SPINE Volume 27, Number 22, pp 2547–2553
©2002, Lippincott Williams & Wilkins, Inc.
Managing Chronic Pain of Spinal Origin After
Lumbar Surgery
The Role of Decompressive Surgery
Frank M. Phillips, MD, and Benjamin Cunningham, MD
Study Design. A literature review was conducted.
Objective. To provide an evidence-based approach for
patients with neurogenic symptoms after lumbar surgery.
Summary of Background Data. Patients may present
with chronic pain of spinal origin after lumbar surgery.
Failure to decompress the involved neural structures ad-
equately or progression of the underlying degenerative
condition may lead to neurologic symptoms.
Methods. A literature search of peer-reviewed publi-
cations that investigate etiologies and treatments for neu-
rogenic pain in patients who have undergone previous
spinal surgery was conducted.
Results. In the absence of profound or progressive
neurologic deficits, most patients with chronic back and
leg pain who have undergone previous spinal surgery
should be treated nonoperatively. Additional decompres-
sive surgical intervention may be justified in patients with
well-defined, discrete pathology amenable to surgical
correction who have been refractory to conservative care.
The surgery typically will include meticulous decompres-
sion of the affected neural structures and may include
arthrodesis to address any deformity or instability.
Conclusions. In a patient presenting with neurogenic
symptoms after lumbar surgery, a meticulous workup is
required to elucidate the source of these symptoms. Sur-
gical indications are similar to those for primary lumbar
spinal surgery and include a well-defined anatomic
source of neural compression that is amenable to a sur-
gical solution. [Key words: claudication, decompression,
failed lumbar surgery reoperation] Spine 2002;27:2547–
2553
Patients with chronic back and leg pain who have under-
gone previous spinal surgery encompass several distinct
diagnostic categories, each of which demands unique
treatment. Differential considerations include residual or
recurrent neural compression, instability, mechanical
pain, deformity, pseudarthrosis, established neural in-
jury, central pain syndromes, behaviorally or psycholog-
ically maintained pain, infection, and undiagnosed neo-
plasm. The patient’s presentation and management will
be dictated by the specific diagnosis. Patients with resid-
ual or recurrent postoperative neurologic symptoms
From the University of Chicago Spine Center, Section of Orthopaedic
Surgery, Chicago, Illinois.
Device Status/Drug Statement: The submitted manuscript does not
contain information about medical devices or drugs.
Conflict of Interest: No funds were received in support of this work. No
benefits in any form have been or will be received from a commercial
party related directly or indirectly to the subject of this manuscript.
Address reprint request to Frank M. Phillips, MD, University of Chi-
cago Spine Center, 4646 North Marine Drive, Chicago, IL 60640,
E-mail: fphillip@weisshospital.org.
DOI: 10.1097/01.BRS.0000032128.28335.E6
amenable to surgical decompression are the focus of this
article.
In evaluating a patient with neurogenic claudication
or radicular symptoms after prior lumbar surgery, it is
important to make an accurate anatomic diagnosis, par-
ticularly if further surgical interventions are being con-
sidered. The more common pathologies causing neuro-
genic symptoms after prior lumbar surgery include
recurrent or persistent disc herniation, central or lateral
spinal stenosis, arachnoiditis– epidural fibrosis, and de-
formity or instability.5,10,39 In certain instances, the pa-
tient’s neurogenic symptoms may represent a failure of
the index surgery. In these cases, the “surgeon’s failure”
usually is attributable to inappropriate patient selection,
errors in surgical decision making or techniques, or mis-
guided patient expectations.40 Another group of patients
may have excellent relief of their symptoms after the
index surgery, but then develop neuro-claudication as
the lumbar degenerative process progresses.
The duration of any symptom-free interval after lum-
bar surgery may indicate the nature of the pathology
responsible for the patient’s symptoms.10 In patients
without any substantial improvement or temporary im-
provement in neurogenic symptoms after spine surgery,
contributing factors may include an incorrect presurgical
diagnosis, inadequate neural decompression, or psycho-
logical and social secondary gain issues. For the patients
who have a pain-free interval of weeks to months, with
subsequent development of neurogenic symptoms, the
clinician should consider a diagnosis of recurrent disc
herniation, battered root, arachnoiditis, or psychological
and social secondary gain issues. When neurogenic
symptoms recur after a pain-free interval of months to
years, recurrent spinal stenosis, disc herniation, or adja-
cent level spinal stenosis should be considered.
Patients with symptomatic neural compression typi-
cally present with lower extremity symptoms that are
greater than axial low back pain, although these symp-
toms frequently coexist. In the absence of profound or
progressive neurologic deficits, most patients should be
treated nonoperatively. Additional intervention may be
justified for patients with well-defined, discrete pathol-
ogy amenable to surgical correction who have been re-
fractory to conservative care. If the patient’s primary
symptoms are neurogenic, any further surgery should be
directed at relieving the nerve compression. The patient
should have an understanding of the specific goals for
any decompressive procedures. Arthrodesis should not
be performed merely because the previous surgery failed,
2547
2548 Spine • Volume 27 • Number 22 • 2002
and should be considered only for patients with docu-
mented deformity, instability, or concurrent discogenic
pain.
The radiographic workup of a patient with neuro-
genic symptoms after prior lumbar surgery is challeng-
ing. Plain radiographs will show the bony extent of the
prior surgery, and may show degenerative changes, in-
stability, or deformity. Computed tomography (CT)
scan after myelography is useful for demonstrating bony
compression of the neural elements, and may be partic-
ularly helpful for visualizing the subarticular zone and
the neural foramens.24 Magnetic resonance imaging
(MRI) is useful for visualizing bony and soft tissue pa-
thologies that may cause spinal stenosis. Direct visual-
ization of the neural elements afforded by MRI may as-
sist in evaluating the source of symptoms in the
previously operated spine.3,6,34,35 Gadolinium enhance-
ment of the MRI is useful for differentiating scar tissue
from disc herniation.35 Although epidural scar tissue is
seen frequently on a postsurgical MRI scan, it seldom is
the source of the patient’s symptoms.42 Imaging studies
should be evaluated carefully for other potentially re-
versible causes of neural compression before any symp-
toms are attributed to postsurgical epidural fibrosis. Af-
ter failed lumbar surgery, provocative testing for pain
generators may provide additional useful information.
This article will discuss patients with chronic pain of
spinal origin after prior lumbar surgery that results from
inadequate decompression, progressive degenerative spi-
nal stenosis, persistent radiculopathy with perineural
scarring, spinal stenosis adjacent to lumbar fusion, failed
discectomy, or postdecompression deformity with spinal
stenosis.
Inadequate Decompression
Failure to perform adequate decompression during the
initial surgery is an avoidable cause of failed back sur-
gery syndrome. In the authors’ experience, failure usu-
ally results from inaccurate diagnosis, unfamiliarity with
the anatomic structures causing neural compression, or
inappropriate limitation of the decompression for fear of
destabilizing the motion segment. When performing
such surgery, the surgeon must adequately decompress
the involved neural structures. When decompression ren-
ders the spine unstable, the surgeon should be prepared
to proceed with lumbar arthrodesis. Determining what
constitutes instability resulting from surgical interrup-
tion of the various motion segment stabilizers is impre-
cise, but the results of biomechanical studies may pro-
vide some objectivity for this determination.1,4 The
extent of bony resection performed can assist the sur-
geon in making an intraoperative decision as to whether
arthrodesis should be performed after laminectomy.
Abumi et al1 found that experimental division of the
interspinous ligament alone did not increase sagittal mo-
tion, but that removal of more than 50% of the facets at
a particular level or complete unilateral facetectomy re-
sults in significant instability. Boden et al4 reported that
destruction of the facet capsule and articular cartilage
significantly destabilized the motion segment. In addi-
tion, the intact pars interarticularis plays an important
role in maintaining stability and should not be inadver-
tently disrupted during decompression.
Patients that have had inadequate neural decompres-
sion may have ongoing claudication symptoms or incom-
plete relief of these symptoms after the initial surgery. If
the patient’s symptoms are likely related to inadequate
neural decompression, the surgeon should consider pro-
ceeding to adequate decompression of the neural ele-
ments. The zones inadequately decompressed most fre-
quently are the lateral recesses and neural foramens24,25
(Figure 1).
Progressive Degenerative Spinal Stenosis
After successful lumbar surgery, spinal stenosis may de-
velop over time as the degenerative condition advances.
Stenosis may occur at the level of the prior surgery, or at
any other lumbar level.32 Management of recurrent spi-
nal stenosis should be approached in a fashion similar to
that for primary spinal stenosis. Appropriate nonopera-
tive treatment should be instituted initially. Surgery
should be considered only after failure of nonsurgical
treatment for patients whose signs and symptoms are
explained adequately by the findings on the imaging
studies.
Conflicting results for repeat lumbar decompressive
surgery have been reported.2,15,19,27,41 Herno et al15 re-
ported worse results for patients undergoing repeat sur-
gery to correct spinal stenosis than for those undergoing
a first spinal stenosis surgery, even when the diagnosis
was confirmed with preoperative myelography. In con-
trast, Turner et al41 reported a meta-analysis of the liter-
ature on lumbar stenosis, noting that there was no asso-
ciation between outcome and previous lumbar surgery.
Biondi and Greenberg2 reported that after revision de-
compression surgery, poor outcomes were associated
with a pain-free interval shorter than 6 months after the
previous operation, negative psychosocial characteris-
tics, and a diagnosis of fibrosis as the pain generator. The
variations in outcomes in these studies probably reflect
differing patient populations, preoperative diagnoses,
surgical techniques, follow-up protocol, and criteria for
success.
In a prospective study, Jonsson and Stromqvist18 eval-
uated patients with documented neural compression af-
ter prior lumbar surgery. In all the patients, the leg pain
was worse than the back pain. Two years after repeat
decompressive surgery, among the 19 patients who had
central spinal stenosis, the results were found to be ex-
cellent in 7 patients, fair in 7 patients, unchanged in 4
patients, and worse in 1 patient. Among the 18 patients
who had lateral recess stenosis, the outcome was excel-
lent in 12 patients, fair in 4 patients, and unchanged in 2
patients. In no case was an arthrodesis performed. Sta-
tistical evaluation showed significantly better results for
patients with single root involvement or a pain-free in-

terval after the previous operation. Sciatica caused by
perineural scarring was seldom improved by repeat sur-
gery. These data suggest that acceptable clinical out-
comes can be obtained in carefully selected patients who
require an additional decompressive procedure.
Persistent Radiculopathy With Perineural Scarring
Patients with postsurgical neuropathic pain and perineu-
ral scarring without other structural neurocompressive
Managing Chronic Pain • Phillips and Cunningham 2549
Figure 1. A 72-year-old woman presented 9 months after a
lumbar decompressive surgery with ongoing severe neuro-
genic claudication. Imaging studies showed inadequate
neural decompression. The patient subsequently underwent
repeat decompressive surgery with relief of her symptoms.
A, Myelogram showing limited midline decompression of L4,
with failure to address spinal stenosis at L3–L4. The prior
midline laminectomy at L4 (open arrow) and the cutoff of the
myelographic dye column cranial to the decompressed level
(solid arrow) are seen. B, Computed tomography myelogram at
L4 –L5 showing inadequate midline neural decompression
(small arrow) and ongoing lateral recess stenosis secondary to
facet hypertrophy (large arrow) that was not addressed at
prior surgery. C, Computed tomography myelogram showing
unaddressed foraminal stenosis at L3–L4 (arrow).
pathologies are not candidates for further surgical de-
compression. Perineural scarring occurs after most spi-
nal decompressive procedures, but it is thought to be an
extremely uncommon cause of clinical failure.5,39 Fac-
tors suggested as contributors to scarring include exces-
sive neural retraction, excessive bleeding, conjoined
nerve roots, and the use of cottonoid patties.17 Perineu-
ral scarring may play a role in the battered root syn-
drome that typically presents with incomplete resolution
2550 Spine • Volume 27 • Number 22 • 2002
of sciatica and increasing radicular symptoms over 3 to 6
months from the time of surgery. At this writing, no form
of surgical treatment or adhesion lysis procedure for this
diagnosis has proved to be safe and effective.47
Spinal Stenosis Adjacent to Lumbar Fusion
Although lumbar fusion successfully eliminates motion
across the treated segment, it has been shown to induce
alterations in load bearing and stresses in adjacent un-
fused motion segments.22,33 A cadaveric study by Quin-
nell and Stockdale33 showed that the levels immediately
adjacent to the fusion accommodate the motion that had
occurred previously at the level of surgery. Clinical stud-
ies have suggested that the alterations in adjacent seg-
ment biomechanics lead to accelerated degenerative
changes and clinical disorders.9,21,23 Lehmann et al23 re-
ported on patients followed a minimum of 21 years after
lumbar fusion. Using radiographic criteria, these authors
found a 42% incidence of adjacent segment stenosis and
a 45% incidence of adjacent segment instability, defined
as anterolisthesis or retrolisthesis of 3 mm or more on
flexion– extension radiographs, except for 5 mm of re-
trolisthesis required at L5–S1, during a median fol-
low-up of 33 years from the time of the lumbar fusion.
Neither the radiographic stenosis nor the instability cor-
related with the clinical symptoms, and repeat lumbar
surgery was performed for only 4.8% of the patients.
Hambly et al12 reported that during a 22-year follow-up
period after lumbar fusion, degenerative changes oc-
curred at the second segment above the lumbar fusion
with frequency equal to that seen at the adjacent level.
They reported no significant difference in radiographic
changes between these patients and a cohort who had
not had surgery. The effects of modern rigid instrumen-
tation and postoperative sagittal imbalance on adjacent
level degeneration are uncertain.
Few studies have reported the results of decompres-
sive surgery directed at spinal stenosis adjacent to a prior
lumbar fusion. Whitecloud et al45 reported on 12 pa-
tients with previous lumbar fusions who underwent de-
compression and fusion of stenotic adjacent segments.
The duration of follow-up evaluation was not provided.
No patient had an excellent result, and 9 of the 12 pa-
tients had fair or poor outcomes. Schlegel et al37 reported
on 58 patients who underwent surgery at lumbar levels
adjacent to previously asymptomatic thoracolumbar or
lumbar fusions. For 37 of these patients, 2-year fol-
low-up data were available. Of the 37 patients, 26 had
good or excellent results 2 years after the surgery. How-
ever, no follow-up outcome data beyond 2 years was
provided. In addition, 7 of the 37 patients required a
subsequent lumbar operation. Patients for whom arthro-
desis was performed at the time of the adjacent segment
surgery tended to have better results.
Phillips et al31 recently reported on 26 patients fol-
lowed for 3 to 14 years (mean, 5 years) after decompres-
sive surgery for spinal stenosis at levels adjacent to a
prior lumbar fusion. In all cases, neurogenic claudication
Table 1. Failures After Discectomy
Sciatica Low Back Pain
Retained disc fragment “Degenerative disc disease”
Recurrent herniated disc Instability/deformity
New level
Same level
Unaddressed bony stenosis
Epidural fibrosis/arachnoiditis
was the primary surgical indication. The mean interval
between fusion surgery and the adjacent segment decom-
pressive surgery was 8 years. On a questionnaire com-
pleted independently by the patients, 15 of the 26 pa-
tients (58%) rated the surgical outcome as completely
satisfactory; 6 patients were neutral toward the surgery;
and 5 patients considered their surgery a failure. The
surgery was generally effective at improving or relieving
lower extremity neurogenic claudication. The strongest
independent predictive factor of patient dissatisfaction
was ongoing postoperative low back pain. Of the 26
patients, 6 required further lumbar surgery during the
follow-up period to address neurocompressive pathol-
ogy or pseudarthrosis. The authors emphasized the im-
portance of addressing stenosis at all involved lumbar
levels, and also suggested a role for instrumented fusion
of the decompressed adjacent segments.
Failed Discectomy
For patients who experience little or no improvement in
sciatic symptoms after a discectomy, retained disc mate-
rial or inadequate bony decompression should be sus-
pected and addressed (Table 1). If sciatica develops after
an asymptomatic period subsequent to discectomy, a re-
current or new-level disc herniation should be consid-
ered. Reported rates for recurrent disc herniation range
from 4% to 12%.43,46
No studies have dealt specifically with nonsurgical
management of a recurrent disc herniation. Surgical se-
lection criteria as stringent as those suggested for surgical
treatment of primary disc herniations should be applied
to patients with sciatica after a prior lumbar discectomy.
These criteria include persistent sciatica nonresponsive
to appropriate conservative treatment, progressive neu-
rologic deficit, and cauda equina syndrome. For investi-
gating the source of sciatica in patients who have had
prior disc surgery, MRI is a useful study. Postgadolinium
injection MRI is useful for differentiating disc material
from scar tissue, with scar tissue showing enhance-
ment.35 It is, however, important to realize that in the
first few months after discectomy, it can be difficult to
differentiate typical postsurgical changes from a recur-
rent or retained disc herniation on MRI.3,6
The literature supports acceptable relief of sciatica and
high patient satisfaction after repeat discectomy with doc-
umented recurrent disc herniation.7,13,16,18,20,30,44 In a
retrospective study, Herron16 evaluated 46 patients who
after previous discectomy were treated for herniated
 Managing Chronic Pain • Phillips and Cunningham 2551

Figure 2. A 62-year-old woman who had a prior L4 –L5 decompression and in situ local bone graft arthrodesis. Postoperative spondylolis-
thesis developed, represented with back pain and neurogenic claudication. The patient was treated with a L3–L5 posterolateral
instrumented fusion and a L4 –L5 transforaminal lumbar interbody fusion with a good clinical outcome. Lateral (A) and anteroposterior (B)
radiographs performed 2 years after L4 –L5 decompression show the development of a Grade 3 L4 –L5 spondylolisthesis. Note the
complete-parts interarticularis removal. C, Computed tomography myelogram showing complete removal of the facets and pars at L4 –L5.
D, Lateral radiograph after the patient was treated with an L3–L5 posterolateral fusion and an L4 –L5 transforaminal lumbar interbody
fusion.

discs with repeat discectomy (at a mean of more than 7
years after previous discectomy). They found that 37 of
the herniations were recurrences, with 13 herniations
occurring at a different level. After repeat discectomy,
69% of the patients had a good clinical outcome. Pa-
tients with work-related injuries and those involved in
litigation had less favorable outcomes. In a prospective
study of 19 patients with recurrent disc herniations, Jon-
sson and Stromqvist18 reported excellent results after re-
decompression in 16 patients. Patel et al30 retrospec-
tively reviewed 41 patients who underwent surgical
exploration for recurrent or persistent sciatica after disc-
ectomy. In 33 patients, disc reherniations were identified.
Of the 33 patients with a reherniation, 19 presented with
persistent or recurrent sciatica within 1 year of their first
operation, and the remaining 14 patients presented with
2552 Spine • Volume 27 • Number 22 • 2002
a late reherniation (after 1 year). The results of repeat
discectomy for the patients with late reherniation were
better than the outcome for the patients with early reher-
niation, and were comparable with the satisfactory out-
come rate of 80% to 95% after primary lumbar discec-
tomy reported in the literature. Weir and Jacobs44
reported on 102 patients who had revision discectomy
and noted outcomes similar to the results reported for
first-time discectomy. Ebeling et al7 reported a satisfac-
tory outcome rate of 81% with microsurgical reopera-
tion after lumbar disc surgery.
Postdecompression Deformity and Spinal Stenosis
Lumbar spinal deformity such as scoliosis or listhesis
may contribute to a reduction in the space available for
the neural elements and neurogenic symptoms.8,11 Neu-
ral compression also may be seen with advanced inter-
vertebral disc degeneration and loss of disc height result-
ing in foraminal narrowing.28 Failure to address an
existing deformity at the time of initial decompression
may result in persistence of low back or neurogenic
symptoms. In other patients a deformity may develop de
novo, or there may be progression of an existing defor-
mity after decompressive surgery. These patients typi-
cally have a period of relief after the decompression, with
development of back pain and associated lower extrem-
ity radiating pain months to years later.29
In patients with lumbar spinal deformity and claudi-
cation symptoms after prior decompressive surgery, it is
difficult to predict which, if any, of the symptoms are
attributable to the deformity, and therefore which pa-
tients might benefit from further surgery. Comprehen-
sive radiographic and provocative testing often is re-
quired to confirm the symptom generators. Progression
of deformity in a patient with low back pain or neuro-
genic symptoms has been suggested as a surgical indica-
tion. The indications for surgical intervention are less
clear in symptomatic patients with nonprogressive defor-
mity after prior decompression.8
In treating a patient after failed lumbar surgery with
spinal stenosis and deformity, it may be necessary to
reduce or stabilize the deformity to relieve the neural
compression effectively and prevent deformity progres-
sion (Figure 2). In a series of 20 patients with postlami-
nectomy instability treated with revision laminectomy
and fusion, Sano et al36 reported relief of symptoms in 18
patients. Nooraie et al26 reported on 12 patients with
postlaminectomy spondylolisthesis who were treated
with redecompression and instrumented intertransverse
arthrodesis. The authors noted fusion rates of 100% for
all the patients with satisfactory results. Although these
studies are retrospective, with small patient numbers,
they suggest that acceptable results may be obtained with
arthrodesis and redecompression of selected patients
who have postlaminectomy instability.
Hansraj et al14 reported on 47 patients with complex
spinal stenosis, 31 of whom had undergone previous
lumbar surgery. The 31 patients presented with spinal
stenosis and deformity, typically scoliosis. All were
treated with redecompression and instrumented postero-
lateral arthrodesis. Overall, more than 90% of the pa-
tients were satisfied with the operation, their ability to
walk, and their spinal balance. In such patients, the use
of spinal instrumentation is helpful both to promote fu-
sion and to assist in indirect neural decompression.38
In general, during reoperation for deformity after prior
decompressive surgery, the authors believe that the
deformity should be stabilized with an instrumented
arthrodesis.
Conclusion
In a patient presenting with neurogenic symptoms after
prior lumbar surgery, a meticulous workup is required to
elucidate the source of these symptoms. Surgical indica-
tions are similar to those for primary lumbar spinal sur-
gery and include a well-defined anatomic source of neu-
ral compression, which is amenable to a surgical
solution. The surgeon must be cognizant of the patient’s
comorbidities and psychological well-being because re-
vision surgery may be a large undertaking with signifi-
cant risk of complications. In addition, the patient
should have realistic expectations for the surgical out-
come, understanding that relief of neurogenic symptoms
will be more reliably predicted than relief of axial pain.
References
1. Abumi K, Panjabi MM, Kramer KM, et al. Biomechanical evaluation of
lumbar spinal instability after graded facetectomies. Spine 1990;15:1142–7.
2. Biondi J, Greenberg BJ. Redecompression and fusion in failed back syndrome
patients. J Spinal Disorder 1990;3:362–9.
3. Boden SD, Davis, DO, Dina TS, et al. Contrast-enhanced MR imaging per-
formed after successful lumbar spine disk surgery: Prospective study. Radi-
ology 1992;182:59 – 64.
4. Boden SD, Martin C, Rudolph R, et al. Increase of motion between lumbar
vertebrae after excision of the capsule and cartilage of the facets: A cadaver
study. J Bone Joint Surg Am 1994;76:1147–53.
5. Burton CV, Kirkaldy-Willis WH, Heithoff KB, et al. Causes of failure of
surgery in the lumbar spine. Clin Orthop Rel Res 1981;157:191–9.
6. Deutsch AL, Howand N, Dawson EG, et al. Lumbar spine following success-
ful surgical discectomy: Magnetic resonance imaging features and indica-
tions. Spine 1993;18:1054 – 60.
7. Ebeling V, Kalbarcyk H, Rueben HJ. Microsurgical reoperation following
lumbar disc surgery: Timing, surgical findings, and outcome in 92 patients.
J Neurosurg 1989;70:397– 404.
8. Frazier DD, Lipson SJ, Fossel AH, et al. Associations between spinal defor-
mity and outcomes after decompression for spinal stenosis. Spine 1997;22:
2025–9.
9. Frymoyer JW, Hanley E, Howe J, et al. A comparison of radiographic find-
ings in fusion and nonfusion patients ten or more years following lumbar disc
surgery. Spine 1979;4:435– 40.
10. Gill K, Frymoyer JW. Management of treatment failures after decompressive
surgery: Surgical alternatives and results. In: Frymoyer JW, ed. The Adult
Spine: Principles and Practice. 2nd ed. Philadelphia: Lippincott-Raven,
2111–33.
11. Grubb SA, Lipscomb HJ, Suh PB. Results of surgical treatment of painful
adult scoliosis. Spine 1994;19:1619 –27.
12. Hambly MF, Wiltse LL, Raghavan N, et al. The transition zone above a
lumbosacral fusion. Spine 1998;23:1785–92.
13. Hanley EN, Shapiro DE. The development of low back pain after excision of
a lumbar disc. J Bone Joint Surg Am 1989;71:719 –21.
14. Hansraj KK, O’Leary PF, Cammisa FP, et al. Decompression, fusion, and
instrumentation surgery for complex lumbar spinal stenosis. Clin Orthop
Rel Res 2001;384:18 –25.
15. Herno A, Airaksinen O, Soari T, et al. Surgical results of lumbar spinal

stenosis: A comparison of patients with or without previous back surgery.
Spine 1995;20:964 –9.
16. Herron L. Recurrent lumbar disc herniation: Results of repeat laminectomy
and discectomy. J Spinal Disorder 1994;71:161– 6.
17. Hoyland JA, Freemont AJ, Denton J, et al. Retained surgical swab debris in
postlaminectomy arachnoiditis and peridural fibrosis. Spine 1989;14:659 – 62.
18. Jonsson B, Stromqvist B. Repeat decompression of lumbar nerve roots: A
prospective two-year evaluation. J Bone Joint Surg Br 1993;75:894 –7.
19. Kim SS, Michelsen CB. Revision surgery for failed back surgery syndrome.
Spine 1992;17:957– 60.
20. Law JD, Lehman RAW, Kirsch WM. Reoperation after lumbar interverte-
bral disc surgery. J Neurosurg 1978;48:259 – 63.
21. Lee CK. Accelerated degeneration of the segment adjacent to a lumbar fu-
sion. Spine 1988;13:375–7.
22. Lee CK, Langrana NA. Lumbosacral spine fusion: A biomechanical study.
Spine 1984;9:574 – 81.
23. Lehmann TR, Spratt KF, Weinstein JN, et al. Long-term follow-up of lower
lumbar fusion patients. Spine 1987;12:97–104.
24. McAfee PC, Ullrich CG, Yuan HA, et al. Computed tomography in degen-
erative spinal stenosis. Clin Orthop 1981;161:221–34.
25. Naylor AJ. Factors in the development of the spinal stenosis syndrome. Bone
Joint Surg Br 1979;61:306 –9.
26. Nooraie H, Taghipour A, Arasteh MM. Lumbar spine fusion with pedicle
fixation with C-D screws for lumbar iatrogenic instability. Arch Orthop
Trauma Surg 1997;116:236 – 8.
27. North RB, Campbell JN, James CS, et al. Failed back surgery syndrome:
5-year follow-up in 102 patients undergoing repeated operation. Neurosur-
gery 1991;28:685–91.
28. Nowicki BH, Haughton VM, Schmidt TA, et al. Occult lumbar lateral spinal
stenosis in neural foramina subjected to physiologic loading. Am J Neuro-
radiol 1996;17:1605–14.
29. Oxner WM, Kang JD. Iatrogenic instability of the lumbar spine. Semin Spine
Surg 2001;13:47–56.
30. Patel N, Pople I, Cummins B. Revisional lumbar microdiscectomy: An anal-
ysis of operative findings and clinical outcome. Br J Neurosurg 1995;9:
733–7.
31. Phillips FM, Carlson GD, Bohlman HH, et al. Results of surgery for spinal
stenosis adjacent to previous lumbar fusion. J Spinal Disord 2000;13:432–7.
32. Postacchini F, Cinott G. Bone regrowth after surgical decompression for
lumbar spinal stenosis. J Bone Joint Surg Br 1992;74:862–9.
Managing Chronic Pain • Phillips and Cunningham 2553
33. Quinnell RC, Stockdale HR. Some experimental observations of the influ-
ence of a single lumbar floating fusion on the remaining lumbar spine. Spine
1981;6:236 – 67.
34. Ross JS, Masaryk TJ, Modic MT, et al. Lumbar spine postoperative assess-
ment with surface-coil MR imaging. Radiology 1987;164:851– 60.
35. Ross JS, Masaryk TJ, Schrader M, et al. MR imaging of the postoperative
lumbar spine: Assessment with gadopentetate dimeglumine. AJR Am J
Roentgenol 1990;155:867–72.
36. Sano S, Yokokura S, Nagata Y, et al. Unstable lumbar spine without hyper-
mobility in postlaminectomy cases: Mechanism of symptoms and effects of
spinal fusion with and without instrumentation. Spine 1990;15:1190 –7.
37. Schlegel JD, Smith JA, Schleusener RL. Lumbar motion segment pathology
adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Spine 1996;
21:970 – 81.
38. Simmons ED, Simmons EH. Spinal stenosis with scoliosis. Spine 1992;17S:
117–20.
39. Spangfort EV. The lumbar disc degeneration: A computer-aided analysis of
2504 operations. Acta Orthop Scand Suppl 1972;142:1–95.
40. Spengler D, Freeman C, Westbrook R, et al. Low back pain following multiple
lumbar spine procedure: Failure of initial selection? Spine 1980;5:356 – 60.
41. Turner JA, Ersek M, Herron L. Surgery for lumbar spinal stenosis: At-
tempted meta-analysis of the literature. Spine 1992;17:1–7.
42. Vogelsang JP, Finkenstaedt M, Vogelsang M, et al. Recurrent pain after
lumbar discectomy: The diagnostic value of peridural scar on MRI. Eur
Spine J 1999;8:475–9.
43. Waddell G. Failure of disc surgery and repeat surgery. Acta Orthop Belg
1987;53:300 –2.
44. Weir BK, Jacobs GA. Reoperation rate following his lumbar discectomy: An
analysis of 662 lumbar discectomies. Spine 1980;5:366 –70.
45. Whitecloud TS, Davis JM, Olive PM. Operative treatment of the degenerated
segment adjacent to a lumbar fusion. Spine 1994;19:531– 6.
46. Wiesel SW, Boden SD, Lauerman WC. The multiple operated low back: An
algorithmic approach. In: Herkowitz HN, Garfin SR, Balderston RA, et al,
eds. Rothman-Simeone the Spine, 4th ed. Philadelphia: WB Saunders, 1999:
1741– 8.
47. Wilkinson HA. Alternative therapies for the failed back syndrome. In: Fry-
moyer JW, ed. The Adult Spine: Principles and Practice, 2nd ed. Philadel-
phia: Lippincott-Raven, 1991:2069 –91.