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Etiologies of Failed Back Surgery Syndrome: A Commentary

Nikolai Bogduk MD
DOI: http://dx.doi.org/10.1046/j.1526-4637.2002.02037.x 215 First published online: 1 September 2002

The term, failed back surgery syndrome, implies that because the patient failed to respond to surgery, the prospects of further medical treatment being successful are poor. Accordingly, in some corners of pain medicine, this diagnostic label is used as a call to terminate conventional, biomedical intervention. Instead, patients are relegated to palliative measures, such as multidisciplinary therapy, that aim to improve function and how the patient might cope with their pain, but with no prospect of eliminating the pain.

This approach to failed back surgery syndrome is based on the inference that once a patient has had surgery, the cause of their back pain cannot be identified and rectified. For this reason, they should not be further investigated and treated. In effect, the diagnosis is nihilistic and defeatist.

There is some merit in using failed back surgery syndrome as a terminal diagnosis—to terminate futile medical investigations and to avoid further iatrogenic injury. However, this pragmatic objective is not a pretext for intellectual defeatism. Failed back surgery syndrome is not necessarily a terminal diagnosis in a biological sense.

The study by Slipman et al. [1] provides optimism in a field previously beset with despondency and despair. In principle, it shows that if sources and causes of pain are looked for in patients with failed back surgery syndrome, often they can be found. In effect, failed back surgery implies not that the patient failed to respond, but that their previous doctors failed to diagnose and treat the cause of their pain correctly. It is an indictment not of patients, but of the system that treats them. Many of the diagnoses established by Slipman et al. could have and should have been diagnosed before the patients were subjected to unnecessary surgery. Had the correct diagnosis been made, the patients could have been saved the indignity of inheriting a diagnosis that effectively denies them any future prospect of being rid of their pain.

However, whereas Slipman et al. provide grounds for optimism, their study falls short of being conclusive. It is perhaps best viewed as a first iteration toward resolving this problem and reducing the number of patients who need to be given a nihilistic and defeatist, diagnostic label.

In the first instance, several of the entities ostensibly diagnosed by Slipman et al. are questionable, taxonomically and clinically. For example, not all practitioners would accept deconditioning, myofascial pain, and degenerative disk disease as legitimate diagnoses. Few practitioners would agree that response to epidural steroids is an essential criterion for the diagnosis of mechanical low back pain.

Nor did Slipman et al. show that their treatment of the conditions they diagnosed resulted in sustained, favorable outcomes. Readers are left only to trust that the treatments provided for specific entities actually do help patients. However, if the treatments do not help, the virtue of making the diagnosis can be seriously questioned.

For these reasons, the results of Slipman et al. should be viewed only as encouraging. Ostensibly, medical diagnoses can be made in patients with failed back surgery syndrome. Conditions can be found that were missed previously and that might still respond to medical treatment. In this regard, failed back surgery syndrome is not necessarily a terminal diagnosis. However, to be convincing and to be truly revolutionary, studies of the sort provided by Slipman et al. need to be repeated more rigorously. They would be convincing if more widely accepted and more tightly defined diagnostic entities were used, and also, if evidence were brought to bear that making the diagnosis resulted in better outcomes than if the patients were treated symptomatically without the benefit of a specific diagnosis.

Such studies would provide the basis for a valid algorithm for the investigation and management of failed back surgery syndrome. Perhaps the same algorithm could be applied before surgery in order to avoid unnecessary or incorrect surgery. Either way, the prospect arises of reducing the number of patients that come to be relegated to a waste-basket diagnosis.


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