Failed back surgery syndrome: are our patients getting a fair deal?

‘The failed back surgery syndrome is easy to recognise but difficult to define,’ wrote Onesti in 2004. ¹ Unfortunately this remains the case today. Despite the existence of numerous definitions for failed back surgery syndrome (FBSS), none has been widely adopted. The failure to adopt a single definition of the condition may reflect the heterogeneous nature of the population described by the term.

In this issue Tharamanathan et al. ² provide an estimate of the possible incidence of FBSS in England of 7853 to 31,414 new cases annually based on data from the Hospital Episode Statistics database. The figures are based on an incidence of FBSS of 10–40%. ³ More recent trial-based evidence has shown failure rates to be procedure specific with a lumbar fusion failure rate of 30–46%, 35–36.2% for lumbar decompressive surgery and 19–25% for microdiscectomy. ⁴

Patients with FBSS start their journey in surgery departments and eventually find their way into the pain clinic via various departments including radiology, physiotherapy and clinical psychology. By the time they reach the pain clinic, these patients are often frustrated, angry, miserable, desperate and in severe pain. The few studies describing the demographics of the FBSS patient indeed paint a grim picture. FBSS patients report a quality of life comparable to that experienced by those with conditions such as cancer or chronic heart failure: ⁵ 67% report an extreme pain or problem and 30% report an extreme problem with everyday activities. ⁶

In a BMJ article, Lina Talbot, a medical registrar and FBSS sufferer herself, provides a poignant account of the agony and confusion inflicted by this condition. She highlights the lack of support and expert help for FBSS sufferers in the UK compared with other conditions. The article also points out the poor outcomes of treatment of FBSS sufferers in pain clinics with an estimate of only one in three patients experiencing 30% pain relief. ⁷ This, as it turns out, is an overestimate as trial evidence later showed that only 9% and 18% of patients experience 50% and 30% pain relief, if we exclude spinal cord stimulation as a treatment option. ⁸

Evidence of the effectiveness of spinal cord stimulation (SCS) specific to the FBSS patient group is derived from two randomised controlled trials;^{8 –10} these demonstrated marked reductions in leg pain with a modest impact on low back pain. Access to SCS in England, however, remains patchy despite a positive recommendation by the National Institute for Health and Clinical Excellence. ¹¹

The aetiology of FBSS remains complex and unclear. The burden of disability associated with FBSS is substantial, as is the cost of treatment; ¹² the evidence for the added value of physiotherapy in FBSS sufferers is limited.^13,14 Evidence for most pharmacological-based interventions is extrapolated from other patient groups, such as diabetic neuropathy and general pain populations, and is often restricted to a short follow-up. ¹⁴ There remains a clear need for evidence synthesis that is specific to this patient group. We hope this issue of the British Journal of Pain will act as a knowledge platform for such evidence generation.