MULTIDISCIPLINARY MANAGEMENT OF REFRACTORY FAILED BACK SURGERY SYNDROME: A COMPLEX CASE REPORT WITH MULTIMODAL INTERVENTIONS AND LITERATURE REVIEW

D. Gemma¹, G. Pulito² | ¹"Cardinale G. Panico" Hospital, Tricase (Lecce); ²"V. Fazzi" Hospital, Lecce

INTRODUCTION
Failed Back Surgery Syndrome (FBSS) is defined by the International Association for the Study of Pain (IASP) as persistent or recurring pain after spinal surgery at the same anatomical location. Affecting 20–40% of patients undergoing spinal procedures in Italy, FBSS poses significant diagnostic, therapeutic, and socioeconomic challenges. It is not a true syndrome but rather a descriptive term encompassing heterogeneous clinical conditions marked by pain unresponsive to previous surgical interventions.
METHODS
This study presents a complex case of a 77-year-old woman with refractory FBSS. Her history includes multiple spinal surgeries—posterior arthrodesis and revisions spanning T3 to the sacrum—with complications such as adjacent segment disease and instrumentation failure. Over a three-year period, the patient underwent a wide array of treatments: pharmacological regimens (NSAIDs, opioids, antidepressants, antiepileptics), interventional pain therapies (epidural steroid injections, periduroscopy with adhesiolysis, pulsed radiofrequency, intrathecal morphine tests), spinal cord stimulation (temporary and permanent), and physical rehabilitation. These interventions were administered across two specialized pain management centers in Southern Italy.
RESULTS
Despite the comprehensive multidisciplinary approach, the patient remained clinically unstable with fluctuating pain intensity (VAS ranging from 4 to 8/10). SCS implantation was initially beneficial but had to be removed due to infection. Attempts with intrafascial botulinum toxin, percutaneous radiofrequency, and autologous PRP offered only partial relief. Intrathecal baclofen and ziconotide were considered but not implemented due to patient refusal. The patient's psychological status and the lack of centralized coordination likely affected treatment outcomes. Literature review indicates that while treatments such as SCS and periduroscopy can provide relief in selected patients, overall evidence remains limited, especially for refractory cases.
CONCLUSIONS
This case highlights the need for early and centralized intervention in FBSS, ideally involving university-level multidisciplinary pain centers. Tailored patient management incorporating medical, surgical, psychological, and rehabilitative approaches is crucial. Psychological screening and support should be integrated early in the treatment pathway to enhance compliance and improve prognosis. Minimally invasive strategies and careful surgical candidate selection are essential to prevent FBSS development. Existing literature emphasizes the superiority of comprehensive, biopsychosocial approaches over repeated surgeries or pharmacological monotherapy in managing chronic post-surgical spinal pain.