Treatment outcomes for patients with failed back surgery

Background: Failed back surgery syndrome (FBSS) is a frequently encountered disease entity following lumbar spinal surgery. Although many plausible reasons have been investigated, the exact pathophysiology remains unknown. Various medications, reoperations, interventions such as spinal cord stimulation, epidural adhesiolysis or epidural injection, exercise therapy, and psychotherapy have been suggested treatment options. However, the evidence of the clinical outcome for each treatment has not been clearly determined. Objectives: To evaluate the outcomes of each treatment modality and to present treatment guidelines for patients with FBSS. Study Design: A systematic review of each treatment regimen in patients with FBSS. Methods: The available literature regarding each modality for the treatment of refractory back pain or radiating pain for FBSS was reviewed. The quality assessment and the level of evidence were analyzed using the “Methodology Checklist” of SIGN (Scottish Intercollegiate Guidelines Network). Data sources included relevant English language literature identified through searches of Pubmed, EMBASE, and Cochrane library from 1980 to Feb 2016. The primary outcome measure was pain relief of back pain or radiating pain for at least 3 months. Secondary outcome measures were improvement of the patient’s functional status, health-related quality of life, return to work, and reduction of opioid use. Results: Twenty-three articles were finally identified and reviewed. Based on our analysis, epidural adhesiolysis showed a short-term (6 to 24 months) effect (grade A) and spinal cord stimulation showed a mid-term (2 or 3 years) effect (grade B). Epidural injections showed a short-term (up to 2 years) effect (grade C). However, other treatments were recommended as grade D or inconclusive. Limitations: The limitations of this systematic review included the rarity of relevant literature. Conclusions: Epidural adhesiolysis or spinal cord stimulation can be effective in order to control chronic back pain or leg pain due to FBSS, and its recommendation grades are A and B, respectively. Other treatments showed poor or inconclusive evidence.