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Failed Back Surgery Syndrome

Causes, Symptoms, Treatments, & Other Resources

Your low back pain was excruciating!. Everything made the pain worse. You agree to have spine surgery and regrettably, your pain is still there. What is Failed Back Surgery Syndrome?  What are the symptoms of failed back surgery?  What is the treatment for Failed Back Surgery Syndrome? Are there other complications associated with spine surgery? Are there regenerative options to treat Failed Back Surgery Syndrome? Let’s dig in.

What Is Failed Back Surgery Syndrome?

Failed Back Surgery Syndrome also called failed back is a clinical condition in which patients who have undergone low back surgery continue to have pain and dysfunction.  Said another way the surgery that was intended to reduce pain and increase function FAILED. That’s right, the surgery failed. You had the surgery, struggled with the pain postoperatively, diligently participated in physical therapy and yet the pain and limitation are still there.  Unfortunately, this occurs frequently.   Estimates range from 20-40% of patients who undergo low back surgery will develop Failed Back Surgery Syndrome (1).

Is low back surgery the answer?  Consider these facts

  • 5-36% of patients who have lumbar disc surgery for disc herniation have a recurrence of their low back and leg pain within 2 years (2)
  • 29.2% of patients who have lumbar stenosis and undergo have surgical decompression (laminectomy) have similar or increased pain at 12 months (3).

What Are the Symptoms of Failed Back Surgery Syndrome

Pain is the most common symptom of Failed Back Surgery Syndrome.  If may be present immediately after surgery or gradually return over the following days.  The severity of the pain may be the same or worse after surgery.  It may be confined to the low back or can radiate into the buttock, posterior thigh, and down the leg.  Other symptoms that may occur include numbness, weakness, and tingling.

Big Toe Numbness

Believe it or not, one of those significant issues that can present as numbness stems from the low back. In the lumbar spine, the nerve that exits the spine at the L5 level branches down through the hip, thigh, knee, lower leg, and, yes, all the way into the foot and toes. So a pinched or irritated nerve at that L5 level in the back can create problems, such as pain, numbness, tingling, and so on, anywhere along the nerve branch. So what can irritate the L5 spinal nerve? The list is long, but it includes disc issues, such as herniated…

Read More About Big Toe Numbness

Calf Muscle Twitching

A twitching calf muscle may seem like no big deal, and if it’s just a temporary annoyance that lasts a couple of days and then goes away, it may be. However, it can also be a warning sign of something bigger, especially if it continues. So, today, we’re going to explain a little about the calf and why it’s not a good idea to ignore calf muscle twitching. If there’s one muscle you’re likely familiar with, it’s the calf muscle. If you reach around and grab your calf and flex it, the muscle you are actually feeling just under the surface is called the gastrocnemius muscle.

Read More About Calf Muscle Twitching

Gluteus Medius Pain

The gluteus medius is one of the major muscles in your buttock and hip. There are three gluteal muscles you have probably heard about: They layer one upon the another much like a layer cake. The gluteus minimus is closest to the body followed by the gluteus medius and then the larger gluteus maximus.Gluteus Minimus – The gluteus minimus is the smallest of the three gluteal muscles. It is a small triangular muscle that lies underneath its bigger brother, the gluteus medius. It functions to stabilize the hip, rotate the thigh, and move the hip in an outward direction.Gluteus Medius -A powerful muscle that starts at the backside of your waist bone…

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Hamstring Pain when Sitting

The hamstring is composed of the three long muscles that are found on the back of the upper leg. These are semitendinosus, semimembranosus, and biceps femoris. All three muscles run down the length of the thigh before they join together to become one tendon that attaches itself to the backside of the lower leg bone, called the Fibula. When these tendons contract it pulls the lower leg downwards towards our feet. The muscle contracts concentrically as it shortens. And relaxes eccentrically as it lengthens. This contraction action is also known as knee flexion. When these muscles are weak or injured it can be difficult to stand on…

Read More About Hamstring Pain when Sitting

Knee Buckling

Knees can buckle, causing a sensation of one or both knees giving out that affects nearly 17% of adults. The knees are regarded to be one of the most essential (and biggest) joints in the human body because they play significant roles in basic activities such as walking and sitting. When our knees begin to feel unstable, weak, or begin giving out, it is easy to become stressed since we rely so heavily on them for movement. The knee can become stable from numerous types of injuries. The knee is kept stable by the following structures: Tendons attach the leg muscles…

Read More About Knee Buckling

Knee Twitching & Spasms

Knee twitching and or spasms are common occurrences that can be caused by a variety of factors. In most cases, it is not a cause for concern and does not require treatment. However, in some instances, knee twitching may be a sign of a more serious condition. Knee twitching is often accompanied by a feeling of pins and needles or tingling in the knee. It may also be accompanied by a burning sensation. The twitching usually occurs intermittently and lasts for a few seconds. There are a number of things that can cause knee twitching. Some of the most common…

Read More About Knee Twitching & Spasms

Leg Feels Disconnected

So what exactly causes the leg to feel disconnected? The hip joint is the connection point between the leg and the rest of the body. The femur in the leg and the acetabulum in the pelvis create the hip joint. So if the left SI joint, for example, in the back and the symphysis pubis joint in the front becomes unstable due to loose supporting ligaments, then the left leg, which is connected between the two joints, is likely to also feel a bit disconnected. Likewise, if the right SI joint were unstable, then the right leg might feel disconnected. How This Patient’s “Disconnected” Leg Was Fixed Despite “leg feels…

Read More About Leg Feels Disconnected

Lower Back Pain When Sitting

After a long day on your feet sitting down is supposed to be way to relaxing. Unfortunately for some sitting for any length of time can be painful. Most people experience low back pain at some point in their life. The lifetime prevalence of low back pain is 85% (1). Let’s take a deeper look at the different types of pain and causes of low back pain when sitting. Pain can present in many different ways. It can be intermitent or constant. The quality of the low back pain can also vary depending upon the actual source of injury. Common examples include: Sharp and Stabbing, Dull and Aching, Throbbing/ Pulsating, Pins and Needles, Burning, Electrical

Read More About Lower Back Pain When Sitting

Lower Back Pain When Standing

When you’re seated, the facet joints in your lower back are in an open and slightly flexed position. When you stand up, these joints compress. If they are painful or have arthritis, you’ll have pain as you stand up because this puts pressure on the painful joints. In addition, if there is any type of movement of one vertebra forward on another (called spondylolisthesis), then this shift will have occurred as you sit. This is called degenerative spondylolisthesis. When you get back up, the vertebrae will come back into position after a few seconds, leading to that awkward “walk it out period” that starts out painful and ends up more normal.

Read More About Lower Back Pain When Standing

Nerve Pain in Knee

Nerve pain in the knee can be very irritating and life-altering during normal activities as well as leisurely pursuits. Nerve pain in the knee can radiate from the lumbar spine, the pelvis, or the small nerves in the knee. It also can begin after surgery from surgical nerve irritation from the incision or can be the type of pain related to knee arthritis. At the Centeno-Schultz Clinic, we are experts in spine, pain management, and non-surgical orthopedics. We perform a thorough physical examination and musculoskeletal ultrasound of your knee to identify the root cause of your pain and how to treat it appropriately….

Read More About Nerve Pain in Knee

Weak in Knees

Weakness in the knee can be a symptom of many different knee conditions. Some of the most common causes of weakness in the knee include ligament tears, meniscus tears, and arthritis. Another important but often overlooked cause of knee weakness is irritation or injury of the nerves in the low back. If you are experiencing any type of weakness in your knee for long durations of time (3 weeks), it is important to see a doctor to determine the cause. Some of the most common symptoms of knee weakness include difficulty standing up from a seated position, difficulty walking, climbing or descending stairs…

Read More About Weak in Knees
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What Are the Causes of Failed Back Surgery Syndrome?

Failed Back Surgery Syndrome can occur for a number of reasons which include preoperative, postoperative, and diagnostic factors.

Preoperative Factor

  • Obesity,
  • smoking,
  • workman’s compensation,
  • ongoing litigation,
  • and psychiatric disorders.

Postoperative Factor

Spine surgery involves removing important structural parts of the spine.  For example, a discectomy involves the removal of a portion or the entire intervertebral disc. Laminectomy is the removal of a bone of the backside of the spine that forms and protects the spinal canal that is called the lamina.  Supporting ligaments, tendons, and muscles are often damaged during these surgeries. The end result is that the spine no longer functions the same.  Said another way as a result of the spine surgery there is a change in the biomechanics of the spine.  A classic example is a spinal fusion.  The ” diseased or injured” disc is removed and the spinal bones are fused together with screws and plates.  Remember that the disc acts like a shock absorber that absorbs and transfers the forces of daily living. After removing a given disc the forces of daily living are redirected above and below the fusion.  This places additional wear and tear on the discs and facet joints above and below the fusion. Over time degeneration and injury occurs along with pain.

Diagnostic Factor

The successful outcome of low back surgery is dependent on the accurate diagnosis of the patient’s etiology of pain. Surgeons are not objective as their training and philosophy are biased toward surgery.  Their recommendations and treatments are not in your best interest.  Consulting with a surgeon about the need for low back surgery is like asking a barber if you need a haircut.

What Is the Treatment for Failed Back Surgery Syndrome?

Being proactive is your best option. Learn about your back pain and work closely with your physician to identify all the potential sources of pain.  Exhaust all conservative therapies.  Key points to remember.

Avoid Low Back Surgery.   There are many different types of low back surgeries.  Fusion is a very popular one where the disc is surgically removed and the two spinal bones are fused together.  Between 1998 and 2008 the number of fusion surgeries in the United States increased by 170.9% from 77,682 to 210,407 (4).  This is big business with a significant income stream for the surgeon, the surgical center, and support staff.  Is it effective?   Let’s look at the literature.

  • 2018 study analyzed the data from 33 randomized controlled trials and other studies comparing spinal fusion to nonoperative solutions for low back and degenerative conditions (5).  Of the 33 reviews, there was only one high quality, unbiased randomized control study that found “clinically meaningful benefits of fusion”.  All the other studies found elective fusion to be no more effective than conservative therapy.
  • A 2015 study randomized participants into two groups:  a surgical fusion group and a nonsurgical, conservative therapy group (6). Back pain, quality of life, and disability were found to be no better with spinal fusion than without. 
  • A different 2015 study demonstrated that spinal fusion for patients with Stenosis improved pain and function no better than physical therapy (7). 
  • A 2018 study that followed patients after lumbar fusion noted that 91% were still on narcotics (8).  Regrettably, 45% were taking higher doses after surgery than before.

Avoid Repeat Back Surgery.  Often times the surgeon will recommend a ” revision” or a second surgery to address the FAILED SURGERY and the patient’s pain.  RUN!  There is a good chance that the second surgery will also fail.  A recent study demonstrated that no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries (9)

Identify the Source or Sources of Low Back Pain. Do not rely exclusively on the MRI.  Have your doctor actually review in detail the MRI study and not the report.  A thorough examination is essential.  At the Centeno-Schultz Clinic, a comprehensive approach is utilized. We view and approach the spine as a Functional Spinal Unit.  This functional unit includes discs, facet joints, ligaments, fascia, and muscles.  These structures work with one another in a highly specialized and dependent manner.  Therefore for the very best results, the spine and all its parts need to be evaluated and treated together.  This novel, comprehensive approach can help you avoid lumbar fusion and its complications.  Treatment options include PRP and your own bone marrow concentrate (BMC) containing stem cells.  PRP is rich in growth factors that can increase blood flow and healing.  To better understand how to avoid lumbar surgery by using precisely guided PRP and BMC injections please click on the video below.

Related: Post-Laminectomy Syndrome

L 4/5 Fusion Surgery

Spinal fusion is a major surgery where one or more spinal bones (vertebrae) are fused together using screws, bolts, and or plates.  The hardware may be placed in the front (anterior) or the back (posterior) of the spine. The disc between the spinal bones is often times removed and replaced with bone or a spacer. L 4/5 refers to the level of the surgery. There are 5 spinal bones in the low back which are numbered from top to bottom L1, L2, L3, L4, and L5.  Sandwiched between each of the spinal bones is a disc.  The disc is named for the two spinal bones it is sandwiched between. 

Read More About L 4/5 Fusion Surgery

L5 S1 Fusion Surgery

Spinal fusion is a major surgery where one or more spinal bones (vertebrae) are fused together using screws, bolts, and or plates. The hardware may be placed in the front (anterior) or the back (posterior) of the spine. The disc between the spinal bones is often times removed and replaced with bone or a spacer. L5 S1 Fusion refers to the level of the surgery. There are 5 spinal bones in the low back which are numbered from top to bottom L1, L2, L3, L4, and L5. Sandwiched between each of the spinal bones is a disc. The disc is named for the two spinal bones it is sandwiched between.

Read More About L5 S1 Fusion Surgery


The other day I was evaluating a patient and reviewing the treatment options for their spine condition.  After discussing prior treatments, we got to the topic of medications taken for pain relief. She explained that she mainly utilized anti-inflammatory (NSAID) medications and then she told me to hold much she takes and has been for many years…..she takes close to 2 grams (2000 milligrams) on a daily basis which equated to about 9-10 capsules of medication per day.  I was shocked, considering she was pre-diabetic and with high blood pressure plus the kicker of it is that her PCP (primary care physician) is ok with this…

Read More About NSAIDs

Perc-FSU – Trusted Alternative to Spinal Fusion

The Perc-FSU Procedure is an injection-based treatment that utilizes the patients’ own blood platelets to bring stability to the spine without the need for the rods, nuts, bolts, and hardware of fusion surgery. “Perc” stands for percutaneous, and “FSU” stands for “Functional Spinal Unit,” which means that the spine is treated as one functioning unit. Up and down the spine, the discs, facet joints, ligaments, and muscles that assist in stabilizing the spine are treated with image-guided injections of PRP and Platelet Lysate to help bring stability to the spine as a whole. It is the trusted alternative to spinal fusion.

Read More About Perc-FSU – Trusted Alternative to Spinal Fusion

Platelet-Rich Plasma (PRP) Injections

PRP is short for platelet-rich plasma, and it is autologous blood with concentrations of platelets above baseline values. The potential benefit of platelet-rich plasma has received considerable interest due to the appeal of a simple, safe, and minimally invasive method of applying growth factors. PRP treatments are a form of regenerative medicine that utilizes the blood healing factors to help the body repair itself by means of injecting PRP into the damaged tissue. In regenerative orthopedics, it is typically used for the treatment of muscle strains, tears, ligament and tendon tears, minor arthritis, and joint instability. There have been more than 30 randomized controlled trials of PRP…

Read More About Platelet-Rich Plasma (PRP) Injections

Thoracic Spine Surgery

Thoracic spine surgery is a major surgery aimed at treating injuries in the thoracic spine. Because of the complex anatomy and close proximity to the heart and lungs, there are significant surgical risks and complications. Surgery on the thoracic spine can take hours and may require deflating the lung in order to gain access to the thoracic injury. Recovery can be lengthy depending upon the specific thoracic spine surgery performed. There are several different types of thoracic spine surgery.  The specific thoracic spine performed depends upon the underlying thoracic injury and a symptoms of the patient.  For example, a thoracic disc herniation…

Read More About Thoracic Spine Surgery

Are there Other complications Associated with Spine Surgery?

Yes.  In addition to the failure of the proposed low back surgery to improve pain and quality of life, there are a number of other long-term complications associated with spinal surgery.  Three very common complications are:

Adjacent Segment Disease

The disc is an important shock absorber.  Fusion surgery removes this important shock absorber which places additional stress and forces on the discs and facet joints above and below the level of the fusion. This additional force in turn can lead to injury of these facet joints and discs leading to degeneration, arthritis, and pain.  This is a real problem, with an incidence of 9% (10).  This can lead to additional surgeries including fusions.  To learn more about this tragic complication please click on the video below.

Spinal Muscle Injury

The spinal muscles provide critical stability and support for the spine. The multifidus is a spinal muscle located deep in the low back.  It is a major stabilizer of the spine.  Unfortunately, lumbar fusion significantly compromises the health and integrity of this muscle (11).   The multifidus muscle can actually shrink in size which is called atrophy.  This is in turn can lead to spine instability, degeneration, arthritis, and pain.   While this is easy to see on MRI it is rarely commented on by the radiologist.  Below are MRI images of the lumbar spine in cross-section.  Progressive atrophy is shown from left to right.  The multifidus is identified by the white dashed ovals.  As the muscle becomes more atrophied the dark muscle is replaced by white fat. This is minimal in the image on the left and is much more pronounced in the image to the far right. The atrophy of important spinal muscles leads to dysfunction and pain.


Surgery removes important structures in the spine.  Surgery also can compromise ligaments, tendons, and muscles all of which provide important support and stability.  Spine surgery typically changes the architecture of the spine which in turn can lead to instability, injury, and pain.

Are there Regenerative Options to Treat Failed Back Surgery Syndrome?

Yes.  The doctors Centeno-Schultz Clinic are experts in the evaluation and treatment of low back pain and failed back surgery syndrome.  In 2005 we were the first clinic in the world to inject BMC into the lumbar disc. Treatment options include PRP and a patient’s own BMC.  All injections are performed under x-ray or ultrasound guidance or both.  Damaged or weakened ligaments can be tightened.  Muscles that are atrophied can be injected with PRP to accelerate repair and healing.  Injured discs can be injected with both PRP and BMC to promote healing. Unlike other clinics, we track outcomes that are available here.

Related: BMC Therapy for Back Pain

In Conclusion

Failed Back Surgery Syndrome is a clinical condition in which patients who have undergone low back surgery continue to have pain and dysfunction. In other words, the surgery failed.  Estimates range from 20-40% of patients who undergo low back surgery will develop Failed Back Surgery Syndrome.  Pain is the most common symptom of Failed Back Surgery Syndrome.  There are a number of reasons for Failed Back Surgery Syndrome which are can be grouped into three major groups:  preoperative, postoperative, and diagnostic factors. The best treatment for Failed Back Surgery Syndrome is to AVOID spine surgery. Spinal surgeries do not carry a high success rate.  Repeat or revision surgeries are even less successful.  Other complications associated with spine surgery include adjacent segment disease, muscle atrophy, and instability.  Regenerative options to treat failed back surgery include PRP and BMC.

Know the truth.  Spinal surgery is not the answer.  Surgeons are biased and advocate for surgical solutions that are not in your best interest. If you or a loved one has ongoing spinal pain please schedule a telemedicine consult with Centeno-Schultz Clinic.  Learn from board-certified, fellowship-trained physicians your treatment options.  It is time to stop the misery and pain associated with spine surgery. Consider the Perc-FSU – the trusted alternative to spinal fusion.

Doctors Who Help with Failed Back Surgery Syndrome

Christopher J. Centeno, MD

Christopher J. Centeno, M.D. is an international expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate in orthopedics. He is board-certified in physical medicine and rehabilitation with a subspecialty of pain medicine through The American Board of Physical Medicine and Rehabilitation. Dr. Centeno is one of the few physicians in the world with extensive experience in the culture expansion of and clinical use of adult bone marrow concentrate to treat orthopedic injuries. His clinic incorporates a variety of revolutionary pain management techniques to bring its broad patient base relief and results. Dr. Centeno treats patients from all over the US who…

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John Schultz, MD

John R. Schultz M.D. is a national expert and specialist in Interventional Orthopedics and the clinical use of bone marrow concentrate for orthopedic injuries. He is board certified in Anesthesiology and Pain Medicine and underwent fellowship training in both. Dr. Schultz has extensive experience with same day as well as culture expanded bone marrow concentrate and sees patients at the CSC Broomfield, Colorado Clinic, as well the Regenexx Clinic in Grand Cayman. Dr. Schultz emphasis is on the evaluation and treatment of thoracic and cervical disc, facet, nerve, and ligament injuries including the non-surgical treatment of Craniocervical instability (CCI). Dr. Schultz trained at George Washington School of…

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John Pitts, M.D.

Dr. Pitts is originally from Chicago, IL but is a medical graduate of Vanderbilt School of Medicine in Nashville, TN. After Vanderbilt, he completed a residency in Physical Medicine and Rehabilitation (PM&R) at Emory University in Atlanta, GA. The focus of PM&R is the restoration of function and quality of life. In residency, he gained much experience in musculoskeletal medicine, rehabilitation, spine, and sports medicine along with some regenerative medicine. He also gained significant experience in fluoroscopically guided spinal procedures and peripheral injections. However, Dr. Pitts wanted to broaden his skills and treatment options beyond the current typical standards of care.

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Jason Markle, D.O.

Post-residency, Dr. Markle was selected to the Interventional Orthopedic Fellowship program at the Centeno-Schultz Clinic. During his fellowship, he gained significant experience in the new field of Interventional Orthopedics and regenerative medicine, honing his skills in advanced injection techniques into the spine and joints treating patients with autologous, bone marrow concentrate and platelet solutions. Dr. Markle then accepted a full-time attending physician position at the Centeno-Schultz Clinic, where he both treats patients and trains Interventional Orthopedics fellows. Dr. Markle is an active member of the Interventional Orthopedic Foundation and serves as a course instructor, where he trains physicians from around the world.

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Brandon T. Money, D.O., M.S.

Dr. Money is an Indiana native who now proudly calls Colorado home. He attended medical school at Kansas City University and then returned to Indiana to complete a Physical Medicine and Rehabilitation residency program at Indiana University, where he was trained on non-surgical methods to improve health and function as well as rehabilitative care following trauma, stroke, spinal cord injury, brain injury, etc. Dr. Money has been following the ideology behind Centeno-Schultz Clinic and Regenexx since he was in medical school, as he believed there had to be a better way to care for patients than the status quo. The human body has incredible healing capabilities…

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Other Resources for Back Surgery

The Spine Owner’s Manual: How to Avoid Back Pain & Life-Altering Surgery

This e-book from Dr. Chris Centeno focuses on the spine and how it functions within the human musculoskeletal system and the body as a whole. Everything in our bodies works together like a well-tuned symphony to support our well-being, and a strong spine (including all of its component parts, such as spinal nerves, ligaments, muscles, etc.) is critical to complete health.

Using the Regenexx SANS approach, The Spine Owner’s Manual provides a series of tests and clearly defined exercises that you can do on your own to measure and monitor your own spinal health. These musculoskeletal tests will allow you to monitor where your own body might be struggling to maintain proper stability, articulation, symmetry, and neuromuscular function.

  • Degenerative Disc Disease Exercises

    Degenerative disc disease (DDD) is a physiological breakdown of the intervertebral discs in the spine. Clinical studies have shown that disc degeneration, or the narrowing of at least one intervertebral space, is prevalent in nearly 60% of the population above 40 years of age(1). DDD can occur in the cervical, thoracic, or lumbar spine. While…

  • 9 Safe and Effective Ways to Crack Your Lower Back

    “Cracking” the back is a safe and effective way to stretch the joints of the spine. This exercise also relieves pain and discomfort in the joints. You’ve probably done it just after waking up or at the end of a long day without really thinking about it. The Benefits Of Cracking Your Lower Back There…

  • Ligaments of the Spine: Understanding Their Importance

    It started as a dull ache and now has progressed.  It feels like a knife in the back of your neck and is preventing you from daily activities.  Medications, rest and conservative treatments have failed.  Your doctor noticed on x-ray that the bones are out of alignment.  He thinks you may have suffered a ligament…

  • Alternatives to Laminectomy

    If you have had an MRI of your spine, you are probably like most patients. You read the MRI report and then google every term on your MRI report from the Radiologist trying to figure out what it all means! Alternatives to Laminectomy should be an important part of that search. Today you’re in luck,…

  • A New Study For Patients With Ongoing Low Back Pain

    The multifidus muscle is an important stabilizer of the lumbar spine. Dr. Schultz discusses what the multifidus muscle is, its importance, what muscle atrophy is, the association between multifidus atrophy and low back pain, and a new, exciting study at the Centeno-Schultz Clinic using PRP injections.

  • How To Heal A Herniated Disc Naturally

    A herniated disc can stop you in your tracks. Dr. Schultz reviews what a disc herniation is, how it is diagnosed, whether it can heal on its own, current treatments, and a natural way to treat a herniated disc.


1.Thomson S. Failed back surgery syndrome – definition, epidemiology and demographics. Br J Pain. 2013;7(1):56-59. doi:10.1177/2049463713479096.

2.Parker SL, Mendenhall SK, Godil SS, et al. Incidence of Low Back Pain After Lumbar Discectomy for Herniated Disc and Its Effect on Patient-reported Outcomes. Clin Orthop Relat Res. 2015;473(6):1988-1999. doi:10.1007/s11999-015-4193-1

3.Daniell JR, Osti OL. Failed Back Surgery Syndrome: A Review Article. Asian Spine J. 2018;12(2):372-379. doi:10.4184/asj.2018.12.2.372

4. Daniell JR, Osti OL. Failed Back Surgery Syndrome: A Review Article. Asian Spine J. 2018;12(2):372-379. doi:10.4184/asj.2018.12.2.372

5. Harris IA, Traeger A, Stanford R, Maher CG, Buchbinder R. Lumbar spine fusion: what is the evidence?. Intern Med J. 2018;48(12):1430-1434. doi:10.1111/imj.14120.

6.Hedlund R, Johansson C, Hägg O, Fritzell P, Tullberg T; Swedish Lumbar Spine Study Group. The long-term outcome of lumbar fusion in the Swedish lumbar spine study. Spine J. 2016;16(5):579-587. doi:10.1016/j.spinee.2015.08.065.

7. Delitto A, Piva SR, Moore CG, Welch WC. Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis. Ann Intern Med. 2015;163(5):397-398. doi:10.7326/L15-5129-4.

8. Deyo RA, Hallvik SE, Hildebran C, et al. Use of prescription opioids before and after an operation for chronic pain (lumbar fusion surgery). Pain. 2018;159(6):1147-1154. doi:10.1097/j.pain.0000000000001202

9. Baber Z, Erdek MA. Failed back surgery syndrome: current perspectives. J Pain Res. 2016;9:979-987. Published 2016 Nov 7. doi:10.2147/JPR.S92776.

10. Greiner-Perth R, Boehm H, Allam Y, Elsaghir H, Franke J. Reoperation rate after instrumented posterior lumbar interbody fusion: a report on 1680 cases. Spine (Phila Pa 1976). 2004 Nov 15;29(22):2516-20.

11.Ghiasi MS, Arjmand N, Shirazi-Adl A, et al. Cross-sectional area of human trunk paraspinal muscles before and after posterior lumbar surgery using magnetic resonance imaging. Eur Spine J. 2016;25(3):774-782. doi:10.1007/s00586-015-4014-y

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