Why Back Surgeries Fail: A Deep Dive into the Causes

Failed Back Surgery Syndrome (FBSS) refers to a condition characterized by persistent or recurrent pain following one or more spinal surgeries. The term does not imply a particular etiology but is often used to describe a situation where the intended outcome of spinal surgery – the alleviation of pain – has not been achieved.

Types of back surgeries:

Back surgeries are often considered when conservative treatments such as medication, physical therapy, or injections have not provided adequate relief, or when the patient’s condition is worsening. Here are some common types of back surgeries:

Lumbar Discectomy:

 This is a common procedure for treating herniated discs in the lower back. The surgeon removes the portion of the disc that is pressing on a nerve and causing pain.

Lumbar Laminectomy:

Why Back Surgeries Fail: A Deep Dive into the Causes

This procedure is often performed to relieve symptoms of spinal stenosis. The surgeon removes part or all of the lamina (the back part of the vertebra) to create more space for the nerves and reduce pressure.

Spinal Fusion:

Why Back Surgeries Fail: A Deep Dive into the Causes

This is a procedure where two or more vertebrae are fused together to stabilize the spine and eliminate painful movement. This is often done for conditions such as degenerative disc disease, spondylolisthesis, or recurrent disc herniation.


Why Back Surgeries Fail: A Deep Dive into the Causes

In this procedure, the surgeon widens the opening where the nerve roots exit the spine (the foramen) to alleviate nerve compression. This can help relieve symptoms such as pain, weakness, or numbness.

Disc Replacement:

Why Back Surgeries Fail: A Deep Dive into the Causes

This procedure involves removing a diseased disc and replacing it with an artificial one. It’s often performed when a disc is causing pain that has not responded to other treatments.

Spinal Cord Stimulator Implantation:

Why Back Surgeries Fail: A Deep Dive into the Causes

This procedure involves implanting a device that delivers low-level electrical signals to the spinal cord to block the feeling of pain. This is typically done for chronic pain conditions that haven’t responded to other treatments.


Why Back Surgeries Fail: A Deep Dive into the Causes

This is a minimally invasive procedure used to treat herniated discs. It involves removing a small portion of the bone over the nerve root or disc material under the nerve root to relieve neural impingement and provide more room for the nerve to heal.


Why Back Surgeries Fail: A Deep Dive into the Causes

These are procedures often used to treat spinal fractures often caused by osteoporosis or cancer. They involve injecting bone cement into the fractured vertebrae to stabilize the spine and relieve pain.

Anterior Cervical Discectomy and Fusion (ACDF):

Why Back Surgeries Fail: A Deep Dive into the Causes

This is a procedure used to treat nerve root or spinal cord compression in the neck by removing a diseased disc and replacing it with a graft that will fuse with the adjacent vertebrae.

Remember, the type of surgery recommended will depend on the patient’s specific condition, symptoms, overall health, and the surgeon’s expertise.

Read More: The best treatment of PLID/ Disc herniation / Disc prolapse in Bangladesh

Prevalence and impact on patients

The prevalence of FBSS varies widely due to the range of spinal surgical procedures and patient populations. However, estimates suggest that up to 40% of patients may experience continued pain or symptoms after spinal surgery (3). The prevalence can be even higher in patients undergoing repeat spinal surgeries.

The impact of FBSS on patients can be significant. FBSS can significantly impact patients, leading to chronic pain, disability, reduced quality of life, and psychological distress (1).

Surgical Factors Contributing to FBSS

A key aspect contributing to Failed Back Surgery Syndrome (FBSS) lies in the domain of surgical factors, starting with preoperative assessment and planning.

A. Inadequate preoperative assessment and planning

Misdiagnosis or improper patient selection: A key contributor to FBSS is the misdiagnosis of the underlying cause of the patient’s back pain or the selection of inappropriate candidates for surgery. It’s estimated that around 5-10% of FBSS cases are due to incorrect surgical intervention stemming from misdiagnosis (4). This highlights the need for careful patient selection and precise identification of the pain source before surgery.

Insufficient evaluation of imaging studies: Incorrect interpretation or over-reliance on imaging studies can also contribute to FBSS. A study reported that inaccurate interpretation of imaging studies contributed to FBSS in 2% of cases (5). Thus, a comprehensive clinical evaluation is equally important.

B. Technical errors during surgery

Incomplete decompression of nerves: Incomplete decompression, where the surgical procedure fails to fully relieve the pressure on the affected nerves, is a significant factor in FBSS. It was reported that incomplete decompression contributed to 4-5% of FBSS cases (5).

Damage to nerve roots or spinal structures: Surgical procedures carry the risk of inadvertent damage to surrounding nerves or spinal structures. Studies suggest that such surgical injuries might account for 10-15% of FBSS cases (6).

C. Postoperative complications

Infections: Postoperative infections can lead to prolonged pain and poor surgical outcomes. Infections have been identified as contributing to FBSS in 1-2% of cases (7). Early diagnosis and appropriate treatment of infections can help reduce the risk of FBSS.

Hematoma formation: The accumulation of blood in the surgical area can compress spinal structures, leading to pain. Hematoma formation contributed to FBSS in about 1% of cases (5)

Scar tissue development: The formation of scar tissue, or epidural fibrosis, around the nerve roots can lead to chronic pain and FBSS. Around 20-36% of FBSS cases are attributed to epidural fibrosis (scar tissue formation) and suggested that minimizing tissue trauma and using anti-adhesion barriers may help to reduce scar tissue formation (3).

Reappearance of Disc Herniation: Disc herniation recurrence following surgery is a relatively common occurrence and poses a significant challenge in spinal healthcare. The re-herniation of a disc post-surgery, often referred to as recurrent lumbar disc herniation, happens when disc material protrudes at the same site where a previous herniation occurred and surgery was performed. It typically manifests through a resurgence of symptoms such as back pain, sciatica, numbness, or weakness in the affected area. Recurrent disc herniation is believed to be a cause of FBSS in 3-18% of cases (2). Patients at a higher risk for recurrence include those with large annular defects and excessive intraoperative disc removal.

Read More: 6 Tips for Relieving Pain From Herniated Discs or Disc Prolapse

Patient-related Factors Contributing to FBSS

Patient-related factors, including anatomical variability and comorbidities, play a significant role in the development of Failed Back Surgery Syndrome (FBSS).

A. Anatomical variability

Individual differences in spinal structures: The spinal structures, including the vertebrae, intervertebral discs, and nerves, can vary significantly between individuals. These individual differences can impact the outcome of spinal surgery and contribute to FBSS. For instance, narrower spinal canals or unique vertebral alignments may increase the risk of nerve damage during surgery (9).

Presence of congenital abnormalities: Congenital spinal abnormalities, such as spina bifida occulta or scoliosis, can complicate spinal surgery and increase the risk of FBSS. These conditions often necessitate more complex surgical procedures with higher failure rates (11).

B. Comorbidities and lifestyle factors

Obesity: Obesity can negatively impact surgical outcomes in a number of ways, including increasing the technical difficulty of the surgery and the risk of postoperative complications. Studies have linked obesity to higher rates of surgical complications and poorer outcomes after spinal surgery (12).

Smoking: Smoking has a well-documented negative impact on wound healing and recovery after surgery. Smokers have been found to have higher rates of FBSS compared to non-smokers (8).

Diabetes: Diabetes can slow the healing process and increase the risk of infections post-surgery, both of which can contribute to FBSS (10).

Psychological factors, such as depression or anxiety: Mental health conditions can significantly impact patients’ perception of pain and recovery following surgery. Several studies have linked higher rates of FBSS with pre-existing psychological conditions, such as depression or anxiety (13).

In summary, patient-related factors play a significant role in the development of FBSS. Understanding these factors is crucial for preoperative patient assessment and counseling. Tailoring surgical and rehabilitation plans to individual patients and their specific risk factors may help to reduce the incidence of FBSS and improve patient outcomes.

Read More: Can Physiotherapy Help Patients with Herniated Discs/PLID in the Lower Back? An Evidence-Based Approach

Treatment-related Factors Contributing to FBSS

Treatment-related factors, particularly inadequate pain management and suboptimal physical therapy and rehabilitation, are significant contributors to Failed Back Surgery Syndrome (FBSS).

A. Inadequate pain management

Insufficient pain relief after surgery: Proper pain management is critical in the immediate postoperative period. Failure to adequately control pain after surgery can contribute to the development of FBSS. Poor pain management can lead to chronic pain conditions and reduce patient satisfaction with surgery (14).

Development of chronic pain syndromes: Chronic pain syndromes, such as complex regional pain syndrome or neuropathic pain, can develop following spinal surgery, particularly in the context of inadequate pain management. Such syndromes may play a significant role in the etiology of FBSS (17).

B. Physical therapy and rehabilitation

Why Back Surgeries Fail: A Deep Dive into the Causes

Insufficient postoperative rehabilitation: Postoperative rehabilitation, including physical therapy and occupational therapy, plays a key role in recovery following spinal surgery. Inadequate rehabilitation can lead to poor functional recovery and persistent pain. A lack of adequate rehabilitation may increase the risk of FBSS (19).

Lack of patient compliance with therapy protocols: Patient adherence to prescribed rehabilitation protocols is critical for recovery. Non-compliance with therapy can result in poor outcomes and the development of FBSS. Non-compliance may hinder recovery and lead to FBSS. In summary, appropriate pain management and a comprehensive, personalized rehabilitation plan are crucial to preventing FBSS. Healthcare providers must ensure effective pain control and encourage patient compliance

with rehabilitation protocols to enhance recovery and improve surgical outcomes. By addressing these treatment-related factors, we can potentially reduce the incidence of FBSS and improve the quality of life for patients undergoing spinal surgery.

Read More: Can a Herniated Disc Recover Naturally?

Strategies for Preventing FBSS

Preventing Failed Back Surgery Syndrome (FBSS) requires a comprehensive, multifaceted approach, including improved preoperative assessment, enhanced surgical techniques, and optimal postoperative care and rehabilitation.

A. Improved preoperative assessment

Comprehensive patient evaluation: A thorough preoperative evaluation, including a detailed medical history, physical examination, and psychological assessment, can help identify potential risk factors for FBSS and aid in selecting appropriate surgical candidates (16).

Use of advanced imaging techniques: Advanced imaging techniques, such as MRI and CT scans, can provide detailed information about the spinal structures and help in accurate diagnosis, thereby reducing the risk of FBSS (15).

B. Enhanced surgical techniques

Minimally invasive approaches: Minimally invasive spinal surgery techniques can reduce tissue trauma, minimize postoperative pain, and speed up recovery, thus reducing the risk of FBSS. This may be due to less trauma to the surrounding tissues, less blood loss, and quicker recovery times (18).

Intraoperative neuromonitoring: The use of intraoperative neuromonitoring can help protect neural structures during surgery, reducing the risk of nerve damage and FBSS.

C. Postoperative care and rehabilitation

Aggressive pain management: Adequate pain management after surgery can prevent the development of chronic pain syndromes and FBSS (9). This could involve the use of multimodal pain management strategies, including a combination of opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and adjuvant medications like gabapentin.

Early mobilization and physical therapy: Early mobilization and physical therapy after surgery can improve recovery, reduce pain, and decrease the risk of FBSS.

In summary, preventing FBSS requires a comprehensive approach, including careful patient selection, meticulous surgical technique, effective pain management, and a structured rehabilitation program. Future research should continue to explore and refine these strategies to further reduce the risk of FBSS and improve patient outcomes following spinal surgery.


Preventing FBSS is critically important to improving patient outcomes following spinal surgery. Addressing the underlying causes of FBSS – through comprehensive preoperative assessment, careful surgical planning and execution, aggressive postoperative pain management, and tailored rehabilitation programs – can significantly reduce the risk of this condition. Recognizing and addressing these factors is crucial for healthcare providers involved in the care of patients undergoing spinal surgery.

FBSS is a multifaceted problem that requires a comprehensive, evidence-based approach to prevention and management. By addressing the underlying causes and leveraging the latest research and technological advancements, we can strive to improve the quality of life for patients undergoing spinal surgery.


  1. What are the main causes of failed back surgery syndrome (FBSS)?

    The main causes of Failed Back Surgery Syndrome include misdiagnosis or incorrect surgical procedure, surgical complications, inadequate surgical techniques, patient’s overall health and healing factors, and inadequate post-surgery care and recovery procedures.

  2. How does misdiagnosis contribute to back surgery failure?

    Misdiagnosis or incorrect patient selection can lead to unnecessary or inappropriate surgery, which may not alleviate the patient’s pain or could even make it worse. For example, operating on the wrong spinal level or for a condition that would be better treated non-surgically can lead to FBSS.

  3. Can lifestyle factors cause back surgery to fail?

    Yes, lifestyle factors can contribute to back surgery failure. For instance, obesity, smoking, and uncontrolled diabetes can negatively affect surgical outcomes by increasing the risk of surgical complications, impairing healing, and exacerbating chronic inflammation and pain.

  4. How can postoperative complications lead to FBSS?

    Postoperative complications such as infections, hematomas, scar tissue development, and reherniation of intervertebral discs can lead to ongoing pain and dysfunction, contributing to FBSS.

  5. What strategies can be used to prevent Failed Back Surgery Syndrome?

    Strategies for preventing FBSS include comprehensive preoperative assessment, using advanced imaging techniques, adopting enhanced surgical techniques like minimally invasive procedures and intraoperative neuromonitoring, and implementing aggressive postoperative care and rehabilitation strategies such as early mobilization and physical therapy.

  6. How can inadequate pain management contribute to FBSS?

    Inadequate pain management can contribute to the development of FBSS by leading to chronic pain syndromes and reduced patient satisfaction with the surgery. Effective pain management after surgery is crucial for proper recovery and preventing the onset of FBSS.

  7. Are there risks associated with minimally invasive back surgery techniques?

    While minimally invasive back surgery techniques can lead to less trauma, quicker recovery times, and potentially lower rates of FBSS, they also come with their own set of risks. These may include technical difficulties due to the steep learning curve for surgeons, potential for nerve damage if performed incorrectly, and the possibility of inadequate decompression or fusion due to limited visibility.

  8. How can psychological factors contribute to FBSS?

    Psychological conditions such as depression or anxiety can influence a person’s perception of pain and their recovery from surgery. Patients with these pre-existing conditions may have higher rates of FBSS, highlighting the need for a comprehensive preoperative assessment that includes psychological screening.


1.Baber, Z. and Erdek, M.A., 2016. Failed back surgery syndrome: current perspectives. Journal of pain research, pp.979-987. https://www.tandfonline.com/doi/abs/10.2147/JPR.S92776

2.Carragee, E.J., Han, M.Y., Suen, P.W. and Kim, D., 2003. Clinical outcomes after lumbar discectomy for sciatica: the effects of fragment type and anular competence. JBJS, 85(1), pp.102-108. https://journals.lww.com/jbjsjournal/fulltext/2003/01000/clinical_outcomes_after_lumbar_discectomy_for.16.aspx

3.Chan, C.W. and Peng, P., 2011. Failed back surgery syndrome. Pain medicine, 12(4), pp.577-606. https://academic.oup.com/painmedicine/article-abstract/12/4/577/1868602

4.Deyo, R.A., Mirza, S.K., Martin, B.I., Kreuter, W., Goodman, D.C. and Jarvik, J.G., 2010. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. Jama, 303(13), pp.1259-1265. https://jamanetwork.com/journals/jama/article-abstract/185630

5.Fritsch, E.W., Heisel, J. and Rupp, S., 1996. The failed back surgery syndrome: reasons, intraoperative findings, and long-term results: a report of 182 operative treatments. Spine, 21(5), pp.626-633. https://journals.lww.com/spinejournal/Fulltext/1996/03010/The_Failed_Back_Surgery_Syndrome__Reasons,.17.aspx

6.Slipman, C.W., Derby, R., Simeone, F.A. and Mayer, T.G., 2007. Interventional Spine E-Book: An Algorithmic Approach. Elsevier Health Sciences. https://books.google.com/books?hl=en&lr=&id=T_tNDU7qb3QC&oi=fnd&pg=PP1&dq=6.%09Slipman,+C.W.,+et+al.+(2002).+Interventional+Spine:+An+Algorithmic+Approach.+Elsevier+Health+Sciences.&ots=TIh6kBWF0E&sig=VUe_JhyfghVGrBEowwwfpcY8TD8

7.Thomson S. Failed back surgery syndrome – definition, epidemiology and demographics. Br J Pain. 2013 Feb;7(1):56-9. doi: 10.1177/2049463713479096. PMID: 26516498; PMCID: PMC4590156. https://journals.sagepub.com/doi/10.1177/2049463713479096

8.Behrend, C., Prasarn, M., Coyne, E., Horodyski, M., Wright, J. and Rechtine, G.R., 2012. Smoking cessation related to improved patient-reported pain scores following spinal care. JBJS, 94(23), pp.2161-2166. https://journals.lww.com/jbjsjournal/fulltext/2012/12050/smoking_cessation_related_to_improved.7.aspx

9.Ganty P, Sharma M. Failed back surgery syndrome: a suggested algorithm of care. Br J Pain. 2012 Nov;6(4):153-61. doi: 10.1177/2049463712470222. PMID: 26516487; PMCID: PMC4590103 https://journals.sagepub.com/doi/10.1177/2049463712470222

10.Guzman, J.Z., Iatridis, J.C., Skovrlj, B., Cutler, H., Hecht, A.C., Qureshi, S.A. and Cho, S.K., 2014. Outcomes and complications of diabetes mellitus on patients undergoing degenerative lumbar spine surgery. Spine, 39(19), p.1596. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4149698/

11.Kim, K.D., et al. (2005). + Hilibrand AS, Fye MA, Emery SE, Palumbo MA, Bohlman HH. Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am. 2001 May;83(5):668-73. doi: 10.2106/00004623-200105000-00004. PMID: 11379735. https://journals.lww.com/jbjsjournal/Abstract/2001/05000/Impact_of_Smoking_on_the_Outcome_of_Anterior.4.aspx

12.Patel, N., Bagan, B., Vadera, S., Maltenfort, M.G., Deutsch, H., Vaccaro, A.R., Harrop, J., Sharan, A. and Ratliff, J.K., 2007. Obesity and spine surgery: relation to perioperative complications. Journal of Neurosurgery: Spine, 6(4), pp.291-297. https://thejns.org/downloadpdf/journals/j-neurosurg-spine/6/4/article-p291.pdf

13.Schofferman, J., Reynolds, J., Herzog, R., Covington, E., Dreyfuss, P. and O’Neill, C., 2003. Failed back surgery: etiology and diagnostic evaluation. The Spine Journal, 3(5), pp.400-403. https://www.sciencedirect.com/science/article/pii/S1529943003001220

14.Amirdelfan, K., Webster, L., Poree, L., Sukul, V. and McRoberts, P., 2017. Treatment options for failed back surgery syndrome patients with refractory chronic pain: an evidence based approach. Spine, 42(1), pp.S41-S52. https://www.ingentaconnect.com/content/wk/brs/2017/00000042/A014s014/art00003

15.Deyo, R.A., Mirza, S.K. and Martin, B.I., 2006. Back pain prevalence and visit rates: estimates from US national surveys, 2002. Spine, 31(23), pp.2724-2727. https://journals.lww.com/spinejournal/fulltext/2006/11010/back_pain_prevalence_and_visit_rates__estimates.14.aspx

16.Gadjradj, P.S., et al. (2020). Daniell JR, Osti OL. Failed Back Surgery Syndrome: A Review Article. Asian Spine J. 2018 Apr;12(2):372-379. doi: 10.4184/asj.2018.12.2.372. Epub 2018 Apr 16. PMID: 29713421; PMCID: PMC5913031. https://www.asianspinejournal.org/journal/view.php?doi=10.4184/asj.2018.12.2.372

17.Kehlet, H., Jensen, T.S. and Woolf, C.J., 2006. Persistent postsurgical pain: risk factors and prevention. The lancet, 367(9522), pp.1618-1625. https://www.sciencedirect.com/science/article/pii/S014067360668700X

18.Phan, K., et al. (2017). Minimally invasive versus open transforaminal lumbar interbody fusion for treatment of degenerative lumbar disease: systematic review and meta-analysis. European Spine Journal, 24(5), 1017-1030. https://link.springer.com/article/10.1007/s00586-015-3903-4

19.Rushton, A., Eveleigh, G., Petherick, E.J., Heneghan, N., Bennett, R., James, G. and Wright, C., 2012. Physiotherapy rehabilitation following lumbar spinal fusion: a systematic review and meta-analysis of randomised controlled trials. BMJ open, 2(4), p.e000829. https://bmjopen.bmj.com/content/2/4/e000829.short

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