My Back Still Hurts After Surgery.What Do I Do Now?
BACK PAIN SERIES — PART 4 OF 4
This is Part 4 of a four-part series we are working on. Each will be linked as they are published online.
Part 1 covers what is the best non-surgical treatment for back pain.
Part 3 covers what you need to think about before you have a back surgery.
By Dr. Matthew Wilson, DC, FIACA | Ashworth Chiropractic, Physical Therapy & Acupuncture | West Des Moines, Iowa
This is one of the most difficult situations in musculoskeletal medicine — and one of the most common ones nobody talks about.
You had surgery. You did what the surgeon recommended. You went through the procedure, the recovery, the post-surgical rehabilitation. And you still hurt. Maybe differently than before, maybe in the same place, maybe somewhere new. But the relief you were hoping for — the relief you were told was likely — didn’t come. Or it came partially, or for a while, and then it faded.
Low back pain after surgery is a very common but unfortunate circumstance.
You are not alone. And you are not imagining it.
Based on articles retrieved from PubMed, estimates from randomized controlled trials indicate that 5 to 50 percent of patients may have an unsuccessful outcome following lumbar spinal surgery. The condition is so common it has its own medical term: Failed Back Surgery Syndrome — FBSS. More recently it has been renamed Persistent Spinal Pain Syndrome Type 2 (PSPS-Type 2), a terminology shift that better reflects the complex, multifactorial nature of what’s happening.
This post is about what to do when you’re in that situation. Why it happens, what conservative care can actually accomplish, and what the honest path forward looks like.
How Common Is This — and Why Doesn’t Anyone Talk About It?
Based on articles retrieved from PubMed, a review published in the British Journal of Pain (Taylor & Taylor, 2012) found that the impact of FBSS on an individual’s health-related quality of life is more disabling than other common chronic conditions including heart failure and motor neuron disease. The same review noted that despite advances in surgical technology and increasing rates of spine surgery, a proportion of individuals continue to suffer — and the understanding of why remains incomplete.
This doesn’t get discussed more openly for several reasons. Surgical outcomes research tends to focus on procedure success rates rather than patient satisfaction rates. Patients often blame themselves — assuming they didn’t recover correctly, didn’t do enough PT, or simply have a pain tolerance problem. And the medical system, having delivered the structural fix, sometimes doesn’t have a clear next step for the patient who didn’t get better.
We do. That’s what this post is about.
Taylor RS, Taylor RJ. The economic impact of failed back surgery syndrome. Br J Pain. 2012;6(4):174-181. DOI: https://doi.org/10.1177/2049463712470887
Why Back Surgery Sometimes Doesn’t Work — The Real Reasons
Understanding why you’re still in pain after surgery is the first step toward doing something about it. The causes fall into several categories — and identifying which one applies to your situation shapes the treatment approach entirely.
Based on articles retrieved from PubMed, a 2024 review published in Pain Practice (van de Minkelis et al.) categorized the origins of persistent post-surgical spinal pain as follows:
Inappropriate Procedure or Wrong-Level Surgery
Sometimes the surgery was performed at a level that wasn’t the primary pain generator — a disc at L4-5 was operated on when the real driver was the facet joints, the sacroiliac joint, or a level above or below. Or the patient’s pain had a significant central sensitization component that structural surgery alone couldn’t address. The imaging finding that prompted surgery was real, but it wasn’t the source of the pain.
This happens in part because imaging is not a direct map of pain. Based on articles retrieved from PubMed, a systematic review of 33 studies covering 3,110 pain-free adults published in the American Journal of Neuroradiology (Brinjikji et al., Mayo Clinic, 2015) found disc degeneration in 37% of asymptomatic 20-year-olds — rising to 96% of pain-free 80-year-olds. Disc protrusion was present in 29% of asymptomatic 20-year-olds. The authors’ conclusion: many imaging findings are part of normal aging and unassociated with pain. An MRI is a static image taken with the spine in an unloaded, supine position. It shows anatomy. It does not identify the pain generator.
A common scenario we see regularly in our clinic: a patient with sciatica-like leg pain, a disc herniation on MRI, a surgical referral — and on clinical examination, the real driver is hip misalignment, piriformis syndrome, or soft tissue movement patterns that have progressively compressed the sciatic nerve through the surrounding tissue. The disc is real on the MRI. But it is secondary — a complicating finding, not the pain generator. What a thorough neurological and orthopedic physical examination reveals is different from what imaging alone shows. When surgery proceeds based primarily on imaging findings without adequate clinical correlation, this category of FBSS is the predictable result.
This is also why we spend real time in our office doing exactly that clinical examination — before any imaging is interpreted and before any surgical decision is endorsed. The picture and the clinical story need to match. When they don’t, the picture should be questioned, not accepted as the final answer.
Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. DOI: https://doi.org/10.3174/ajnr.A4173
This is more common than patients are told, and it underlies some of the most frustrating post-surgical presentations — where the surgical site looks clean on post-op imaging but the patient’s pain is unchanged.
Technical Failure
This includes situations where the surgical goals weren’t fully achieved: incomplete decompression, a retained disc fragment, pseudoarthrosis (failure of a fusion to solidly heal), or hardware complications. These are structural issues that may require revision surgery — and they need to be identified on imaging before conservative care is pursued, because the treatment approach is fundamentally different.
Biomechanical Sequelae of Surgery
Surgery changes the mechanics of the spine. Fusion eliminates motion at one level and increases stress at adjacent levels — a well-documented phenomenon called adjacent segment disease. Fusion to the sacrum alters sacroiliac joint mechanics. Laminectomy changes the load distribution across posterior structures. Muscle retraction during surgery causes denervation and atrophy of the paraspinal muscles that support the spine.
These biomechanical consequences can produce new pain — distinct from the original complaint — that emerges in the months and years following surgery. They often respond well to targeted rehabilitation and manual care, which is why this category is one of the most treatable.
Surgical Complications
These include epidural fibrosis — scar tissue formation around the nerve roots that causes ongoing compression and irritation — battered root syndrome from nerve root trauma during surgery, and arachnoiditis, an inflammatory condition of the membrane surrounding the spinal cord. These are genuine structural complications that require specific management approaches.
Central Sensitization
This is perhaps the most underappreciated cause of post-surgical pain persistence — and the one most commonly overlooked. Central sensitization is the process by which the nervous system becomes hypersensitive to pain signals after prolonged chronic pain exposure. The brain and spinal cord essentially get ‘tuned up’ to amplify pain signals, and that tuning doesn’t automatically reset when the structural problem is surgically corrected.
A patient who lived with significant disc-related pain for two years before surgery has a nervous system that has been in high-sensitivity mode for two years. That doesn’t normalize in six weeks of post-surgical healing. Addressing central sensitization requires specific approaches — including graded exercise, pain education, behavioral strategies, and sometimes acupuncture or other neuromodulatory treatments.
van de Minkelis J, et al. Persistent spinal pain syndrome type 2. Pain Pract. 2024;24(7):919-936. DOI: https://doi.org/10.1111/papr.13379
The most important thing to understand: continued pain after surgery is almost never ‘all in your head.’ It is a real physiological phenomenon with identifiable causes — and in most cases, a meaningful path forward exists. The question is which cause applies to your situation and what approach it calls for.
What the Evidence Says About Treatment After Failed Back Surgery
Based on articles retrieved from PubMed, a 2023 umbrella systematic review published in Spine Surgery and Related Research (Gallego et al.) — reviewing systematic reviews and randomized controlled trials on treatment effectiveness for FBSS — concluded that the therapeutic approach must be individualized, and that treatment should start with conservative management before escalating to more invasive interventions.
That conclusion matters. Even in the peer-reviewed surgical literature, conservative care is recognized as the appropriate starting point for most FBSS presentations. The post-surgical patient who hasn’t yet had a structured, targeted conservative care program has not yet exhausted their options.
Gallego H, et al. Treatment Options for Failed Back Surgery Syndrome: An Umbrella Systematic Review. Spine Surg Relat Res. 2023;8(2):143-154. DOI: https://doi.org/10.22603/ssrr.2023-0032
What Conservative Care Can Actually Do After Surgery
Not everything. We won’t pretend otherwise. But for many of the causes listed above — biomechanical sequelae, central sensitization, muscle dysfunction, adjacent segment stress, residual soft tissue restriction — conservative care is genuinely effective. Here’s how we approach post-surgical back pain at Ashworth:
Targeted Physical Therapy — Rebuilding What Surgery Didn’t Fix
Surgery corrected a structural problem. What it didn’t do is rebuild the muscular support system, restore normal movement patterns, or address the compensations the body built over years of pain. Those things require targeted, progressive rehabilitation.
Kelly Brown Gross, PT, MPT, WCS designs individualized post-surgical rehabilitation programs built around your specific surgical history, your current functional deficits, and your goals. This is not a generic post-surgical exercise program. It’s an assessment of what your body is actually doing — and a targeted plan to address what it isn’t doing correctly.
For patients who did post-surgical PT at a hospital outpatient clinic and plateaued — this is often where we see the most meaningful progress. The specialization level matters. The amount of individualized attention matters. Kelly sees one patient at a time for 45 minutes. That’s a fundamentally different experience than a shared session in a gym-style clinic.
Postural Restoration — Addressing Biomechanical Sequelae
The biomechanical changes that surgery creates — altered load distribution, adjacent segment stress, sacroiliac joint dysfunction after lumbar fusion — respond particularly well to Postural Restoration (PRI) work. PRI identifies and addresses the asymmetrical movement patterns and pelvic positioning that place uneven stress on the post-surgical spine, and systematically trains more balanced movement.
This is specialized work. Dr. Matt’s PRI training is directly relevant to post-surgical patients dealing with adjacent segment issues, pelvic dysfunction, or the mechanical consequences of altered spinal biomechanics after fusion or decompression.
Chiropractic Care — Appropriate to the Post-Surgical Spine
Post-surgical chiropractic requires a different approach than pre-surgical care. High-velocity, low-amplitude thrust manipulation at a fused or recently operated level is generally not appropriate. But that represents a small fraction of what chiropractic care involves.
At Ashworth, post-surgical chiropractic focuses on:
- Mobilization of adjacent segments that are under increased stress due to fusion or altered mechanics
- Lumbar flexion-distraction — gentle, non-thrust traction-based technique that is well-tolerated post-surgically and addresses residual nerve root irritation
- Instrument-assisted adjusting of specific segments where appropriate — lower force, more specific than manual thrust
- Soft tissue work via Graston Technique for the chronic paraspinal tension and scar tissue that accompanies post-surgical presentations
Acupuncture — Neuromodulation for Central Sensitization
For patients whose pain has a significant central sensitization component — where the nervous system is amplifying pain signals beyond what the structural picture would predict — acupuncture is one of the most evidence-supported neuromodulatory tools available without a prescription or invasive procedure.
Dr. Matt holds a Fellowship in Acupuncture (FIACA) and uses acupuncture specifically for its neuromodulatory effects in post-surgical patients with chronic pain, sleep disruption, and sensitization. It is not a cure for central sensitization — but it is a meaningful part of a multimodal approach to reducing the nervous system’s amplified pain response.
Shockwave Therapy — Addressing Soft Tissue Complications
For patients with post-surgical soft tissue complications — chronic trigger points in the paraspinal muscles, tendinopathy in adjacent structures that has developed during the recovery period, or tissue-level changes from immobility and surgical trauma — focused shockwave therapy addresses pathology that manual therapy and exercise alone may not fully resolve.
The biological mechanism is well-established: shockwave stimulates neovascularization, collagen synthesis, and stem cell recruitment in chronically deprived tissue. For post-surgical patients whose soft tissue has been restricted, atrophied, or compromised by the surgical process and recovery, this tissue-level stimulus can produce meaningful improvement in tissue quality and symptom reduction.
Laser Therapy — Reducing Residual Inflammation
Low-level laser therapy at the levels we use at Ashworth has an emerging evidence base for pain modulation and inflammation reduction in chronic post-surgical presentations. It is non-invasive, non-pharmacological, and is used as a component of a comprehensive care plan — not a standalone treatment.
Functional Medicine — When the Answer Is Systemic
Sometimes post-surgical pain persistence has a systemic component that is contributing to poor healing, chronic inflammation, or amplified pain sensitivity. Nutrient deficiencies, hormonal imbalances, gut dysbiosis, and chronic inflammatory states all affect tissue healing and pain processing. Dr. Matt’s functional medicine training allows us to evaluate these factors when the clinical picture suggests a systemic driver — and to address them with targeted, minimally invasive interventions.
What to Realistically Expect — Honest Answers
We want to be straight with you about this, because post-surgical patients have often already been through a process that didn’t deliver what was promised, and they deserve honesty.
- Not all post-surgical pain resolves completely with conservative care. Some structural complications — significant epidural fibrosis, pseudoarthrosis, hardware failure — require further surgical evaluation.
- Central sensitization is treatable but takes time. The nervous system doesn’t reset quickly. Meaningful improvement in centrally sensitized pain typically takes weeks to months of consistent, appropriate treatment.
- Adjacent segment disease is manageable but progressive. We can reduce the mechanical stress on adjacent segments and significantly improve function and reduce pain — but we can’t stop the underlying degenerative process entirely.
- Many post-surgical patients do significantly better with the right conservative approach than they did in their initial post-surgical rehabilitation. We see this regularly.
The patients who do best are those who come in with a complete picture of their surgical history, their imaging, and what they’ve already tried — and who commit to a structured, honest assessment and a plan built around what’s actually driving their ongoing pain.
If you had back surgery and you’re still in significant pain — you have not reached the end of your options. You have reached the end of what that particular path offered. A different approach, applied to what’s actually happening in your specific situation, may produce meaningfully different results.
What to Bring to Your First Appointment
Post-surgical presentations benefit enormously from a complete clinical picture. When you come in, bring:
- Operative report from your surgery — what was done, at what levels, with what hardware if applicable
- Post-operative imaging — MRI or CT after surgery, if you have it
- Pre-operative imaging — for comparison
- A clear description of your current symptoms — where the pain is, what makes it better and worse, how it differs from your pre-surgical pain
- A list of what you’ve tried since surgery and how you responded
The more complete the picture, the more targeted the evaluation — and the more specific the plan we can build.
Common Questions
Is it too soon after surgery to start conservative care?
It depends on the procedure and how your healing is progressing. Most post-surgical patients can begin gentle, appropriate rehabilitation earlier than they expect — often within a few weeks of the procedure. Waiting too long to start movement and rehabilitation is one of the factors that contributes to worse long-term outcomes. We’ll evaluate where you are and what’s appropriate for your specific timeline.
My surgeon says the surgery was a success. Why am I still in pain?
‘Surgical success’ typically refers to the structural goal — the decompression was complete, the fusion is solid, there are no complications on imaging. It does not mean the patient’s pain resolved. These are different things, and the gap between them is exactly what FBSS describes. Your surgeon is likely telling you the truth about the structural outcome. That doesn’t mean the pain isn’t real, or that nothing can be done about it.
Should I get a second surgical opinion?
If revision surgery is being recommended, a second opinion is always reasonable — and most surgeons expect it. The considerations for revision surgery are more complex than for primary surgery, the complication profiles are higher, and the outcomes are more variable. Make sure any revision recommendation is based on a clearly identified correctable structural problem — not simply because the first surgery didn’t provide adequate relief.
Can you work alongside my surgical team?
Yes — and we prefer it. We communicate with referring providers when helpful, and we’ll tell you directly when something we’re seeing suggests you need further surgical evaluation. Our goal is getting you the best outcome, not maintaining a relationship with you as a patient. If the best outcome involves a conversation with your surgeon, we’ll support that.
I’ve already tried physical therapy after my surgery. Why would this be different?
Several reasons. First, the timing and staging of post-surgical rehabilitation matters enormously — generic PT immediately after surgery is different from targeted rehabilitation months later when the picture is clearer. Second, the specialization level matters: Kelly Brown Gross brings over 20 years of orthopedic PT experience and advanced credentials that most post-surgical PT settings don’t have. Third, our integrated approach — combining PT, chiropractic, acupuncture, shockwave, and laser under one coordinated plan — addresses multiple drivers simultaneously rather than one at a time. We regularly see post-surgical patients who plateaued in other settings achieve meaningful improvement here.
Still in pain after back surgery? Let’s figure out why.
Clinical References
The following peer-reviewed studies were retrieved from PubMed and cited in this article.
- Taylor RS, Taylor RJ. The economic impact of failed back surgery syndrome. Br J Pain. 2012;6(4):174-181. DOI: https://doi.org/10.1177/2049463712470887
- van de Minkelis J, et al. Persistent spinal pain syndrome type 2. Pain Pract. 2024;24(7):919-936. DOI: https://doi.org/10.1111/papr.13379
- Gallego H, et al. Treatment Options for Failed Back Surgery Syndrome: An Umbrella Systematic Review of Systematic Reviews on the Effectiveness of Therapeutic Interventions. Spine Surg Relat Res. 2023;8(2):143-154. DOI: https://doi.org/10.22603/ssrr.2023-0032
- Alizadeh R, Sharifzadeh SR. Pathogenesis, etiology and treatment of failed back surgery syndrome. Neurochirurgie. 2021;68(4):426-431. DOI: https://doi.org/10.1016/j.neuchi.2021.09.005
About the Author
Dr. Matthew Wilson, DC, FIACA, CCWP is the lead clinician at Ashworth Chiropractic, Physical Therapy & Acupuncture in West Des Moines, Iowa. He is a Palmer College of Chiropractic honors graduate with advanced training in Postural Restoration (PRI), Graston Technique, acupuncture (FIACA), dry needling, laser therapy, and functional medicine. He works alongside Kelly Brown Gross, PT, MPT, WCS — whose 20+ years of orthopedic physical therapy experience and Women’s Health Certified Specialist designation make Ashworth one of the most credentialed conservative care practices in Iowa for complex post-surgical presentations.
