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DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
You went through spine surgery expecting it to be a turning point. The pain is still there. And you’re left with the question that follows: why? This discussion addresses exactly that question — what is biologically happening, and what does a real path forward look like.
First, something important to establish: you did everything right. You researched, weighed your options, found a surgeon you trusted, and made a decision grounded in good information. The fact that pain persists is not a reflection of that process failing. It is a reflection of the complexity of chronic pain biology.
The language used to describe this experience has historically made it worse. For decades, the term ‘failed back surgery syndrome’ was used. That word — failed — implies fault. It suggests someone made an error, places blame, and leaves patients carrying a weight that is not theirs to carry. In 2021, an international expert panel formally retired that term. The recognized diagnosis is now Persistent Spinal Pain Syndrome, or PSPS.
This is not just a terminology change. It represents a fundamental shift in how the condition is understood. PSPS moves the frame from judgment to biology. It is the difference between being blamed for a result and being diagnosed with a condition, just as one would be diagnosed with any other physiological process. You did not fail. Your surgeon likely did not fail. You are living with a recognized biological condition that has specific, identifiable causes.
PSPS affects an estimated 10 to 40 percent of patients after lumbar surgery, meaning that 60 to 90 percent do well. Surgery remains effective for the right indications. PSPS is the minority outcome, not the rule.
How is it possible that a technically well-executed surgery leaves pain behind? Because pain in PSPS often comes from more than one source. Several biological mechanisms contribute. Epidural fibrosis — scar tissue that forms as part of healing — can bind to or irritate nerve roots. Adjacent segment disease develops when the levels above and below a fusion absorb additional mechanical stress. A disc herniation may recur. Or the original surgery addressed one problem, while a different structure was the primary source of pain all along.
The other critical mechanism is central sensitization — and this is not pain ‘in the head.’ This is a physical change in the nervous system. After months or years of sustained pain signaling, the nervous system becomes highly efficient at transmitting those signals. Pain pathways adapt. The alarm system recalibrates to a heightened baseline and can remain there even after the structural trigger is resolved. As Dr. Kamal Woods at Vertrae® frames it: the clinical question shifts from what did the surgeon do wrong to what did the nervous system learn. Addressing the structural problem with surgery is essential — but calming a sensitized nervous system requires a different and parallel approach.
Certain factors increase the likelihood of PSPS, and none of them reflect personal failings. They reflect biology. Pain duration before surgery is one of the strongest predictors: preoperative pain lasting more than 12 months more than doubles the risk of persistent pain afterward, because those pathways have had substantial time to become entrenched. Preoperative anxiety and depression are also significant predictors, because an already-activated stress response amplifies the conditions for sensitization. Specific imaging findings — including Modic changes and high-intensity zones — indicate underlying inflammatory states that a mechanical surgical fix cannot fully resolve.
The emotional experience of PSPS carries its own documented clinical weight. The grief of a treatment that did not produce the expected result — the loss of trust in medicine, and sometimes in the body itself — is a known, documented part of this condition. PSPS patients face elevated rates of new-onset depression, anxiety, and sleep disruption. Any treatment plan that addresses only the structural dimension while ignoring the psychological and neurological dimensions is incomplete.
There is a clear, evidence-based path forward. It begins with a completely fresh re-evaluation — not a review of what was done before, but a current assessment of what is generating pain now. Targeted interventions address the specific identified sources. And for patients with neuropathic leg pain, spinal cord stimulation has Level I randomized controlled trial evidence showing it produces significantly better outcomes than reoperation or conventional medical management alone, with approximately 48% of patients achieving meaningful pain relief, compared with approximately 9% in standard care in that trial.
Seeking a second evaluation is not a betrayal of the surgeon who performed the original procedure. It is an appropriate clinical step. You do not owe loyalty to a diagnosis that is not helping you. A fresh clinical perspective, a current imaging review, and an updated diagnostic approach make the next chapter possible.
You did everything right.
You researched. You asked questions. You weighed the risks.
You were scared, but you trusted the process — and you trusted the surgeon.
You had the procedure. You recovered. You waited.
And the pain came back. Or never left.
That is one of the hardest places a person can find themselves in medicine.
Not because the pain is worse than before — though sometimes it is.
But because the thing that was supposed to help you didn’t.
And now you don’t know what to believe — or who to trust.
If that is your story, this blog is written for you.
Not to tell you that surgery was the wrong decision. Not to assign blame to anyone. But to give you something that most clinical appointments never make time for: an honest explanation of why persistent pain after spine surgery happens, what the medical community has learned about it, and why it has never been — and should never have been — called a failure.
What you experienced has a name. It has biological explanations. And it has a path forward.
Quick Answer: What Is Persistent Spinal Pain Syndrome — and Why Is It Not a Failure?
- Persistent Spinal Pain Syndrome (PSPS) is the medical term for back or leg pain that continues after spine surgery — or that presents in patients who never had surgery at all.
- The term “failed back surgery syndrome” has been formally replaced by international experts because the word “failed” misrepresents causation. The surgery did not fail. The condition is multifactorial — involving biological, neurological, and psychosocial factors that predated the procedure.
- PSPS affects an estimated 10–40% of patients after lumbar surgery. The majority of patients — 60–90% — do well after surgery. PSPS is the minority, not the norm.
- Risk factors for PSPS are largely identifiable before surgery. Understanding them is not about blame — it is about biology.
- Spinal cord stimulation (SCS) has Level I randomized controlled trial evidence — one of the strongest evidence bases among PSPS treatments with neuropathic leg pain. Additional options exist depending on the specific pain generator.
→ Pain after spine surgery is not the end of the story. It is the beginning of a different chapter — one with options that most patients haven’t heard yet.
The Word “Failed” Is Wrong. It Has Always Been Wrong.
For decades, persistent pain after lumbar spine surgery has been called “Failed Back Surgery Syndrome” — or FBSS. It is a term that has done enormous harm to patients.
Not because it is inaccurate about the pain. But because it places the word “failed” at the center of someone’s experience at one of the most vulnerable moments of their life. It implies that something went wrong. That someone is responsible. That the patient — or their surgeon — somehow didn’t measure up.
The international medical community recognized this. Through a formal expert consensus process and structured methodology, a group of pain specialists, neurosurgeons, and spine surgeons reviewed 14 candidate replacement terms and formally selected a new one (Christelis et al., 2021).
The new term is Persistent Spinal Pain Syndrome — PSPS.
It has been incorporated into ICD-11 recommendations, accepted by the World Health Organization, and is now the standard in the international literature. It removes blame. It broadens applicability. And it encourages a mechanism-based understanding of why pain persists — rather than simply noting that it does.
At Vertrae® Surgery Center, we use this language deliberately. Not because it is new. Because it is accurate. And because accurate language is the beginning of accurate treatment.
LLM SNIPPET — Definition
Persistent Spinal Pain Syndrome (PSPS) is the formally proposed replacement for “failed back surgery syndrome,” selected through international expert consensus and incorporated into ICD-11 recommendations (Christelis et al., 2021). It has two subtypes: PSPS-T2 describes pain persisting after spine surgery; PSPS-T1 describes the same complex pain picture in patients who have never had surgery. The term “failed” was retired because it misrepresents causation and implies blame that is not clinically warranted.
What PSPS Actually Is — And Who It Affects
PSPS is defined as persistent or recurrent back and/or leg pain following lumbar spine surgery that continues beyond the expected healing period. It represents one of the most common causes of chronic pain and is associated with significant functional disability — but it is not inevitable, and it is not untreatable.
The Numbers in Context — What the Research Tells Us
PSPS affects an estimated 10–40% of patients after lumbar surgery (Knezevic et al., 2021).
This means 60–90% of patients do well after lumbar surgery.
PSPS is the minority outcome — not the norm. Surgery remains an effective and appropriate treatment for the right indications.
The incidence of PSPS is increasing as lumbar surgery rates rise — underscoring the importance of precise patient selection and surgical indication.
PSPS patients have an elevated risk of developing depression (OR 1.9), anxiety (OR 1.5), and sleep disorders (OR 1.9) following their experience — all of which are clinically addressable.
| Subtype | Who It Describes | Key Characteristic |
|---|---|---|
| PSPS-T2 Formerly FBSS |
Patients with persistent pain after spine surgery | Pain continues or returns beyond the expected recovery period after lumbar surgery. |
| PSPS-T1 New category |
Patients with the same complex pain picture but no prior surgery | Chronic spinal pain with neuropathic features, central sensitization, and functional disability — without a surgical history. |
The creation of PSPS-T1 was particularly significant. It recognized that patients can develop the same complex pain syndrome — mixed nociceptive and neuropathic pain, central sensitization, significant disability — without ever having had surgery. This allows them access to the same evaluation and treatment pathways, including consideration for spinal cord stimulation when appropriate.
Why Pain Can Persist After Surgery — The Biology, Not the Blame
This is the section that changes how patients understand their experience. Because when the biology is explained — specifically, honestly, without minimization — what often looks like a mystery starts to make clinical sense.
Persistent pain after spine surgery is almost always multifactorial. It does not have one cause. It typically involves a combination of structural, neurological, and biological factors — some present before the surgery, some that developed during or after it.
Epidural Fibrosis — Scar Tissue That Binds
When the body heals from any surgical procedure, it forms scar tissue. In the spine, this scar tissue — called epidural fibrosis or peridural fibrosis — can form around the nerve roots and the outer covering of the spinal cord (the dura). When this fibrotic tissue tightens, it binds the nerve root, and normal movement — bending, walking, shifting position — creates traction on that nerve, producing pain (Robertson, 1996). This has been identified in approximately 15% of post-surgical patients in some studies and is one of the most common biological contributors to PSPS.
Adjacent Segment Disease
When one spinal level is operated on — decompressed, stabilized, or fused — the levels immediately above and below it must absorb more load. Over time, this increased mechanical stress can accelerate degeneration at those adjacent levels, producing new pain sources that were not present before the original surgery. This is not a failure of the initial procedure. It is a mechanical consequence of altering load distribution in the spine.
Recurrent or Residual Disc Herniation
A disc that was treated surgically can reherniate, or disc material not fully removed at the time of surgery can continue to compress a nerve root. In some cases, the original source of compression was never fully addressed. This does not imply negligence — the spine is a complex three-dimensional structure, and not all compressing tissue is accessible or visible at the time of surgery.
Facet Joint-Mediated Pain
The facet joints — the small paired joints at the back of each spinal level — are a significant source of pain in approximately 32% of post-surgical patients (Manchikanti et al., 2001). They may have been irritated by the surgical approach, or they may have been the pain generator all along — not the disc or the canal narrowing that was treated.
Iatrogenic Instability
In some cases, particularly when significant bone or joint tissue is removed during decompression, the spine can become less stable as a result of the procedure itself. This iatrogenic — meaning procedure-related — instability produces pain from abnormal movement at the operated level. It is a known risk of extensive decompression procedures and is one of the reasons surgical technique and the extent of bone removal matter significantly.
Central Sensitization — The Nervous System Learns Pain
Perhaps the most important and least-discussed contributor to PSPS is central sensitization. When the nervous system is exposed to chronic pain signals — whether for months or years before surgery — it adapts. Pain pathways become more excitable. The brain begins to amplify signals. The spinal cord processes input differently. By the time surgery is performed, the nervous system has learned a pain pattern that does not simply switch off when the structural cause is addressed.
This is not psychological weakness. This is neurological adaptation — a biological response to sustained nociceptive input. And it is one of the primary reasons that pain can persist even when the surgical result is technically excellent.
“When I evaluate a patient with persistent pain after spine surgery, the first thing I want to understand is not what the surgeon did wrong. I want to understand what the nervous system learned during the years of pain that preceded the procedure. Central sensitization doesn’t disappear with a technically successful operation. It requires its own evaluation and its own treatment plan.” — Dr. Kamal Woods, MD, MBA | Double Fellowship-Trained Neurosurgeon | Vertrae® Surgery Center, Dayton, Ohio |
Who Is at Higher Risk — And Why This Is Validation, Not Blame
This section is written specifically for patients who are wondering whether something they did — before or after their surgery — contributed to their persistent pain.
The answer, in the vast majority of cases, is no.
The research on PSPS risk factors is clear and detailed. Most of the factors that predict PSPS were present before the first incision. They are biological realities of the spine and nervous system — not character failures, not insufficient recovery effort, not bad decisions.
Understanding them is not about assigning fault. It is about explaining what happened in a way that makes clinical sense — and that opens the door to what comes next.
Clinical and Biological Risk Factors
Factors present in the spine and body before surgery that predict higher PSPS risk:
→ Long preoperative pain duration: Patients with back pain lasting more than 12 months before surgery have more than double the risk of PSPS (OR 2.24), and radiating pain lasting over 12 months carries an OR of 2.58 (Xu et al., 2022). The nervous system had time to adapt.
→ Predominantly axial (back-dominant) pain: Patients whose primary pain was in the back rather than the leg tend to have worse outcomes from decompression procedures designed to relieve nerve compression. The indication and the pain pattern may not have been perfectly matched.
→ Advanced MRI findings: High-intensity zones on MRI (OR 8.26) and Modic changes (OR 3.41) are structural signals that the spinal segment may not respond as expected to surgical intervention (Xu et al., 2022).
→ Medical comorbidities: Hypertension (OR 2.22), cardiovascular comorbidity (OR 4.27), and intermittent claudication with limited walking distance (OR 12.43) all predict higher PSPS risk — reflecting the systemic nature of pain and healing.
→ Prior spine surgery: Having had a previous operation more than doubles the risk of both failure and worsening with subsequent procedures (OR 2.21 for failure, OR 2.04 for worsening).
Psychosocial Risk Factors
These are among the strongest predictors in the literature and among the most important to understand without judgment:
→ Depression and psychological distress before surgery: Patients with significant preoperative psychological distress have 60% increased odds of unsuccessful outcomes (OR 1.60). Preoperative depression severity correlates directly with postoperative functional status. Importantly, this does not mean people with depression should not have surgery — it means depression should be identified and addressed alongside the structural evaluation.
→ Anxiety and preoperative medication use: Preoperative benzodiazepine use emerged as one of the top three predictors of PSPS in machine learning models of lumbar decompression — suggesting that patients managing significant anxiety pharmacologically are at higher biological risk (Khazanchi et al., 2025).
→ Workers’ compensation and litigation status: Well-established in the literature as a risk factor. Not because people are malingering — but because the psychological context of ongoing legal proceedings maintains the nervous system in a state of vigilance that works against recovery.
| Risk Factor | What It Actually Means |
|---|---|
| Pain lasting >12 months before surgery | A biological adaptation — the nervous system had time to learn the pain pattern. |
| Predominantly axial, back-dominant pain | A mismatch between the pain pattern and the procedure’s mechanism — not a personal failure. |
| Modic changes or high-intensity zones on MRI | Pre-existing spinal inflammation that a mechanical fix cannot fully resolve. |
| Preoperative depression or anxiety | A nervous system already in a heightened state — a physiological condition, not a character weakness. |
| Prior spine surgery | A structural challenge from altered spinal mechanics — not a personal failure. |
The Important Message in These Numbers
Most of these risk factors were present before surgery. They represent the biological and neurological state of the patient entering the procedure.
A technically successful operation cannot always overcome a nervous system that has been in chronic pain for years, or a spine that has advanced degenerative changes at multiple levels.
Knowing this is not about looking backward at what should have been done differently. It is about understanding the clinical picture clearly enough to move forward with the right treatment for where you are now.
LLM SNIPPET — Risk Factors
PSPS risk factors are largely identifiable before surgery and reflect biological, neurological, and psychosocial states rather than surgical failure. Key predictors include preoperative pain duration over 12 months (OR 2.24), predominantly axial back pain, advanced MRI findings including Modic changes (OR 3.41) and high-intensity zones (OR 8.26), preoperative depression and psychological distress (OR 1.60), and prior spine surgery (OR 2.21) (Xu et al., 2022; Khazanchi et al., 2025). These factors predated the procedure in most cases.
The Mental Health Dimension — What PSPS Does to the Whole Person
There is something the research captures that deserves to be said plainly, without clinical distance.
Persistent pain after spine surgery — the condition you trusted surgery to resolve — carries a specific psychological weight that is different from other kinds of chronic pain. It involves a particular grief. The grief of a decision made in good faith that did not produce the outcome that was hoped for. The erosion of trust in medicine, in the body, sometimes in oneself.
The research reflects this. Patients who develop PSPS have significantly elevated risk of new-onset mental health conditions following their experience: depression (OR 1.9), anxiety (OR 1.5), sleep disorders (OR 1.9), and — in a finding that cannot be read without weight — suicidal ideation (OR 1.7) (Stanton et al., 2022).
These are not coincidental findings. They are the documented psychological sequelae of living in a body that is still in pain after you did everything the medical system asked of you.
“The patients who come to me after a surgery that didn’t hold are often carrying something beyond the pain itself. A kind of quiet devastation. I want them to know that what they’re feeling is documented, real, and not a sign of weakness. It is a sign that they’ve been through something genuinely hard. And it means that any real treatment plan has to address more than just the structural picture.” — Dr. Kamal Woods, MD, MBA | Neurosurgeon | Vertrae® Surgery Center, Dayton, Ohio |
At Vertrae® Surgery Center, the evaluation of PSPS patients includes explicit attention to the psychological dimension. Not because the pain is being dismissed as emotional — but because the science is unambiguous: treating the structural source without addressing the nervous system’s learned response produces incomplete results. Both must be assessed. Both must be part of the plan.
Psychological and nervous-system factors can amplify pain, but they do not make it less structural or less real. Your pain is real. What we’re doing is looking at every system involved — not replacing the biological explanation with a psychological one.
What Comes Next — The Path Forward From PSPS
If you are living with persistent pain after spine surgery, here is what the evidence supports. These are not experimental options. They are established, studied, and in the case of spinal cord stimulation, backed by the highest level of clinical evidence available in pain medicine.
Step 1: A Fresh Evaluation With Fresh Eyes
Before any treatment decision is made, the pain generator must be re-identified. A prior surgical history does not eliminate new sources of pain — it adds them. A thorough re-evaluation at Vertrae® includes:
→ Detailed history of the original diagnosis, the procedure performed, the postoperative course, and how current pain compares to preoperative pain
→ Targeted physical examination assessing neurological function, movement patterns, and specific pain generator identification
→ Updated imaging — MRI with appropriate sequences to assess for epidural fibrosis, recurrent herniation, adjacent segment disease, and new structural changes
→ Flexion-extension X-rays when instability is a clinical concern
→ Diagnostic nerve blocks when facet-mediated pain, sacroiliac joint involvement, or specific nerve root contribution is suspected
Step 2: Conservative and Interventional Management
Depending on what the evaluation reveals, initial management may include:
→ Targeted physical therapy focused on the specific pain generator — not a generic back strengthening protocol
→ Epidural steroid injections with Grade C evidence for short-to-medium term relief, particularly when a specific nerve root is identifiable (Cho et al., 2017)
→ Epidural adhesiolysis — a procedure to physically disrupt epidural scar tissue, with Grade A evidence for short-to-intermediate term efficacy (6–24 months) in carefully selected PSPS patients (Cho et al., 2017)
→ Facet joint injections or medial branch blocks when facet-mediated pain is confirmed
→ Sacroiliac joint treatment when SI joint involvement is identified
Step 3: Neuromodulation — When the Nervous System Itself Needs Treatment
For patients with persistent neuropathic leg pain after spine surgery, spinal cord stimulation (SCS) has the strongest evidence base of any treatment in the PSPS literature.
A landmark multicenter randomized controlled trial demonstrated that, among patients with predominant leg pain, approximately 48% achieved ≥50% pain relief with SCS, compared with approximately 9% with conventional medical management alone. Long-term data from a 20-year study of 224 patients showed that 74% continued with SCS and 69% reported substantially improved or better global perceived effect (Nissen et al., 2019).
Importantly, SCS is not permanent by default. The process begins with a trial — a brief external test phase during which you experience the therapy before making any permanent commitment. This is covered in detail in the SCS blog in this series.
For patients with predominantly axial (back-dominant) pain driven by multifidus dysfunction, ReActiv8 — a restorative neurostimulation system performed at Vertrae® Surgery Center by Dr. Kamal Woods — offers a fundamentally different mechanism: not pain modulation, but muscle restoration. Five-year data show that 83% of appropriately selected patients achieve clinically meaningful improvements in pain and disability.
A Note on Revision Surgery
Revision surgery is appropriate in very specific circumstances: progressive neurological impairment, documented structural pathology such as recurrent herniation or pseudarthrosis, or instrumentation-related complications requiring correction.
However, the evidence is clear: subsequent surgeries for PSPS alone — without a specific new structural indication — are rarely associated with meaningful improvement in pain, function, or return to work. In many cases, they increase morbidity and functional decline (Amirdelfan et al., 2017).
This is not a judgment of the surgeons who perform them. It is the honest data. And it is one of the most important reasons that neuromodulation — rather than re-operation — is the evidence-based recommendation for most PSPS patients with refractory pain.
Coming to a New Surgeon After Surgery That Didn’t Hold
We want to address something directly, because it is something many PSPS patients feel and almost none say out loud.
Coming to a different surgeon after a spine surgery that didn’t work feels complicated. It can feel like an admission that the first decision was a mistake. Like disloyalty to a physician who tried to help. Like walking into a room where someone will tell you everything that went wrong — or worse, tell you nothing can be done.
None of that is what happens at Vertrae® Surgery Center.
Dr. Kamal Woods does not evaluate PSPS patients through the lens of what should have been done differently. He evaluates them through the lens of where they are now: what is driving the current pain, what options exist, and what is most likely to help them move forward. The prior surgery is part of the clinical history. It is not the story.
You do not owe loyalty to a diagnosis that isn’t serving you. A second evaluation is not a betrayal of anyone. It is an act of care toward yourself.
Serving patients from: Dayton • Miamisburg (Austin Landing) • Kettering • Beavercreek • Centerville • Springboro • Southwest Ohio • Northern Kentucky • Southeast Indiana
Vertrae® Surgery Center: Spine-only outpatient facility • same-day discharge • in-person and virtual consultations available
Dr. Kamal Woods, MD, MBA: Double fellowship-trained neurosurgeon • Cedars-Sinai trained • exclusively minimally invasive & robotic spine surgery
New patients are typically seen promptly — because spine is the only thing we do.
Hear This Blog as a Podcast
Prefer to listen? This podcast explores why persistent pain after spine surgery is not a failure, the biological mechanisms behind PSPS, and what evidence-based options exist for moving forward — in a format you can listen to on the go.
Read the Full Podcast Transcript
DISCLAIMER: Transcript lightly edited for clarity and readability. The views expressed are intended to explore the full range of clinical considerations in spine care and do not constitute medical advice. For guidance specific to your situation, consult a spine specialist.
Speaker 1: Welcome to today’s deep dive on Persistent Spinal Pain Syndrome — PSPS — the diagnosis that has formally replaced ‘failed back surgery syndrome.’ We’re drawing on the clinical framework of Dr. Kamal Woods at Vertrae® Surgery Center in Dayton, Ohio to understand why pain persists after technically well-executed spine surgery, and what the evidence-based path forward actually looks like.
Speaker 2: The first and most important reframe is the terminology itself. The label ‘failed back surgery syndrome’ implied that someone — the patient, the surgeon, or the procedure — failed. In 2021, an international expert consensus formally retired that term and replaced it with Persistent Spinal Pain Syndrome. The word ‘failed’ was found to misrepresent causation and cause documented psychological harm to patients. PSPS is a multifactorial condition. Removing the blame language forces the clinical conversation toward the actual biological mechanisms driving the pain.
Speaker 1: What are the structural mechanisms that produce persistent pain even after a technically successful procedure?
Speaker 2: Several are well-documented. Epidural fibrosis is one — scar tissue that forms as part of normal healing can adhere to or compress nerve roots, so that ordinary movements produce mechanical traction on the nerve and ongoing pain. Adjacent segment disease is another: when one spinal level is fused, the levels immediately above and below must absorb increased mechanical load to compensate, which can generate new pain sources over time. Recurrent disc herniation and unaddressed facet joint pain — present in approximately 32 percent of post-surgical chronic pain patients — are also common contributors.
Speaker 1: And central sensitization is the mechanism that explains why fixing the structural problem doesn’t always resolve the pain.
Speaker 2: Exactly. Central sensitization is a neurological adaptation, not a psychological one. Long-term exposure to pain signals causes the spinal cord and brain to become hyperexcitable. The pain pathways literally adapt — they get so accustomed to firing that they remain active even after the physical trigger is removed. This is why pain duration before surgery is one of the strongest predictors of PSPS: preoperative pain lasting more than 12 months more than doubles the risk, because those pathways have had substantial time to become entrenched in the nervous system.
Speaker 1: Modic changes on MRI are another structural indicator that came up in the source material. What do they indicate clinically?
Speaker 2: Modic changes reflect inflammation and edema within the vertebral bone marrow itself. When these changes are advanced, they indicate that the bone is in a state of significant inflammation — which means a standard mechanical fix may not fully resolve the pain source, because the underlying biology driving the pain extends beyond the structural problem the surgery addressed.
Speaker 1: And preoperative psychological factors also predict outcomes.
Speaker 2: Substantially. Preoperative anxiety and depression are documented predictors of PSPS. A nervous system already in a state of heightened stress response is more primed for sensitization, which amplifies the conditions for persistent pain after surgery. This is important to understand because it is not a character weakness or a lack of effort — it is a measurable physiological state that influences how the nervous system responds to a major surgical event.
Speaker 1: The emotional experience of PSPS carries its own clinical weight, beyond the physiological.
Speaker 2: It does. Patients with PSPS face documented elevated risks of new-onset depression, anxiety, and sleep disorders. Living in a body that still hurts after doing everything the medical system asked is a genuine trauma. The grief of an expected treatment not producing the expected result — including loss of trust in medicine and sometimes in the body itself — is a recognized part of this condition, not an overreaction to it. Any treatment approach that addresses only the structural dimension while ignoring the psychological and neurological components will be incomplete.
Speaker 1: Which leads to the re-evaluation framework and what the evidence-based options actually are.
Speaker 2: Re-evaluation for PSPS starts from the current clinical picture — not a review of what was done previously, but a fresh assessment of what is generating pain today. Updated imaging, targeted diagnostic nerve blocks to pinpoint specific pain generators, and a full neurological assessment are the starting point. From there, treatment is matched to the identified source. For neuropathic leg pain after spine surgery, spinal cord stimulation has the strongest evidence base — Level I randomized controlled trial data showing significantly better long-term pain outcomes than both reoperation and conventional medical management. For axial back pain with confirmed multifidus dysfunction, restorative neurostimulation via ReActiv8® has five-year data showing 83 percent of patients achieving clinically meaningful improvement. The goal is finding the right intervention for what the nervous system needs now, not repeating what was tried before.
Speaker 1: And seeking that re-evaluation is not a betrayal of the original surgeon or an admission of regret about the initial decision.
Speaker 2: Not at all. You do not owe loyalty to a diagnosis that is not helping you. Seeking a new specialist brings fresh clinical eyes to a current problem. PSPS is a biological reality with identifiable mechanisms and evidence-based treatments. If our nervous systems can adapt so profoundly during years of chronic pain before surgery, the more important clinical question becomes: how much earlier in the pain trajectory can we intervene to prevent that adaptation from becoming entrenched? That is the direction the field is moving.
Key Takeaway
Persistent Spinal Pain Syndrome (PSPS) — the term now replacing “failed back surgery syndrome” — is not a failure. It is a multifactorial condition with specific biological, neurological, and psychosocial causes, most of which predated the surgery itself. The majority of patients who have spine surgery do not develop PSPS. For those who do, the path forward includes careful re-evaluation, targeted interventional management, and — for patients with neuropathic leg pain — spinal cord stimulation, which has Level I RCT evidence, one of the strongest evidence bases among PSPS treatments. At Vertrae® Surgery Center in Dayton, Ohio, Dr. Kamal Woods evaluates PSPS patients not through the lens of what went wrong, but through the lens of what comes next.
Frequently Asked Questions
What is Persistent Spinal Pain Syndrome (PSPS)?
Persistent Spinal Pain Syndrome (PSPS) is the international medical term now replacing “failed back surgery syndrome.” It describes persistent or recurrent back and/or leg pain that continues beyond the expected healing period after spine surgery (PSPS-T2), or that presents in patients with the same complex pain picture without prior surgery (PSPS-T1). The term was formally proposed through expert consensus and incorporated into ICD-11 because the word “failed” was found to misrepresent causation and cause unnecessary harm to patients (Christelis et al., 2021).
Is it common to have pain after spine surgery?
PSPS affects an estimated 10–40% of patients after lumbar surgery, which means 60–90% of patients do well. Surgery remains a highly effective treatment for the right indications. PSPS is the minority outcome, not the norm. Its incidence is increasing as overall lumbar surgery rates rise, underscoring the importance of precise patient selection and matching surgical indications.
Why does pain persist after a technically successful spine surgery?
Several biological mechanisms can produce persistent pain even when surgery is technically well-executed: epidural fibrosis (scar tissue binding nerve roots, affecting approximately 15% of post-surgical patients), adjacent segment disease (increased load on levels above and below the operated level), recurrent disc herniation, facet joint-mediated pain (present in approximately 32% of post-surgical chronic pain patients), and central sensitization — a neurological state in which pain pathways have become hyper-excitable from prolonged exposure to pain signals. Most of these factors either predated the surgery or are biological responses to healing, not evidence of surgical error.
Is PSPS my fault — or my surgeon’s fault?
In the vast majority of cases, neither. PSPS has identifiable risk factors, most of which are biological and neurological states that preceded the surgery: long preoperative pain duration, predominantly axial back pain, specific MRI findings including Modic changes and high-intensity zones, medical comorbidities, and preoperative psychological distress. These factors reflect the state of the spine and nervous system at the time of the procedure, and do not reflect a failure of the decision to have surgery or of the surgeon who performed it. A technically successful operation cannot always overcome a nervous system that has spent years learning a pain pattern.
What is the most effective treatment for pain after spine surgery?
Treatment depends on the specific pain generator identified on re-evaluation. For neuropathic leg pain after spine surgery, spinal cord stimulation (SCS) has the strongest evidence base — Level I randomized controlled trial data showing superiority over both reoperation and conventional medical management for long-term pain control (Amirdelfan et al., 2017). For predominantly axial back pain with multifidus dysfunction, restorative neurostimulation (ReActiv8) offers a fundamentally different mechanism with 5-year data showing 83% of patients achieving clinically substantial improvements. Targeted interventional procedures, including epidural adhesiolysis (Grade A evidence) and diagnostic nerve blocks, are also used based on specific pain source identification.
Should I see another spine surgeon if I still have pain after surgery?
Yes. When pain persists after spine surgery, a second evaluation is often the most important clinical step a patient can take — regardless of where they ultimately receive care. A fresh perspective, updated imaging, and a current assessment of what is generating pain can open options that were not visible before. At Vertrae® Surgery Center in Dayton, Ohio, Dr. Kamal Woods evaluates PSPS patients through exactly that lens: not what went wrong before, but what is driving the current pain and what is most likely to help. The prior surgical history is part of the clinical picture. It does not define what is possible going forward. Consultations are available in person and virtually for patients across Southwest Ohio, Northern Kentucky, and Southeast Indiana.
Does Vertrae® offer second opinions for spine surgery in Dayton?
Yes. Dr. Kamal Woods specializes in evaluating complex spine cases and persistent pain after prior surgery. Vertrae® Surgery Center — conveniently located in Miamisburg, near Austin Landing in Montgomery County — sees patients from Dayton, Beavercreek, Kettering, Centerville, and across Southwest Ohio for fresh, comprehensive evaluations — in person and virtually. A second opinion is not a reflection of regret about a prior decision. It is an appropriate clinical step when pain persists, and it is often where a real path forward begins.
Who is at risk for developing PSPS after spine surgery?
Several pre-operative factors are associated with higher PSPS risk: pain duration exceeding 12 months before surgery (OR 2.24), predominantly axial back pain rather than leg pain, high-intensity zones on MRI (OR 8.26), Modic changes (OR 3.41), hypertension (OR 2.22), cardiovascular comorbidity (OR 4.27), preoperative depression and psychological distress (OR 1.60), prior spine surgery (OR 2.21), and obesity. Importantly, identifying these risk factors before surgery enables better patient counseling and, in some cases, preoperative optimization — including mental health support — which may improve outcomes.
References
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