Risk factors for failed back surgery syndrome following open posterior lumbar surgery for degenerative lumbar disease

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Method : A multivariate regression analysis was performed for 333 consecutive patients to identify potential risk factors for FBSS. Clinical outcomes were evaluated by the validated North American Spine Society (NASS) Questionnaire and numerical rating scale (NRS) for pain. Demographics, diagnostic characteristics, surgical data, radiographic parameters for each patient were analyzed. Result : 16.8％ of the included patients were classified as FBSS. Univariate analysis showed that age, hypertension, symptom location, intermittent claudication, preoperative pain NRS-leg, HIZ, Modic changes (MCs), surgical strategy and postoperative rehabilitation were related to FBSS. Multivariate logistic regression analysis demonstrated that preoperative NRS-leg (OR:0.80, 95%CI:0.71-0.91, P=0.001), hypertension (OR: 2.22, 95%CI: 1.10-4.51, P=0.027), intermittent claudication with waking distance > 100m (OR: 4.07, 95%CI: 1.75-9.47, P=0.001) and waking distance ≤ 100m (OR: 12.43, 95%CI: 5.54-27.92, P＜0.001), HIZ (OR: 8.26, 95%CI: 4.00-17.04, P＜0.001), MCs (OR: 3.41, 95%CI: 1.73-6.71, P＜0.001), postoperative rehabilitation (OR: 2.63, 95%CI: 1.13-6.12 , P=0.024) were risk factors for FBSS. Conclusion : Open posterior lumbar surgery is an effective treatment for DLD which provide pain reduction and lumbar curve improvement with a considerable satisfaction rate. Lower preoperative NRS-leg, hypertension, intermittent claudication, HIZ, MCs and postoperative rehabilitation are risk factors for FBSS, who can serve as a tool for clinicians to identify at-risk population and provide more effective management to mitigate the doctor-patient contradicts and further occupation of medical resources. failed back surgery syndrome degenerative lumbar disease patient satisfaction risk factors lumbar spine surgery Figures Figure 1 Figure 2 Background In the past three decades, low back pain (LBP) has been the main cause of non-fatal health loss, and the resulting burden poses a severe challenge to the coping ability of health care systems in various countries[ 1 ]. Degenerative lumbar disease (DLD) is the main cause of LBP, whose prevalence is positively correlated with the increase of age. With the aggravation of population aging, more and more attention has been paid to this very disease[ 2 , 3 ]. Traditional posterior open surgery is a classic and effective surgical method for DLD. Nonetheless, as the sophistication of lumbar surgery technology and the increasing number of its implementation, more and more researchers have realized that although the structural deficits of the initial operation have been excluded, postoperative persistent pain and/or numbness in the back or legs still afflict the patients, which result in dissatisfaction. On the other hand, some patients are still not satisfied even though they have achieved clinical improvement in disability or pain[ 4 ]. Failed back Surgery syndrome (FBSS) is a term used to describe patients' dissatisfaction with the effect of lumbar surgery[ 5 ]. Over the 40 years since this concept was proposed, the definition of FBSS has been gradually diluted and generalized. A large number of terms have emerged to describe the same condition[ 6 , 7 ], which has derived heterogeneous diagnostic criteria. (Table 1 ) Table 1 A summary of diagnostic criteria and characteristics of FBSS Study Diagnostic criteria Characteristics Merskey et al. [ 42 ] Lumbar (cervical) pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal (origin) pain originally in the same topographical distribution -Unknown origin Leveque et al. [ 43 ] Chronic radicular pain that has recurred or persists in the same distribution despite anatomically satisfactory previous spinal surgery -Recurred or persists -Anatomically satisfactory surgery Waguespack et al. [ 44 ] The outcome of lumbar spine surgery does not meet the pre-surgical expectations of the patient and surgeon -Didn’t meet the pre-surgical expectations Kumar et al.[ 45 ] Patients suffer from chronic neuropathic pain with a mean leg pain intensity of > 5 cm on a Visual Analog Scale (VAS) from 0 cm to 10 cm following anatomically successful spinal surgery. -Anatomically satisfactory surgery -VAS༞5/10 Bokov et al.[ 16 ] Patients with a pain intensity of no less than 40 on the 100-point VAS and at least a 40% decrease on the Oswestry Disability Index (ODI). -VAS > 40/100 -ODI decrease < 40% Bordoni et al.[ 5 ] Patient who underwent spinal surgery, irrespective of type or intervention area, with persistent pain in the lumbosacral region with or without it radiating to the leg despite the intervention for up to 3 months -The duration of symptoms > 3 months and conservative treatment was ineffective Andres et al.[ 46 ] Patients with chronic, intractable pain (> 5/10 on Numeric Rating Scale) of the trunk and/or limbs that has remained refractory to conservative therapy for at least 6 months. -The duration of symptoms > 6 months -NRS༞5/10 Cho et al.[ 47 ] Patients show chronic back pain or leg pain after successfully performed lumbar surgery without specific reasons such as compressive lesions, infection. - A large number of studies have been conducted on the risk factors of FBSS, and psychiatric disorders such as depression and insomnia have been proved to be associated with FBSS[ 8 , 9 ]. To the best of our knowledge, however, there is no research on the relationship between FBSS and the inherent characteristics of DLD, including but not limited to symptoms distribution, degree of intermittent claudication, radiographic parameters and more. It is also unclear whether postoperative rehabilitation affect the incidence of FBSS. Here, in order to explore the risk factors of FBSS after traditional posterior open surgery, we put forward a more comprehensive diagnostic criterion built on the existing literature and conducted a retrospective study based on prospectively collected data. We hope that this study will increase clinicians' understanding of FBSS and have a positive impact on its management. Methods Study design and participants This was a retrospective review of prospectively collected data which incorporated DLD patients who underwent traditional posterior open surgery between January 2018 and August 2020 with a minimum of 3-month follow-up at a single institution. Traditional posterior open surgery, which refers to discectomy, posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) was performed by 6 senior spine surgeons in our institution. The inclusion criteria were: (1) the patients were older than 18 years; (2) the diagnosis of DLD, including lumbar disc herniation, lumbar spinal stenosis, degenerative spondylolisthesis (Meyerding I-II) was confirmed by X-ray photographs, computer tomography (CT) and magnetic resonance imaging (MRI). (3) all patients met the surgical indication of DLD. Patients who met the following criteria were excluded: (1) definite iatrogenic injury; (2) severe or progressive psychotic disorders; (3) an active workman’s compensation claim or medical disputes; (4) lumbar surgical history; (5) presence of trauma, neoplasm, infection, congenital deformations. Here, a more quantitative and systematic definition of FBSS was developed as following: An intractable pain or sensory deficits of low back and/or limbs postoperatively that has remained refractory to conservative treatment (>3 months), which led to a dissatisfaction with the outcome of the surgery[10]. As for satisfaction, this research adopted the related questions in the validated North American Spine Society (NASS) questionnaire[11] in the form of telephone follow-up to evaluate. Clinical and radiological outcomes The following data were collected preoperatively: age, gender, diagnosis, chronic comorbidity such as hypertension and diabetes mellitus. The location of symptoms (low back pain without lower extremity symptoms, unilateral or bilateral lower extremity symptoms), duration of symptoms, concomitant intermittent claudication (IC), history of exacerbation, history of long-term analgesic use (≥6 months), Preoperative and postoperative Numerical Rating Scale (NRS)-back and NRS-leg were also analyzed in this study. NRS is an assessment instrument on a scale ranging from 0 to 10, where 0 represented “no pain” and 10 represented “extreme pain”. The following two categorized parameters were also analyzed. Surgical data: surgical strategy, surgical segment, operation duration and postoperative rehabilitation. Postoperative rehabilitation refers to treatment under the guidance of physiotherapist rather than self-management. Radiographic outcomes: high intensity zone (HIZ) and Modic changes (MCs) in MRI. Lumbar lordosis (the Cobb angle between L1 vertebral superior endplate and S1 vertebral superior endplate) and segmental lordosis (the Cobb angle between the superior endplate of the superior vertebra and the inferior endplate of the inferior vertebra) (Fig.1) [ 53] were measured at pre-operation and immediate post-operation[12]. To avoid bias, all information was collected by a study personnel unrelated to the operation. Statistics Continuous data are expressed as mean ± standard deviation and categorical data are given as frequency and/or percentage. Independent or paired sample t-test was performed on the data subject to normal distribution, for those who don’t obey normal distribution, Mann-Whitney U test was conducted. Categorical data between two groups were analyzed using the Fisher exact test or chi-squared test, as appropriate. Covariate selection for the multivariate analysis was based on P <0.05 in univariate analysis. SPSS version 26.0 software (IBM Corporation, USA) was used to analyze the data. P<0.05 was considered as being statistically significant. Results A total of 333 patients were enrolled in this study. All clinical outcome scores and radiographic parameters were significantly improved postoperatively (P༜0.001).(Table 2 )56 patients meeting the inclusion criteria were regarded as the FBSS + group, with an incidence rate of 16.8%. Reasons of dissatisfaction were revealed through further follow-up: 40 people suffered from persistent postoperative pain, 9 people afflicted by unrelieved or even aggravated numbness, 2 people due to no improvement in lower extremity muscle strength. 2 patients with pain and numbness at the same time and 3 patients with pain accompanied by lower limb weakness. Table 2 Clinical outcome and radiographic parameters Pre-operation Post-operation P value NRS-Back pain 6.3 ± 2.8 1.6 ± 1.9 < 0.001 NRS-Leg pain 7.2 ± 2.3 0.8 ± 1.6 < 0.001 Lumbar lordosis (°) 31.6 ± 13.8 38.4 ± 11.5 < 0.001 Segmental lordosis (°) 15.6 ± 9.4 20.5 ± 9.5 < 0.001 Demographics of the patients was shown in Table 3 . The mean age of FBSS + group and FBSS- group was 60.6 years and 53.8 years respectfully. Patients with hypertension accounted for 64.7% in FBSS + group, the counterpart was 22.6% in FBSS- group. Univariate analysis showed that the age of patients suffered from FBSS was significantly older than those who didn’t (P < 0.05). The comorbidity of hypertension in the FBSS + group was more common than that in the FBSS- group (P < 0.05). There was no significant difference in gender, diabetes mellitus and diagnosis between the two groups. Table 3 Demographics FBSS+ (n = 56) FBSS- (n = 277) P value Age(Year) 60.6 ± 10.2 53.8 ± 13.8 0.001 Gender(Male/Female) 18/38 118/159 0.147 Hypertension(Yes/No) 22/34 51/226 0.001 Diabetes mellitus(Yes/No) 10/46 29/248 0.117 Diagnosis(n) 0.972 Stable spinal stenosis 47 233 Spondylolisthesis 9 44 Table 4 presented diagnostic characteristics of patients. Univariate analysis illustrated that the distribution of lower extremity symptoms might be related to the occurrence of FBSS. Patients without IC were less likely to develop FBSS (17.3% vs 60.7%, P < 0.05). Compared with the FBSS- group, the preoperative NRS-leg was significantly lower in patients with FBSS (6.3 ± 2.7 vs 7.3 ± 2.2, P < 0.05). Table 4 Diagnostic characteristics FBSS+ (n = 56) FBSS- (n = 277) P value Symptom location(n) 0.03 Low back pain without limb symptoms 3 6 Unilateral limb symptom 31 201 Bilateral limb symptom 22 70 Symptom duration(Month) 70.64 ± 95.2 57.9 ± 70.1 0.766 Aggravation(Yes/No) 40/16 220/57 0.187 Claudication(n) 100m 12 28 Claudication distances ≤ 100m 22 20 Analgesic application(Yes/No) 34/22 175/102 0.728 Pre-op NRS-Back pain 6.1 ± 3.1 6.3 ± 2.8 0.836 Pre-op NRS-Leg pain 6.3 ± 2.7 7.3 ± 2.2 0.005 Comparison of the FBSS incidence among different surgical techniques showed significant differences. Postoperative rehabilitation may have an effect on the incidence of FBSS (P < 0.05) as shown in Table 5 . Table 6 showed that HIZ and MCs on MRI were more prevalent in the FBSS + group than those in the FBSS- group. Table 5 Surgical data FBSS+ (n = 56) FBSS- (n = 277) P value Type of surgery 0.031 Laminectomy 1 27 PLIF 18 119 PLF 14 59 PLIF + PLF 23 72 Levels of surgery 0.098 1 26 165 2 27 100 3 3 12 Surgery time (minutes) 151.2 ± 59.2 144.2 ± 53.7 0.602 Rehabilitation(Yes/No) 13/43 31/246 0.015 Table 6 Radiographic parameters FBSS+ (n = 56) FBSS- (n = 277) P value HIZ(Yes/No) 29/12 185/35 0.041 Modic changes(Yes/No) 16/25 190/87 < 0.001 Pre-op LL (°) 31.1 ± 13.1 31.7 ± 13.9 0.608 Pre-op SL (°) 15.9 ± 9.2 15.5 ± 9.4 0.951 Results of the multivariate logistic regression analysis are shown in Fig. 2 . A lower preoperative NRS-leg (OR:0.80, 95%CI:0.71–0.91, P = 0.001), hypertension (OR: 2.22, 95%CI: 1.10–4.51, P = 0.027), intermittent claudication with waking distance ༞100m (OR: 4.07, 95%CI: 1.75–9.47, P = 0.001), intermittent claudication with waking distance ≤ 100m (OR: 12.43, 95%CI: 5.54–27.92, P༜0.001), HIZ (OR: 8.26, 95%CI: 4.00-17.04, P༜0.001) and MCs (OR: 3.41, 95%CI: 1.73–6.71, P༜0.001) on MRI, postoperative rehabilitation (OR: 2.63, 95%CI: 1.13–6.12, P = 0.024) were the independent risk factors of FBSS. Discussion Failed back surgery syndrome (FBSS) was controversial since it was proposed in the 1970s because of its various definitions and diagnostic criteria[ 13 , 14 ].The definition of ‘dissatisfaction’ and ‘persistent pain’ was equated simplistically and misused. In fact, patients with optimistic expectations for surgery had higher degree of satisfaction in despite of similar postoperative pain scores[ 15 ], which highlighted the necessity of our modification. The present study introduced a quantitative satisfaction evaluation in order to standardize the definition of FBSS. The prevalence of FBSS ranges from 10–40% according to different researches[ 16 , 17 ]. Persistent pain, frequent hospitalization and the resulting heavy financial burden will not only aggravate the doctor-patient contradicts, but also lead to an excessive occupation of medical resources[ 18 ]. Unfortunately, most of the existing studies focused on the psychological factors of patients, while ignoring the inherent characteristics of DLD[ 8 , 9 , 14 ]. This research, on the other hand, based on the comprehensive analysis of disease characteristics and identified a series of independent risk factors of FBSS in order to arouse the vigilance of clinicians and patients, so as to manage high-risk population effectively and promptly. Studies conducted in different medical centers have proved that hypertension has an adverse effect on chronic pain[ 19 , 20 ]. What’s more, the intake of antihypertensive agents may increase pain sensitivity[ 21 ]. Hypertension is significantly associated with postoperative dissatisfaction for adult spinal deformities according to a multicenter retrospective study [ 22 ]. We speculate that this effect may be related to hypertension-mediated sympathetic nervous system dysfunction, which lead to a significant rise in neurological complications following operation[ 23 ]. At the same time, chronic pain caused by DLD plays an important role in blood pressure regulation by compromising inhibitory descending pathways and reducing the sensitivity of baroreceptors, which result in the impairment of cardiovascular regulation function with a concomitant increase in blood pressure. A vicious circle of ‘pain-hypertension-pain’ was formed eventually [ 24 – 26 ]. The current study confirms the negative effect of IC on spinal surgery. Based on five-year follow-up, a retrospective study noted that walking distance was significantly correlated with postoperative satisfaction of patients with DLD[ 27 ]. Sigmundsson et al.[ 28 ] analyzed 5100 patients collected prospectively and found that the rate of satisfaction reported by patients with walking distance > 1000m was 2.4 times higher than that of patients with walking distance < 100m. Similarly, a prospective study [ 29 ]reported that the risk of postoperative dissatisfaction could be increased by 10.3 times under the condition of walking difficulty who also showed a significant correlation with symptoms that may bring about FBSS, such as postoperative back pain, leg pain and numbness. In the context of the rampant pandemic, NRS, whose reliability had been fully corroborated, is favored by clinicians due to its comprehensibility and higher compliance [ 30 ]. A retrospective cohort study[ 11 ] indicated that preoperative NRS leg pain was the only predictor of patient satisfaction following TLIF, which is analogous to our conclusion : for every 1-point increase in preoperative NRS-leg, the risk of FBSS is reduced by 20%. On the one hand, the operation leads to greater improvement in patients afflicted to more severe limb pain and result in increased satisfaction[ 31 ]. On the other hand, patients with lower NRS leg pain have more complicated operation willingness than those with higher NRS because of relatively mild neurologic symptoms. When patients with prolonged illness have to resort to surgery, whom they tended to regard as ‘the final solution’, holding too high or even unrealistic expectations that fully restore to health or return to work immediate postoperatively would finally result in dissatisfaction, even if the operation did improve neurological function to some extent. HIZ and MCs, the reliable biomarkers of persist pain, play an important role in the course of DLD by inducing inflammatory response[ 32 , 33 ]. Preoperative MCs suggests poor clinical improvement and slow recovery [ 34 ], while HIZ indicates severe disc degeneration/displacement and the resulting severe, prolonged low back pain[ 35 ]. In addition, refractory or even aggravated pain/numbness caused by HIZ or MCs outside the surgical segment may be another reason for the dissatisfaction of FBSS patients. Contrary to a general impression, our result confirms that admission for rehabilitation treatment is a risk factor for FBSS. In this study, only 44 people were hospitalized for rehabilitation postoperatively, accounting for 13.2% of the total. Most of patients said it was out of economic considerations, while others were skeptical of the treatment itself. Despite a lot of research, there is no definite conclusion about mode and timing of postoperative rehabilitation, and even the necessity of hospitalization for it [ 36 , 37 ]. In fact, a number of RCTs and systematic reviews had pointed out the limited benefits of rehabilitation relative to self-management in terms of improving of pain, walking ability, return to work, working ability, satisfaction and amelioration of poor surgical results [ 36 , 38 – 40 ]. A similar effect of rehabilitation and sham treatment suggests that psychologic factors have a substantial effect on efficacy assessment[ 41 ]. In this case, the behavior of being hospitalized for further treatment implies the dissatisfaction with the effect of surgery, which can be further deepened with the extension of hospital stay and the increase of cost. There are several limitations in this study. First, a relatively short follow-up time may mask changes in outcome indicators due to other degeneration in long-term follow-up. From another perspective, it enables us to rule out new symptoms caused by deterioration of the degeneration and use the above risk factors to identify risk groups efficiently. Besides, the conclusions derived from this single-center, retrospective study still need to be verified by high-quality RCTs with a rigorous standard of diagnosis. Even so, we believe these risk factors can provide theoretical support for medical providers and encourage them to pay more attention to the management of high-risk groups. Conclusions Open posterior lumbar surgery is an effective treatment for DLD which provide pain reduction and lumbar curve improvement with a considerable satisfaction rate. Lower preoperative NRS-leg, hypertension, intermittent claudication, HIZ, MCs and postoperative rehabilitation are risk factors for FBSS, who can serve as a tool for clinicians to identify at-risk population and provide more effective management to mitigate the doctor-patient contradicts and further occupation of medical resources. Abbreviations CT, Computer tomography DLD, Degenerative lumbar disease FBSS, Failed back surgery syndrome HIZ, High intensity zone IC, Intermittent claudication LBP, Low back pain MCs, Modic changes MRI, Magnetic resonance imaging NRS, Numerical rating scale NASS, North American Spine Society PLIF, Posterior lumbar interbody fusion RCT, Randomized controlled trial TLIF, Transforaminal lumbar interbody fusion Declarations Ethics approval and consent to participate: This study was approved by the ethics committee of China-Japan Union Hospital of Jilin University and was therefore performed in accordance with ethical standards. All patients provided their informed consent prior to inclusion in the study. Consent for publication: All the authors listed have agreed to the submission of this paper. Competing interests: None. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions: W.X. and R.G. conceived and designed the study. W.X., B.R. analyzed the data and wrote the manuscript. J.Z., W.L. followed up the patients and collected the data. All authors have read and approved the manuscript. Acknowledgments The authors appreciate all the assistance and cooperation from the doctors and nurses of China-Japan Union Hospital of Jilin University. Availability of Data and Materials To avoid privacy compromise of research participants, the data will not be disclosed. Requests for data not shown in this manuscript can be made to the corresponding author. 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Spine J 17:720-726. doi: 10.1016/j.spinee.2017.01.010 Schistad EI, Espeland A, Rygh LJ, Roe C, Gjerstad J (2014) The association between Modic changes and pain during 1-year follow-up in patients with lumbar radicular pain. Skeletal Radiol 43:1271-1279. doi: 10.1007/s00256-014-1928-0 Teraguchi M, Cheung JPY, Karppinen J, Bow C, Hashizume H, Luk KDK, Cheung KMC, Samartzis D (2020) Lumbar high-intensity zones on MRI: imaging biomarkers for severe, prolonged low back pain and sciatica in a population-based cohort. Spine J 20:1025-1034. doi: 10.1016/j.spinee.2020.02.015 Aalto TJ, Leinonen V, Herno A, Alen M, Kroger H, Turunen V, Savolainen S, Saari T, Airaksinen O (2011) Postoperative rehabilitation does not improve functional outcome in lumbar spinal stenosis: a prospective study with 2-year postoperative follow-up. Eur Spine J 20:1331-1340. doi: 10.1007/s00586-011-1781-y Kernc D, Strojnik V, Vengust R (2018) Early initiation of a strength training based rehabilitation after lumbar spine fusion improves core muscle strength: a randomized controlled trial. J Orthop Surg Res 13:151. doi: 10.1186/s13018-018-0853-7 Mannion AF, Denzler R, Dvorak J, Muntener M, Grob D (2007) A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine. Eur Spine J 16:1101-1117. doi: 10.1007/s00586-007-0399-6 Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW (2014) Rehabilitation after lumbar disc surgery. Cochrane Database Syst Rev:CD003007. doi: 10.1002/14651858.CD003007.pub3 Paulsen RT, Rasmussen J, Carreon LY, Andersen MO (2020) Return to work after surgery for lumbar disc herniation, secondary analyses from a randomized controlled trial comparing supervised rehabilitation versus home exercises. Spine J 20:41-47. doi: 10.1016/j.spinee.2019.09.019 Erdogmus CB, Resch KL, Sabitzer R, Muller H, Nuhr M, Schoggl A, Posch M, Osterode W, Ungersbock K, Ebenbichler GR (2007) Physiotherapy-based rehabilitation following disc herniation operation: results of a randomized clinical trial. Spine (Phila Pa 1976) 32:2041-2049. doi: 10.1097/BRS.0b013e318145a386 Merskey H, Bogduk N (1994) Lumbar spinal or radicular pain after failed spinal surgery. Classification of Chronic Pain Seattle Leveque JC, Villavicencio AT, Bulsara KR, Rubin L, Gorecki JP (2001) Spinal cord stimulation for failed back surgery syndrome. Neuromodulation 4:1-9. doi: 10.1046/j.1525-1403.2001.00001.x Waguespack A, Schofferman J, Slosar P, Reynolds J (2002) Etiology of long-term failures of lumbar spine surgery. Pain Med 3:18-22. doi: 10.1046/j.1526-4637.2002.02007.x Kumar K, North R, Taylor R, Sculpher M, Van den Abeele C, Gehring M, Jacques L, Eldabe S, Meglio M, Molet J, Thomson S, O'Callaghan J, Eisenberg E, Milbouw G, Fortini G, Richardson J, Buchser E, Tracey S, Reny P, Brookes M, Sabene S, Cano P, Banks C, Pengelly L, Adler R, Leruth S, Kelly C, Jacobs M (2005) Spinal Cord Stimulation vs. Conventional Medical Management: A Prospective, Randomized, Controlled, Multicenter Study of Patients with Failed Back Surgery Syndrome (PROCESS Study). Neuromodulation 8:213-218. doi: 10.1111/j.1525-1403.2005.00027.x De Andres J, Monsalve-Dolz V, Fabregat-Cid G, Villanueva-Perez V, Harutyunyan A, Asensio-Samper JM, Sanchis-Lopez N (2017) Prospective, Randomized Blind Effect-on-Outcome Study of Conventional vs High-Frequency Spinal Cord Stimulation in Patients with Pain and Disability Due to Failed Back Surgery Syndrome. Pain Med 18:2401-2421. doi: 10.1093/pm/pnx241 Cho JH, Lee JH, Song KS, Hong JY, Joo YS, Lee DH, Hwang CJ, Lee CS (2017) Treatment Outcomes for Patients with Failed Back Surgery. Pain Physician 20:E29-E43 Cite Share Download PDF Status: Published Journal Publication published 31 Dec, 2022 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Major revision 15 Jul, 2022 Reviewers agreed at journal 15 Jun, 2022 Reviewers invited by journal 15 Jun, 2022 Editor invited by journal 13 Jun, 2022 Editor assigned by journal 17 May, 2022 First submitted to journal 04 May, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1622094","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":113791570,"identity":"1041607f-e154-40f5-8db3-65c5269d04b0","order_by":0,"name":"Wenbo Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYHACNoYPBjYMDMzMDQwMPBYgEQOCWhhnFKQBtTCCtEgQp4WZ58NhIA3SwkCEFoMbOWYPeAzOR/O3MzZ/YJCRSGxgb94mwVBzB6cWyRk55gYSBrdzZxxmbJMAOiyxgedYmQTDsWc4tfBL5G6TMABqaQBqYQBrkcgxk2BsOIzbIyAtCQbncucfBjkMpEX+DX4tYFsOGBzI3XCYsQHiMAke/Foke95/N2wwSM7dCPJLAo+EcRtPWrFFwjHcWgyOp6U9/vPHLnfe+cOHP3zssZHtZz+88caHGtxaUEFiDygxAEECkRqA4AfxSkfBKBgFo2DkAACno1DaYqol5AAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-4863-5617","institution":"China-Japan Union Hospital of Jilin University","correspondingAuthor":true,"prefix":"","firstName":"Wenbo","middleName":"","lastName":"Xu","suffix":""},{"id":113791571,"identity":"a5e09b6c-f505-43d2-b221-4f9ca76c7015","order_by":1,"name":"Bingbing Ran","email":"","orcid":"","institution":"Jilin Provice People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bingbing","middleName":"","lastName":"Ran","suffix":""},{"id":113791572,"identity":"10753e01-5efd-417e-8434-115631ec2afb","order_by":2,"name":"Jianhui Zhao","email":"","orcid":"","institution":"China-Japan Union Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Jianhui","middleName":"","lastName":"Zhao","suffix":""},{"id":113791573,"identity":"222c8a31-486a-4b0f-aa1e-699e2c14ea84","order_by":3,"name":"Wenqi Luo","email":"","orcid":"","institution":"China-Japan Union Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Wenqi","middleName":"","lastName":"Luo","suffix":""},{"id":113791574,"identity":"eaaad016-615a-4519-9785-84bd0da59846","order_by":4,"name":"Rui Gu","email":"","orcid":"","institution":"China-Japan Union Hospital of Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Gu","suffix":""}],"badges":[],"createdAt":"2022-05-04 12:45:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1622094/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1622094/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-022-06066-2","type":"published","date":"2022-12-31T18:07:08+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":22944523,"identity":"907520fe-f1cc-4e3a-8506-58c4fcd76822","added_by":"auto","created_at":"2022-06-22 15:50:06","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":242759,"visible":true,"origin":"","legend":"\u003cp\u003eThe measurement of lumbar lordosis and segmental lordosis at pre-operation and immediate post-operation\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-1622094/v1/2d3af3fc79a559520512c6e8.jpeg"},{"id":22944522,"identity":"335f75df-2804-45d1-b7e6-1bc45fcbc4e4","added_by":"auto","created_at":"2022-06-22 15:50:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18796,"visible":true,"origin":"","legend":"\u003cp\u003eMultivariate logistic regression analysis: independent risk factors of FBSS\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-1622094/v1/fa768b22902c1267fd668877.png"},{"id":44715072,"identity":"326b2a01-1dc2-4d8a-93be-29ad1e3f6c30","added_by":"auto","created_at":"2023-10-16 18:12:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":416078,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1622094/v1/6409ee51-1f66-4f9a-9d5f-ed963b80d1ad.pdf"}],"financialInterests":"","formattedTitle":"Risk factors for failed back surgery syndrome following open posterior lumbar surgery for degenerative lumbar disease","fulltext":[{"header":"Background","content":"\u003cp\u003eIn the past three decades, low back pain (LBP) has been the main cause of non-fatal health loss, and the resulting burden poses a severe challenge to the coping ability of health care systems in various countries[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Degenerative lumbar disease (DLD) is the main cause of LBP, whose prevalence is positively correlated with the increase of age. With the aggravation of population aging, more and more attention has been paid to this very disease[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTraditional posterior open surgery is a classic and effective surgical method for DLD. Nonetheless, as the sophistication of lumbar surgery technology and the increasing number of its implementation, more and more researchers have realized that although the structural deficits of the initial operation have been excluded, postoperative persistent pain and/or numbness in the back or legs still afflict the patients, which result in dissatisfaction. On the other hand, some patients are still not satisfied even though they have achieved clinical improvement in disability or pain[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFailed back Surgery syndrome (FBSS) is a term used to describe patients' dissatisfaction with the effect of lumbar surgery[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Over the 40 years since this concept was proposed, the definition of FBSS has been gradually diluted and generalized. A large number of terms have emerged to describe the same condition[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], which has derived heterogeneous diagnostic criteria. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA summary of diagnostic criteria and characteristics of FBSS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiagnostic criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMerskey et al. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLumbar (cervical) pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal (origin) pain originally in the same topographical distribution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-Unknown origin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeveque et al. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChronic radicular pain that has recurred or persists in the same distribution despite anatomically satisfactory previous spinal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-Recurred or persists\u003c/p\u003e \u003cp\u003e-Anatomically satisfactory surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWaguespack et al. [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe outcome of lumbar spine surgery does not meet the pre-surgical expectations of the patient and surgeon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-Didn\u0026rsquo;t meet the pre-surgical expectations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKumar et al.[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients suffer from chronic neuropathic pain with a mean leg pain intensity of \u0026gt;\u0026thinsp;5 cm on a Visual Analog Scale (VAS) from 0 cm to 10 cm following anatomically successful spinal surgery.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-Anatomically satisfactory surgery\u003c/p\u003e \u003cp\u003e-VAS༞5/10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBokov et al.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients with a pain intensity of no less than 40 on the 100-point VAS and at least a 40% decrease on the Oswestry Disability Index (ODI).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-VAS\u0026thinsp;\u0026gt;\u0026thinsp;40/100\u003c/p\u003e \u003cp\u003e-ODI decrease\u0026thinsp;\u0026lt;\u0026thinsp;40%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBordoni et al.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient who underwent spinal surgery, irrespective of type or intervention area, with persistent pain in the lumbosacral region with or without it radiating to the leg despite the intervention for up to 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-The duration of symptoms\u0026thinsp;\u0026gt;\u0026thinsp;3 months and conservative treatment was ineffective\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAndres et al.[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients with chronic, intractable pain (\u0026gt;\u0026thinsp;5/10 on Numeric Rating Scale) of the trunk and/or limbs that has remained refractory to conservative therapy for at least 6 months.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-The duration of symptoms\u0026thinsp;\u0026gt;\u0026thinsp;6 months\u003c/p\u003e \u003cp\u003e-NRS༞5/10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCho et al.[\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatients show chronic back pain or leg pain after successfully performed lumbar surgery without specific reasons such as compressive lesions, infection.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA large number of studies have been conducted on the risk factors of FBSS, and psychiatric disorders such as depression and insomnia have been proved to be associated with FBSS[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. To the best of our knowledge, however, there is no research on the relationship between FBSS and the inherent characteristics of DLD, including but not limited to symptoms distribution, degree of intermittent claudication, radiographic parameters and more. It is also unclear whether postoperative rehabilitation affect the incidence of FBSS.\u003c/p\u003e \u003cp\u003eHere, in order to explore the risk factors of FBSS after traditional posterior open surgery, we put forward a more comprehensive diagnostic criterion built on the existing literature and conducted a retrospective study based on prospectively collected data. We hope that this study will increase clinicians' understanding of FBSS and have a positive impact on its management.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective review of prospectively collected data which incorporated DLD patients who underwent traditional posterior open surgery between January 2018 and August 2020 with a minimum of 3-month follow-up at a single institution. Traditional posterior open surgery, which refers to discectomy, posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) was performed by 6 senior spine surgeons in our institution.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were: (1) the patients were older than 18 years; (2) the diagnosis of DLD, including lumbar disc herniation, lumbar spinal stenosis, degenerative spondylolisthesis (Meyerding I-II) was confirmed by X-ray photographs, computer tomography (CT) and magnetic resonance imaging (MRI). (3) all patients met the surgical indication of DLD. Patients who met the following criteria were excluded: (1) definite iatrogenic injury; (2) severe or progressive psychotic disorders; (3) an active workman\u0026rsquo;s compensation claim or medical disputes; (4) lumbar surgical history; (5) presence of trauma, neoplasm, infection, congenital deformations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHere, a more quantitative and systematic definition of FBSS was developed as following: An intractable pain or sensory deficits of low back and/or limbs postoperatively that has remained refractory to conservative treatment (\u0026gt;3 months), which led to a dissatisfaction with the outcome of the surgery[10]. As for satisfaction, this research adopted the related questions in the validated North American Spine Society (NASS) questionnaire[11]\u0026nbsp;in the form of telephone follow-up to evaluate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical and radiological outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following data were collected preoperatively: age, gender, diagnosis, chronic comorbidity such as hypertension and diabetes mellitus. The location of symptoms (low back pain without lower extremity symptoms, unilateral or bilateral lower extremity symptoms), duration of symptoms, concomitant intermittent claudication (IC), history of exacerbation, history of long-term analgesic use (\u0026ge;6 months), Preoperative and postoperative Numerical Rating Scale (NRS)-back and NRS-leg were also analyzed in this study. NRS is an assessment instrument on a scale ranging from 0 to 10, where 0 represented \u0026ldquo;no pain\u0026rdquo; and 10 represented \u0026ldquo;extreme pain\u0026rdquo;.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following two categorized parameters were also analyzed. Surgical data: surgical strategy, surgical segment, operation duration and postoperative rehabilitation. Postoperative rehabilitation refers to treatment under the guidance of physiotherapist rather than self-management. Radiographic outcomes: high intensity zone (HIZ) and Modic changes (MCs) in MRI. Lumbar lordosis (the Cobb angle between L1 vertebral superior endplate and S1 vertebral superior endplate) and segmental lordosis (the Cobb angle between the superior endplate of the superior vertebra and the inferior endplate of the inferior vertebra) (Fig.1) \u003cstrong\u003e[\u003c/strong\u003e53] were measured at pre-operation and immediate post-operation[12]. To avoid bias, all information was collected by a study personnel unrelated to the operation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous data are expressed as mean \u0026plusmn; standard deviation and categorical data are given as frequency and/or percentage. Independent or paired sample t-test was performed on the data subject to normal distribution, for those who don\u0026rsquo;t obey normal distribution, Mann-Whitney U test was conducted. Categorical data between two groups were analyzed using the Fisher exact test or chi-squared test, as appropriate. Covariate selection for the multivariate analysis was based on P \u0026lt;0.05 in univariate analysis. SPSS version 26.0 software (IBM Corporation, USA) was used to analyze the data. P\u0026lt;0.05 was considered as being statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 333 patients were enrolled in this study. All clinical outcome scores and radiographic parameters were significantly improved postoperatively (P༜0.001).(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)56 patients meeting the inclusion criteria were regarded as the FBSS\u0026thinsp;+\u0026thinsp;group, with an incidence rate of 16.8%. Reasons of dissatisfaction were revealed through further follow-up: 40 people suffered from persistent postoperative pain, 9 people afflicted by unrelieved or even aggravated numbness, 2 people due to no improvement in lower extremity muscle strength. 2 patients with pain and numbness at the same time and 3 patients with pain accompanied by lower limb weakness.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcome and radiographic parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNRS-Back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNRS-Leg pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar lordosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e31.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e38.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmental lordosis (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDemographics of the patients was shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean age of FBSS\u0026thinsp;+\u0026thinsp;group and FBSS- group was 60.6 years and 53.8 years respectfully. Patients with hypertension accounted for 64.7% in FBSS\u0026thinsp;+\u0026thinsp;group, the counterpart was 22.6% in FBSS- group. Univariate analysis showed that the age of patients suffered from FBSS was significantly older than those who didn\u0026rsquo;t (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The comorbidity of hypertension in the FBSS\u0026thinsp;+\u0026thinsp;group was more common than that in the FBSS- group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). There was no significant difference in gender, diabetes mellitus and diagnosis between the two groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFBSS+\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFBSS-\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;277)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge(Year)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender(Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e118/159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.147\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22/34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51/226\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10/46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29/248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis(n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.972\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStable spinal stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e233\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpondylolisthesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presented diagnostic characteristics of patients. Univariate analysis illustrated that the distribution of lower extremity symptoms might be related to the occurrence of FBSS. Patients without IC were less likely to develop FBSS (17.3% vs 60.7%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Compared with the FBSS- group, the preoperative NRS-leg was significantly lower in patients with FBSS (6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 vs 7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDiagnostic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eFBSS+\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFBSS-\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;277)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom location(n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.03\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow back pain without limb symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral limb symptom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral limb symptom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom duration(Month)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e70.64\u0026thinsp;\u0026plusmn;\u0026thinsp;95.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e57.9\u0026thinsp;\u0026plusmn;\u0026thinsp;70.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAggravation(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e40/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e220/57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eClaudication(n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eNo Claudication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eClaudication distances\u0026thinsp;\u0026gt;\u0026thinsp;100m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eClaudication distances\u0026thinsp;\u0026le;\u0026thinsp;100m\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAnalgesic application(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e175/102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.728\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePre-op NRS-Back pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.836\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePre-op NRS-Leg pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparison of the FBSS incidence among different surgical techniques showed significant differences. Postoperative rehabilitation may have an effect on the incidence of FBSS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) as shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e showed that HIZ and MCs on MRI were more prevalent in the FBSS\u0026thinsp;+\u0026thinsp;group than those in the FBSS- group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSurgical data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFBSS+\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFBSS-\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;277)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.031\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaminectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLIF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLIF\u0026thinsp;+\u0026thinsp;PLF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevels of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151.2\u0026thinsp;\u0026plusmn;\u0026thinsp;59.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e144.2\u0026thinsp;\u0026plusmn;\u0026thinsp;53.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRehabilitation(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31/246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiographic parameters\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFBSS+\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFBSS-\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;277)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHIZ(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29/12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185/35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.041\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModic changes(Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e190/87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-op LL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;13.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.608\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-op SL (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.951\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eResults of the multivariate logistic regression analysis are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A lower preoperative NRS-leg (OR:0.80, 95%CI:0.71\u0026ndash;0.91, P\u0026thinsp;=\u0026thinsp;0.001), hypertension (OR: 2.22, 95%CI: 1.10\u0026ndash;4.51, P\u0026thinsp;=\u0026thinsp;0.027), intermittent claudication with waking distance ༞100m (OR: 4.07, 95%CI: 1.75\u0026ndash;9.47, P\u0026thinsp;=\u0026thinsp;0.001), intermittent claudication with waking distance\u0026thinsp;\u0026le;\u0026thinsp;100m (OR: 12.43, 95%CI: 5.54\u0026ndash;27.92, P༜0.001), HIZ (OR: 8.26, 95%CI: 4.00-17.04, P༜0.001) and MCs (OR: 3.41, 95%CI: 1.73\u0026ndash;6.71, P༜0.001) on MRI, postoperative rehabilitation (OR: 2.63, 95%CI: 1.13\u0026ndash;6.12, P\u0026thinsp;=\u0026thinsp;0.024) were the independent risk factors of FBSS.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFailed back surgery syndrome (FBSS) was controversial since it was proposed in the 1970s because of its various definitions and diagnostic criteria[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].The definition of \u0026lsquo;dissatisfaction\u0026rsquo; and \u0026lsquo;persistent pain\u0026rsquo; was equated simplistically and misused. In fact, patients with optimistic expectations for surgery had higher degree of satisfaction in despite of similar postoperative pain scores[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], which highlighted the necessity of our modification. The present study introduced a quantitative satisfaction evaluation in order to standardize the definition of FBSS.\u003c/p\u003e \u003cp\u003eThe prevalence of FBSS ranges from 10\u0026ndash;40% according to different researches[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Persistent pain, frequent hospitalization and the resulting heavy financial burden will not only aggravate the doctor-patient contradicts, but also lead to an excessive occupation of medical resources[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Unfortunately, most of the existing studies focused on the psychological factors of patients, while ignoring the inherent characteristics of DLD[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This research, on the other hand, based on the comprehensive analysis of disease characteristics and identified a series of independent risk factors of FBSS in order to arouse the vigilance of clinicians and patients, so as to manage high-risk population effectively and promptly.\u003c/p\u003e \u003cp\u003eStudies conducted in different medical centers have proved that hypertension has an adverse effect on chronic pain[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. What\u0026rsquo;s more, the intake of antihypertensive agents may increase pain sensitivity[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Hypertension is significantly associated with postoperative dissatisfaction for adult spinal deformities according to a multicenter retrospective study [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. We speculate that this effect may be related to hypertension-mediated sympathetic nervous system dysfunction, which lead to a significant rise in neurological complications following operation[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. At the same time, chronic pain caused by DLD plays an important role in blood pressure regulation by compromising inhibitory descending pathways and reducing the sensitivity of baroreceptors, which result in the impairment of cardiovascular regulation function with a concomitant increase in blood pressure. A vicious circle of \u0026lsquo;pain-hypertension-pain\u0026rsquo; was formed eventually [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current study confirms the negative effect of IC on spinal surgery. Based on five-year follow-up, a retrospective study noted that walking distance was significantly correlated with postoperative satisfaction of patients with DLD[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Sigmundsson et al.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] analyzed 5100 patients collected prospectively and found that the rate of satisfaction reported by patients with walking distance\u0026thinsp;\u0026gt;\u0026thinsp;1000m was 2.4 times higher than that of patients with walking distance\u0026thinsp;\u0026lt;\u0026thinsp;100m. Similarly, a prospective study [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]reported that the risk of postoperative dissatisfaction could be increased by 10.3 times under the condition of walking difficulty who also showed a significant correlation with symptoms that may bring about FBSS, such as postoperative back pain, leg pain and numbness.\u003c/p\u003e \u003cp\u003eIn the context of the rampant pandemic, NRS, whose reliability had been fully corroborated, is favored by clinicians due to its comprehensibility and higher compliance [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A retrospective cohort study[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] indicated that preoperative NRS leg pain was the only predictor of patient satisfaction following TLIF, which is analogous to our conclusion : for every 1-point increase in preoperative NRS-leg, the risk of FBSS is reduced by 20%. On the one hand, the operation leads to greater improvement in patients afflicted to more severe limb pain and result in increased satisfaction[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. On the other hand, patients with lower NRS leg pain have more complicated operation willingness than those with higher NRS because of relatively mild neurologic symptoms. When patients with prolonged illness have to resort to surgery, whom they tended to regard as \u0026lsquo;the final solution\u0026rsquo;, holding too high or even unrealistic expectations that fully restore to health or return to work immediate postoperatively would finally result in dissatisfaction, even if the operation did improve neurological function to some extent.\u003c/p\u003e \u003cp\u003eHIZ and MCs, the reliable biomarkers of persist pain, play an important role in the course of DLD by inducing inflammatory response[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Preoperative MCs suggests poor clinical improvement and slow recovery [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], while HIZ indicates severe disc degeneration/displacement and the resulting severe, prolonged low back pain[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In addition, refractory or even aggravated pain/numbness caused by HIZ or MCs outside the surgical segment may be another reason for the dissatisfaction of FBSS patients.\u003c/p\u003e \u003cp\u003eContrary to a general impression, our result confirms that admission for rehabilitation treatment is a risk factor for FBSS. In this study, only 44 people were hospitalized for rehabilitation postoperatively, accounting for 13.2% of the total. Most of patients said it was out of economic considerations, while others were skeptical of the treatment itself. Despite a lot of research, there is no definite conclusion about mode and timing of postoperative rehabilitation, and even the necessity of hospitalization for it [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In fact, a number of RCTs and systematic reviews had pointed out the limited benefits of rehabilitation relative to self-management in terms of improving of pain, walking ability, return to work, working ability, satisfaction and amelioration of poor surgical results [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan additionalcitationids=\"CR39\" citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. A similar effect of rehabilitation and sham treatment suggests that psychologic factors have a substantial effect on efficacy assessment[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. In this case, the behavior of being hospitalized for further treatment implies the dissatisfaction with the effect of surgery, which can be further deepened with the extension of hospital stay and the increase of cost.\u003c/p\u003e \u003cp\u003eThere are several limitations in this study. First, a relatively short follow-up time may mask changes in outcome indicators due to other degeneration in long-term follow-up. From another perspective, it enables us to rule out new symptoms caused by deterioration of the degeneration and use the above risk factors to identify risk groups efficiently. Besides, the conclusions derived from this single-center, retrospective study still need to be verified by high-quality RCTs with a rigorous standard of diagnosis. Even so, we believe these risk factors can provide theoretical support for medical providers and encourage them to pay more attention to the management of high-risk groups.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOpen posterior lumbar surgery is an effective treatment for DLD which provide pain reduction and lumbar curve improvement with a considerable satisfaction rate. Lower preoperative NRS-leg, hypertension, intermittent claudication, HIZ, MCs and postoperative rehabilitation are risk factors for FBSS, who can serve as a tool for clinicians to identify at-risk population and provide more effective management to mitigate the doctor-patient contradicts and further occupation of medical resources.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT, Computer tomography\u003c/p\u003e\n\u003cp\u003eDLD, Degenerative lumbar disease\u003c/p\u003e\n\u003cp\u003eFBSS, Failed back surgery syndrome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIZ, High intensity zone \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIC, Intermittent claudication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLBP, Low back pain\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMCs, Modic changes\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMRI, Magnetic resonance imaging \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNRS, Numerical rating scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNASS, North American Spine Society \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePLIF, Posterior lumbar interbody fusion \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCT, Randomized controlled trial\u003c/p\u003e\n\u003cp\u003eTLIF, Transforaminal lumbar interbody fusion \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of China-Japan Union Hospital of Jilin University and was therefore performed in accordance with ethical standards. All patients provided their informed consent prior to inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors listed have agreed to the submission of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eW.X. and R.G. conceived and designed the study. W.X., B.R. analyzed the data and wrote the manuscript. J.Z., W.L. followed up the patients and collected the data. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors appreciate all the assistance and cooperation from the doctors and nurses of China-Japan Union Hospital of Jilin University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo avoid privacy compromise of research participants, the data will not be disclosed. Requests for data not shown in this manuscript can be made to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDisease GBD, Injury I, Prevalence C (2018) Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. 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Spine (Phila Pa 1976) 32:2041-2049. doi: 10.1097/BRS.0b013e318145a386\u003c/li\u003e\n\u003cli\u003eMerskey H, Bogduk N (1994) Lumbar spinal or radicular pain after failed spinal surgery. Classification of Chronic Pain Seattle\u003c/li\u003e\n\u003cli\u003eLeveque JC, Villavicencio AT, Bulsara KR, Rubin L, Gorecki JP (2001) Spinal cord stimulation for failed back surgery syndrome. Neuromodulation 4:1-9. doi: 10.1046/j.1525-1403.2001.00001.x\u003c/li\u003e\n\u003cli\u003eWaguespack A, Schofferman J, Slosar P, Reynolds J (2002) Etiology of long-term failures of lumbar spine surgery. Pain Med 3:18-22. doi: 10.1046/j.1526-4637.2002.02007.x\u003c/li\u003e\n\u003cli\u003eKumar K, North R, Taylor R, Sculpher M, Van den Abeele C, Gehring M, Jacques L, Eldabe S, Meglio M, Molet J, Thomson S, O\u0026apos;Callaghan J, Eisenberg E, Milbouw G, Fortini G, Richardson J, Buchser E, Tracey S, Reny P, Brookes M, Sabene S, Cano P, Banks C, Pengelly L, Adler R, Leruth S, Kelly C, Jacobs M (2005) Spinal Cord Stimulation vs. Conventional Medical Management: A Prospective, Randomized, Controlled, Multicenter Study of Patients with Failed Back Surgery Syndrome (PROCESS Study). Neuromodulation 8:213-218. doi: 10.1111/j.1525-1403.2005.00027.x\u003c/li\u003e\n\u003cli\u003eDe Andres J, Monsalve-Dolz V, Fabregat-Cid G, Villanueva-Perez V, Harutyunyan A, Asensio-Samper JM, Sanchis-Lopez N (2017) Prospective, Randomized Blind Effect-on-Outcome Study of Conventional vs High-Frequency Spinal Cord Stimulation in Patients with Pain and Disability Due to Failed Back Surgery Syndrome. Pain Med 18:2401-2421. doi: 10.1093/pm/pnx241\u003c/li\u003e\n\u003cli\u003eCho JH, Lee JH, Song KS, Hong JY, Joo YS, Lee DH, Hwang CJ, Lee CS (2017) Treatment Outcomes for Patients with Failed Back Surgery. Pain Physician 20:E29-E43\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"failed back surgery syndrome, degenerative lumbar disease, patient satisfaction, risk factors, lumbar spine surgery","lastPublishedDoi":"10.21203/rs.3.rs-1622094/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1622094/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: \u003c/p\u003e\u003cp\u003eWe aimed to investigate the incidence and risk factors for failed back surgery syndrome (FBSS) following open posterior lumbar surgery for degenerative lumbar disease (DLD).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: \u003c/p\u003e\u003cp\u003eA multivariate regression analysis was performed for 333 consecutive patients to identify potential risk factors for FBSS. Clinical outcomes were evaluated by the validated North American Spine Society (NASS) Questionnaire and numerical rating scale (NRS) for pain. Demographics, diagnostic characteristics, surgical data, radiographic parameters for each patient were analyzed. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e: \u003c/p\u003e\u003cp\u003e16.8％ of the included patients were classified as FBSS. Univariate analysis showed that age, hypertension, symptom location, intermittent claudication, preoperative pain NRS-leg, HIZ, Modic changes (MCs), surgical strategy and postoperative rehabilitation were related to FBSS. Multivariate logistic regression analysis demonstrated that preoperative NRS-leg (OR:0.80, 95%CI:0.71-0.91, P=0.001), hypertension (OR: 2.22, 95%CI: 1.10-4.51, P=0.027), intermittent claudication with waking distance \u0026gt; 100m (OR: 4.07, 95%CI: 1.75-9.47, P=0.001) and waking distance ≤ 100m (OR: 12.43, 95%CI: 5.54-27.92, P＜0.001), HIZ (OR: 8.26, 95%CI: 4.00-17.04, P＜0.001), MCs (OR: 3.41, 95%CI: 1.73-6.71, P＜0.001), postoperative rehabilitation (OR: 2.63, 95%CI: 1.13-6.12 , P=0.024) were risk factors for FBSS.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: \u003c/p\u003e\u003cp\u003eOpen posterior lumbar surgery is an effective treatment for DLD which provide pain reduction and lumbar curve improvement with a considerable satisfaction rate. Lower preoperative NRS-leg, hypertension, intermittent claudication, HIZ, MCs and postoperative rehabilitation are risk factors for FBSS, who can serve as a tool for clinicians to identify at-risk population and provide more effective management to mitigate the doctor-patient contradicts and further occupation of medical resources.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Risk factors for failed back surgery syndrome following open posterior lumbar surgery for degenerative lumbar disease","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-06-22 15:50:04","doi":"10.21203/rs.3.rs-1622094/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-15T18:23:02+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2022-06-15T15:26:27+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-06-15T12:54:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"BMC Musculoskeletal Disorders","date":"2022-06-13T09:28:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-17T13:59:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2022-05-04T08:38:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0a4f197b-ebdd-4c12-a85b-444b4a998ed4","owner":[],"postedDate":"June 22nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T18:09:44+00:00","versionOfRecord":{"articleIdentity":"rs-1622094","link":"https://doi.org/10.1186/s12891-022-06066-2","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2022-12-31 18:07:08","publishedOnDateReadable":"December 31st, 2022"},"versionCreatedAt":"2022-06-22 15:50:04","video":"","vorDoi":"10.1186/s12891-022-06066-2","vorDoiUrl":"https://doi.org/10.1186/s12891-022-06066-2","workflowStages":[]},"version":"v1","identity":"rs-1622094","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1622094","identity":"rs-1622094","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}