Diagnosis of Failed Back Surgery Syndrome

Failed back surgery syndrome (FBSS), failed back surgery (FBS) and post-laminectomy syndrome are terms used to describe a condition that develops when spine surgery doesn’t relieve a patient’s pre-operative symptoms. This can occur weeks, months or years after the surgical procedure and may involve new problems (eg, chronic back pain). There are many different causes of FBSS. Your doctor (eg, spine surgeon, specialist) can determine if your symptoms point to FBS by performing a comprehensive physical and neurological evaluation to confirm a diagnosis. Understanding the cause and diagnosis can help lead the way to a treatment solution.
Tablet displaying the word "Pain", stethoscope and pills in the background.Diagnosis of failed back surgery involves a comprehensive physical exam and neurological evaluation and in-depth review of your back or neck pain, symptoms and medical history. Photo Source: 123RF.com.

Failed Back Surgery Syndrome: Steps in the Diagnostic Process

Diagnosing FBSS involves a comprehensive approach. In other words, your doctor not only asks you questions but also performs tests to better understand your pain and symptoms. The process of detecting the cause of failed back surgery may include all or some of the steps below:

  • Medical history
  • Review of emotional wellbeing and lifestyle habits
  • Physical exam
  • Neurological exam
  • Review of current symptoms
  • Imaging (eg, x-ray)

Medical history
The first step to diagnosing failed back surgery—and any spinal disorder—is a review of your medical history. The details of your past and current health history give your doctor insight into your general health. Be prepared to inform your doctor about any allergies, previous and current diagnoses (include any co-existing medical conditions, such as diabetes and cardiovascular disease), and over-the-counter and/or prescription medications you take, including vitamins and supplements.

It is also important to discuss any treatments you’ve tried to relieve your pain and other symptoms. This includes medications, physical therapy, chiropractic, injection therapies, and others—and the effectiveness of any treatment tried.

Review of emotional wellbeing and lifestyle habits
Back pain and emotional wellbeing are closely linked, which is why your doctor focuses some time on your psychosocial health. Tell your doctor if you have a diagnosis of depression, anxiety, or other mental and emotional health—or if you have thoughts or feelings of depression.

Mental and emotional health is integral to pain management, and people with psychosocial health disorders may have heightened awareness of pain. That doesn’t mean the pain isn’t real or simply “in your head,” rather, this information will help your doctor fully address the pain you’re experiencing—both physical and emotional—in his or her treatment plan.

Your doctor will also want to discuss your lifestyle. Smoking, obesity, sleep problems, and activity/exercise levels will help your doctor paint an accurate picture of your health and lead the way toward the potential cause of your FBS.

Physical exam
After reviewing your medical history, your doctor may perform a physical exam to help evaluate the underlying cause of your pain and symptoms. Your doctor may touch and feel—or palpate—certain parts of your spine to identify areas of spasm, tenderness, or swelling. Your doctor may also ask you to do physical movements and activities, such as walk across the room (which will show gait problems), bend or twist (to see your range of motion), simply stand (to test balance, posture, and spinal alignment). In addition, the  doctor may also perform special diagnostic movements (eg, straight-leg raise test) to recreate and pinpoint the source of your pain.

Neurological exam
The neurological exam is intended to gauge the health of your nerves and identify areas of nerve dysfunction. The neurological exam identifies muscle weakness, abnormal sensations (eg, pinprick sensations or numbness), and radiculopathy (eg, pain that runs from the low back down to the feet). Your doctor may test your spinal nerve health by gently moving a cotton swab or pin across your skin to test feeling in your extremities, flex and extend your arms and legs to test for weakness, or use a rubber hammer to test reflexes.

Review of current symptoms
Your doctor will also obviously want to know the reason for your visit, so be prepared to discuss your current symptoms in as much detail as possible. During this part of the diagnostic process, your doctor may ask you to “rate” your pain. Pain is subjective and can’t be measured with 100% accuracy, but certain tests will help your doctor better understand your pain. These tests include:

  • Visual Analog Scale. Using a scale from 0 (no pain) to 10 (worst pain imaginable), the patient rates their pain.
  • Oswestry Disability Index. 10 questions the patient answers help to reveal how pain affects their quality of life.
  • Pain Drawing. Illustration of the front and back of the body allows a patient to mark where they feel pain and describe its characteristics (eg, aching, burning).

Pain scale, from least to greatest.Your doctor will ask you to rate your pain using a numeric scale called a Visual Analog Scale. Photo Source: 123RF.com.Your doctor will also ask you describe your pain by asking questions, such as:

  • Where is your pain located?
  • When did your pain start?
  • Did your pain develop suddenly?
  • Is your pain constant?
  • Does your pain get worse during or after certain activities?
  • Does your pain affect your daily life or mood?

Your doctor will also want to know about any “red flag” symptoms, including problems with bowel/bladder function and new nerve symptoms. These symptoms may warrant emergency medical attention.

Imaging
Imaging scans, such as x-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI), provide valuable information about your spinal disorder, its cause and helps to confirm a diagnosis. The choice of imaging scan may depend on the original diagnosis that led to your spine surgery in the first place.

To help illustrate, if you had spine surgery to treat a spinal deformity, your doctor may order standing x-rays to view alignment of your entire vertebral column. However, x-ray imaging cannot clearly define the spine’s soft or non-bony structures. Perhaps the x-ray suggests a recurrent herniated disc or spinal stenosis. In such situations, to gain more in-depth information, your doctor may opt to use CT or MRI scanning sometimes with and without a contrast dye to highlight significant areas of diagnostic value.

MRI is generally the best test to evaluate lower back pain problems. In patients who have had prior instrumentation, there may be too much artifact or distortion of the MRI images to see what is happening. Additionally, MRI does not visualize metal instrumentation well. Therefore, a CT scan is often also necessary to better assess if the bones have fused adequately and instrumentation positioning. Sometimes a CT myelogram is necessary where dye is placed into the spinal canal and then a CT scan is obtained of the spine.

From Failed Back Surgery Diagnosis to Treatment

Receiving a diagnosis of failed back surgery can be frustrating and frightening, but it can also be liberating. Once your doctor confirms the cause, he or she can get to work on creating a treatment plan that addresses your pain and symptoms. In most cases, your doctor will recommend non-surgical treatments for failed back surgery syndrome symptoms, as success rates for recurrent spine surgeries get lower with each subsequent surgery. However, your specific case may warrant spine surgery to relieve your FBSS/FBS-related pain and symptoms.

Updated on: 02/06/19
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