Epidural steroids for treating “failed back surgery syndrome.” Is fluoroscopy really necessary? Anesth Analg 1999;88:367-72.  Back to cited text no. 68
Helm Ii S, Benyamin RM, Chopra P, Deer TR, Justiz R. Percutaneous adhesiolysis in the management of chronic low back pain in post lumbar surgery syndrome and spinal stenosis: A systematic review. Pain Physician 2012;15:E435-62.  Back to cited text no. 69
Kim SB, Lee KW, Lee JH, Kim MA, An BW. The effect of hyaluronidase in interlaminar lumbar epidural injection for failed back surgery syndrome. Ann Rehabil Med 2012;36:466-73.  Back to cited text no. 70
Dreyfuss P, Halbrook B, Pauza K, Joshi A, McLarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine (Phila Pa 1976) 2000;25:1270-7.  Back to cited text no. 71
Hutchinson AJP, Ball S, Andrews JCH, Jones GG. The effectiveness of acupuncture in treating chronic non-specific low back pain: A systematic review of the literature. J Orthop Surg 2012;7:36.  Back to cited text no. 72
Jackson CP, Brown MD. Is there a role for exercise in the treatment of patients with low back pain? Clin Orthop Relat Res 1983;179:39-45.  Back to cited text no. 73
Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database Syst Rev 008;8:CD003008  Back to cited text no. 74
Winkelmuller M, Winkelmuller W. Long term effects of continuous intrathecal opioid treatment on chronic pain of non-malignant etiology. J Neurosurg 1996;85:458-67.  Back to cited text no. 75
Kreis PG, Fishman SM. Spinal Cord Stimulation Percutaneous Implantation Techniques. New York: Oxford University Press; 1999. p. 3-5 preface. 13-8, 71-92, 115-9, 131-45.  Back to cited text no. 76
Taylor R, Ryan J, O'Donnell R, Eldabe S, Kumar K, North RB. The cost effectiveness of spinal cord stimulation in the treatment of failed back surgery syndrome. Clin J Pain 2010;26:463-9.  Back to cited text no. 77
Kumar K, Rizvi S. Cost-effectiveness of spinal cord stimulation therapy in the management of chronic pain. Pain Med 2013;14:1-19.  Back to cited text no. 78
North RB, Kidd DA, Frrohki F, Piantadosi S. Spinal cord stimulation versus repeated spine surgery for chronic pain: A randomized control trial. Neurosurgery 2005;56:98-107.  Back to cited text no. 79
McCracken LM, Turk DC. Behavioral and cognitive–behavioral treatment for chronic pain. Outcome, predictors of outcome, and treatment process. Spine 2002;27:2564-73.  Back to cited text no. 80
Turner JA. Educational and behavioral interventions for back pain in primary care. Spine 1996;21:2851-9.  Back to cited text no. 81
van Tulder MW, Koes BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: A systematic review of randomized controlled trials of the most common interventions. Spine 1997;22:2128-56.  Back to cited text no. 82
Kim SS, Michelsen CB. Revision surgery for failed back surgery syndrome. Spine (Phila Pa 1976) 1992;17:957-60.  Back to cited text no. 83


  [Table 1], [Table 2]


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