New Term Proposed for Persistent Back Pain

The term ‘failed back surgery syndrome (FBSS)’ is commonly used to describe patients who deal with persistent pain after back surgery. However, many specialists have deemed this term an inadequate label because it misrepresents the causation of the patient’s pain. In a recent study published in Pain Medicine, an international group of specialists was established to propose a broadly applicable and more precise clinical term. They believe their suggestion, ‘Persistent Spinal Pain Syndrome (PSPS),’ is more cohesive, accurate and can easily be incorporated into the new International Classification of Diseases (ICD-11).

The term FBSS first came about in the late 1970s and early 1980s through a series of publications from Burton, and its use expanded from there. Several alternative definitions and revisions have been proposed but none gained traction.

“FBSS has become a catch-all term for patients who experience persistent or recurring pain after surgery,” says Michael Stanton-Hicks, MD, one of the authors on the study and a pain specialist in Cleveland Clinic’s Department of Pain Management. “One of the failures of the term is that by generically labeling all patients as having FBSS ignores the range of factors that may contribute to the condition. It also limits an understanding of the condition. Furthermore, by including ‘surgery’ in the label, it is frequently misinterpreted to mean that the surgery was performed incorrectly, which is often not the case or that surgery was never involved.”

Goals with new term

The revised classification for chronic pain by the International Association for the Study of Pain as part of ICD-11 includes the third-level term ‘chronic pain after spinal surgery.’ However, the primary objective of the present study was to create a new term that clarifies or enhances this term. The authors identified a few basic requirements for a new term, which included simplicity, accuracy and broad acceptance, as well as identifying the key aspects of the location, mechanism and etiology of the pain. In addition, there was also an emphasis on developing a term that not only guided diagnosis and treatment but also clinical and public health research.

“There are several mechanisms of the spine that can cause pain,” says Dr. Stanton-Hicks. “These include the vertebral column, nervous system, muscles, gait or psychosocial factors, such as depression or traumatic experiences. Further complicating this, is that these factors can interact with each other, which makes pinpointing the actual cause of the pain very difficult. This uncertainty highlights the importance of a precise term in order to be as clinically informative as possible.”

Ambiguity with present ICD-11 terms

The article identifies a couple of issues with the current term from ICD-11, chronic pain after spinal surgery (CPSS), which states: ‘Pain that develops or increases in intensity after a surgical procedure or a tissue injury.’ “CPSS is not a direct replacement for FBSS,” explains Dr. Stanton-Hicks. “It also may not be an appropriate alternative when surgery is not known to be the cause of the patient’s pain. There is also not really any clarity in regard to cases where late relapse/recurrence occurred after initially successful surgery. Then, perhaps most importantly, cases where there was no prior surgery are essentially treated just like postsurgical cases where surgery was clearly not the cause of the chronic symptoms.”

The term PSPS was chosen after widespread discussion, followed by a consensus workshop which employed a Delphi technique similar to the process used to select ‘Complex regional pain syndrome’ (CRPS). The origin of the term stems from to the nature of the sustained upright posture of Homo sapiens, which the authors argue creates a persistent predisposition to a chronic pain syndrome. This authors also believe the term covers the diverse potential symptoms of a syndrome of chronic pain or recurrent pain of spinal origin, paresthesia, numbness, stiffness, muscle spasms and weakness. Subtypes may also be incorporated with PSPS to provide additional information about the location and pathophysiology of the pain.

“One of the primary deficiencies of FBSS is the pejorative nature of the term in that any mention of pain related to surgery can be misinterpreted to imply that the surgery was performed poorly and is the cause of chronic pain,” explains Dr. Stanton-Hicks. “This kind of circumstance illustrates a need and an opportunity for the introduction of a broad and cohesive new term like PSPS.”

Looking ahead

The authors note that the term CPSS was created to overcome some of the failures of FBSS, but these two terms are not equivalent. PSPS, on the other hand, can account for chronic and/or recurrent symptoms after spinal surgery and other treatments and in the absence of such treatments, including surgery, which CPSS does not. Additionally, while chronic usually refers to a period of more than three months, the adjective persistent implies a sense of a prior situation which then continues despite interventions, such as surgery, or altered circumstances. The authors suggest that this aspect allows PSPS to become readily incorporated into ICD-11 codes.

“PSPS is more encompassing and more fundamental in principle than either FBSS or CPSS,” says Dr. Stanton-Hicks. “The term provides clarification and should fit well as a replacement of FBSS. It could be incorporated into ICD-11, and while it may take time for all parties — insurance carriers, the biomedical industries, commissioning and regulatory bodies and government agencies — to move away from FBSS, the framework PSPS offers should lead to improved clarity and diagnostic framework for physicians and improved care for patients.”