Failed Back Surgery Syndrome FBSS: Classification and Treatment
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Oct 20, 2025
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About This Presentation
Unlock a practical, clinician-first framework for Failed Back Surgery Syndrome (FBSS)—from mechanism-based classification to step-wise interventional and neuromodulation treatments. This 40-slide deck distills a comprehensive lecture into actionable algorithms covering Group 1 (Same Pain), Group 2...
Slide Content
Failed Back
Surgery
Syndrome (FBSS)
(FBSS)
Classification & Treatment
A clinically oriented, mechanism-based approach to persistent post-surgical spine pain for clinicians
and trainees in spine surgery, pain medicine, and rehabilitation.
Surgery
Syndrome (FBSS)
(FBSS)
Classification & Treatment
A clinically oriented, mechanism-based approach to persistent post-surgical spine pain for clinicians
and trainees in spine surgery, pain medicine, and rehabilitation.
Why "Failed Back Surgery Syndrome" is a Misnomer
The term "Failed Back Surgery Syndrome" is fundamentally
flawed and misleading. Persistent post-operative pain occurs
after many types of surgical procedures across multiple
specialties—the spine is not unique in this regard. The
persistence of pain does not necessarily indicate surgical failure.
More accurately, FBSS represents a syndrome—a heterogeneous
cluster of potential mechanisms and pain generators—rather
than a single disease entity with unified pathophysiology. This
distinction is critical for diagnostic and therapeutic decision-
making.
In contemporary practice, we should move away from this
stigmatizing terminology and instead focus on mechanism -
based diagnosis that identifies the specific pain generator.
The term "Failed Back Surgery Syndrome" is fundamentally
flawed and misleading. Persistent post-operative pain occurs
after many types of surgical procedures across multiple
specialties—the spine is not unique in this regard. The
persistence of pain does not necessarily indicate surgical failure.
More accurately, FBSS represents a syndrome—a heterogeneous
cluster of potential mechanisms and pain generators—rather
than a single disease entity with unified pathophysiology. This
distinction is critical for diagnostic and therapeutic decision-
making.
In contemporary practice, we should move away from this
stigmatizing terminology and instead focus on mechanism -
based diagnosis that identifies the specific pain generator.
Working Definition of FBSS
Temporal Definition
Persistent or new pain occurring after any spine
surgery, manifesting at any time point from weeks
to years post-operatively. The timeline is non-
specific and varies widely among patients.
Clinical Construct
FBSS is a clinical diagnosis based on history,
examination, and targeted testing. There is no
single underlying pathophysiology—multiple
mechanisms may contribute simultaneously or
sequentially.
Imaging Limitations
Imaging alone cannot define or diagnose FBSS.
MRI findings must be interpreted in the context of
clinical presentation, as many "abnormalities" are
incidental and asymptomatic.
This working definition emphasizes the need for comprehensive clinical correlation rather than relying on any single diagnostic
modality. The heterogeneity of FBSS demands individualized evaluation.
Temporal Definition
Persistent or new pain occurring after any spine
surgery, manifesting at any time point from weeks
to years post-operatively. The timeline is non-
specific and varies widely among patients.
Clinical Construct
FBSS is a clinical diagnosis based on history,
examination, and targeted testing. There is no
single underlying pathophysiology—multiple
mechanisms may contribute simultaneously or
sequentially.
Imaging Limitations
Imaging alone cannot define or diagnose FBSS.
MRI findings must be interpreted in the context of
clinical presentation, as many "abnormalities" are
incidental and asymptomatic.
This working definition emphasizes the need for comprehensive clinical correlation rather than relying on any single diagnostic
modality. The heterogeneity of FBSS demands individualized evaluation.
Imaging Pitfalls in FBSS Evaluation
Critical principle: Imaging findings do not equal pain generators. Always correlate history, physical examination, and diagnostic
blocks before attributing symptoms to radiographic abnormalities.
High Prevalence of Incidental
Findings
Large-scale studies demonstrate that disc
bulges, annular tears, facet arthropathy, and
other "abnormalities" are extremely common in
asymptomatic adults. The prevalence increases
with age, with many findings present in over 50%
of pain-free individuals.
Painless Structural Changes
Disc protrusions and even frank extrusions can be
completely asymptomatic. The presence of
neural compression on imaging does not
necessarily indicate that structure is the source of
clinical symptoms.
Clinical Correlation Imperative
Imperative
Every imaging finding must be tested against the
clinical story. Use history to identify pain
character and distribution, examination to
identify objective signs, and diagnostic blocks to
confirm suspected generators before proceeding
with treatment.
Critical principle: Imaging findings do not equal pain generators. Always correlate history, physical examination, and diagnostic
blocks before attributing symptoms to radiographic abnormalities.
High Prevalence of Incidental
Findings
Large-scale studies demonstrate that disc
bulges, annular tears, facet arthropathy, and
other "abnormalities" are extremely common in
asymptomatic adults. The prevalence increases
with age, with many findings present in over 50%
of pain-free individuals.
Painless Structural Changes
Disc protrusions and even frank extrusions can be
completely asymptomatic. The presence of
neural compression on imaging does not
necessarily indicate that structure is the source of
clinical symptoms.
Clinical Correlation Imperative
Imperative
Every imaging finding must be tested against the
clinical story. Use history to identify pain
character and distribution, examination to
identify objective signs, and diagnostic blocks to
confirm suspected generators before proceeding
with treatment.
Clinical Classification Framework
A practical, mechanism-oriented approach to FBSS begins with classifying the pain pattern relative to the pre-operative baseline. This single step dramatically narrows
the differential diagnosis and guides subsequent workup.
Group 1: Same Pain
Pain character and distribution remain unchanged from pre-operative presentation. Suggests the surgery addressed the wrong generator or a target-
generator mismatch occurred.
Group 2: Modified Pain
Pain pattern has changed after surgery—often radicular symptoms improve but new axial or different distribution pain emerges. Think surgical sequelae:
epidural fibrosis, adjacent segment disease, or myofascial changes.
Group 3: New Pain
Completely new pain phenotype in a different territory. Represents de novo pathology unrelated to the original surgical indication—new SIJ dysfunction, hip
osteoarthritis, compression fractures, or peripheral neuropathy.
This classification system provides a structured framework that prevents diagnostic confusion and ensures systematic evaluation of potential pain generators.
A practical, mechanism-oriented approach to FBSS begins with classifying the pain pattern relative to the pre-operative baseline. This single step dramatically narrows
the differential diagnosis and guides subsequent workup.
Group 1: Same Pain
Pain character and distribution remain unchanged from pre-operative presentation. Suggests the surgery addressed the wrong generator or a target-
generator mismatch occurred.
Group 2: Modified Pain
Pain pattern has changed after surgery—often radicular symptoms improve but new axial or different distribution pain emerges. Think surgical sequelae:
epidural fibrosis, adjacent segment disease, or myofascial changes.
Group 3: New Pain
Completely new pain phenotype in a different territory. Represents de novo pathology unrelated to the original surgical indication—new SIJ dysfunction, hip
osteoarthritis, compression fractures, or peripheral neuropathy.
This classification system provides a structured framework that prevents diagnostic confusion and ensures systematic evaluation of potential pain generators.
Group 1
Same Pain Pattern
Same Pain Pattern
Group 1 Overview: Target-Generator Mismatch
Group 1 patients present with pain that is essentially unchanged from their
pre-operative presentation in both character and distribution. This scenario
strongly suggests a target-generator mismatch: the surgery was technically
successful, but the wrong pain source was addressed.
These cases often involve pain generators that are poorly predicted by MRI
alone. Common culprits include facet joints, sacroiliac joints, myofascial
structures, and unrecognized fibromyalgia. In multilevel degenerative
disease, surgery may have been performed at the wrong level.
The key to Group 1 management is confirming the true pain generator
through targeted diagnostic blocks before attempting definitive treatment.
Never assume the imaging tells the complete story.
Clinical Pearl: If the pain hasn't changed post-operatively,
you likely didn't treat the actual generator. Go back to first
principles and re-evaluate with blocks.
Group 1 patients present with pain that is essentially unchanged from their
pre-operative presentation in both character and distribution. This scenario
strongly suggests a target-generator mismatch: the surgery was technically
successful, but the wrong pain source was addressed.
These cases often involve pain generators that are poorly predicted by MRI
alone. Common culprits include facet joints, sacroiliac joints, myofascial
structures, and unrecognized fibromyalgia. In multilevel degenerative
disease, surgery may have been performed at the wrong level.
The key to Group 1 management is confirming the true pain generator
through targeted diagnostic blocks before attempting definitive treatment.
Never assume the imaging tells the complete story.
Clinical Pearl: If the pain hasn't changed post-operatively,
you likely didn't treat the actual generator. Go back to first
principles and re-evaluate with blocks.
Group 1: Facet Joint Pain
Clinical Presentation
Axial low-back pain worse with extension, rotation,
and prolonged standing. Characteristic sit-to-stand
exacerbation. Focal paraspinal tenderness over
affected levels on examination.
Diagnostic Approach
Poor imaging-pain concordance (~25-27%
sensitivity). MRI findings of facet arthropathy do not
predict pain response. Confirm diagnosis with dual
comparative medial branch blocks using strict
criteria: ≥80% pain relief with short-acting, then long-
acting local anesthetic.
Definitive Treatment
Radiofrequency ablation (RFA) of medial branches
provides 6-24 months of relief in properly selected
patients. Proceed to RFA only after dual positive
blocks. Repeat as needed when pain recurs.
Clinical Presentation
Axial low-back pain worse with extension, rotation,
and prolonged standing. Characteristic sit-to-stand
exacerbation. Focal paraspinal tenderness over
affected levels on examination.
Diagnostic Approach
Poor imaging-pain concordance (~25-27%
sensitivity). MRI findings of facet arthropathy do not
predict pain response. Confirm diagnosis with dual
comparative medial branch blocks using strict
criteria: ≥80% pain relief with short-acting, then long-
acting local anesthetic.
Definitive Treatment
Radiofrequency ablation (RFA) of medial branches
provides 6-24 months of relief in properly selected
patients. Proceed to RFA only after dual positive
blocks. Repeat as needed when pain recurs.
Group 1: Sacroiliac Joint Pain
Clinical Features
Buttock or posterior superior iliac spine (PSIS) point tenderness with pain worse during sitting,
transfers, and single-leg stance. Patients often describe difficulty with transitions: sit-to-stand,
rolling in bed, getting in and out of cars.
Provocation maneuvers (Gaenslen's, FABER, thigh thrust, distraction, compression) can support
the diagnosis but are not definitive. Clusters of 3+ positive tests improve specificity but cannot
replace diagnostic injection.
01
Imaging-Pain Concordance
Approximately 45% concordance between MRI findings and pain source —better than facets
but still insufficient for diagnosis without blocks.
02
Diagnostic Confirmation
Intra-articular SIJ block with local anesthetic under fluoroscopic or ultrasound guidance.
Adequate fill of joint space required; some advocate for dual blocks as with facets.
03
Treatment Options
Intra-articular steroid injection, lateral branch radiofrequency ablation for extra-articular
pain, or minimally invasive SIJ fusion for confirmed mechanical instability refractory to
conservative care.
Clinical Features
Buttock or posterior superior iliac spine (PSIS) point tenderness with pain worse during sitting,
transfers, and single-leg stance. Patients often describe difficulty with transitions: sit-to-stand,
rolling in bed, getting in and out of cars.
Provocation maneuvers (Gaenslen's, FABER, thigh thrust, distraction, compression) can support
the diagnosis but are not definitive. Clusters of 3+ positive tests improve specificity but cannot
replace diagnostic injection.
01
Imaging-Pain Concordance
Approximately 45% concordance between MRI findings and pain source —better than facets
but still insufficient for diagnosis without blocks.
02
Diagnostic Confirmation
Intra-articular SIJ block with local anesthetic under fluoroscopic or ultrasound guidance.
Adequate fill of joint space required; some advocate for dual blocks as with facets.
03
Treatment Options
Intra-articular steroid injection, lateral branch radiofrequency ablation for extra-articular
pain, or minimally invasive SIJ fusion for confirmed mechanical instability refractory to
conservative care.
Group 1: Myofascial Pain—Psoas & Quadratus
Lumborum
Myofascial pain syndromes are frequently overlooked contributors to persistent axial back pain after spine surgery. The psoas and
quadratus lumborum (QL) muscles deserve particular attention.
Psoas Syndrome
Deep lumbar pain with hip flexion contracture and
antalgic posture. Severe psoas spasm can entrap
branches of the lumbar plexus, producing
pseudo-radicular symptoms. Thomas test
positivity and pain with resisted hip flexion
suggest psoas involvement.
QL Dysfunction
The QL provides lumbar stability and is often
overloaded in patients with surgical fusion or
altered biomechanics. Pain is typically deep,
unilateral, and worse with side-bending. Hip
mechanics and gait abnormalities frequently
coexist.
Diagnosis & Treatment
Confirm with focused physical examination
demonstrating trigger points and symptom
reproduction with palpation.
Diagnostic/therapeutic trigger point injections
(TPIs) with local anesthetic confirm the generator.
Treat with serial TPIs, targeted stretching
protocols, and manual therapy.
Lumborum
Myofascial pain syndromes are frequently overlooked contributors to persistent axial back pain after spine surgery. The psoas and
quadratus lumborum (QL) muscles deserve particular attention.
Psoas Syndrome
Deep lumbar pain with hip flexion contracture and
antalgic posture. Severe psoas spasm can entrap
branches of the lumbar plexus, producing
pseudo-radicular symptoms. Thomas test
positivity and pain with resisted hip flexion
suggest psoas involvement.
QL Dysfunction
The QL provides lumbar stability and is often
overloaded in patients with surgical fusion or
altered biomechanics. Pain is typically deep,
unilateral, and worse with side-bending. Hip
mechanics and gait abnormalities frequently
coexist.
Diagnosis & Treatment
Confirm with focused physical examination
demonstrating trigger points and symptom
reproduction with palpation.
Diagnostic/therapeutic trigger point injections
(TPIs) with local anesthetic confirm the generator.
Treat with serial TPIs, targeted stretching
protocols, and manual therapy.
Group 1: Piriformis & Deep Gluteal Syndrome
Clinical Presentation
Posterior hip and leg pain with profound seated intolerance—
patients cannot tolerate sitting for more than a few minutes. Pain
typically radiates down the posterior thigh, sometimes into the
calf. FAIR test (Flexion-Adduction-Internal Rotation) is
characteristically positive.
The sciatic nerve and its common peroneal variant may traverse
through the piriformis muscle belly in up to 20% of individuals,
making them susceptible to compression with muscle spasm or
hypertrophy.
This syndrome is frequently misdiagnosed as radiculopathy,
leading to unnecessary surgical interventions.
Management Strategy
Confirm diagnosis with image-guided (ultrasound or fluoroscopy) local anesthetic injection into the piriformis muscle. Positive
response validates the diagnosis and guides treatment.
Therapeutic approach includes trigger point injections, botulinum toxin for refractory cases, targeted stretching (figure-4 stretch),
piriformis-specific strengthening, and manual therapy techniques. Address hip biomechanics and gluteal weakness.
Clinical Presentation
Posterior hip and leg pain with profound seated intolerance—
patients cannot tolerate sitting for more than a few minutes. Pain
typically radiates down the posterior thigh, sometimes into the
calf. FAIR test (Flexion-Adduction-Internal Rotation) is
characteristically positive.
The sciatic nerve and its common peroneal variant may traverse
through the piriformis muscle belly in up to 20% of individuals,
making them susceptible to compression with muscle spasm or
hypertrophy.
This syndrome is frequently misdiagnosed as radiculopathy,
leading to unnecessary surgical interventions.
Management Strategy
Confirm diagnosis with image-guided (ultrasound or fluoroscopy) local anesthetic injection into the piriformis muscle. Positive
response validates the diagnosis and guides treatment.
Therapeutic approach includes trigger point injections, botulinum toxin for refractory cases, targeted stretching (figure-4 stretch),
piriformis-specific strengthening, and manual therapy techniques. Address hip biomechanics and gluteal weakness.
Group 1: Fibromyalgia—The Great Mimicker
Fibromyalgia (FM) is remarkably prevalent in pain clinic populations, affecting approximately 20% of patients. Its ability to mimic radiculopathy makes it a critical
diagnostic consideration in FBSS evaluation.
Radiculopathy Mimicry
FM produces positive straight leg raise tests, paresthesias in dermatomal
distributions, and diffuse lower extremity pain—all features that can be
mistaken for nerve root compression. Many FM patients undergo unnecessary
spine surgery.
Core Clinical Features
Non-restorative sleep is nearly universal. Patients describe profound fatigue
disproportionate to activity, cognitive symptoms ("fibro fog"), mood
disturbance, and multiple somatic complaints including IBS, headaches, and
TMJ pain.
Diagnostic Approach
Use the 2016 revised fibromyalgia diagnostic criteria: widespread pain index
and symptom severity scale. Formal FM scoring improves diagnostic
accuracy. Screen all chronic pain patients, especially those with poor surgical
outcomes.
Management Priority
Manage fibromyalgia FIRST before attributing residual symptoms to spine
pathology. Address sleep restoration, initiate graded aerobic exercise,
consider SNRIs (duloxetine, milnacipran) or pregabalin/gabapentin.
Cognitive-behavioral therapy is evidence-based. Then re-evaluate spine-
specific pain.
Fibromyalgia (FM) is remarkably prevalent in pain clinic populations, affecting approximately 20% of patients. Its ability to mimic radiculopathy makes it a critical
diagnostic consideration in FBSS evaluation.
Radiculopathy Mimicry
FM produces positive straight leg raise tests, paresthesias in dermatomal
distributions, and diffuse lower extremity pain—all features that can be
mistaken for nerve root compression. Many FM patients undergo unnecessary
spine surgery.
Core Clinical Features
Non-restorative sleep is nearly universal. Patients describe profound fatigue
disproportionate to activity, cognitive symptoms ("fibro fog"), mood
disturbance, and multiple somatic complaints including IBS, headaches, and
TMJ pain.
Diagnostic Approach
Use the 2016 revised fibromyalgia diagnostic criteria: widespread pain index
and symptom severity scale. Formal FM scoring improves diagnostic
accuracy. Screen all chronic pain patients, especially those with poor surgical
outcomes.
Management Priority
Manage fibromyalgia FIRST before attributing residual symptoms to spine
pathology. Address sleep restoration, initiate graded aerobic exercise,
consider SNRIs (duloxetine, milnacipran) or pregabalin/gabapentin.
Cognitive-behavioral therapy is evidence-based. Then re-evaluate spine-
specific pain.
Group 1: Multilevel Disc Disease
In patients with multilevel degenerative disease, single-level surgical decompression or fusion
may fail to address the dominant pain generator. The MRI shows "abnormalities" at L3-4, L4-5, and
L5-S1—but which level is actually responsible for the patient's symptoms?
This scenario is particularly common in older patients with multi-segment stenosis or disc
degeneration. The imaging can be misleading, showing similar degrees of pathology at multiple
levels.
Strategy: Use staged diagnostic discography or selective nerve root blocks to identify the
primary pain generator before committing to surgical intervention. This approach
improves outcomes and prevents unnecessary multilevel fusions.
Consider provocative discography at multiple levels (where available) or selective epidural/nerve
root blocks to prioritize the true symptomatic level. Document percentage pain relief and
functional improvement with each injection to guide decision-making.
In patients with multilevel degenerative disease, single-level surgical decompression or fusion
may fail to address the dominant pain generator. The MRI shows "abnormalities" at L3-4, L4-5, and
L5-S1—but which level is actually responsible for the patient's symptoms?
This scenario is particularly common in older patients with multi-segment stenosis or disc
degeneration. The imaging can be misleading, showing similar degrees of pathology at multiple
levels.
Strategy: Use staged diagnostic discography or selective nerve root blocks to identify the
primary pain generator before committing to surgical intervention. This approach
improves outcomes and prevents unnecessary multilevel fusions.
Consider provocative discography at multiple levels (where available) or selective epidural/nerve
root blocks to prioritize the true symptomatic level. Document percentage pain relief and
functional improvement with each injection to guide decision-making.
Group 1: Diagnostic Strategy
01
History-Driven Hypothesis
Start with detailed pain history: character (neuropathic burning/shooting vs
nociceptive aching/throbbing), distribution (dermatomal vs sclerotomal vs
myotomal), and aggravating factors. This determines which structures to test.
02
Targeted Diagnostic Blocks
Use small-volume, image-guided blocks to test hypothesized pain generators.
Facet medial branch blocks (0.3-0.5 mL per nerve), intra-articular SIJ blocks (1-2
mL), selective nerve root blocks (1-1.5 mL), or trigger point injections. Document
baseline pain score, relief percentage, and duration.
03
Confirmatory Testing
Require reproducible substantial relief (≥50% but ideally ≥80%) with appropriate
duration for the anesthetic used. For facets and SIJ, consider dual blocks with
short- and long-acting anesthetics to reduce false positives. Correlate relief with
functional improvement.
04
Proceed to Definitive Therapy
Only after achieving reproducible diagnostic block confirmation should you
proceed to definitive treatment (RFA, surgery, neuromodulation). This stepwise
approach dramatically improves outcomes and prevents unnecessary
procedures.
01
History-Driven Hypothesis
Start with detailed pain history: character (neuropathic burning/shooting vs
nociceptive aching/throbbing), distribution (dermatomal vs sclerotomal vs
myotomal), and aggravating factors. This determines which structures to test.
02
Targeted Diagnostic Blocks
Use small-volume, image-guided blocks to test hypothesized pain generators.
Facet medial branch blocks (0.3-0.5 mL per nerve), intra-articular SIJ blocks (1-2
mL), selective nerve root blocks (1-1.5 mL), or trigger point injections. Document
baseline pain score, relief percentage, and duration.
03
Confirmatory Testing
Require reproducible substantial relief (≥50% but ideally ≥80%) with appropriate
duration for the anesthetic used. For facets and SIJ, consider dual blocks with
short- and long-acting anesthetics to reduce false positives. Correlate relief with
functional improvement.
04
Proceed to Definitive Therapy
Only after achieving reproducible diagnostic block confirmation should you
proceed to definitive treatment (RFA, surgery, neuromodulation). This stepwise
approach dramatically improves outcomes and prevents unnecessary
procedures.
Group 1: Treatment Algorithm Summary
Facet Joint Pain
Dual diagnostic medial branch blocks → Radiofrequency ablation of medial
branches. Expected relief: 6-24 months. Repeat RFA as needed upon pain
recurrence.
Sacroiliac Joint
Intra-articular diagnostic block → Intra-articular steroid injection +/- lateral
branch radiofrequency ablation. Consider minimally invasive fusion for
confirmed mechanical instability.
Myofascial Pain
Diagnostic trigger point injections → Serial therapeutic TPIs with local
anesthetic +/- botulinum toxin. Concurrent stretching protocols, manual
therapy, and biomechanical optimization.
Fibromyalgia
Patient education and expectation setting → Sleep restoration → Graded
aerobic exercise → Pharmacotherapy (SNRIs: duloxetine/milnacipran; or
pregabalin/gabapentin) → Cognitive-behavioral therapy. Multidisciplinary
approach essential.
All Group 1 treatments require concurrent rehabilitation addressing biomechanics, core stability, flexibility, and activity modification. Treat the generator, but don't
neglect the kinetic chain.
Facet Joint Pain
Dual diagnostic medial branch blocks → Radiofrequency ablation of medial
branches. Expected relief: 6-24 months. Repeat RFA as needed upon pain
recurrence.
Sacroiliac Joint
Intra-articular diagnostic block → Intra-articular steroid injection +/- lateral
branch radiofrequency ablation. Consider minimally invasive fusion for
confirmed mechanical instability.
Myofascial Pain
Diagnostic trigger point injections → Serial therapeutic TPIs with local
anesthetic +/- botulinum toxin. Concurrent stretching protocols, manual
therapy, and biomechanical optimization.
Fibromyalgia
Patient education and expectation setting → Sleep restoration → Graded
aerobic exercise → Pharmacotherapy (SNRIs: duloxetine/milnacipran; or
pregabalin/gabapentin) → Cognitive-behavioral therapy. Multidisciplinary
approach essential.
All Group 1 treatments require concurrent rehabilitation addressing biomechanics, core stability, flexibility, and activity modification. Treat the generator, but don't
neglect the kinetic chain.
Group 2
Modified Pain Pattern
Modified Pain Pattern
Group 2 Overview: Modified Pain After Surgery
Group 2 represents patients whose pain pattern has changed following surgery. Typically, the original radicular symptoms improve or resolve, but new back-dominant
pain or a different symptom distribution emerges. This scenario suggests surgical sequelae or altered biomechanics rather than true complications.
Sequelae vs Complications
Distinguish between expected sequelae of
surgery (epidural fibrosis, adjacent segment
stress, muscular changes) and true surgical
complications (infection, pseudoarthrosis,
hardware failure). The former are common; the
latter require urgent surgical evaluation.
Common Group 2 Generators
Epidural fibrosis with nerve root tethering,
adjacent segment facet overload, post-surgical
myofascial pain syndromes, and complex
regional pain syndrome (CRPS) are the most
frequent causes of modified pain patterns. Each
requires specific diagnostic and therapeutic
approaches.
Timeline Considerations
Modified pain can emerge at any point:
immediately post-operative (suggesting
complication or incorrect level), within 6-12
months (fibrosis formation), or years later
(adjacent segment disease). Timeline helps
narrow differential diagnosis.
Group 2 represents patients whose pain pattern has changed following surgery. Typically, the original radicular symptoms improve or resolve, but new back-dominant
pain or a different symptom distribution emerges. This scenario suggests surgical sequelae or altered biomechanics rather than true complications.
Sequelae vs Complications
Distinguish between expected sequelae of
surgery (epidural fibrosis, adjacent segment
stress, muscular changes) and true surgical
complications (infection, pseudoarthrosis,
hardware failure). The former are common; the
latter require urgent surgical evaluation.
Common Group 2 Generators
Epidural fibrosis with nerve root tethering,
adjacent segment facet overload, post-surgical
myofascial pain syndromes, and complex
regional pain syndrome (CRPS) are the most
frequent causes of modified pain patterns. Each
requires specific diagnostic and therapeutic
approaches.
Timeline Considerations
Modified pain can emerge at any point:
immediately post-operative (suggesting
complication or incorrect level), within 6-12
months (fibrosis formation), or years later
(adjacent segment disease). Timeline helps
narrow differential diagnosis.
Surgical Complications to Exclude First
Rule of thumb: Before attributing pain to benign sequelae, systematically exclude true surgical complications that require immediate intervention.
Infection
Surgical site infection, discitis, or epidural abscess. Look for fever, elevated
inflammatory markers (ESR/CRP), wound drainage, or systemic symptoms.
Early MRI with gadolinium if suspected. Requires urgent surgical and
infectious disease consultation.
Pseudoarthrosis
Failed fusion with persistent motion at intended fusion site. Presents with
mechanical axial pain worse with activity. Flexion-extension radiographs or
CT may demonstrate motion. May require revision surgery if confirmed and
symptomatic.
Pedicle Fracture & Hardware Issues
Pedicle fracture, screw loosening, or rod breakage. Usually associated with
mechanical pain and crepitus. Plain films or CT demonstrate hardware
failure. Implant migration can cause new neural compression requiring
revision.
Implant Malposition or Reaction
Misplaced pedicle screws causing new nerve root compression, or metal
allergy/inflammatory reaction to implants. CT better than MRI for hardware
evaluation. Consider metal ion testing if systemic symptoms present.
Red flags or systemic features warrant prompt surgical review and appropriate imaging before proceeding with pain management interventions.
Rule of thumb: Before attributing pain to benign sequelae, systematically exclude true surgical complications that require immediate intervention.
Infection
Surgical site infection, discitis, or epidural abscess. Look for fever, elevated
inflammatory markers (ESR/CRP), wound drainage, or systemic symptoms.
Early MRI with gadolinium if suspected. Requires urgent surgical and
infectious disease consultation.
Pseudoarthrosis
Failed fusion with persistent motion at intended fusion site. Presents with
mechanical axial pain worse with activity. Flexion-extension radiographs or
CT may demonstrate motion. May require revision surgery if confirmed and
symptomatic.
Pedicle Fracture & Hardware Issues
Pedicle fracture, screw loosening, or rod breakage. Usually associated with
mechanical pain and crepitus. Plain films or CT demonstrate hardware
failure. Implant migration can cause new neural compression requiring
revision.
Implant Malposition or Reaction
Misplaced pedicle screws causing new nerve root compression, or metal
allergy/inflammatory reaction to implants. CT better than MRI for hardware
evaluation. Consider metal ion testing if systemic symptoms present.
Red flags or systemic features warrant prompt surgical review and appropriate imaging before proceeding with pain management interventions.
Epidural Fibrosis: Pathophysiology
Epidural fibrosis (EF) represents scar tissue formation around the dura and nerve roots following surgery, inflammation, disc
herniation, or infection. This fibrotic tissue is a normal healing response but can become pathologic when it tethers neural
structures.
Understanding the location of fibrosis is critical: posterior epidural fibrosis rarely causes pain because the posterior dura has
minimal nociceptive innervation. In contrast, anterior and anterolateral epidural fibrosis can tether the pain-sensitive anterior
dura and nerve roots, producing symptoms.
Anterior tethering restricts normal dural motion during spinal flexion-extension and may compress nerve roots against bony
structures. This creates a mixed picture: vague diffuse axial back pain from dural traction combined with radicular symptoms
from root compression.
Clinical Pearl: The amount of fibrosis on MRI does not correlate with pain severity. Some patients
with extensive fibrosis are asymptomatic, while others with minimal scarring have severe
symptoms.
Epidural fibrosis can contribute to central or lateral stenosis, producing neurogenic claudication patterns. The combination of mechanical tethering and vascular compromise creates a complex pain syndrome.
Epidural fibrosis (EF) represents scar tissue formation around the dura and nerve roots following surgery, inflammation, disc
herniation, or infection. This fibrotic tissue is a normal healing response but can become pathologic when it tethers neural
structures.
Understanding the location of fibrosis is critical: posterior epidural fibrosis rarely causes pain because the posterior dura has
minimal nociceptive innervation. In contrast, anterior and anterolateral epidural fibrosis can tether the pain-sensitive anterior
dura and nerve roots, producing symptoms.
Anterior tethering restricts normal dural motion during spinal flexion-extension and may compress nerve roots against bony
structures. This creates a mixed picture: vague diffuse axial back pain from dural traction combined with radicular symptoms
from root compression.
Clinical Pearl: The amount of fibrosis on MRI does not correlate with pain severity. Some patients
with extensive fibrosis are asymptomatic, while others with minimal scarring have severe
symptoms.
Epidural fibrosis can contribute to central or lateral stenosis, producing neurogenic claudication patterns. The combination of mechanical tethering and vascular compromise creates a complex pain syndrome.
Epidural Fibrosis: Anterior vs Posterior Dura
Anterior Dura: Pain-Sensitive
The anterior dura is richly innervated with nociceptive fibers from the
sinuvertebral nerve. Tethering of anterior dura by fibrosis produces deep,
diffuse axial pain that is often difficult to localize. Patients describe it as a "deep
ache" or "pulling sensation" that worsens with position changes and movement.
Posterior Dura: Minimally Nociceptive
The posterior dura has sparse nociceptive innervation and is generally
insensate. Posterior epidural fibrosis visible on MRI is usually clinically silent and
does not require treatment. This is why laminectomy (posterior approach)
rarely produces painful fibrosis despite extensive scarring.
This anatomic distinction explains why not all epidural fibrosis causes pain and why anterior epidural access is targeted during adhesiolysis procedures. Treatment
must address anterior epidural space to be effective.
Anterior Dura: Pain-Sensitive
The anterior dura is richly innervated with nociceptive fibers from the
sinuvertebral nerve. Tethering of anterior dura by fibrosis produces deep,
diffuse axial pain that is often difficult to localize. Patients describe it as a "deep
ache" or "pulling sensation" that worsens with position changes and movement.
Posterior Dura: Minimally Nociceptive
The posterior dura has sparse nociceptive innervation and is generally
insensate. Posterior epidural fibrosis visible on MRI is usually clinically silent and
does not require treatment. This is why laminectomy (posterior approach)
rarely produces painful fibrosis despite extensive scarring.
This anatomic distinction explains why not all epidural fibrosis causes pain and why anterior epidural access is targeted during adhesiolysis procedures. Treatment
must address anterior epidural space to be effective.
Endoscopic Grading of Epidural Fibrosis
Direct visualization via epiduroscopy allows classification of fibrosis density and organization, which influences treatment approach and prognosis. This grading system
helps predict which cases will respond to medical adhesiolysis versus requiring mechanical or laser lysis.
Grade 1: Minimal Fibrosis
Flimsy, filmy strands of adhesions that are easily displaced. Often non-
surgical patients with post-inflammatory changes. Typically respond well to
epidural steroids alone without requiring lysis.
Grade 2: Recent Active Fibrosis
Angry pink or red vascularized scar tissue, usually ≤6 months post-injury or
surgery. Represents active inflammation and proliferative healing. Responds
favorably to hyaluronidase and catheter-based adhesiolysis.
Grade 3: Mature Dense Fibrosis
Pale, contracted, avascular scar tissue representing mature collagen
remodeling. Harder to lysate with medical means alone. May require
mechanical separation or laser assistance via epiduroscopy. Relief less
predictable.
Grade 4: Pan-Segmental Dense Fibrosis
Circumferential dense scarring obliterating normal anatomy. Epiduroscope
passage is difficult or impossible. Represents worst-case scenario. Medical
lysis rarely effective; mechanical epiduroscopic adhesiolysis is preferred but
technically challenging. Consider SCS earlier in these patients.
Direct visualization via epiduroscopy allows classification of fibrosis density and organization, which influences treatment approach and prognosis. This grading system
helps predict which cases will respond to medical adhesiolysis versus requiring mechanical or laser lysis.
Grade 1: Minimal Fibrosis
Flimsy, filmy strands of adhesions that are easily displaced. Often non-
surgical patients with post-inflammatory changes. Typically respond well to
epidural steroids alone without requiring lysis.
Grade 2: Recent Active Fibrosis
Angry pink or red vascularized scar tissue, usually ≤6 months post-injury or
surgery. Represents active inflammation and proliferative healing. Responds
favorably to hyaluronidase and catheter-based adhesiolysis.
Grade 3: Mature Dense Fibrosis
Pale, contracted, avascular scar tissue representing mature collagen
remodeling. Harder to lysate with medical means alone. May require
mechanical separation or laser assistance via epiduroscopy. Relief less
predictable.
Grade 4: Pan-Segmental Dense Fibrosis
Circumferential dense scarring obliterating normal anatomy. Epiduroscope
passage is difficult or impossible. Represents worst-case scenario. Medical
lysis rarely effective; mechanical epiduroscopic adhesiolysis is preferred but
technically challenging. Consider SCS earlier in these patients.
Epidural Fibrosis: Clinical Presentation
The clinical presentation of symptomatic epidural fibrosis is notoriously variable and can mimic numerous other pain syndromes. This diagnostic challenge often leads
to delayed recognition and treatment.
Symptom Heterogeneity
Patients may describe axial back pain, radicular leg pain, neurogenic
claudication, or mixed patterns. The pain quality varies: burning neuropathic
symptoms, deep aching, or sharp lancinating pains. Some patients report
"pulling" or "tightness" with movement.
Symptoms may be position-dependent: worse with forward flexion (stretching
tethered roots), prolonged standing (venous congestion), or transitional
movements. The variability makes pattern recognition difficult.
Diagnosis of Exclusion
Epidural fibrosis is often diagnosed by exclusion after systematically ruling out
other Group 2 generators: facet pain, SIJ dysfunction, myofascial pain, and
surgical complications. The diagnosis is supported but not proven by MRI findings
of epidural enhancement.
Definitive diagnosis requires correlating epidurography findings with clinical
symptoms—filling defects at symptomatic levels strengthen the diagnosis.
The clinical presentation of symptomatic epidural fibrosis is notoriously variable and can mimic numerous other pain syndromes. This diagnostic challenge often leads
to delayed recognition and treatment.
Symptom Heterogeneity
Patients may describe axial back pain, radicular leg pain, neurogenic
claudication, or mixed patterns. The pain quality varies: burning neuropathic
symptoms, deep aching, or sharp lancinating pains. Some patients report
"pulling" or "tightness" with movement.
Symptoms may be position-dependent: worse with forward flexion (stretching
tethered roots), prolonged standing (venous congestion), or transitional
movements. The variability makes pattern recognition difficult.
Diagnosis of Exclusion
Epidural fibrosis is often diagnosed by exclusion after systematically ruling out
other Group 2 generators: facet pain, SIJ dysfunction, myofascial pain, and
surgical complications. The diagnosis is supported but not proven by MRI findings
of epidural enhancement.
Definitive diagnosis requires correlating epidurography findings with clinical
symptoms—filling defects at symptomatic levels strengthen the diagnosis.
Diagnosis of Epidural Fibrosis: Epidurography
01
Caudal Access Technique
Caudal epidural access is preferred for epidurography
to avoid direct needle trauma through scarred
posterior epidural space. Use loss-of-resistance
technique with careful aspiration to confirm epidural
placement and exclude intravascular positioning.
02
Contrast Injection & Interpretation
Inject non-ionic contrast under live fluoroscopy to
delineate filling defects. Use sufficient volume (10-20
mL incrementally) to opacify the target nerve roots
and epidural space to L1-2 or above. Filling defects,
loculations, or asymmetric flow patterns indicate
fibrosis.
03
Clinical Correlation
Correlate contrast flow patterns with symptom
distribution. If contrast reaches the L5 root but not S1,
and the patient has S1 radiculopathy, you've identified
the problem. Provocative injection (reproducing
concordant pain) further validates the diagnosis.
Safety principle: Avoid continuous forceful injection against significant resistance. Excessive pressure can cause intracranial hypertension, headache, or very
rarely, neurologic complications. Inject slowly, incrementally, and watch for flow patterns.
01
Caudal Access Technique
Caudal epidural access is preferred for epidurography
to avoid direct needle trauma through scarred
posterior epidural space. Use loss-of-resistance
technique with careful aspiration to confirm epidural
placement and exclude intravascular positioning.
02
Contrast Injection & Interpretation
Inject non-ionic contrast under live fluoroscopy to
delineate filling defects. Use sufficient volume (10-20
mL incrementally) to opacify the target nerve roots
and epidural space to L1-2 or above. Filling defects,
loculations, or asymmetric flow patterns indicate
fibrosis.
03
Clinical Correlation
Correlate contrast flow patterns with symptom
distribution. If contrast reaches the L5 root but not S1,
and the patient has S1 radiculopathy, you've identified
the problem. Provocative injection (reproducing
concordant pain) further validates the diagnosis.
Safety principle: Avoid continuous forceful injection against significant resistance. Excessive pressure can cause intracranial hypertension, headache, or very
rarely, neurologic complications. Inject slowly, incrementally, and watch for flow patterns.
Volumetric Epidural Adhesiolysis (Caudal Approach)
Technique Overview
Caudal volumetric adhesiolysis uses enzymatic and hydrostatic forces to separate adhesions throughout the
epidural space. This "closed" technique doesn't require catheter steering but relies on volume to reach target
areas.
Protocol: After confirming epidural placement, inject hyaluronidase (typically 1,500 IU) to enzymatically break
down hyaluronic acid in scar tissue. Wait 10-15 minutes for enzymatic effect. Then perform saline distension with
total volume up to 40 mL (incremental 5-10 mL aliquots), "pushing" through adhesions. Finish with local anesthetic
(10-20 mL) and steroid (40-80 mg methylprednisolone).
Expected Relief Duration
Relief typically lasts 3-12 months, though highly variable. Younger patients with recent fibrosis
respond better than elderly patients with chronic dense scarring. Serial procedures may be
needed.
Safety Considerations
The major risk is rapid high-pressure injection causing elevated CSF pressure with severe
headache, visual changes, or rarely neurologic sequelae. Inject slowly, watch pressure, and stop if
significant resistance. Use preservative-free medications only.
Technique Overview
Caudal volumetric adhesiolysis uses enzymatic and hydrostatic forces to separate adhesions throughout the
epidural space. This "closed" technique doesn't require catheter steering but relies on volume to reach target
areas.
Protocol: After confirming epidural placement, inject hyaluronidase (typically 1,500 IU) to enzymatically break
down hyaluronic acid in scar tissue. Wait 10-15 minutes for enzymatic effect. Then perform saline distension with
total volume up to 40 mL (incremental 5-10 mL aliquots), "pushing" through adhesions. Finish with local anesthetic
(10-20 mL) and steroid (40-80 mg methylprednisolone).
Expected Relief Duration
Relief typically lasts 3-12 months, though highly variable. Younger patients with recent fibrosis
respond better than elderly patients with chronic dense scarring. Serial procedures may be
needed.
Safety Considerations
The major risk is rapid high-pressure injection causing elevated CSF pressure with severe
headache, visual changes, or rarely neurologic sequelae. Inject slowly, watch pressure, and stop if
significant resistance. Use preservative-free medications only.
Targeted Catheter Adhesiolysis (Racz Procedure)
The Racz catheter technique allows targeted navigation to the anterior epidural space at specific symptomatic levels, providing mechanical lysis in addition to
chemical adhesiolysis. This approach is more precise than volumetric caudal epidurals.
1
Day 1: Catheter Placement
Steerable catheter advanced caudally under fluoroscopy to anterior epidural
space at target level. Confirm position with contrast. Mechanical lysis as
catheter passes through adhesions. Inject hypertonic saline 10% (5-10 mL),
local anesthetic, and steroid. Leave catheter in place.
2
Day 2: Repeat Injection
Confirm catheter position. Second dose of hypertonic saline, LA, and steroid
through indwelling catheter. The multi-day protocol enhances lysis.
3
Day 3: Final Treatment
Final medication administration and catheter removal. Total hypertonic saline
should not exceed 20 mL over the series to minimize neurotoxicity risk.
Expected relief duration is longer than volumetric adhesiolysis: approximately 6-24 months in responders. The procedure is more invasive, time-intensive, and costly
than caudal volumetric lysis, but provides superior targeted effect. Reserve for patients who have failed simpler approaches or require level-specific treatment.
The Racz catheter technique allows targeted navigation to the anterior epidural space at specific symptomatic levels, providing mechanical lysis in addition to
chemical adhesiolysis. This approach is more precise than volumetric caudal epidurals.
1
Day 1: Catheter Placement
Steerable catheter advanced caudally under fluoroscopy to anterior epidural
space at target level. Confirm position with contrast. Mechanical lysis as
catheter passes through adhesions. Inject hypertonic saline 10% (5-10 mL),
local anesthetic, and steroid. Leave catheter in place.
2
Day 2: Repeat Injection
Confirm catheter position. Second dose of hypertonic saline, LA, and steroid
through indwelling catheter. The multi-day protocol enhances lysis.
3
Day 3: Final Treatment
Final medication administration and catheter removal. Total hypertonic saline
should not exceed 20 mL over the series to minimize neurotoxicity risk.
Expected relief duration is longer than volumetric adhesiolysis: approximately 6-24 months in responders. The procedure is more invasive, time-intensive, and costly
than caudal volumetric lysis, but provides superior targeted effect. Reserve for patients who have failed simpler approaches or require level-specific treatment.
Epiduroscopic Adhesiolysis
Epiduroscopy (spinal endoscopy) allows direct visualization of the epidural space with mechanical adhesiolysis
under visual guidance. This is the most invasive and expensive adhesiolysis option but provides the best results for
dense mature fibrosis.
Technical capabilities: The flexible epiduroscope provides video visualization of adhesions, nerve roots, and anatomy.
Instruments can be passed through working channels to mechanically separate dense scar. Laser or bipolar
coagulation controls bleeding and lyses tissue. Direct visualization reduces complication risk.
Optimal Candidates
Preferred for Grade 3-4 dense mature fibrosis or patients
who have failed catheter-based lysis. Allows treatment of
complex patterns including circumferential scarring and
multi-level disease in a single session.
Outcomes & Duration
Relief duration up to 3 years in best responders, though
highly variable. Recurrence of adhesions is common—scar
tissue tends to reform over time. Serial procedures may be
needed, but diminishing returns occur.
Cost-Benefit Considerations
Higher consumable costs (epiduroscope, instruments, OR
time) compared to fluoroscopy-guided procedures.
Improved outcomes in properly selected patients may justify
costs. Availability limited to specialized centers.
Epiduroscopy (spinal endoscopy) allows direct visualization of the epidural space with mechanical adhesiolysis
under visual guidance. This is the most invasive and expensive adhesiolysis option but provides the best results for
dense mature fibrosis.
Technical capabilities: The flexible epiduroscope provides video visualization of adhesions, nerve roots, and anatomy.
Instruments can be passed through working channels to mechanically separate dense scar. Laser or bipolar
coagulation controls bleeding and lyses tissue. Direct visualization reduces complication risk.
Optimal Candidates
Preferred for Grade 3-4 dense mature fibrosis or patients
who have failed catheter-based lysis. Allows treatment of
complex patterns including circumferential scarring and
multi-level disease in a single session.
Outcomes & Duration
Relief duration up to 3 years in best responders, though
highly variable. Recurrence of adhesions is common—scar
tissue tends to reform over time. Serial procedures may be
needed, but diminishing returns occur.
Cost-Benefit Considerations
Higher consumable costs (epiduroscope, instruments, OR
time) compared to fluoroscopy-guided procedures.
Improved outcomes in properly selected patients may justify
costs. Availability limited to specialized centers.
Adjacent Segment Facet Overload
Rigid spinal fusion transfers motion and load to adjacent unfused segments, accelerating degenerative changes at these levels. Adjacent segment facet arthropathy is
particularly common, occurring in approximately one-third of fusion patients.
Biomechanical Mechanism
When one or more segments are rigidly fixed, the
mobile segments immediately above and below
must compensate by increasing their range of
motion. This hypermobility increases facet loading,
accelerating cartilage wear and arthropathy
development.
Clinical Presentation
Patients develop new axial back pain months to
years after fusion, typically worse with extension
and rotation—classic facetogenic pattern. Pain is
often at the level immediately above or below the
fusion construct. Examination reveals paravertebral
tenderness at affected levels.
Diagnosis & Treatment
MRI may show facet arthropathy at adjacent levels,
but imaging findings don't predict pain. Confirm
with dual comparative medial branch blocks at
suspected adjacent levels using strict >80% relief
criteria. Treat confirmed cases with radiofrequency
ablation. Concurrent core rehabilitation essential to
reduce facet loading.
Rigid spinal fusion transfers motion and load to adjacent unfused segments, accelerating degenerative changes at these levels. Adjacent segment facet arthropathy is
particularly common, occurring in approximately one-third of fusion patients.
Biomechanical Mechanism
When one or more segments are rigidly fixed, the
mobile segments immediately above and below
must compensate by increasing their range of
motion. This hypermobility increases facet loading,
accelerating cartilage wear and arthropathy
development.
Clinical Presentation
Patients develop new axial back pain months to
years after fusion, typically worse with extension
and rotation—classic facetogenic pattern. Pain is
often at the level immediately above or below the
fusion construct. Examination reveals paravertebral
tenderness at affected levels.
Diagnosis & Treatment
MRI may show facet arthropathy at adjacent levels,
but imaging findings don't predict pain. Confirm
with dual comparative medial branch blocks at
suspected adjacent levels using strict >80% relief
criteria. Treat confirmed cases with radiofrequency
ablation. Concurrent core rehabilitation essential to
reduce facet loading.
Post-operative Myofascial Pain & CRPS
Myofascial Pain Syndromes
Surgical trauma and altered biomechanics frequently trigger myofascial pain in paraspinal, QL, and gluteal muscles. The surgical dissection itself,
positioning during surgery, and subsequent guarding all contribute. Fusion patients lose spinal mobility and overload muscular stabilizers.
Management: Identify trigger points through systematic examination. Treat with TPIs combining local anesthetic with or without corticosteroid. Address
concurrent biomechanical dysfunction—hip weakness, core instability, flexibility deficits. Manual therapy and dry needling are complementary
approaches.
Complex Regional Pain Syndrome
CRPS can develop after spine surgery in susceptible individuals, particularly those with pre-existing pain sensitization or psychological distress. Type 2
CRPS follows nerve injury during surgery.
Clinical features: Disproportionate pain, allodynia, temperature/color changes, edema, motor dysfunction, and trophic changes in a regional distribution.
Diagnosis remains clinical using Budapest criteria.
Treatment imperatives: Early aggressive treatment prevents progression. Initiate neuropathic pain medications (gabapentinoids, SNRIs, TCAs), physical
therapy with desensitization techniques, and consider sympathetic blocks (lumbar sympathetic for lower extremity). Spinal cord stimulation is highly
effective for refractory CRPS.
Myofascial Pain Syndromes
Surgical trauma and altered biomechanics frequently trigger myofascial pain in paraspinal, QL, and gluteal muscles. The surgical dissection itself,
positioning during surgery, and subsequent guarding all contribute. Fusion patients lose spinal mobility and overload muscular stabilizers.
Management: Identify trigger points through systematic examination. Treat with TPIs combining local anesthetic with or without corticosteroid. Address
concurrent biomechanical dysfunction—hip weakness, core instability, flexibility deficits. Manual therapy and dry needling are complementary
approaches.
Complex Regional Pain Syndrome
CRPS can develop after spine surgery in susceptible individuals, particularly those with pre-existing pain sensitization or psychological distress. Type 2
CRPS follows nerve injury during surgery.
Clinical features: Disproportionate pain, allodynia, temperature/color changes, edema, motor dysfunction, and trophic changes in a regional distribution.
Diagnosis remains clinical using Budapest criteria.
Treatment imperatives: Early aggressive treatment prevents progression. Initiate neuropathic pain medications (gabapentinoids, SNRIs, TCAs), physical
therapy with desensitization techniques, and consider sympathetic blocks (lumbar sympathetic for lower extremity). Spinal cord stimulation is highly
effective for refractory CRPS.
Epidural Fibrosis: Recurrence & Expectations
Manage expectations: Epidural adhesiolysis provides temporary to intermediate relief, not permanent cure. Adhesions have a strong tendency to reform over time.
3-12
Months Average Relief
Volumetric caudal adhesiolysis
6-24
Months Average Relief
Targeted catheter (Racz) adhesiolysis
12-36
Months Average Relief
Epiduroscopic adhesiolysis with mechanical lysis
These timeframes represent averages—individual responses vary widely based on fibrosis grade, age, activity level, and underlying pathology. Some patients experience
longer relief; others have minimal benefit.
Strategic principle: Avoid endless cycles of repeated adhesiolysis with diminishing returns. If a patient requires 3-4 lysis procedures within 12-18 months, consider
alternative treatments—particularly spinal cord stimulation—rather than continuing the same intervention.
Serial adhesiolysis may be appropriate for patients who achieve significant functional improvement lasting 6+ months between procedures. However, the goal is quality of life
enhancement, not just pain score reduction. Escalate care appropriately when adhesiolysis fails to provide durable benefit.
Manage expectations: Epidural adhesiolysis provides temporary to intermediate relief, not permanent cure. Adhesions have a strong tendency to reform over time.
3-12
Months Average Relief
Volumetric caudal adhesiolysis
6-24
Months Average Relief
Targeted catheter (Racz) adhesiolysis
12-36
Months Average Relief
Epiduroscopic adhesiolysis with mechanical lysis
These timeframes represent averages—individual responses vary widely based on fibrosis grade, age, activity level, and underlying pathology. Some patients experience
longer relief; others have minimal benefit.
Strategic principle: Avoid endless cycles of repeated adhesiolysis with diminishing returns. If a patient requires 3-4 lysis procedures within 12-18 months, consider
alternative treatments—particularly spinal cord stimulation—rather than continuing the same intervention.
Serial adhesiolysis may be appropriate for patients who achieve significant functional improvement lasting 6+ months between procedures. However, the goal is quality of life
enhancement, not just pain score reduction. Escalate care appropriately when adhesiolysis fails to provide durable benefit.
Spinal Cord Stimulation: Rationale in FBSS
Spinal cord stimulation (SCS) has the strongest evidence base of any intervention for FBSS, with multiple high-quality RCTs demonstrating superiority to conventional
medical management and repeat surgery. SCS offers a key advantage: it modulates pain without disturbing epidural scar tissue.
Evidence Base
Level 1 evidence from multiple RCTs (PROCESS trial, others) shows SCS
provides superior pain relief, functional improvement, and quality of life
compared to repeat surgery or conventional medical management in
FBSS. Long-term follow-up data support durability.
Mixed Pain Patterns
SCS effectively treats both axial back pain and radicular leg pain—the
typical FBSS presentation. Modern waveforms (burst, high-frequency)
improve axial pain coverage, historically the weaker indication. Particularly
effective for neuropathic pain components.
CRPS Management
SCS is considered gold-standard for medication-refractory CRPS after
limb trauma or surgery. When CRPS complicates spine surgery, SCS
addresses both conditions simultaneously. Earlier intervention in CRPS
improves outcomes.
Non-Destructive Approach
Unlike adhesiolysis or revision surgery, SCS doesn't disrupt tissue or create
new scarring. The leads are placed above the surgical field, avoiding
challenging anatomy. Reversible if ineffective. Preserves future treatment
options.
Consider SCS earlier in the treatment algorithm when epidural fibrosis recurs after 2-3 lysis procedures, or when pain is intractable despite comprehensive multimodal
management.
Spinal cord stimulation (SCS) has the strongest evidence base of any intervention for FBSS, with multiple high-quality RCTs demonstrating superiority to conventional
medical management and repeat surgery. SCS offers a key advantage: it modulates pain without disturbing epidural scar tissue.
Evidence Base
Level 1 evidence from multiple RCTs (PROCESS trial, others) shows SCS
provides superior pain relief, functional improvement, and quality of life
compared to repeat surgery or conventional medical management in
FBSS. Long-term follow-up data support durability.
Mixed Pain Patterns
SCS effectively treats both axial back pain and radicular leg pain—the
typical FBSS presentation. Modern waveforms (burst, high-frequency)
improve axial pain coverage, historically the weaker indication. Particularly
effective for neuropathic pain components.
CRPS Management
SCS is considered gold-standard for medication-refractory CRPS after
limb trauma or surgery. When CRPS complicates spine surgery, SCS
addresses both conditions simultaneously. Earlier intervention in CRPS
improves outcomes.
Non-Destructive Approach
Unlike adhesiolysis or revision surgery, SCS doesn't disrupt tissue or create
new scarring. The leads are placed above the surgical field, avoiding
challenging anatomy. Reversible if ineffective. Preserves future treatment
options.
Consider SCS earlier in the treatment algorithm when epidural fibrosis recurs after 2-3 lysis procedures, or when pain is intractable despite comprehensive multimodal
management.
SCS Lead Placement Principles in FBSS
Avoiding the Surgical Field
The primary technical consideration in FBSS is placing leads above the surgical field to avoid epidural scarring. Attempting to pass leads through
dense posterior fibrosis is technically difficult, risks dural puncture, and often fails to achieve adequate coverage.
Standard approach: For L4-S1 radiculopathy and low back pain, place leads in the mid-thoracic spine, typically around T8-T10. This location is
cephalad to most lumbar fusion constructs and provides coverage of lumbosacral dermatomes. Adjust based on patient -specific pain distribution.
Use fluoroscopy or CT guidance for lead placement in the thoracic spine. Ensure midline or paramedian positioning for optimal coverage. Test
stimulation confirms appropriate paresthesia coverage or, with newer waveforms, appropriate non-paresthesia effects.
Technical note: T8 is a common target for L5-S1 coverage, but individual anatomy varies. Intraoperative testing
during trial ensures adequate coverage before permanent implantation. Modern SCS systems allow
programming flexibility to optimize coverage post-implant.
Paresthesia-Based Systems
Traditional tonic stimulation produces paresthesias that should overlap painful areas. Test during trial to confirm appropriate
dermatomal coverage. Patient feedback guides final lead positioning.
Paresthesia-Free Systems
High-frequency (10 kHz) and burst waveforms don't produce paresthesias. Positioning is less critical for subjective coverage but still
requires anatomically appropriate placement. These waveforms may provide superior axial pain relief.
Avoiding the Surgical Field
The primary technical consideration in FBSS is placing leads above the surgical field to avoid epidural scarring. Attempting to pass leads through
dense posterior fibrosis is technically difficult, risks dural puncture, and often fails to achieve adequate coverage.
Standard approach: For L4-S1 radiculopathy and low back pain, place leads in the mid-thoracic spine, typically around T8-T10. This location is
cephalad to most lumbar fusion constructs and provides coverage of lumbosacral dermatomes. Adjust based on patient -specific pain distribution.
Use fluoroscopy or CT guidance for lead placement in the thoracic spine. Ensure midline or paramedian positioning for optimal coverage. Test
stimulation confirms appropriate paresthesia coverage or, with newer waveforms, appropriate non-paresthesia effects.
Technical note: T8 is a common target for L5-S1 coverage, but individual anatomy varies. Intraoperative testing
during trial ensures adequate coverage before permanent implantation. Modern SCS systems allow
programming flexibility to optimize coverage post-implant.
Paresthesia-Based Systems
Traditional tonic stimulation produces paresthesias that should overlap painful areas. Test during trial to confirm appropriate
dermatomal coverage. Patient feedback guides final lead positioning.
Paresthesia-Free Systems
High-frequency (10 kHz) and burst waveforms don't produce paresthesias. Positioning is less critical for subjective coverage but still
requires anatomically appropriate placement. These waveforms may provide superior axial pain relief.
SCS Outcomes & Patient Counseling
Appropriate patient selection and expectation management are critical for SCS success. This is not a cure, but rather a tool to improve function and quality of life while
reducing pain and medication requirements.
Realistic Treatment Goals
Set specific, measurable goals: 50-70% pain reduction (not 100% elimination), improved sleep quality, increased activity tolerance, reduced opioid use. Functional
goals matter more than pain scores—return to work, social engagement, hobbies. Quality of life improvement is the ultimate metric.
Activity Precautions
Discuss activity restrictions after implantation: avoid extreme spinal flexion/extension/rotation for 6-8 weeks during lead stabilization. No heavy lifting initially.
Permanent restrictions depend on device type—some systems more robust than others. MRI compatibility varies by device.
Device Specifics
Explain rechargeable vs non-rechargeable battery options (longevity, patient compliance factors). Programming adjustments expect ed—not "set and forget."
Discuss revision/replacement timelines. Address costs and insurance coverage upfront.
Multidisciplinary Follow-up
SCS works best within comprehensive pain management: concurrent physical therapy, psychological support, medication optimizat ion, sleep hygiene. Regular
follow-up for programming adjustments and troubleshooting improves long -term outcomes. Patient engagement correlates with success.
Appropriate patient selection and expectation management are critical for SCS success. This is not a cure, but rather a tool to improve function and quality of life while
reducing pain and medication requirements.
Realistic Treatment Goals
Set specific, measurable goals: 50-70% pain reduction (not 100% elimination), improved sleep quality, increased activity tolerance, reduced opioid use. Functional
goals matter more than pain scores—return to work, social engagement, hobbies. Quality of life improvement is the ultimate metric.
Activity Precautions
Discuss activity restrictions after implantation: avoid extreme spinal flexion/extension/rotation for 6-8 weeks during lead stabilization. No heavy lifting initially.
Permanent restrictions depend on device type—some systems more robust than others. MRI compatibility varies by device.
Device Specifics
Explain rechargeable vs non-rechargeable battery options (longevity, patient compliance factors). Programming adjustments expect ed—not "set and forget."
Discuss revision/replacement timelines. Address costs and insurance coverage upfront.
Multidisciplinary Follow-up
SCS works best within comprehensive pain management: concurrent physical therapy, psychological support, medication optimizat ion, sleep hygiene. Regular
follow-up for programming adjustments and troubleshooting improves long -term outcomes. Patient engagement correlates with success.
Group 3
New Pain, New Pathology
New Pain, New Pathology
Group 3: De Novo Pathology
Group 3 represents patients with completely new pain phenotypes occurring after spine surgery—pain in different locations, with different character, unrelated to the
original surgical indication. This is de novo pathology, not a consequence of the surgery itself.
New SIJ
Dysfunction
Altered biomechanics
after fusion can
precipitate sacroiliac
joint pain. The rigid
lumbar spine transfers
increased load to SI
joints. Diagnose with
intra-articular blocks;
treat accordingly.
Hip
Osteoarthritis
Hip OA can develop or
progress
independently,
causing groin/anterior
thigh pain mimicking
L2-3 radiculopathy.
Distinguish with hip
exam maneuvers
(FABER, FADIR) and
diagnostic hip
injection.
Osteoporotic
Fractures
Vertebral compression
fractures from
osteoporosis present
as acute-onset severe
back pain. Plain films
or MRI with STIR
sequences identify
acute fractures. Treat
with bracing,
analgesia, ± vertebral
augmentation.
Peripheral
Neuropathy
Diabetic or other
metabolic/toxic
neuropathies produce
distal symmetric
burning pain. EMG/NCS
confirms. Manage
underlying condition;
symptomatic
treatment with
gabapentinoids,
duloxetine, topicals.
The key with Group 3 is starting from first principles: obtain a complete history and examination without anchoring on the previous surgery. Diagnose and treat the
actual pain generator.
Group 3 represents patients with completely new pain phenotypes occurring after spine surgery—pain in different locations, with different character, unrelated to the
original surgical indication. This is de novo pathology, not a consequence of the surgery itself.
New SIJ
Dysfunction
Altered biomechanics
after fusion can
precipitate sacroiliac
joint pain. The rigid
lumbar spine transfers
increased load to SI
joints. Diagnose with
intra-articular blocks;
treat accordingly.
Hip
Osteoarthritis
Hip OA can develop or
progress
independently,
causing groin/anterior
thigh pain mimicking
L2-3 radiculopathy.
Distinguish with hip
exam maneuvers
(FABER, FADIR) and
diagnostic hip
injection.
Osteoporotic
Fractures
Vertebral compression
fractures from
osteoporosis present
as acute-onset severe
back pain. Plain films
or MRI with STIR
sequences identify
acute fractures. Treat
with bracing,
analgesia, ± vertebral
augmentation.
Peripheral
Neuropathy
Diabetic or other
metabolic/toxic
neuropathies produce
distal symmetric
burning pain. EMG/NCS
confirms. Manage
underlying condition;
symptomatic
treatment with
gabapentinoids,
duloxetine, topicals.
The key with Group 3 is starting from first principles: obtain a complete history and examination without anchoring on the previous surgery. Diagnose and treat the
actual pain generator.
Diagnostic Algorithm: Step 1—Classify Pain Pattern
The single most important initial step in evaluating FBSS is classifying the pain pattern relative to pre-operative baseline. This classification immediately narrows your
differential diagnosis and guides testing.
Same Pain
Unchanged character & distribution → Target-
generator mismatch. Think facet, SIJ, myofascial,
fibromyalgia, wrong level.
Modified Pain
Changed pattern after surgery → Surgical
sequelae. Think epidural fibrosis, adjacent segment
disease, myofascial pain, CRPS.
New Pain
Different phenotype & territory → De novo
pathology. Think new SIJ, hip OA, fractures,
peripheral neuropathy. Start fresh.
Ask the patient directly: "How does your current pain compare to what you felt before surgery—same location and type, different but related, or completely new?" Their
answer guides everything that follows.
The single most important initial step in evaluating FBSS is classifying the pain pattern relative to pre-operative baseline. This classification immediately narrows your
differential diagnosis and guides testing.
Same Pain
Unchanged character & distribution → Target-
generator mismatch. Think facet, SIJ, myofascial,
fibromyalgia, wrong level.
Modified Pain
Changed pattern after surgery → Surgical
sequelae. Think epidural fibrosis, adjacent segment
disease, myofascial pain, CRPS.
New Pain
Different phenotype & territory → De novo
pathology. Think new SIJ, hip OA, fractures,
peripheral neuropathy. Start fresh.
Ask the patient directly: "How does your current pain compare to what you felt before surgery—same location and type, different but related, or completely new?" Their
answer guides everything that follows.
Algorithm: Step 2—Exclude Red Flags
Safety first: Before attributing pain to benign causes, systematically rule out emergent conditions requiring urgent surgical or medical intervention.
Infection
Fever, systemic symptoms, elevated inflammatory markers (ESR, CRP), wound
concerns. Obtain MRI with gadolinium if suspected. Urgent surgical
consultation for epidural abscess, discitis, or deep wound infection.
New Neurologic Deficits
Progressive weakness, bowel/bladder dysfunction, saddle anesthesia. Urgent
MRI to exclude hematoma, abscess, or neural compression from hardware
malposition. Emergent surgical evaluation required.
Red Flag Symptoms
Unexplained weight loss, night pain, history of malignancy (rule out metastatic
disease). Unexplained fever or rigors. Constitutional symptoms. Age >50 with
new severe pain (consider fracture, malignancy).
Urgent Imaging Indications
Obtain MRI or CT promptly when red flags present. Use gadolinium contrast for
suspected infection. Plain films for hardware integrity. Don't delay imaging
when clinical suspicion is high—err on the side of caution.
Once serious pathology is excluded, proceed with systematic evaluation based on pain classification. Missing a surgical emergency by prematurely attributing pain to
chronic causes is the most serious error in FBSS evaluation.
Safety first: Before attributing pain to benign causes, systematically rule out emergent conditions requiring urgent surgical or medical intervention.
Infection
Fever, systemic symptoms, elevated inflammatory markers (ESR, CRP), wound
concerns. Obtain MRI with gadolinium if suspected. Urgent surgical
consultation for epidural abscess, discitis, or deep wound infection.
New Neurologic Deficits
Progressive weakness, bowel/bladder dysfunction, saddle anesthesia. Urgent
MRI to exclude hematoma, abscess, or neural compression from hardware
malposition. Emergent surgical evaluation required.
Red Flag Symptoms
Unexplained weight loss, night pain, history of malignancy (rule out metastatic
disease). Unexplained fever or rigors. Constitutional symptoms. Age >50 with
new severe pain (consider fracture, malignancy).
Urgent Imaging Indications
Obtain MRI or CT promptly when red flags present. Use gadolinium contrast for
suspected infection. Plain films for hardware integrity. Don't delay imaging
when clinical suspicion is high—err on the side of caution.
Once serious pathology is excluded, proceed with systematic evaluation based on pain classification. Missing a surgical emergency by prematurely attributing pain to
chronic causes is the most serious error in FBSS evaluation.
Algorithm: Step 3—Map Pain Generators & Confirm
Confirm
After classifying pain pattern and excluding red flags, use pain character and distribution to generate anatomic hypotheses, then confirm with targeted diagnostic
blocks before definitive treatment.
01
Character Analysis
Neuropathic (burning, shooting, electric) suggests
nerve involvement—radiculopathy, peripheral
neuropathy, CRPS. Nociceptive (aching, throbbing,
sharp) suggests musculoskeletal—facet, SIJ,
myofascial, fracture. Mixed patterns common.
02
Distribution Mapping
Dermatomal = nerve root. Sclerotomal (deep, poorly
localized) = facet or disc. Regional (buttock, groin) =
SIJ or hip. Diffuse/multifocal = consider fibromyalgia,
central sensitization.
03
Generate Hypotheses
Based on character + distribution + exam findings, list
probable pain generators in order of likelihood.
Consider multiple contributors—pain is rarely from a
single source in FBSS.
04
Diagnostic Blocks
Test hypotheses with small-volume image-guided blocks: facet MBBs, SIJ intra-
articular, selective nerve root, trigger points. Use strict criteria: >80% relief ideal,
>50% minimum. Correlate relief with function.
05
Confirm Before Treatment
Only proceed to definitive therapy after reproducible diagnostic block
confirmation. This prevents unnecessary procedures and improves outcomes. If
blocks are negative, reconsider diagnosis—don't push forward anyway.
Confirm
After classifying pain pattern and excluding red flags, use pain character and distribution to generate anatomic hypotheses, then confirm with targeted diagnostic
blocks before definitive treatment.
01
Character Analysis
Neuropathic (burning, shooting, electric) suggests
nerve involvement—radiculopathy, peripheral
neuropathy, CRPS. Nociceptive (aching, throbbing,
sharp) suggests musculoskeletal—facet, SIJ,
myofascial, fracture. Mixed patterns common.
02
Distribution Mapping
Dermatomal = nerve root. Sclerotomal (deep, poorly
localized) = facet or disc. Regional (buttock, groin) =
SIJ or hip. Diffuse/multifocal = consider fibromyalgia,
central sensitization.
03
Generate Hypotheses
Based on character + distribution + exam findings, list
probable pain generators in order of likelihood.
Consider multiple contributors—pain is rarely from a
single source in FBSS.
04
Diagnostic Blocks
Test hypotheses with small-volume image-guided blocks: facet MBBs, SIJ intra-
articular, selective nerve root, trigger points. Use strict criteria: >80% relief ideal,
>50% minimum. Correlate relief with function.
05
Confirm Before Treatment
Only proceed to definitive therapy after reproducible diagnostic block
confirmation. This prevents unnecessary procedures and improves outcomes. If
blocks are negative, reconsider diagnosis—don't push forward anyway.
Procedural Pearls & Common Pitfalls
Treat the Patient, Not the MRI
Match symptoms to anatomy through blocks, not imaging. Many MRI
"abnormalities" are incidental. Conversely, some pain generators (facets, SIJ,
myofascial) look normal on MRI. Clinical correlation is everything.
Anterior vs Posterior Dura
Anterior dura is pain-sensitive; posterior is not. Epidural fibrosis matters only if
anterior/anterolateral. Target adhesiolysis to anterior epidural space.
Posterior fibrosis on MRI may be clinically irrelevant.
Epidural Volume & Pressure
Use incremental volumes during epidurography and adhesiolysis. Never force
injection against high resistance continuously—risk of intracranial pressure
spikes. Slow, gentle, watch for flow. Safety first.
Avoid Shotgun Procedures
Don't perform multilevel facet RFA, SIJ injection, and trigger points all at once
hoping something works. Test and prove each target individually. Sequential
approach with clear diagnostic endpoints improves outcomes and
understanding.
Treat the Patient, Not the MRI
Match symptoms to anatomy through blocks, not imaging. Many MRI
"abnormalities" are incidental. Conversely, some pain generators (facets, SIJ,
myofascial) look normal on MRI. Clinical correlation is everything.
Anterior vs Posterior Dura
Anterior dura is pain-sensitive; posterior is not. Epidural fibrosis matters only if
anterior/anterolateral. Target adhesiolysis to anterior epidural space.
Posterior fibrosis on MRI may be clinically irrelevant.
Epidural Volume & Pressure
Use incremental volumes during epidurography and adhesiolysis. Never force
injection against high resistance continuously—risk of intracranial pressure
spikes. Slow, gentle, watch for flow. Safety first.
Avoid Shotgun Procedures
Don't perform multilevel facet RFA, SIJ injection, and trigger points all at once
hoping something works. Test and prove each target individually. Sequential
approach with clear diagnostic endpoints improves outcomes and
understanding.
Prevention & Pre-operative Decision Quality
The best treatment for FBSS is preventing it through high-quality surgical decision-making. When clinical picture and imaging don't align, pause and investigate further before proceeding to surgery.
Pre-operative Diagnostic Blocks
When a patient's symptoms don't clearly match MRI findings, perform diagnostic blocks before surgery to clarify the pain generator. This is
particularly important in multilevel disease where surgery is contemplated.
Use staged blocks to prioritize the dominant symptomatic level or structure. If facet blocks provide >80% relief and epidural injection provides
minimal benefit, surgical decompression may not help.
Better to delay surgery and confirm the target than operate on the wrong level and create FBSS.
Patient Education
Set realistic expectations pre-operatively. Discuss the possibility that surgery may not fully resolve pain, especially in multilevel disease or
chronic pain patients. Address comorbidities like fibromyalgia before surgery.
Explain that epidural fibrosis occurs in all surgeries but is symptomatic in only some patients. Discuss recurrence risks and potential need for
additional interventions. Informed patients have better outcomes.
The best treatment for FBSS is preventing it through high-quality surgical decision-making. When clinical picture and imaging don't align, pause and investigate further before proceeding to surgery.
Pre-operative Diagnostic Blocks
When a patient's symptoms don't clearly match MRI findings, perform diagnostic blocks before surgery to clarify the pain generator. This is
particularly important in multilevel disease where surgery is contemplated.
Use staged blocks to prioritize the dominant symptomatic level or structure. If facet blocks provide >80% relief and epidural injection provides
minimal benefit, surgical decompression may not help.
Better to delay surgery and confirm the target than operate on the wrong level and create FBSS.
Patient Education
Set realistic expectations pre-operatively. Discuss the possibility that surgery may not fully resolve pain, especially in multilevel disease or
chronic pain patients. Address comorbidities like fibromyalgia before surgery.
Explain that epidural fibrosis occurs in all surgeries but is symptomatic in only some patients. Discuss recurrence risks and potential need for
additional interventions. Informed patients have better outcomes.
Case Vignette: Elite Footballer with Evolving FBSS
Presentation: Elite professional footballer underwent L5-S1 microdiscectomy for radiculopathy. Initial excellent relief, but pain gradually returned over 6 months with
modified pattern—less leg pain, more axial back pain with activity.
1
Initial Evaluation
MRI showed posterior epidural
fibrosis. Diagnostic blocks: facet
MBBs and SIJ blocks negative.
Epidurography demonstrated filling
defect at L5-S1 anterior epidural
space correlating with symptoms.
2
First Intervention
Epiduroscopy revealed Grade 3
dense white scar. Mechanical and
laser adhesiolysis performed.
Excellent initial relief—returned to
training and competition for 8
months.
3
Recurrence
Pain recurred with similar pattern.
Repeat epiduroscopy showed scar
reformation. Second lysis provided
only 4 months relief. Diminishing
returns evident—classic recurrent
fibrosis pattern.
4
Escalation
Given recurrence and shortened
relief duration, SCS trial performed
with T8 lead placement. Excellent
coverage and functional
improvement. Permanent implant
placed. Returned to professional
sport.
Lessons: This case illustrates typical epidural fibrosis recurrence despite high-quality adhesiolysis, the importance of recognizing diminishing returns, and the value of
timely escalation to spinal cord stimulation. SCS allowed a professional athlete to return to elite competition—functional outcome that wouldn't have been achieved
with repeated lysis attempts.
Presentation: Elite professional footballer underwent L5-S1 microdiscectomy for radiculopathy. Initial excellent relief, but pain gradually returned over 6 months with
modified pattern—less leg pain, more axial back pain with activity.
1
Initial Evaluation
MRI showed posterior epidural
fibrosis. Diagnostic blocks: facet
MBBs and SIJ blocks negative.
Epidurography demonstrated filling
defect at L5-S1 anterior epidural
space correlating with symptoms.
2
First Intervention
Epiduroscopy revealed Grade 3
dense white scar. Mechanical and
laser adhesiolysis performed.
Excellent initial relief—returned to
training and competition for 8
months.
3
Recurrence
Pain recurred with similar pattern.
Repeat epiduroscopy showed scar
reformation. Second lysis provided
only 4 months relief. Diminishing
returns evident—classic recurrent
fibrosis pattern.
4
Escalation
Given recurrence and shortened
relief duration, SCS trial performed
with T8 lead placement. Excellent
coverage and functional
improvement. Permanent implant
placed. Returned to professional
sport.
Lessons: This case illustrates typical epidural fibrosis recurrence despite high-quality adhesiolysis, the importance of recognizing diminishing returns, and the value of
timely escalation to spinal cord stimulation. SCS allowed a professional athlete to return to elite competition—functional outcome that wouldn't have been achieved
with repeated lysis attempts.
Rehabilitation & Secondary Prevention
Regardless of the specific intervention chosen, comprehensive rehabilitation is essential for optimal outcomes and prevention of recurrence. Physical therapy is not optional—
it's central to durable pain relief.
Core Stabilization
Multifidus atrophy occurs rapidly after spine surgery and persists without targeted
training. Core stabilization exercises (transversus abdominis activation, planks,
dead bugs) restore dynamic spinal stability and reduce load on pain-sensitive
structures.
Hip Girdle Strengthening
Hip abductor and extensor weakness contributes to aberrant movement patterns
that overload the spine. Strengthen gluteus medius, gluteus maximus, and hip
external rotators through targeted exercises—clamshells, bridges, squats, lateral
band walks.
Flexibility Training
Tight hamstrings increase lumbar flexion demands. Hip flexor contractures alter
pelvic tilt and increase lordosis. Address both through sustained stretching
protocols—hamstring stretches, Thomas stretch for hip flexors, piriformis figure-4
stretch.
Graded Activity Progression
Use quota-based rather than pain-contingent progression to restore activity
tolerance. Set time or distance goals that gradually increase regardless of pain
fluctuations. Prevents deconditioning and fear-avoidance. Aquatic therapy useful
for deconditioned patients.
For fibromyalgia patients, emphasize sleep restoration as the foundation. Non-restorative sleep perpetuates pain and prevents rehabilitation progress. Address sleep hygiene,
consider low-dose TCAs (amitriptyline), treat concurrent sleep apnea.
Regardless of the specific intervention chosen, comprehensive rehabilitation is essential for optimal outcomes and prevention of recurrence. Physical therapy is not optional—
it's central to durable pain relief.
Core Stabilization
Multifidus atrophy occurs rapidly after spine surgery and persists without targeted
training. Core stabilization exercises (transversus abdominis activation, planks,
dead bugs) restore dynamic spinal stability and reduce load on pain-sensitive
structures.
Hip Girdle Strengthening
Hip abductor and extensor weakness contributes to aberrant movement patterns
that overload the spine. Strengthen gluteus medius, gluteus maximus, and hip
external rotators through targeted exercises—clamshells, bridges, squats, lateral
band walks.
Flexibility Training
Tight hamstrings increase lumbar flexion demands. Hip flexor contractures alter
pelvic tilt and increase lordosis. Address both through sustained stretching
protocols—hamstring stretches, Thomas stretch for hip flexors, piriformis figure-4
stretch.
Graded Activity Progression
Use quota-based rather than pain-contingent progression to restore activity
tolerance. Set time or distance goals that gradually increase regardless of pain
fluctuations. Prevents deconditioning and fear-avoidance. Aquatic therapy useful
for deconditioned patients.
For fibromyalgia patients, emphasize sleep restoration as the foundation. Non-restorative sleep perpetuates pain and prevents rehabilitation progress. Address sleep hygiene,
consider low-dose TCAs (amitriptyline), treat concurrent sleep apnea.
Take-Home Messages
FBSS is a Syndrome
Failed Back Surgery Syndrome is not a single
disease—it's a heterogeneous cluster of pain
generators. Treat the specific generator you can prove
through diagnostic blocks, not the MRI abnormality.
Use Three-Group Classification
Classify pain as Same (Group 1: target-generator
mismatch), Modified (Group 2: surgical sequelae), or
New (Group 3: de novo pathology). This single step
guides your entire diagnostic workup and
dramatically narrows possibilities.
Blocks Before Big Moves
Always confirm pain generators with small-volume
diagnostic blocks before definitive procedures. Facet
blocks before RFA, SIJ blocks before fusion,
epidurography before adhesiolysis. Don't guess—
prove it.
Epidural Fibrosis Relief is Time-Limited
Adhesiolysis provides months, not years, of relief. Scar tissue tends to reform.
Recognize diminishing returns after 2-3 procedures within 12-18 months. Consider
spinal cord stimulation earlier rather than repeating failed interventions endlessly.
Screen for Common Comorbidities
Always evaluate for adjacent segment facet pain, myofascial contributors (psoas,
QL, piriformis, paraspinals), and fibromyalgia. These are frequently overlooked
generators that respond to targeted treatment. Don't anchor on imaging findings
alone.
FBSS is a Syndrome
Failed Back Surgery Syndrome is not a single
disease—it's a heterogeneous cluster of pain
generators. Treat the specific generator you can prove
through diagnostic blocks, not the MRI abnormality.
Use Three-Group Classification
Classify pain as Same (Group 1: target-generator
mismatch), Modified (Group 2: surgical sequelae), or
New (Group 3: de novo pathology). This single step
guides your entire diagnostic workup and
dramatically narrows possibilities.
Blocks Before Big Moves
Always confirm pain generators with small-volume
diagnostic blocks before definitive procedures. Facet
blocks before RFA, SIJ blocks before fusion,
epidurography before adhesiolysis. Don't guess—
prove it.
Epidural Fibrosis Relief is Time-Limited
Adhesiolysis provides months, not years, of relief. Scar tissue tends to reform.
Recognize diminishing returns after 2-3 procedures within 12-18 months. Consider
spinal cord stimulation earlier rather than repeating failed interventions endlessly.
Screen for Common Comorbidities
Always evaluate for adjacent segment facet pain, myofascial contributors (psoas,
QL, piriformis, paraspinals), and fibromyalgia. These are frequently overlooked
generators that respond to targeted treatment. Don't anchor on imaging findings
alone.
Supplemental Resources & Local Protocols
This final slide serves as a placeholder for institution-specific protocols, referral pathways, and additional educational resources. Customize this content based on your
local practice environment and available resources.
Suggested Additions:
•Local contact information for multidisciplinary spine conference
•Institution-specific protocols for diagnostic blocks
•Referral pathways for interventional pain, neurosurgery, physiatry
•Formulary information for neuropathic pain medications
•Physical therapy protocols and preferred providers
•Psychological support resources (CBT, pain psychology)
Recommended Resources:
•North American Spine Society clinical guidelines
•ASIPP guidelines for interventional procedures
•International Neuromodulation Society SCS guidelines
•Fibromyalgia diagnostic criteria (2016 revision)
•Budapest criteria for CRPS diagnosis
•Institution's electronic medical record documentation templates
Consider adding flowcharts, decision trees, or quick-reference cards summarizing the diagnostic algorithm for convenient clinical use at the point of care.
This final slide serves as a placeholder for institution-specific protocols, referral pathways, and additional educational resources. Customize this content based on your
local practice environment and available resources.
Suggested Additions:
•Local contact information for multidisciplinary spine conference
•Institution-specific protocols for diagnostic blocks
•Referral pathways for interventional pain, neurosurgery, physiatry
•Formulary information for neuropathic pain medications
•Physical therapy protocols and preferred providers
•Psychological support resources (CBT, pain psychology)
Recommended Resources:
•North American Spine Society clinical guidelines
•ASIPP guidelines for interventional procedures
•International Neuromodulation Society SCS guidelines
•Fibromyalgia diagnostic criteria (2016 revision)
•Budapest criteria for CRPS diagnosis
•Institution's electronic medical record documentation templates
Consider adding flowcharts, decision trees, or quick-reference cards summarizing the diagnostic algorithm for convenient clinical use at the point of care.
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