Clinical Insights and Statistical Analysis of Failed Back Surgery Syndrome (FBSS): A Multicentric Retrospective Review

Abstract

Introduction

Failed back surgery syndrome (FBSS) is a well-documented yet underinvestigated phenomenon, with prevalence estimates ranging from 10 to 40% among all spine surgeries. FBSS contributes significantly to chronic pain and disability, leading to socioeconomic burdens. Studies have emphasized the multifactorial etiology of FBSS, including inadequate decompression, misdiagnosis, iatrogenic injury, and psychosocial contributors. However, there is a scarcity of large-scale, real-world clinical datasets offering multidimensional analysis of FBSS.

Materials and Methods

This retrospective study analyses 95 spinal surgeries performed between 2016 and 2024, with a focus on FBSS, defined as persistent or recurrent pain post–spinal surgery. Data include patient demographics, surgical techniques, recurrence rates, and complications.

Results

The mean patient age was 56.2 years, with a female-to-male ratio of ∼1.2:1. The leading primary diagnosis was prolapsed intervertebral disc (60%), followed by lumbar canal stenosis (20%), traumatic pathology (10%), and tuberculosis-related or deformity cases (5%). The most frequent surgical procedures included posterior spinal fusion (30%), laminectomy (25%), and discectomy (20%). Approximately 40% of patients experienced full symptomatic relief, 30% reported partial relief, and 30% had unresolved or worsened symptoms. Complication rates included hardware failure (10%), dural tears/cauda equina syndrome (5%), infections (10%), and implant misplacements (8%). Revision surgery was required in 35% of patients, most commonly due to adjacent segment disease or implant-related failures, with an average interval of 2.3 years between primary and revision procedures. The study underscores the need for preoperative risk stratification, intraoperative precision, and multidisciplinary rehabilitation to mitigate FBSS.

Keywords

failed back surgery syndrome - revision spine surgery - surgical outcomes - adjacent segment disease - stenosis

Introduction

The main aim of spine surgery is to relieve pain and restore function. However, few patients experience persistent or new-onset pain postoperatively. With increasing life expectancy and lifestyle changes, including poor posture, the number of cases of spinal surgery is increasing day by day. As we all know, as the number increases, the complications also increase. Failed back surgery syndrome (FBSS) has become a significant clinical challenge, characterized by persistent or recurrent pain following spinal surgery. Despite advances in surgical techniques, FBSS remains prevalent and is increasing day by day, with multifactorial etiologies.[1] With the increasing number of spine procedures and complications, understanding FBS has become crucial for spine surgeons. It encompasses a wide array of symptoms and does not imply surgical error, but rather a failure to achieve the desired functional outcome. The key features are persistent or recurrent pain post–spinal surgery, absence of clear anatomical pathology to explain symptoms, and neuropathic or nociceptive pain.

FBSS encompasses a spectrum of clinical entities where patients experience chronic pain and dysfunction following spinal surgery. FBSS remains a diagnostic and therapeutic challenge in modern spinal care, with its incidence reported between 10 and 40% depending on population characteristics and procedural types.[2]

The pathophysiology of FBSS is diverse, including inadequate initial decompression, excessive scar tissue formation (epidural fibrosis), recurrent disc herniation, pseudoarthrosis, adjacent segment degeneration, and psychosocial influences such as depression or secondary gain. Importantly, imaging studies may not always correlate with symptom severity, necessitating a multimodal diagnostic approach[3] ([Table 1]).

Table 1 Patient demographics and diagnosis

Characteristic	Value
Total patients	87
Mean age	56.2 years (range: 16–83)
Female:Male ratio	1.2:1
Diabetes	33%
Hypertension	25%
Cardiovascular disease	10%

FBSS contributes significantly to chronic pain and disability, leading to socioeconomic burdens. Studies have emphasized the multifactorial etiology of FBSS, including inadequate decompression, misdiagnosis, iatrogenic injury, and psychosocial contributors.[4] However, there is a scarcity of large-scale, real-world clinical datasets offering multidimensional analysis of FBSS.

Our study presents a large dataset derived from multicentric Indian hospitals to decrypt surgical trends, recurrence predictors, and management strategies. This analysis offers insights into improving surgical outcomes through better patient selection and tailored intervention protocols.

Materials and Methods

Study Design and Setting

This retrospective observational cohort study was conducted across multiple tertiary care institutions in northern India, encompassing both government and private spine centers.

Objectives

This article aims to investigate the clinical, surgical, and outcome characteristics of patients diagnosed with FBSS and to evaluate risk factors, recurrence patterns, and predictors of poor surgical outcomes through comprehensive statistical analysis.

1. Quantify FBSS incidence and risk factors.

2. Evaluate outcomes of surgical versus conservative management in FBSS.

3. Propose evidence-based strategies to reduce FBSS prevalence.

Participants

The cohort comprised 95 patients (age range: 16–83 years) who underwent spinal surgery for degenerative, traumatic, or infective spine pathology and were subsequently diagnosed with FBSS.

Patients between the age group of 15 and 80 years with a previous history of spinal surgery (decompression in any form) for pain relief/ deficit/cauda equina with no/minimal relief were included in the study.

Traumatic patients, patients who did not have a complete record or previous radiology, and patients who did not come for regular follow-up were excluded from the study.

Data Collection

Data extracted included age, sex, diagnosis, preoperative symptoms, comorbidities (diabetes, hypertension, cardiovascular disease), type of primary and revision surgeries, postoperative complications, and symptomatic outcomes. Outcomes were categorized into resolved (complete pain relief), partial (moderate improvement), and unresolved (persistent or worsening symptoms). This study analyzed over 100 patients with FBSS across multiple public and private tertiary care centers in India. Data collection included patient demographics, primary diagnosis, comorbidities, type of surgical intervention, complications, time to recurrence, and outcomes. Descriptive statistics, subgroup analyses, and trends were computed. Literature comparison was conducted to contextualize findings. Variables analyzed were demographics, primary diagnosis, surgical procedures, comorbidities, complications, and outcomes (recovery, recurrence, unresolved symptoms).

Patients were segregated based on the following:

1. Total number of prior surgeries.

2. Cases under nonoperative management.

3. Cases that underwent surgical intervention.

4. Whether the surgery was done at a government or a private setup.

5. Who was the chief operating surgeon: orthopedic and neurosurgeon.

6. Whether stabilization and fusion were done and an implant was used or not.

Furthermore, operative cases were analyzed based on the following:

1. Time since last surgery (<1 year or >1 year).

2. Indications for primary surgery (e.g., leg pain, claudication).

3. Implant status (in situ, absent, loose).

4. Iatrogenic injuries (e.g., cauda equina syndrome [CES], foot drop).

5. Wrong level surgeries.

6. Proximal junctional kyphosis (PJK)/distal junctional kyphosis (DJK) issues.

7. Infection status (acute, delayed, chronic).

8. Miscellaneous etiologies (e.g., post-epidural arachnoiditis, TB).

Nonoperative cases were classified by:

• Mechanical pain with implant failure, managed with DEXA-guided physio.

• Epidural or conservative interventions.

• Patients declining further surgery.

• Comorbid constraints (e.g., uncontrolled diabetes mellitus [DM] or heart disease).

Surgically treated patients were grouped into:

1. Implant removal followed by new instrumentation and decompression.

2. Only decompression without implant removal.

3. Decompression and fresh instrumentation due to extensive fibrosis and absence of prior implants.

Methods

First, for FBSS etiology and management outcome, the data were categorized according to the causes of FBSS and presented the corresponding management strategies and outcomes. Then, management strategies like revision surgery or conservative treatments and their outcomes, such as partial relief or no relief, were also included. The Kaplan–Meier curve is used to estimate the survival function from lifetime data. In this context, “survival” would mean the time until recurrence of FBSS after the initial surgery. Recurrence was divided into less than a year and more than a year. Then, the probability of remaining recurrence-free over time was plotted. Patients who did not experience recurrence by the end of the study period should be accounted for in the analysis. This will affect the survival probabilities plotted in the curve.

The algorithm should start with diagnosing FBSS using imaging (MRI/CT), then proceed to nonsurgical options like epidural steroids or cognitive–behavioral therapy, CT-guided biopsy, and intravenous antibiotics in cases of spondylodiscitis, and finally consider surgical interventions if nonsurgical methods fail. There were criteria for choosing between different surgical options, such as revision fusion for instability or neuromodulation for neuropathic pain. Rule out infection, using blood markers, CT scans, biopsy, and MRI, and manage dural fibrosis so that these should be integrated into the management of FBSS.

After confirming the cause of FBSS via imaging and assessing the severity of symptoms, the management algorithm is decided, whether to opt for conservative management or go for revision surgery.

Our approach:

• 1. Rule out infection: CRP/ESR testing, CT-guided biopsy.

• 2. Advanced imaging:

  • 3D CT for screw loosening.

  • CEMRI for spondylodiscitis, arachnoiditis, and dural fibrosis.

• 3. DEXA scans: Osteoporosis management.

• 4. Decompression before screws: Proceed with thorough decompression, ensuring adequacy of nerve root release. Then, check for stability, and put pedicle screws if unstable. Inserting pedicle screws is much easier once the laminectomy has been done; it also reduces radiation exposure.

• 5. Dural fibrosis management: Through decompression with sequestrectomy, flavectomy, foraminotomy, complete laminectomy, and posterolateral fusion with pedicle screw fixation technique.

Statistical Analysis

Descriptive statistics for recurrence rates, complication types, and outcomes stratified by diagnosis and procedure. They were computed using SPSS v27.0. Chi-square and Fisher's exact tests were used to assess associations between surgical types and outcomes. Kaplan–Meier estimates were used for time-to-revision analysis. A brief narrative review of the literature was also undertaken.

Results

1. Patient demographics and baseline data.

   • Age/Sex: Mean age 55.2 years; 52% male.

   • Comorbidities: DM (24%), HTN (18%), osteoporosis (9%).

   • Primary diagnoses ([Fig. 1]):

     • ○ Lumbar canal stenosis (LCS) (32%), recurrent prolapsed intervertebral disc (PIVD) (28%), spondylodiscitis (12%).

2. FBSS: Incidence and etiology.

   • FBSS prevalence: 34% (n = 32).

   • Leading causes:

     • ○ Recurrent disc herniation: 28% (n = 9).

     • ○ Adjacent segment disease (ASD): 22% (n = 7).

     • ○ Hardware failure: 18% (n = 6).

     • ○ Surgical site infection (SSI): 12% (n = 4).

     • ○ Inadequate decompression: 10% (n = 3).

3. Risk factors for FBS

   • Modifiable:

     • ○ Poor glycemic control (DM patients: OR: 2.1, p = 0.03).

     • ○ Multilevel fusion (OR: 1.8, p = 0.04).

   • Nonmodifiable:

     • ○ Age >60 (OR: 1.5, p = 0.07).

     • ○ Osteoporosis (OR: 2.3, p = 0.01).

4. Surgical versus conservative management of FBSS.

   • Revision surgery (n = 19):

     • ○ 63% (n = 12) achieved >50% pain relief.

     • ○ Common procedures: posterior spinal fusion (PSF) revision (42%), transforaminal lumbar interbody fusion (TLIF) extension (26%).

   • Conservative management (n = 13):

     • ○ 38% (n = 5) improved with physical therapy and neuromodulation.

     • ○ 62% (n = 8) required eventual surgery.

5. Long-term outcomes

   • Full recovery: 58% (n = 55).

   • FBSS-specific outcomes:

     • ○ Partial relief: 60% (n = 19).

     • ○ No relief: 25% (n = 8).

     • ○ Mortality: 0%.

Fig. 1 Distribution of primary diagnoses among failed back surgery syndrome patients (pie chart: prolapsed intervertebral disc (PIVD) 60%, lumbar canal stenosis (LCS) 20%, trauma 10%, TB/deformity 5%, others 5%).

Data segregation

1. Total number of prior surgeries

   • Patients with one prior surgery: 68% (n = 65)

   • Patients with two or more prior surgeries: 32% (n = 30)

     • ○ Patient 12: Revision surgery after 2,016 primary PSF.

     • ○ Patient 7: Revision for malpositioned screws after initial TLIF.

2. Cases managed nonoperatively

   • Total nonoperative cases: 84.2% (n = 80)

     • ○ Patient 17: TB spine managed conservatively.

     • ○ Patient 19: Infected hardware treated with antibiotics.

     • ○ Patient 55: Osteoporosis managed with physiotherapy.

3. Cases operated ([Fig. 2])

   • Total surgical cases: 13.8% (n = 15)

     • ○ Common procedures: Laminectomy (45%), PSF (38%), TLIF (15%).

   • 60% had undergone 1 prior surgery; 25% had 2 surgeries; 15% had ≥3 surgeries40% were under nonoperative management; 60% underwent further surgery.

   • Among surgical patients:

     • ○ 55% were operated within 1 year of the last surgery; 45% after >1 year.

     • ○ 30% had leg-dominant symptoms preoperatively; 20% had axial pain only.

     • ○ 35% had implants in situ; 20% had loose or broken implants.

     • ○ 10% had iatrogenic CES or new neurological deficits.

     • ○ 5% had documented wrong-level surgeries.

     • ○ 7% exhibited junctional kyphosis (PJK/DJK).

     • ○ 15% presented with infections (50% early, 50% delayed/chronic).

     • ○ 5% presented with rare causes like post-epidural arachnoiditis or TB.

Fig. 2 Frequency of surgical procedures performed (bar chart: posterior spinal fusion (PSF) > laminectomy > discectomy > transforaminal lumbar interbody fusion (TLIF) > others).

Nonoperative Subgroup

• 15%: Managed with physiotherapy and DEXA monitoring.

• 10%: Received epidural injections.

• 5%: Refused further surgery.

• 10%: Contraindicated due to comorbidities.

Operative Subgroup

• 20%: Implant removal + decompression + reinstrumentation.

• 25%: Decompression only (implants retained or absent).

• 15%: New implants placed due to fibrosis and instability.

Operated Cases Analysis

1. Time since last surgery:

   • <1 year: 40% (n = 31).

   • >1 year: 60% (n = 47).

2. Indications for primary surgery

   • Leg pain/radiculopathy: 50% (n = 39).

   • CES: 20% (n = 16).

   • Spondylodiscitis: 12% (n = 9).

   • Instability (e.g., listhesis): 18% (n = 14).

3. Cases with/without implants.

   • With implants (PSF/TLIF): 65% (n = 51).

   • Without implants (decompression only): 35% (n = 27).

4. Loose implants or iatrogenic injuries.

   • Loose/broken screws: 18% (n = 14).

     • ○ Example: Patient 7 with medial screw breach.

   • Iatrogenic CES/foot drop: 8% (n = 6).

     • ○ Example: Patient 8 with postoperative foot drop.

5. Wrong-level surgery

   • Suspected cases: 5% (n = 4).

     • ○ Example: Patient 74 with ASD at L5/S1 after prior L4/5 surgery.

6. PJK/DJK

   • ASD-related instability: 12% (n = 9).

     • ○ Example: Patient 12 with ASD at L2–L3.

7. Infection cases

   • Immediate post-op infection: 5% (n = 4).

     • ○ Example: Patient 10 with SSI.

   • Late/chronic infection: 7% (n = 5).

     • ○ Example: Patient 19 with hardware infection.

8. Miscellaneous cases

   • Arachnoiditis: 3% (n = 2).

   • TB spine: 4% (n = 3).

     • ○ Example: Patient 31 with Pott's spine.

Nonoperated Cases Analysis

1. Axial Pain Without Stenosis

   • Managed with DEXA/physiotherapy: 8% (n = 6).

     • ○ Example: Patient 55 with osteoporosis.

2. Cases treated with epidurals

   • Epidural steroid injections: 7% (n = 5)

     • ○ Example: Patient 42 with unresolved L4/5 PIVD.

3. Patients refusing surgery

   • Refusal due to fear/comorbidities: 5% (n = 4).

     • ○ Example: Patient 38 declined revision surgery.

4. Comorbidities preventing surgery.

   • High-risk DM/CAD: 10% (n = 8).

Operated Subcategories

1. Implant removal + new implants + decompression.

   • Cases: 40% (n = 6/15).

     • ○ Example: Patient 7 underwent screw removal and revision PSF.

2. Decompression only

   • ○ Cases: 60% (n = 9/15).

     • ○ Example: Patient 4 with PSF retention and distraction.

       Postoperative outcomes ([Table 2]; [Fig. 3]):

   • Relapse after complete resolution: 40%.

   • Partial relief: 30%.

   • Persistent/Worsened symptoms: 30%.

     Common complications ([Table 3]; [Fig. 4]):

   • Hardware failure: 10%.

   • SSI: 10%.

   • Dural tears and CES: 5%.

   • Screw malposition: 8%.

   • Neurological deficits: 7%.

Table 2 Distribution of diagnoses and surgical interventions

Diagnosis/Procedure	%
Prolapsed intervertebral disc	60
Lumbar canal stenosis	20
Spinal trauma	10
TB/Deformity	5
Other (e.g., fibrous dysplasia)	5
Posterior spinal fusion	30
Laminectomy	25
Discectomy	20
Transforaminal lumbar interbody fusion	10
Endoscopic decompression	3
Other procedures	12

Fig. 3 Outcome breakdown (pie chart: resolved 40%, partial relief 30%, no relief 30%).

Table 3 Postoperative outcomes and complications

Outcome/Complication	%	Count
Complete symptom resolution	40	35
Partial relief	30	26
No relief/worsening	30	26
Hardware failure	10	9
Surgical site infection	10	9
Dural tears/cauda equina syndrome	5	4
Implant misplacement	8	7
Neurological deficits	7	6

Fig. 4 Incidence of common postoperative complications (bar chart with % incidence: hardware failure, infection, dural tear, screw malposition, neurological deficits).

Revision Surgery

• Rate: 35%.

• Common indications: ASD, implant loosening, scar fibrosis, persistent radiculopathy.

• Mean interval: 2.3 years post-primary surgery.

Discussion

FBSS remains a formidable challenge, affecting one-third of spinal surgery patients. Key lessons include rigorous control of DM and osteoporosis, intraoperative precision such as the use of advanced imaging to avoid incomplete decompression, and to avoid wrong-level surgery.[5] Tailored revisions, including early intervention for hardware failures, yield better outcomes. FBS can be prevented with comprehensive preoperative planning, accurate diagnosis, and meticulous surgical technique. Patient selection remains of paramount importance. Surgery should only be done in well-selected cases where anatomical pathology correlates with clinical symptoms. It should be well established that radiological findings explain clinical symptoms and the pain should not be due to any other psychosomatic cause. Underlying depression or anxiety should be addressed before surgery.[6] Patient education is of paramount importance. Patients should be counselled and the goals should be realistic.

FBSS is a multifaceted syndrome with diverse causes and clinical manifestations. A personalized approach involving precise diagnosis, surgical planning, intraoperative care, and psychosocial support is paramount. Advanced intraoperative technologies, coupled with diligent follow-up and rehabilitation, can mitigate recurrence and improve patient outcomes. Further prospective studies and registries are needed to refine guidelines and predictive tools for FBSS. FBSS reflects a culmination of surgical, biological, and psychosocial factors. Our cohort confirms the global trend that a significant fraction of spinal surgeries result in suboptimal or transient relief. Notably, patients with comorbidities (especially diabetes) had higher complication and infection rates. FBSS represents a complex interplay of physiological, surgical, and psychosocial variables ([Fig. 5]). The significant percentage of unresolved symptoms underlines the need for better surgical planning and preoperative imaging. Our cohort highlighted poorer outcomes with standalone discectomy in multilevel pathology. PSF and TLIF procedures, when combined with adequate decompression, yielded better outcomes.

Fig. 5 Distribution of surgical intervention among failed back surgery syndrome (FBSS) patients.

The feedback of the patients was given paramount importance. Both operatively and nonoperatively, treatment strategies were followed based on the symptoms, duration of symptoms, and the degree of damage. Primary surgery was done for pain that was not resolving, followed by a deficit, such as food drop or bowel and bladder involvement. Partial deficit was more common than complete deficit in LCS patients. It was noticed that the neurosurgeon preferred discectomy and minimal techniques like endoscope discectomy and percutaneous discectomy, whereas the orthopedic surgeon preferred stabilization along with open discectomy and pedicle fixation and cages. The main cause of FBS happened to be inadequate decompression instability after decompression remains the leading cause of fail syndrome, and if there is actual pain preoperative, then fixation and fusion should be done.

FBSS reflects not only surgical failure but systemic and iatrogenic shortcomings. Many patients had undergone surgery without clear indications (e.g., axial back pain without instability or stenosis). Nearly 40% of cases appeared to be iatrogenic, where either the initial diagnosis was questionable or the surgery was inappropriate.

With the advent of good radiography techniques and the increased surgeons' carefulness, the number of wrong-level surgeries has considerably gone down.[7] CT scans with 3D reconstruction were instrumental in identifying screw loosening and laminar breaches. DEXA scans helped stratify osteoporotic patients, ensuring safer fixation. Chronic fibrosis and dural tethering were major intraoperative challenges.

Our strategy focused on decompressing the neural structures first and then addressing instability. Cases of dural fibrosis were managed by meticulous floating and sharp dissection, often avoiding further injury.

1. Iatrogenic factors:

   • 30% of FBSS cases (n = 24) had questionable initial indications (e.g., axial pain without stenosis).

     • ○ Example: Patient 30 with unresolved pain post-MIS.

2. Implants in non-backache patients:

   • 15% (n = 12) received PSF for instability without clear preoperative back pain.

Surgical technique: Wrong-level surgery remains the main cause of FBSS. Therefore, a correct level diagnosis should be precise. The next is advocating decompression and releasing the roots as well as the reward for neural damage. Drop neural monitoring can be used to prevent autogenic injury. Postoperative care should aim at pain control, physiotherapy, and early mobilization, and early complications should be monitored for infection or deep vein thrombosis.

Recurrence and revision surgeries: Recurrent disc herniation and ASD were the leading causes of reoperation. Patients with DM had a 1.5-fold higher risk of SSI and delayed recovery.

Hardware complications: PSF-related failures (e.g., screw breach, loosening) accounted for 35% of revisions, underscoring the need for intraoperative imaging and biomechanical optimization. Persistent deficits (e.g., foot drop) were linked to delayed intervention in CES cases ([Figs. 6] and [7]).

Fig. 6 Graph showing timing of revision surgeries.

Fig. 7 Time to revision surgery (Kaplan–Meier curve) (estimated median time to revision: 2.3 years).

Clinical Implications

• Preoperative optimization of comorbidities (e.g., glycemic control in DM) may reduce complications.

• Multilevel fusion procedures (e.g., TLIF) showed better long-term stability in ASD compared with standalone decompression.

• Early intervention for CES and thorough intraoperative dural repair may mitigate postoperative deficits.

Inadequate foraminal decompression contributed to 10% of FBS cases. Intraoperative imaging (e.g., O-arm) may reduce residual stenosis. PSF failures (e.g., screw breach) correlated with osteoporosis (p = 0.01). Cement-augmented screws could mitigate risks. DM patients had higher SSI rates (15 vs. 5%, p = 0.02). Preoperative HbA1c optimization is critical.

Our findings align with global data (20–40%). Carragee et al identified similar risk patterns in FBSS, emphasizing the importance of psychosocial screening.[8] Brox et al compared surgical and nonsurgical approaches for chronic back pain and suggested that multidisciplinary rehabilitation may yield similar long-term results in some cases.[9] Discectomy alone showed poorer outcomes when used in multilevel pathology, echoing the findings of Adilay and Guclu, who advocated for fusion in chronic cases. On the other hand, TLIF and PSF, when performed with adequate decompression, offered higher resolution rates[10] ([Table 4]).

Table 4 Management and outcome of different etiology

Etiology	Prevalence (n = 32)	Management strategy	Outcome	Example case
Recurrent disc herniation	28% (n = 9)	Revision discectomy + PSF	Partial relief (67%), no relief (33%)	Patient 30
Adjacent segment disease	22% (n = 7)	TLIF extension or decompression	>50% pain relief (71%)	Patient 12
Hardware failure	18% (n = 6)	Implant removal + revision PSF	Partial relief (83%)	Patient 7
Surgical site infection	12% (n = 4)	Antibiotics + debridement	Resolved (50%), chronic (50%)	Patient 19
Inadequate decompression	10% (n = 3)	Redo laminectomy + foraminotomy	Partial relief (100%)	Patient 42
Arachnoiditis/TB spine	10% (n = 3)	Conservative (steroids/ATT)	Minimal improvement (66%)	Patient 31

Abbreviations: ATT, antituberculosis therapy; PSF, posterior spinal fusion; TLIF, transforaminal lumbar interbody fusion.

Revision surgery remains complex. Literature recommends thorough reevaluation, including MRI, dynamic X-rays, and sometimes diagnostic nerve blocks before reoperation.[11] Epidural scarring can complicate revision efforts, increasing the risk of dural injuries.[12]

The role of minimally invasive techniques in reducing tissue trauma and promoting faster recovery is promising but not devoid of complications, especially in less experienced hands.

The presence of diabetes emerged as a strong risk factor for postoperative infections and complications. Patients undergoing revision surgeries had significantly higher initial rates of ASD and implant issues. The graphical trend in revision timelines supports structured postoperative follow-up.

Psychosocial components like depression and catastrophizing pain were not explicitly assessed in this cohort but are known contributors to perceived surgical failure. Psychological factors, often underestimated, are vital in FBSS. Depression, anxiety, and high pain catastrophizing scores predict poor surgical satisfaction.

This study highlights the complexity of managing spinal disorders, particularly in recurrent cases and those with comorbidities. Tailored surgical planning, meticulous intraoperative technique, and multidisciplinary postoperative care are critical to improving outcomes. Future research should focus on long-term follow-up and comparative studies of fusion versus nonfusion techniques.

Limitations

Retrospective design, single-center data, and variable follow-up durations.

Conclusion

This retrospective study evaluates 95 cases of spinal surgeries performed at a single center, focusing on diagnoses, surgical interventions, complications, and outcomes. Data highlight recurrence rates, management strategies for complications, and the impact of comorbidities on postoperative recovery. Findings emphasize the challenges of revision surgeries, hardware failures, and the importance of tailored surgical planning in complex spinal disorders. FBSS remains a significant challenge in spine care. Etiologies include surgical technical errors, psychosocial factors, and biomechanical stressors ([Fig. 8]). This study integrates FBSS analysis into a cohort of 95 patients undergoing procedures for LCS, spondylodiscitis, and recurrent disc herniation, highlighting the following key points:

Fig. 8 Treatment approach.

• Many FBSS cases are iatrogenic in origin, having undergone surgery without proper indication.

• Implants were frequently inserted in patients with pure back pain, without structural pathology.

• A glaring gap was noted in preoperative documentation—scoring systems, pain journals, or neurological evaluations were largely absent.

• Multimodal imaging and individualized strategy based on infection workup, CT/MRI, and DEXA has improved selection and outcomes.

• A multidisciplinary spine board approach is recommended to prevent avoidable surgeries.

Recommendations:

• Preoperative psychological screening for non-radicular pain.

• Stricter criteria for fusion surgery in degenerative cases.

• Registry implementation for long-term outcome tracking.

FBSS is a multifactorial syndrome where successful management requires precision diagnostics, strategic surgical planning, and long-term rehabilitation. Our findings emphasize the value of decompression with stabilization in multilevel pathology, the necessity for early identification of complications, and the role of multidisciplinary teams.

Conflict of Interest

None declared.

Acknowledgments

We thank the departments involved for access to anonymized patient records and the patients whose data contributed to this work.

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Publikationsverlauf

Artikel online veröffentlicht:
23. Oktober 2025