Persistent Spinal Pain Syndrome Type 2

Patients who develop Persistent Spinal Pain Syndrome Type 2 (PSPS Type 2) have already undergone one or more spinal surgeries due to back and/or leg pain. The term PSPS Type 2 replaces the previously used terms «Failed Back Surgery Syndrome» (FBSS) and «post-laminectomy syndrome,» which were perceived as stigmatizing. Since its inclusion in the ICD-11, the term PSPS Type 2 has therefore become the preferred term. *

Over the past few decades, the number of back surgeries has risen significantly worldwide. However, depending on the study, approximately 10 to 40% of patients continue to experience pain despite having undergone back surgery.

The success rate decreases with each additional back surgery. Various systematic reviews consistently cite the following approximate figures:

• 70–90% after the first surgery
• 30% after the second surgery
• 15% after the third surgery
• 5% after the fourth surgery

It is often impossible to determine with certainty where this pain comes from.

Possible causes include surgery that was not strictly medically necessary, technical problems during the procedure, biomechanical changes resulting from the surgery (e.g., wear and tear of an adjacent spinal segment, muscle atrophy, or instability), as well as complications such as scarring or inflammation. *

The longer patients suffer from Type 2 PSPS, the more difficult treatment becomes. Chronic back pain can be compounded by additional burdens, including stress, low self-esteem, unemployment, financial problems, and depression.

Studies show that patients with Type 2 PSPS have a lower quality of life compared to people with other chronic pain conditions such as rheumatoid arthritis, osteoarthritis, or fibromyalgia. In addition, they experience more severe pain, take opioids more frequently, and are more often unable to work. *

Several studies describe health-related quality of life as comparable to that of people with chronic heart failure or cancer. Up to two-thirds of those affected report extreme pain, and about 30 % report extreme limitations in daily life. *

Persistent Spinal Pain Syndrome Type 2 (PSPS Type 2) can be treated conservatively, with interventional procedures, or through neuromodulation.

A recent systematic review with a network meta-analysis shows that neuromodulation – particularly spinal cord stimulation – is the most effective form of treatment for pain relief in PSPS Type 2, followed by conservative treatment options *. The body of research explicitly emphasizes that an interdisciplinary treatment approach tailored to the individual patient is crucial, as the various treatment modalities vary in effectiveness and often need to be combined.

The treatment focuses on muscle training. Physical therapy can help with this. Depending on the diagnosis, it can be combined with pain medication or psychosomatic pain therapy.

Transcutaneous electrical nerve stimulation (TENS) can also be used as a complementary treatment. In this procedure, electrodes placed on the skin deliver weak electrical impulses. These can block pain and reduce the need for pain medication. TENS is usually used in addition to physical therapy, pain medication, and other conservative treatments.

If conservative treatments do not provide sufficient pain relief, interventional procedures may be considered. These include:

• targeted infiltrations
• Treatments using radiofrequency current, such as radiofrequency ablation or pulsed radiofrequency therapy (PRF) of the spinal ganglia
• thermocoagulation. In this procedure, a fine wire is guided through a cannula to the specific nerve structure transmitting the pain. The affected nerve fiber is then ablated. The procedure is minimally invasive.

Neuromodulation uses electrical impulses to influence how nerve signals are transmitted. If conservative and interventional treatments do not provide sufficient relief for Type 2 PSPS, spinal cord stimulation may be considered. *

It has proven particularly effective for chronic nerve pain in the arms or legs that does not respond adequately to other treatments.

In carefully selected patients, it can also relieve back pain. Several studies have shown, in direct comparison, significantly better long-term results than repeat back surgery. *