Top Causes of Failed Back Surgery

Back surgery is often regarded as a last-resort intervention for patients suffering from chronic, disabling pain unresponsive to conservative care. Many people place high hopes in a spine operation, expecting pain relief, improved mobility, and a return to normal life. Unfortunately, in a significant minority of cases, surgery does not deliver the expected outcome. Instead, patients may continue to experience pain or even worsen symptoms. This situation is commonly referred to as “failed back surgery syndrome” (FBSS) or “persistent spinal pain syndrome.”

At Big Apple Spine & Orthopedics, under the direction of Dr. Grigoriy Arutyunyan, we work every day with patients who have undergone one or more spinal surgeries elsewhere and still suffer from ongoing discomfort. As a prominent NYC orthopedic spine surgeon and Manhattan spine surgeon, Dr. Arutyunyan integrates expert evaluation, revision strategies, and personalized back pain treatment in NYC to help salvage difficult cases.

In this blog, we’ll explore the top causes of failed back surgery, break down contributing risk factors, and propose how expert spine surgeons can reduce the chances of failure. Whether you are a patient considering spine surgery or a professional in the field, understanding these pitfalls is essential to achieving better outcomes.

What Is “Failed Back Surgery Syndrome” (FBSS)?

Before diving into causes, it is important to clarify what we mean by a “failed” back surgery. The term is somewhat misleading, because the surgery itself may have gone perfectly, yet the patient may still develop pain or complications.

The International Association for the Study of Pain defines FBSS as lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location. NCBI In other words, FBSS encompasses scenarios where pain was not resolved or has recurred after one or more spinal surgeries.

Some synonyms or related terminologies include “post-laminectomy syndrome,” “persistent spinal pain,” or “persistent spinal pain syndrome type 2.”:

• Persistent or recurrent low back pain

• Radicular symptoms (pain radiating down the legs, numbness, tingling)

• New pain patterns (either at the same or adjacent spinal levels)
  

It is important to understand that FBSS is not an entity with a single cause, but rather a syndrome of overlapping factors. Each case must be assessed on its own merits.

Broad Categories of Failure

From studies, reviews, and clinical experience, the causes of failed back surgery can be grouped roughly into three broad categories:

1. Preoperative / Patient-related factors

2. Intraoperative / Surgical technique factors

3. Postoperative / Environmental and biological factors

Each category holds multiple potential specific causes. We will examine them systematically, showing how they may lead to failure and what strategies are used to mitigate risk.

1. Preoperative / Patient-Related Risk Factors

Misdiagnosis or Incomplete Diagnosis / Poor Patient Selection

One of the most fundamental causes of failure is that the surgeon operates on the wrong target or misunderstands the underlying pain generator. If the root cause of a patient’s pain is misdiagnosed, then no technically perfect surgery can reliably deliver long-term relief.

• Many spinal conditions manifest overlapping symptoms: disc herniation, facet arthropathy, sacroiliac joint dysfunction, spinal stenosis, and neural inflammation can mimic each other.

• If imaging is over-relied upon without adequate clinicopathologic correlation, the surgeon may treat the wrong level or structure.

• Sometimes multi-level disease exists, but surgery is performed on a single level, leaving untreated sources of pain at adjacent levels.

• In particular, patients whose pain is axial (mechanical low back pain) without a clear radicular component may fare less well with decompression surgery alone.

• Psychological factors such as depression, anxiety, poor coping, or somatization also increase the risk of unsatisfactory outcomes. Several studies highlight that up to two-thirds of patients with FBSS have pre-existing depression or mood disorders.

A prominent risk is performing surgery in a patient who is a poor candidate because of the absence of a clearly identifiable pain generator or because non-operative options have not been fully exhausted. 

At Big Apple Spine & Orthopedics, Dr. Arutyunyan emphasizes a rigorous preoperative diagnostic algorithm. This often includes correlation of history, advanced imaging (MRI, CT, dynamic films), diagnostic injections (nerve root blocks, facet blocks, sacroiliac joint blocks), and psychological screening. Such comprehensive evaluation helps minimize the risk of “operating blind.”

Comorbidities and Risk Factors (Smoking, Obesity, Bone Quality)

Certain patient factors increase the chance of suboptimal healing, complications, or biomechanical imbalances, ultimately contributing to surgical failure.

• Smoking: Nicotine impairs bone metabolism, reduces vascularity, and promotes scar formation. Many spine surgeons consider smoking a relative contraindication to fusion procedures. 

• Obesity: Excess weight can increase mechanical stress on surgical constructs and accelerate adjacent segment degeneration.

• Osteoporosis or poor bone quality: Weak bones may not support instrumentation or grafts reliably, leading to failure of fusion or hardware loosening.

• Diabetes, malnutrition, immune compromise: These conditions raise the risk of delayed healing, infection, or hardware complications.

• Multiple prior surgeries: Patients who have already undergone spinal procedures have altered anatomy, scar formation, and less tissue reserve, increasing the difficulty and risk of revision surgery. 

Mitigating these risks often involves optimizing medical status preoperatively (e.g. smoking cessation, weight loss, bone health optimization) and carefully counseling patients about realistic expectations.

2. Intraoperative / Surgical Technique-Related Causes

Even with optimal patient selection, there is still significant potential for technical or surgical factors to lead to unsatisfactory outcomes.

Inadequate Decompression / Residual Compression

In decompression surgeries (like laminectomy, discectomy, foraminotomy), the primary goal is to eliminate mechanical compression on neural elements. Failure to fully decompress the nerve roots or spinal canal may leave residual sources of compression.

• Sometimes a surgeon misses a sequestered fragment, a lateral recess stenosis, or contralateral compression.

• In other cases, incomplete removal of hypertrophied facet joints, ligamentum flavum, or osteophytes can leave persistent pressure.

• If the surgical exposure is too limited (especially in minimally invasive approaches), it is possible that parts of compression are left untreated. 

• Occasionally the surgery is performed at the wrong spinal level, a grave error that may render the procedure ineffective. 

A meticulous surgical plan, intraoperative imaging (e.g. fluoroscopy, navigation), and neural monitoring can help reduce these errors.

Surgical Error, Malposition, or Iatrogenic Damage

Human error may occur even in the hands of experienced spine surgeons.

• Misplacement of screws, clamps, or cages may violate neural structures, breach the canal, or impinge soft tissue.

• Use of electrocautery, retraction, or dissection may inadvertently injure nerve roots or the dura.

• Overzealous resection of supporting structures (e.g. facets, lamina) may introduce instability.

• In multilevel fusion surgery, failing to restore alignment or balance can create abnormal forces at adjacent levels.

• Failure to achieve adequate instrumentation rigidity or fusion environment (e.g. poor graft packing, under-sized implants) may predispose to nonunion.

Dr. Arutyunyan and his colleagues at Big Apple Spine & Orthopedics use Computer Assisted Spine Surgery (CASS) and robotic guidance to enhance precision and avoid malposition. Big Apple Spine & Orthopedics These advanced platforms provide real-time feedback and 3D mapping to reduce technical risk.

Iatrogenic Instability / Segmental Instability

By removing or disrupting stabilizing elements (e.g. facets, ligaments, lamina), or failing to reconstruct appropriately, the surgically treated segment may become unstable and generate pain.

• After a microdiscectomy or laminectomy, segmental instability may emerge over time, particularly if the patient had pre-existing subtle instability. 

• When instrumentation or fusion is attempted without restoring alignment or sagittal balance, adjacent segments may compensate and degenerate (“transition syndrome” / adjacent segment disease).

• Under-engineered constructs or insufficient fusion mass can allow micro-motion, pain, and eventual failure (pseudoarthrosis).

Failure of Fusion (Pseudoarthrosis) / Hardware Issues

In surgeries involving fusion, the success depends not only on decompression, but on achieving solid bone bridging (arthrodesis) and durable instrumentation.

• Pseudoarthrosis occurs when the bone fails to unite—as a functional nonunion. Patients may continue to experience pain at the surgical site, and instrumentation may loosen. 

• The risk of pseudoarthrosis is magnified by smoking, poor bone quality, long segment fusion, and inadequate graft biology or mechanics.

• Hardware complications—such as screw loosening, breakage, rod fracture, or graft subsidence—can compromise stability and lead to recurrence of symptoms.

• Lack of proper load sharing between the hardware and bone graft can overstress either component.

Dr. Arutyunyan recognizes that beyond mere instrumentation, fusion success depends on biology, biomechanics, and surgical finesse. At Big Apple Spine & Orthopedics, revision and salvage strategies often focus on augmenting fusion with structural grafts, biologics, and rebalancing.

Scar Tissue (Epidural Fibrosis) / Adhesions

Postoperative scar (fibrosis) is a nearly universal occurrence after spinal surgery. In many patients, it is benign; but in some, excessive scar formation can entrap nerve roots and become a source of pain.

• Epidural scarring is estimated to be implicated in 20–36% of FBSS cases. 

• Adhesions can tether nerve roots, restrict their mobility, and lead to mechanical stretch or ischemia.

• In severe cases, arachnoiditis (inflammation and fibrosis of the subarachnoid membranes) may occur, complicating revision surgery. 

• Scar tissue tends to accumulate especially in multilevel decompressions or reoperations due to repeated exposure.

Some surgeons attempt to mitigate scarring via intraoperative barriers (e.g. fat grafts, gels), but the effectiveness is inconsistent. Scar is often one of the unavoidable risks of any spinal procedure.

Adjacent Segment Disease / Degeneration (“Transition Syndrome”)

When one or more segments are fused, the biomechanics of the spine change. The adjacent (non-fused) levels absorb additional stress, which can lead to accelerated degeneration—disc wear, facet arthropathy, ligament hypertrophy, and instability. This phenomenon is known as adjacent segment disease (ASD) or transition syndrome.

• Studies suggest that up to 36% of fusion patients develop transition changes at five years. PMC+1

• New pain originating from these adjacent levels may mimic or overshadow the original symptoms, leading patients to believe their original surgery has “failed.”

• In long fusions, the risk of ASD increases due to longer lever arms and mechanical demand on adjacent junctional zones.

In revision planning, a skilled spine surgeon must assess adjacent levels and anticipate potential stress points. Sometimes the decision must be made to extend the fusion or provide prophylactic support.

3. Postoperative / Biological and Environmental Contributors

Even when the surgeon executes the plan flawlessly, postoperative and biological factors play a strong role in determining long-term success.

Progressive Degeneration or New Pathology

Spinal degeneration is often ongoing. A patient may develop new disc herniations, facet arthrosis, ligamentous hypertrophy, or stenosis at levels not originally operated. These new problems can contribute to pain even if the primary operated level is stable. 

This is especially prominent in patients with widespread degenerative disease at baseline.

Infections / Postoperative Complications

Postoperative infections—superficial or deep—are known to occur in spinal surgery, particularly when instrumentation is involved.

• Infection rates range from near 0% up to 12%, depending on complexity and comorbidities. 

• Infected instrumentation or graft sites may compromise stability and fusion, causing pain and sometimes necessitating removal of hardware.

• Hematoma, wound dehiscence, or CSF leaks may also contribute to additional scarring, nerve irritation, or instability.

Insufficient Rehabilitation / Poor Postoperative Care

Success after back surgery is not merely mechanical; rehabilitation, physical therapy, lifestyle modification, and compliance are essential.

• Inadequate rehabilitation, poor core strengthening, or failure to retrain proper movement patterns can hinder recovery.

• Patients who resume heavy activity prematurely or who fail to adhere to postoperative restrictions may overload the surgical site.

• Unaddressed psychosocial factors (fear-avoidance, depression, catastrophizing) can limit the benefit of surgery and lead to deconditioning and chronic pain.

Psychological and Behavioral Factors

Ongoing research underscores the mind‐body interaction in chronic pain. Patients with unresolved psychological stress, depression, anxiety, or catastrophizing may perceive pain more intensely and recover less well.

• Some studies find that psychological factors predict postsurgical outcomes more strongly than imaging abnormalities. 

• In patients with persistent postoperative pain, secondary gains (disability compensation, litigation) may complicate recovery.

Why These Failures Matter: The Human and Economic Toll

When back surgery fails, the consequences are serious:

• Patients suffer ongoing or worsening pain, neurological deficits, and reduced quality of life

• Functional loss, weight gain, mood deterioration, and social isolation may follow

• Repeat surgeries (revision) are more complex, riskier, and less likely to succeed

• Healthcare costs escalate sharply, with more imaging, therapies, and interventions

• Some patients may drift into chronic pain syndromes, narcotic dependence, or disability

Because of these potential outcomes, the decision to operate should never be taken lightly. Expert surgeons like Manhattan spine surgeon Dr. Arutyunyan stress shared decision-making, realistic expectations, and rigorous risk-benefit evaluation.

Strategies to Prevent or Mitigate Failed Back Surgery

Understanding failure modes allows us to adopt strategies to reduce risk and improve patient outcomes.

Meticulous Preoperative Workup

• Correlate imaging findings with clinical symptoms and objective tests

• Use diagnostic injections (nerve block, facet block, SI joint block) to localize pain generators

• Screen for psychological risk factors and offer cognitive/behavioral support

• Optimize medical comorbidities (smoking cessation, nutrition, bone health, weight loss)

• Seek second opinions (especially for high-risk or borderline cases)

Sophisticated Surgical Planning and Technique

• Leverage navigation, robotics, and intraoperative imaging to minimize error

• Choose the ideal approach (open vs minimally invasive) based on anatomy and pathology

• Ensure appropriate exposure without sacrificing necessary stability

• Plan for alignment restoration in multi-level fusions

• Use rigid instrumentation, quality graft material/biology, and proper graft containment

• Consider prophylactic augmentation of adjacent levels when risk is high

Postoperative Care and Rehabilitation

• Design individualized physical therapy plans targeting core strength, mobility, posture

• Monitor for signs of infection or complication, and intervene early

• Gradually advance activity with close clinical guidance

• Provide pain management that avoids overreliance on narcotics

• Offer psychological support, behavioral therapy, or pain coping training as needed

Revision or Salvage Interventions

For patients already experiencing FBSS, a tailored revision strategy is often required. Dr. Arutyunyan, at Big Apple Spine & Orthopedics, evaluates several possibilities:

• Targeted decompression of previously untreated or new compressive lesions

• Removal or adjustment of malpositioned hardware

• Fusion extension or stabilization of new segments

• Use of biologics or structural grafts to enhance fusion in a revision setting

• Epidural adhesion removal or nerve mobilization

• Neuromodulation (e.g. spinal cord stimulation) or pain interventions when surgery is not viable

The success of revision surgery depends on precisely identifying the pain generator(s) and carefully balancing risk and reward.

Key Takeaways and Advice for Patients

1. Choose a surgeon with revision and complex spine experience. Surgeons who understand failure modes are better equipped to plan durable outcomes.

2. Insist on a thorough preoperative evaluation. Seek clinical correlation, advanced diagnostics, and psychological screening.

3. Understand your own comorbidities. Smoking, obesity, bone health, and mental wellness matter significantly.

4. Manage expectations. Spine surgery is rarely a magic bullet; success depends on many factors and often incremental improvement.

5. Stay engaged in rehabilitation. Postoperative care, physical therapy, posture retraining, and lifestyle adaptation are essential.

6. If pain returns, act early. Early diagnosis of complications or adjacent level issues allows less invasive salvage options.

7. Consider second opinions, especially in high-risk or recurrent cases. A fresh perspective may identify overlooked pain generators.

At Big Apple Spine & Orthopedics, Dr. Arutyunyan encourages shared decision-making. He is not only a NYC orthopedic spine surgeon but also a Manhattan spine surgeon committed to safety, precision, and patient-centered care in back pain treatment in NYC.

Conclusion

Failed back surgery is a sobering reminder that spine surgery, while powerful, is not foolproof. Its success depends on a symphony of factors: accurate diagnosis, patient optimization, surgical precision, biologic healing, and postoperative care.

By understanding the top causes of failed back surgery—from misdiagnosis, inadequate decompression, instability, fusion failure, scar formation, to adjacent segment disease—patients and surgeons together can minimize risk and improve outcomes.