Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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New postoperative red flags
Fever, wound change, rapidly escalating pain, new motor or sphincter deficit, saddle change or acute deformity after spinal surgery is not routine persistent pain.
Action: Arrange urgent operative-team review, full neurological examination and cause-matched MRI or CT with infection and haemostasis assessment; treat compression, sepsis or instability before chronic-pain formulation.
Synopsis
Replace a blame-laden label with mechanism-based assessment of persistent spinal pain after surgery, exclude urgent and correctable causes, and select rehabilitation, reoperation or neuromodulation safely.
Failed back-surgery syndrome is imprecise and can imply blame. Persistent spinal pain syndrome type 2 records that relevant surgery occurred without assuming it caused every current symptom.
First separate an emergency or surgically correctable lesion from chronic nociceptive, neuropathic, nociplastic or mixed pain; pain after surgery is not one mechanism.
The worked case keeps red-flag exclusion, imaging correlation, mechanism formulation and coordinated outcome review visible in Rapid mode.
Key red flags
New weakness, saddle or bladder symptoms after surgery demands emergency assessment for recurrent compression, haematoma, infection or implant complication.
Fever, wound erythema or drainage, raised inflammatory markers or severe night pain raises discitis, osteomyelitis or epidural infection concern.
Sudden mechanical pain, deformity, implant breakage or motion-related symptoms may indicate pseudarthrosis, cage migration or construct failure.
Progressive weight loss, cancer features, fracture risk or pain unrelated to posture requires a new diagnosis rather than automatic attribution to the previous operation.
New postoperative emergency
Fever, rapidly increasing pain, new weakness, saddle or sphincter change after prior surgery is not chronic PSPS: arrange immediate spinal surgical review, neurological examination and inflammatory/microbiological assessment. Use urgent cause-matched imaging: MRI of the area for suspected compression or infection, with and without IV contrast or without contrast according to the question and contrast suitability; add CT when bone, implant or construct failure must be defined.
Reasoning priorities
01
Full operative and symptom reconstruction
Compare preoperative target, procedure, immediate response and timing and distribution of current pain and deficit.
No relief suggests wrong or persistent target; new pain suggests complication or new mechanism; late recurrence suggests new degeneration, adjacent disease or non-union.
Worked reasoning
Worked casePersistent leg pain after discectomy
An adult has neuropathic leg pain months after lumbar surgery without new weakness, fever or sphincter change.
Context: reconstruct the original indication, operative level and early response; map current pain, neurology, function, medicines, sleep, mood and work, while explicitly screening for infection, CES and progressive deficit.
Reasoning: use MRI and targeted imaging to exclude recurrent disc, residual compression, instability, non-union or another correctable lesion; formulate neuropathic, nociceptive and nociplastic contributions rather than stopping at FBSS.
Outcome: if no proportionate surgical target exists, deliver coordinated physical and psychological rehabilitation with medicine rationalisation; consider SCS only when the adult NICE neuropathic-pain criteria and trial are met.
Verification: follow pain, function, sleep, participation and adverse effects; for implants, also monitor programming benefit, wound, infection, lead position, battery and MRI restrictions over the long term.
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.
NICE TA159 spinal cord stimulationNICE technology appraisal TA159, published 22 October 2008 and review decision retained 2014; recommendations 1.1–1.5 and evidence interpretation read 13 September 2026. Applies to adults with severe chronic neuropathic pain despite conventional management, assessed by an experienced multidisciplinary team and after a successful stimulation trial. Chapter-specific use: failed back-surgery syndrome.
NICE NG193 chronic pain assessmentNICE NG193, published 7 April 2021; person-centred assessment, flare/change review, pain impact and chronic primary versus secondary pain scope read 13 September 2026. It guides assessment of any chronic pain but treatment recommendations in the guideline are specific to chronic primary pain unless stated. Chapter-specific use: failed back-surgery syndrome.
Persistent spinal pain syndrome terminology consensusChristelis et al., Pain Medicine 2021; full consensus, taxonomy and mechanism sections read 13 September 2026. PSPS type 2 describes persistent spinal pain where relevant surgery has occurred without assuming the operation caused every symptom; it is terminology consensus, not a treatment guideline. Chapter-specific use: failed back-surgery syndrome.
Persistent spinal pain syndrome mechanism-based recommendationsThomson et al., Pain Practice 2026, DOI 10.1111/papr.70104; abstract, classification, anatomy, mechanism and certainty framework read 13 September 2026. International task-force recommendations support mechanism-based selection across conservative care, reoperation and neuromodulation; UK access still follows NICE. Chapter-specific use: failed back-surgery syndrome.
ACR Appropriateness Criteria: Suspected Spine InfectionCurrent ACR imaging criteria; variants 2 (recent intervention, including surgery with or without hardware) and 3 (new neurological deficit or cauda equina syndrome) rate MRI of the area without and with IV contrast and MRI without IV contrast as usually appropriate. CT with or without IV contrast may be appropriate in the recent-intervention variant for selected bony or implant questions.