Dr. Hiro K

Video 05

Still in pain after back surgery? A spine surgeon on what comes next

About one in five people still have pain after lower back surgery. Why it happens, when a second operation makes sense, and the evidence for and against spinal cord stimulation, including the placebo trial.

In short

  • About 1 in 5 people still have pain after lower back surgery. You are not rare, and you are not imagining it.
  • A disc that comes back on a scan often causes no symptoms. What matters is whether the scan matches what you feel.
  • A second operation helps less often than the first, but it is not hopeless: in Norway about 46% still did well even after three or more operations.
  • In the US, about half of Medicare patients with musculoskeletal pain received opioids in a year; in Japan, strong opioids are rarely used for chronic back pain. In a year-long trial, opioids gave no better function than non-opioid medicines.
  • Stimulation has real evidence and real counter-evidence. In the placebo-controlled trial, disability improved by about 9 points even with the device off.
  • Whatever you are offered, ask: was it tested against a sham, how long did the benefit last, who paid for the study, and if it does not work, can it be undone?

Summary

Persistent pain after spine surgery is common: in a UK study of more than ten thousand people, about one in five still had pain afterwards. The newer name, persistent spinal pain syndrome, does not put the blame on you, or even necessarily on the surgery. The causes vary: a nerve pinched again, the level next to a fusion wearing out, a fusion that did not heal, scar around the nerve, a nerve that stays sensitized, or pain that was coming from somewhere else all along.

A scan alone should not send you back to the operating room. About one in four people had a disc come back on their scans within two years, but more than half of them had no symptoms. When a nerve is clearly pinched again and the symptoms match, I operate, often with another decompression rather than a fusion. But the odds change the second time: satisfaction and pain relief after a repeat operation are lower than after the first.

Spinal cord stimulation did better than a repeat operation and than medical care in two classic trials in this group. But in a Norwegian trial where the device was switched on and off without patients knowing, people improved almost as much with it off, and a Cochrane review concluded that stimulation probably does not beat placebo for back pain. That verdict rests on one six-month trial of one stimulation mode in fifty people, and the newer approaches have not been tested that way yet. My own patients do better than the review suggests, but my results have no placebo group. Try it first, aim for half the pain, and keep it only if it truly helps.

Sources

  1. In the UK, about one in five people who had lower back surgery still had persistent pain afterwards.

    10,216 people in UK primary care and hospital records. Persistent postoperative pain: 20.8%, based on records rather than questionnaires. Funded with links to Medtronic.

    Weir S, Samnaliev M, Kuo TC, et al. The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). BMJ Open. 2017;7(9):e017585. PubMed 28893756 · DOI

  2. "Persistent spinal pain syndrome" has been proposed to replace the older name "failed back surgery syndrome."

    An expert consensus proposal, linked to the international disease classification (ICD-11). Many of the authors work in neuromodulation.

    Christelis N, Simpson B, Russo M, et al. Persistent spinal pain syndrome: a proposal for failed back surgery syndrome and ICD-11. Pain Med. 2021;22(4):807-818. PubMed 33779730 · DOI

  3. People with a lot of scar around the nerve on MRI were about three times more likely to have their leg pain come back.

    197 patients after disc surgery, assessed with MRI. Extensive scar was linked to recurrent leg pain about 3.2 times as often. The patients came from a trial of an anti-scar gel.

    Ross JS, Robertson JT, Frederickson RC, et al. Association between peridural scar and recurrent radicular pain after lumbar discectomy: magnetic resonance evaluation. Neurosurgery. 1996;38(4):855-861. PubMed 8692415

  4. About one in four people had a disc come back on their scans within two years, but more than half of them had no symptoms.

    108 patients scanned repeatedly for 2 years after disc surgery. Recurrent disc on imaging: 23.1%. Without symptoms: 13%. With symptoms: 10.2%.

    Lebow RL, Adogwa O, Parker SL, et al. Asymptomatic same-site recurrent disc herniation after lumbar discectomy: results of a prospective longitudinal study with 2-year serial imaging. Spine (Phila Pa 1976). 2011;36(25):2147-2151. PubMed 21343849 · DOI

  5. In Sweden, people who had a second operation for a disc that came back were less often satisfied than after their first.

    Swedish spine register, 13,562 operations. Satisfied: 79% after a first disc operation vs 58% after an operation for a recurrent disc. Some differences may be smaller than patients would notice.

    Fritzell P, Knutsson B, Sanden B, et al. Recurrent versus primary lumbar disc herniation surgery: patient-reported outcomes in the Swedish Spine Register Swespine. Clin Orthop Relat Res. 2015;473(6):1978-1984. PubMed 24711131 · DOI

  6. In UK data, persistent pain after a repeat operation was about twice as common as after the first.

    Same UK records as above. Persistent pain: 39.5% after a reoperation vs 19.5% after the first operation.

    Weir S, Kuo TC, Samnaliev M, et al. Reoperation following lumbar spinal surgery: costs and outcomes in a UK population cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). Eur Spine J. 2019;28(4):863-871. PubMed 30701310 · DOI

  7. For spinal stenosis, a large Norwegian registry was less gloomy: many people did well even after several earlier operations.

    8,919 patients in the Norwegian spine register. Success: 57.1% with no prior surgery vs 46.3% after three or more prior operations.

    Alhaug OK, Dolatowski FC. Redefining Oswestry Disability Index success criteria to assess the effect of consecutive surgeries on lumbar spinal stenosis. Spine J. 2024;24(12):2305-2313. PubMed 39276870 · DOI

  8. For back pain after disc surgery, an exercise and coaching program did about as well as a fusion.

    60 patients randomized in Norway. Success: 50% after fusion vs 48% after exercise with coaching. A small trial.

    Brox JI, Reikerås O, Nygaard Ø, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006;122(1-2):145-155. PubMed 16545523 · DOI

  9. In the US, about half of Medicare patients with back, neck or joint pain received opioids in a single year.

    20% sample of Medicare. Opioid use: 56.7% in 2016, 46.5% in 2019. Includes joint pain, not only back pain.

    Moyo P, Vaillant J, Girard A, et al. Prevalence of opioid and nonopioid pain management therapies among Medicare beneficiaries with musculoskeletal pain conditions from 2016 to 2019. Drug Alcohol Depend. 2023;248:109930. PubMed 37269776 · DOI

  10. In Japan, strong opioids are rarely used for chronic back pain; when an opioid is used, it is usually a mild one.

    256,402 patients with chronic back pain in Japanese claims data. NSAIDs about 90%, pregabalin 39%, weak opioids 20.6%; opioid prescription was uncommon, and weak when prescribed.

    Akazawa M, Mimura W, Togo K, et al. Patterns of drug treatment in patients with osteoarthritis and chronic low back pain in Japan: a retrospective database study. J Pain Res. 2019;12:1631-1648. PubMed 31190973 · DOI

  11. After a year, people on opioids functioned no better than people on non-opioid medicines, and had more side effects.

    240 US veterans with chronic back pain or hip or knee arthritis, randomized for 12 months. Pain-related function did not differ; side effects were more common with opioids.

    Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872-882. PubMed 29509867 · DOI

  12. People on higher opioid doses before a stimulator were more likely to have it removed later.

    5,476 US insurance claims. A daily dose of 90 mg morphine-equivalent or more before the implant: odds of removal 1.57 times higher. An association, not proof of cause.

    Sharan AD, Riley J, Falowski S, et al. Association of opioid usage with spinal cord stimulation outcomes. Pain Med. 2018;19(4):699-707. PubMed 29244102 · DOI

  13. Against a repeat operation, more people did well with stimulation, and far more crossed over to stimulation than away from it.

    50 patients randomized. Success: 9 of 19 with stimulation vs 3 of 26 with reoperation. Crossed over: 14 of 26 from reoperation to stimulation, 5 of 24 the other way. Not blinded.

    North RB, Kidd DH, Farrokhi F, et al. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56(1):98-106. PubMed 15617591 · DOI

  14. About half of the stimulation group got at least half their leg pain relief at six months, against fewer than one in ten on medical care.

    100 patients with leg pain after back surgery, randomized. At least 50% leg pain relief at 6 months: 48% vs 9%. No sham control.

    Kumar K, Taylor RS, Jacques L, et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomised controlled trial in patients with failed back surgery syndrome. Pain. 2007;132(1-2):179-188. PubMed 17845835 · DOI

  15. At two years the difference held, but about three in ten needed another procedure on the device.

    Same trial at 24 months. At least 50% leg pain relief: 37% vs 2%. Device-related procedures: 31%. Many patients crossed over between groups.

    Kumar K, Taylor RS, Jacques L, et al. The effects of spinal cord stimulation in neuropathic pain are sustained: a 24-month follow-up of the prospective randomized controlled multicenter trial of the effectiveness of spinal cord stimulation. Neurosurgery. 2008;63(4):762-770. PubMed 18981888 · DOI

  16. When the device was switched between real and placebo stimulation without patients knowing, people improved almost as much with it off.

    50 patients with leg pain after back surgery, each given 3 months of burst stimulation and 3 months of placebo in random order. Disability: -10.6 with stimulation vs -9.3 with placebo, no significant difference; no secondary outcome differed either. Public funding, no conflicts reported.

    Hara S, Andresen H, Solheim O, et al. Effect of spinal cord burst stimulation vs placebo stimulation on disability in patients with chronic radicular pain after lumbar spine surgery: a randomized clinical trial. JAMA. 2022;328(15):1506-1514. PubMed 36255427 · DOI

  17. An independent Cochrane review concluded that stimulation probably does not beat placebo for back pain and should not be used outside research trials.

    13 studies. Probably no better than placebo (moderate certainty). The six-month placebo comparison rests on the one trial above, and no trial measured long-term back pain against placebo.

    Traeger AC, Gilbert SE, Harris IA, et al. Spinal cord stimulation for low back pain. Cochrane Database Syst Rev. 2023;3(3):CD014789. PubMed 36878313 · DOI

  18. In real-world US data, about one in five people needed their stimulator revised or removed within two years, and opioid use did not fall.

    7,560 patients in US insurance claims. Revision or removal: 22.1%. No reduction in opioid use at 2 years compared with conventional care. Observational.

    Dhruva SS, Murillo J, Ameli O, et al. Long-term outcomes in use of opioids, nonpharmacologic pain interventions, and total costs of spinal cord stimulators compared with conventional medical therapy for chronic pain. JAMA Neurol. 2023;80(1):18-29. PubMed 36441532 · DOI

  19. Structured exercise has been tested in about 250 trials, and it reliably lowers pain, modestly.

    249 trials. Compared with no treatment, usual care or placebo, pain was 15.2 points lower on a 0-100 scale (moderate certainty), a clinically important difference.

    Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790. PubMed 34580864 · DOI

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