Persistent Spinal Pain Syndrome (PSPS) is a chronic pain condition characterized by persistent or recurrent spinal pain lasting longer than three months, which may or may not follow spinal surgery or other interventions. PSPS replaces older terms such as “failed back surgery syndrome” to encompass both postoperative and non-surgical chronic spinal pain under one umbrella, improving diagnostic clarity and guiding treatment choices PMCIASP.
Anatomy of the Spine and Pain-Generating Structures
Understanding PSPS begins with the anatomy of the spinal column and its supporting tissues—common sources of chronic pain.
Vertebral Column (Bony Structure)
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Structure & Location: 33 irregular bones (vertebrae) stacked from the skull base to the coccyx, divided into cervical (7), thoracic (12), lumbar (5), sacral (5 fused), coccygeal (4 fused) regions TeachMeAnatomy.
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Blood Supply: Segmental arteries (posterior intercostal, lumbar, iliolumbar, vertebral) branch from the aorta (or vertebral/ascending cervical in the neck), supplying vertebral bodies and arches Kenhub.
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Nerve Supply: 31 pairs of spinal nerves exit via intervertebral foramina, innervating bone, joints, ligaments, and skin.
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Functions:
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Weight bearing
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Protecting the spinal cord
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Facilitating motion (flexion/extension, rotation)
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Shock absorption (with intervertebral discs)
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Attachment for muscles/ligaments
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Transmitting mechanical loads during movement
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Intervertebral Discs
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Structure: Outer annulus fibrosus (collagen ring) surrounding inner nucleus pulposus (gelatinous).
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Blood & Nerve Supply: Avascular in adults; nutrients diffuse through vertebral endplates. Pain fibers penetrate outer annulus only.
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Functions: Cushioning, shock absorption, permitting spine flexibility.
Facet (Zygapophysial) Joints
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Structure & Location: Synovial joints between superior and inferior articular processes of adjacent vertebrae.
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Blood Supply: Branches of dorsal branches of segmental arteries.
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Nerve Supply: Medial branches of dorsal rami.
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Functions: Guiding and limiting spinal motion, providing stability.
Ligaments
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Key Ligaments: Anterior/posterior longitudinal, ligamentum flavum, interspinous, supraspinous.
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Blood & Nerve: Sparse vascularity; sensory fibers in outer fibers contribute to pain when sprained.
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Functions: Limiting excessive motion, protecting spinal cord and discs.
Paraspinal Muscles
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Examples: Multifidus, erector spinae group.
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Origin & Insertion: Span from pelvis/ribs to vertebrae and ribs.
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Blood Supply: Branches from segmental arteries.
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Nerve Supply: Dorsal rami of spinal nerves.
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Functions: Postural support, spinal extension, proprioception.
Types of PSPS
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PSPS Type 1: Chronic spinal pain without prior spinal surgery PMC.
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PSPS Type 2: Persistent or new spinal pain after surgery for back or leg pain (e.g., laminectomy, discectomy, fusion) PMC.
Causes of PSPS
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Muscle or ligament strain from overuse, poor posture, or sudden movements Mayo Clinic
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Bulging or herniated disc pressing on neural structures Mayo Clinic
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Degenerative disc disease due to age-related disc wear Cleveland Clinic
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Facet joint arthritis causing joint inflammation and pain NCBI
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Spinal stenosis narrowing the spinal canal and compressing nerves Verywell Health
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Spondylolisthesis forward slippage of a vertebra causing instability Cleveland Clinic
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Spinal fractures from trauma or osteoporosis leading to persistent pain Mayo Clinic
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Scoliosis creating uneven mechanical stress on spinal structures Mayo Clinic
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Osteoarthritis degenerative wear of spinal joints Mayo Clinic
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Ankylosing spondylitis inflammatory fusion of spinal vertebrae Mayo Clinic
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Sacroiliitis inflammation of the sacroiliac joints Mayo Clinic
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Epidural fibrosis scar tissue enveloping nerve roots after surgery Neuromodulation
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Pseudarthrosis (failed spinal fusion) causing instability and pain Medical News Today
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Adjacent segment disease accelerated degeneration above/below fused levels Wikipedia
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Arachnoiditis inflammation of the spinal arachnoid membrane Wikipedia
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Infection (discitis, osteomyelitis, epidural abscess) producing chronic pain Wikipedia
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Spinal tumors (primary or metastatic) compressing spinal tissues Mayo ClinicVerywell Health
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Osteoporosis-related compression fractures weakening vertebrae Verywell Health
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Psychological factors (depression, anxiety, catastrophizing) amplifying pain perception PMC
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Central sensitization (abnormal pain processing in the nervous system) Wikipedia
Symptoms of PSPS
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Persistent low back pain Wikipedia
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Leg pain or sciatica radiating down the lower limb Wikipedia
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Diffuse, dull aching sensation in the back Wikipedia
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Sharp, pricking or stabbing pain in the extremities Wikipedia
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Numbness in legs or back regions Wikipedia
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Tingling (paresthesia) sensations Texas Back Institute
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Muscle spasms in the back Texas Back Institute
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Limited mobility and stiffness Texas Back Institute
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Weakness in lower extremities Texas Back Institute
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Sleep disturbances/insomnia due to discomfort Texas Back Institute
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Allodynia (pain from non-painful stimuli) Wikipedia
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Hyperalgesia (increased sensitivity to painful stimuli) Wikipedia
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Pain at a different spinal level than the original surgery Wikipedia
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Inability to fully recuperate despite surgery Wikipedia
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Anxiety related to chronic pain Wikipedia
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Depression stemming from persistent pain Wikipedia
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Dependence on pain medications Wikipedia
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Regional weakness or whole-leg weakness on exam PM&R KnowledgeNow
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Exaggerated pain behavior disproportionate to findings PM&R KnowledgeNow
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Change in straight-leg raise test results PM&R KnowledgeNow
Diagnostic Tests for PSPS
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Medical history & physical exam to assess pain characteristics Verywell Health
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Plain X-ray to evaluate bony alignment and hardware Verywell Health
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CT scan for detailed bone imaging and fusion assessment Verywell Health
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MRI to visualize soft tissues, discs, and nerve compression Verywell Health
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Discography (provocative discogram) to pinpoint symptomatic discs Verywell Health
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Myelography (contrast injection) to differentiate scar from re-herniation Wikipedia
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Electromyography (EMG) to detect nerve dysfunction Health
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Nerve conduction studies (NCS) to assess peripheral nerve integrity Health
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Straight-leg raise & distraction tests for nerve tension PM&R KnowledgeNow
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Palpation for tenderness to localize pain generators PM&R KnowledgeNow
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Axial loading test (pain with vertical pressure on the spine) PM&R KnowledgeNow
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Diagnostic epidural or facet joint injections to confirm pain source Neuromodulation
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Radiofrequency neurotomy as both a diagnostic and therapeutic tool Neuromodulation
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Selective nerve root block under imaging guidance Neuromodulation
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Psychological assessment for depression, anxiety, catastrophizing PMC
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Flexion-extension X-rays to detect spinal instability Mayo Clinic
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Bone mineral density (DXA) scan for osteoporosis evaluation Mayo Clinic
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Laboratory tests (ESR, CRP) to rule out infection/inflammation Mayo Clinic
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Metabolic blood tests (glucose, thyroid) to identify systemic contributors Mayo Clinic
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Functional capacity evaluation to assess impact on daily activities Mayo Clinic
Non-Pharmacological Treatments
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Physical therapy: structured back exercises and traction Verywell Health
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Lifestyle modifications: regular exercise, weight management, smoking cessation Verywell Health
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Cognitive behavioral therapy (CBT) for pain coping Verywell Health
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Acupuncture for symptom relief Verywell Health
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Spinal cord stimulation (SCS) using implanted electrodes Physiopedia
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Transcutaneous electrical nerve stimulation (TENS) Wikipedia
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Microcurrent electrical neuromuscular stimulation Wikipedia
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Spinal manipulation (chiropractic care) Wikipedia
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Massage therapy to reduce muscle tension Wikipedia
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Heat therapy (thermotherapy) Wikipedia
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Cold therapy (cryotherapy) Wikipedia
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Therapeutic ultrasound Wikipedia
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Manual neuromuscular stimulation Wikipedia
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Behavioral medicine (multidisciplinary rehab) Wikipedia
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Cognitive–behavioral rehabilitation as part of multidisciplinary care PMC
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Patient education & self-management Physiopedia
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Core stabilization exercises (e.g., Pilates) Verywell Health
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Graded exercise therapy despite discomfort Neuromodulation
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Pain coping skills training Neuromodulation
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Referral to pain specialist for comprehensive planning Neuromodulation
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Ergonomic modifications (workplace and home) Mayo Clinic
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Mindfulness-based stress reduction Mayo Clinic
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Relaxation & breathing exercises Mayo Clinic
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Sleep hygiene improvements to aid recovery Mayo Clinic
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Endoscopic transforaminal lumbar discectomy (minimally invasive surgery) Wikipedia
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Hydrotherapy/aquatic exercise in warm water pools Physiopedia
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Postural training & correction Mayo Clinic
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Ergonomic seating/supports Mayo Clinic
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Assistive devices (e.g., lumbar braces) in select cases Mayo Clinic
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Manipulation under anesthesia (MUA) to release surgical adhesions
Common Medications
| Drug | Drug Class | Typical Dosage | Timing | Notable Side Effects |
|---|---|---|---|---|
| Ibuprofen | NSAID | 200–800 mg PO every 6–8 h | With meals | GI upset, renal impairment |
| Naproxen | NSAID | 250–500 mg PO BID | With meals | GI bleeding, hypertension |
| Diclofenac | NSAID | 50 mg PO TID | With food | Liver enzyme elevation |
| Celecoxib | COX-2 inhibitor | 100–200 mg PO BID | With or without food | Cardiovascular risk |
| Acetaminophen | Analgesic | 500–1000 mg PO every 6 h (max 4 g/day) | PRN pain | Hepatotoxicity |
| Aspirin | NSAID | 325–650 mg PO every 4 h | With food | Bleeding, tinnitus |
| Tramadol | Opioid (weak) | 50–100 mg PO every 4–6 h (max 400 mg/day) | PRN severe pain | Dizziness, constipation |
| Oxycodone | Opioid | 5–10 mg PO every 4–6 h | PRN severe pain | Respiratory depression |
| Amitriptyline | TCA (antidepressant) | 10–50 mg PO HS | At bedtime | Sedation, dry mouth |
| Duloxetine | SNRI | 30–60 mg PO daily | Morning | Nausea, insomnia |
| Gabapentin | Anticonvulsant | 300–600 mg PO TID | TID | Somnolence, peripheral edema |
| Pregabalin | Anticonvulsant | 75–150 mg PO BID | BID | Weight gain, dizziness |
| Baclofen | Muscle relaxant | 5–20 mg PO TID | TID | Drowsiness, weakness |
| Cyclobenzaprine | Muscle relaxant | 5–10 mg PO TID | TID | Anticholinergic effects |
| Lidocaine patch 5% | Topical analgesic | Apply up to 3 patches for 12 h/day | PRN localized pain | Skin irritation |
| Capsaicin cream | Topical analgesic | Apply 3–4 times daily | PRN | Burning sensation |
| Methylprednisolone | Corticosteroid | 4–48 mg PO daily (tapering) | Morning | Weight gain, osteoporosis |
| Prednisone | Corticosteroid | 5–60 mg PO daily (tapering) | Morning | Hyperglycemia, adrenal suppression |
| Cyclooxygenase-3 inhib | Selective COX-3 inhib | Experimental | — | — |
| Methocarbamol | Muscle relaxant | 1500 mg PO QID | QID | GI upset, dizziness |
Dietary Supplements
| Supplement | Typical Dosage | Function | Proposed Mechanism |
|---|---|---|---|
| Glucosamine | 1500 mg PO daily | Joint cartilage support | Precursor for glycosaminoglycans |
| Chondroitin | 1200 mg PO daily | Cartilage maintenance | Inhibits cartilage-degrading enzymes |
| Omega-3 (EPA/DHA) | 1000–3000 mg PO daily | Anti-inflammatory | Modulates eicosanoid synthesis |
| Vitamin D3 | 1000–2000 IU PO daily | Bone health | Calcium absorption, bone mineralization |
| Calcium | 1000–1200 mg PO daily | Bone strength | Bone mineral component |
| Magnesium | 300–400 mg PO daily | Muscle relaxation | Cofactor in muscle contraction/relaxation |
| Turmeric (Curcumin) | 500–1000 mg PO BID | Anti-inflammatory | Inhibits NF-κB signaling |
| Boswellia | 300–400 mg PO TID | Anti-inflammatory | 5-LOX inhibition |
| Bromelain | 500 mg PO TID | Decreases swelling | Proteolytic enzyme reducing inflammation |
| Devil’s Claw | 600 mg PO daily | Analgesic | Inhibits COX and LOX pathways |
Regenerative/Advanced Therapies
| Therapy | Dosage/Protocol | Functional Goal | Mechanism |
|---|---|---|---|
| Alendronate (Bisphosphonate) | 70 mg PO weekly | Bone density increase | Inhibits osteoclast-mediated resorption |
| Zoledronic acid | 5 mg IV annually | Prevent fractures | Potent osteoclast inhibitor |
| Teriparatide (PTH analog) | 20 µg SC daily | Bone formation | Stimulates osteoblast activity |
| Hyaluronic acid injections | 1–2 mL intra-discal or joint | Lubrication | Viscoelastic cushioning |
| Platelet-rich plasma (PRP) | 3–5 mL autologous injection | Tissue healing | Growth factor-mediated repair |
| Mesenchymal stem cell injection | 1–2×10⁶ cells per disc/joint | Regeneration | Differentiation into disc/cartilage cells |
| Bone morphogenetic protein-2 | Onlay graft in fusion surgery | Fusion enhancement | Induces osteogenesis |
| Autologous conditioned serum | 2–4 mL injections weekly × 3 | Anti-inflammatory | IL-1 receptor antagonist upregulation |
| Bone marrow concentrate | 5–10 mL injected | Regeneration | MSC and growth factor delivery |
| Growth hormone (GH) | 0.1–0.3 IU/kg/day SC | Tissue healing | Stimulates cell proliferation |
Surgical Options
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Microdiscectomy
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Laminectomy
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Spinal fusion (posterolateral, interbody)
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Foraminotomy
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Artificial disc replacement
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Vertebroplasty
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Kyphoplasty
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Facet rhizotomy (radiofrequency ablation)
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Spinal cord stimulator implantation
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Decompression with stabilization
Prevention Strategies
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Maintain healthy weight
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Regular core-strengthening exercises
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Ergonomically optimized workspace
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Proper lifting techniques
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Balanced nutrition (calcium, vitamin D)
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Smoking cessation
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Good posture habits
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Frequent activity breaks when seated
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Use of supportive footwear
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Stress management and relaxation
When to See a Doctor
Seek prompt evaluation if you experience any of the following red-flag signs:
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Severe or progressive neurological deficit (weakness, numbness)
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Loss of bowel or bladder control
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Unexplained weight loss or fever
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History of cancer or significant trauma
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Severe night pain unrelieved by position
Frequently Asked Questions
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What exactly is PSPS?
– Chronic spinal pain persisting ≥3 months, with or without prior surgery. -
How is PSPS different from “failed back surgery syndrome”?
– PSPS includes both surgical and non-surgical chronic pain, removing stigma of “failure.” -
Can PSPS occur after non-surgical treatments?
– Yes; any intervention (e.g., injections, radiofrequency) may trigger persistent pain. -
What role do psychosocial factors play?
– Depression, anxiety, and poor coping can amplify pain perception and disability. -
Is PSPS curable?
– There’s no one-size-fits-all cure; management focuses on pain reduction and function. -
Are imaging studies always necessary?
– Not for “non-specific” pain; used selectively for red-flag symptoms or surgical planning. -
What non-drug treatments are most effective?
– Active rehabilitation (exercise, CBT, ergonomics) has strong evidence for long-term benefit. -
When are opioids appropriate?
– Reserved for severe, refractory cases under close supervision due to risks. -
Can supplements help?
– Some (e.g., vitamin D, glucosamine) may support bone/joint health but are adjuncts only. -
What is the role of regenerative injections?
– Early research (PRP, stem cells) shows promise but requires further validation. -
When is surgery indicated?
– For structural compression (e.g., herniated disc, spinal instability) unresponsive to conservative care. -
How long before I see improvement?
– Multimodal treatment may take weeks to months; consistency is key. -
Can lifestyle changes alone manage PSPS?
– In mild cases, weight loss, exercise, and posture adjustments may suffice. -
What is spinal cord stimulation?
– Implantable device delivering electrical pulses to modulate pain signals. -
How can I prevent PSPS after surgery?
– Adhere to rehabilitation protocols, avoid tobacco, and maintain core strength.
Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.
The article is written by Team Rxharun and reviewed by the Rx Editorial Board Members
Last Updated: May 06, 2025.
