Help for Long-lasting Pain After a Back Surgery

Pain is normal in the weeks following back surgery, as tissues heal, nerves regain normal function, and inflammation decreases. However, some people may have pain beyond the three to six month period that is considered a normal healing time.

Persistent pain or the onset of a new type of pain after back surgery is known as failed back surgical syndrome (FBBS). A person’s medical conditions, past surgical history, and coping mechanisms can all influence the development of FBSS.

Treatment for FBSS requires a team approach and good communication between patient and doctors. If you suffer from this type of pain, a pain specialist can help. Involving a pain specialist in your care early in the period after your surgery can maximize your chances for recovery and good pain control.

Long-lasting pain after back surgery

Long-lasting pain is more common with certain surgeries such as amputations and mastectomies but may occur after back surgeries. FBBS is a challenging problem and one where the anatomical source of pain is not always clear.

A major issue is that back surgery results in subtle changes to the biomechanical movement of the spine. These changes, combined with the original issues (herniated discs, etc) that led to the surgery, can cause imbalances and repetitive stress in certain areas of the spine muscles, joints, and nerves. Unfortunately, this stress can lead to chronic pain, even if the surgery was performed perfectly and without complications.

It is important to note that FBSS is not an appropriate term for cases in which new (pain) issues have arisen after surgery and that require evaluation for a possible repeat surgery.

Persistent back pain after a successful surgery

Some people have long-lasting pain after a back surgery that was technically flawless. In these situations, imaging tests, such as MRIs and CTs performed after surgery do not show any significant abnormalities that would indicate a need for repeat surgery.

These people may have neuropathic pain (NP), a condition where nerve fibers become overactive and send inappropriate pain signals to the spinal cord and brain. In this case, there is no constriction or narrowing that is squeezing a spinal nerve.

Some facts about NP:

• NP is unlike the usual pain you have immediately after an injury. It can reach unbearable levels and can last for years if left untreated.
• It has distinct symptoms and is often described as a dull back pain and/or a severe, sharp, electric-like sensation in a leg.
• There is a 9% risk for NP after back surgery. It can start due to direct surgical nerve trauma or the irritation of nerves that become trapped in scar tissue. It can also arise without a defined cause.
• People with a history of chronic NP before the back surgery, may continue to have long-lasting pain after the surgery. This happens even if the surgery corrects the original pain problem, such as a herniated disc, degenerative changes (wear and tear), or a pinched nerve.
• Treatment for NP differs from treatments for other types of back pain. Opioids and anti-inflammatories do not work well for NP. Effective treatments include antidepressant or anticonvulsant medications, nerve blocks, and spinal cord stimulator/ pain pump implants.

Risks for FBSS

You are more likely to have long-lasting pain after a back surgery with:

• Chronic smoking. Smoking decreases your ability to deliver oxygen to tissues. It leads to a poor fusion (healing) between backbones and slows the healing of skin incisions.
• Progressive disease. While an initial surgery may have fixed your initial pain problem, a new problem may start after surgery. For example, you may have a new disc herniation that requires treatment.
• Scar tissue formation. Scar tissue forms after surgery and interferes with blood flow and oxygen supply to back tissues that need to heal. Scar tissue may tether a nerve, causing pain.
• Muscle pain. New-onset muscle tension in the back is fairly common after surgery. However, muscle tension can improve with treatment and should be addressed early, to prevent long-lasting pain (myofascial pain syndrome). For more information, click here.
• Pain from the hardware. Some patients who had metal hardware installed as part of their surgery can have pain due to the hardware rubbing on nearby ligaments and muscle.
• Loose or fractured hardware. Excess movement between two backbones that should have fused together after surgery, can loosen surgical screws and cause instability at the level of the fusion. In severe cases, the pressure on the hardware can even cause the rods or screws to break. This requires another surgery.
• A history of multiple back surgeries. A second surgery is sometimes needed to fix issues that started during the first surgery. However, additional surgery may increase the risk of spinal neuropathic pain and biomechanical changes to the natural spine.
• Psychological and social factors.Depression, anxiety, and stress can affect people with chronic pain. They may increase the duration and intensity of pain a person has after a surgery.

Do I have FBSS?

A follow-up visit with your medical team can clarify if you have FBSS. If you have continued pain after surgery, it is important to follow up with a pain medicine specialist as well as a spine surgeon. Your doctor will do an evaluation that includes a medical history and a neurologic exam that can reveal if you have FBSS.

Your doctors may order the following tests, to clarify if you have FBSS:

• X-ray (radiography). Evaluates bone structures, spine alignment, and ensures that surgical hardware (rods, screws, plates) is intact.
• Magnetic resonance imaging (MRI). Can diagnose most back problems, such as pinched nerves and herniated discs. Image quality may be poor if you have surgical hardware.
• Computerized tomography (CT). Often used to show if bones fused well after surgery. Useful in people with surgical hardware.
• Discography. A procedure that evaluates disc pain.
• Electromyography (EMG). Studies that show how nerves function.
• Diagnostic injections. Epidurals and nerve blocks performed by a pain specialist can reveal the cause of your back pain.

FBSS Treatment

In order to treat FBSS, it is important to have a team approach and open communication between the patient, surgeon, and pain specialist.

Some people find that back surgery helped with their initial problem, but experience a new type of pain afterward. Other people have a history of chronic, neuropathic pain that predispose them to long-lasting pain after their back surgery. A pain specialist can help you understand why you continue to have pain.

He or she may offer several treatments:

1. Oral Medications

During treatment for FBSS you should continue strengthening your back with physical therapy, if possible. Your pain specialist will offer some new medications, to control the different types of pain that can start after a surgery.

• Medications that fight inflammation. Medications like Advil (Ibuprophen) and Naproxen (Aleve) help reduce pain from swelling in your back tissues. While over the counter, these medications can have serious side effects and risks if taken too often. Discuss with your doctor if you are taking these medications for longer than 2 weeks.
• Muscle Relaxants. These medications decrease muscle spasms by working at the level of the brain and spinal cord.
• Opioids. Immediately after surgery, opioids can control severe pain. However, they lose their efficiency over time and can increase pain levels in the long term.
• Anticonvulsants. Gabapentin (Neurontin) has been shown to decrease pain in patients with FBSS. Studies show that the risk for FBSS is reduced if a person starts taking Pregabalin (Lyrica) before surgery.

2. Procedures for pain relief

If you continue to have pain despite taking the appropriate medications, your pain specialist will offer several non-surgical, pain-relief procedures.

• Epidural injections. This is a common treatment for both mid-back pain and one-sided leg pain.
• Selective nerve root block. This injection helps find the cause for your back pain and it treats back/leg pain due to a pinched nerve. Steroid, numbing medication, or a combination of the two is injected at the site where nerves exit the spine.
• Joint injections. Facet joint injections place steroid and/or numbing medication directly in a painful back joint. Medial branch blocks temporarily numb up the nerves that carry pain sensations to the back joints.
• Dissolving scar tissue. Newly formed scar tissue is a common cause for FBSS, affecting 8-14% of people who have back surgery. However, the injection of a special type of saline solution into the epidural space can remove the adhesions. This relieves pressure on tethered nerves and allows pain-relief medications to spread better during an ESI.
• Treatments for disc pain. Treatments applied to the painful outer disc ring, include intra-discal electrothermal therapy (IDET), discTRODE, or Methylene Blue Injections.

3. Device Implant

• Spinal Cord Stimulation (SCS). This is an established treatment for many chronic pain conditions, including neuropathic back pain and FBSS. Spinal cord stimulators are small devices that send electrical signals to the spinal cord, in order to block pain. To read more about this treatment, click here.
• Intrathecal (Pain) Pump. This small medical device delivers medications directly to the spinal cord. It produces a stronger and faster pain relief effect and fewer side effects than medications in pill form. To read more about this treatment, click here.