Case Study · 06
Axial back pain persisting four years after lumbar fusion
A patient in their late fifties with predominantly axial low back pain four years after an L4–S1 fusion. Hardware intact, fusion solid, no recurrent stenosis. Two years of medication, injections and physical therapy without durable benefit. Treated with a 10 kHz spinal cord stimulator following a successful seven-day trial.
At a glance
- Patient
- Late 50s
- Region
- Axial lumbar, bilateral buttock
- Procedure
- 10 kHz SCS, T8–T10 leads
- Outcome
- Sustained at 18 months
When imaging shows a solid fusion and no compressive lesion, but the back pain is worse than before surgery — what is left to offer?
Patient names are omitted from this account. The clinical course and reported outcome describe an actual treated case and do not predict another person's response.
Clinical Summary
What the patient came in with
Presentation
Constant deep aching across the lower back with bilateral buttock referral, worse with standing and walking, partially relieved by sitting. Baseline pain 8/10 average, 4/10 at best, 10/10 at worst. Oswestry Disability Index in the severe range.
The patient could not stand at a kitchen counter for more than five minutes, had stopped driving distances over thirty minutes, and had left a job that required being on their feet.
Prior treatment
L4–S1 posterolateral fusion four years earlier for spondylolisthesis with neurogenic claudication. The leg symptoms resolved and never returned — the back pain, which had been secondary before surgery, became dominant afterwards.
Since then: two courses of formal physical therapy, medial branch blocks with transient relief, radiofrequency ablation at the levels above the fusion with three months of partial benefit, gabapentin, duloxetine, and intermittent opioids that the patient wished to stop.
Imaging and examination
MRI and CT demonstrated a solid arthrodesis with intact instrumentation, no adjacent segment stenosis of clinical significance, and no recurrent disc herniation. Nothing on imaging explained the severity of the pain — which is itself the finding.
Examination showed no focal neurological deficit, negative straight leg raise, tenderness across the paraspinal musculature, and marked deconditioning of the lumbar extensors.
Why neuromodulation was considered
The pain was axial and predominantly neuropathic in character, refractory to reasonable conservative and interventional care, with no further surgical target. This is the population in which persistent spinal pain syndrome is diagnosed — a term preferred to 'failed back surgery syndrome' because the operation did what it was intended to do.
A 10 kHz platform was selected because the published evidence for axial back pain is strongest with that waveform, and because the patient specifically did not want a therapy that produced tingling.
Procedure
Trial, then permanent implant
Two separate procedures, separated by a week of ordinary life. Nothing permanent happened until the trial had produced an answer.
01
AP fluoroscopic view
Epidural access
Paramedian access to the posterior epidural space at a lower thoracic interspace under live fluoroscopy, using loss-of-resistance technique with the patient prone and lightly sedated.
02
AP fluoroscopic view
Lead advancement
Two eight-contact percutaneous leads advanced cephalad and positioned to span the T8–T10 vertebral bodies, straddling the physiological midline. With 10 kHz therapy, placement is anatomic — no intraoperative paresthesia mapping is required.
03
Lateral fluoroscopic view
Lateral confirmation
Lateral imaging confirms the leads lie in the dorsal epidural space rather than having tracked ventrally or laterally. This view is not optional; the AP view alone cannot distinguish dorsal from ventral position.
04
Seven days at home
Trial period
Leads anchored to the skin, connected to an external generator, and the patient sent home to live normally within activity restrictions. Programming adjusted remotely on day two and day four.
05
AP fluoroscopic view
Permanent implant
After a clearly successful trial, permanent leads placed at the same levels and tunnelled to a generator pocket in the upper buttock. Trial leads had already been removed in the office, without anaesthesia.
Follow-Up
What happened afterwards
The trial week
The patient recorded pain scores morning and evening, plus a short note on what they had been able to do. By day three, average pain had fallen from 8/10 to 3/10. By day six they had stood through a full grocery shop for the first time in three years.
That functional detail mattered more in the decision than the numbers did.
First three months
Incisional soreness for roughly two weeks, expected and self-limited. Activity restrictions lifted at six weeks once healing was confirmed. Two programming visits to refine the program set.
Gabapentin tapered and stopped by month three. Opioids stopped by month two.
Twelve to eighteen months
Average pain 3/10, worst 6/10 during flares that now resolve within a day rather than a week. Oswestry improved from severe to moderate disability.
The patient returned to part-time work and resumed regular walking. No lead migration, no infection, no revision.
Outcome
Function recovered before pain scores fully caught up
8/10 → 3/10
Average pain, sustained at 18 months
- Trial result
- Clear responder by day 3
- Opioids
- Discontinued by month 2
- Neuropathic agents
- Discontinued by month 3
- Complications
- None to 18 months
Clinical pearl
A solid fusion and a clean MRI do not mean there is nothing wrong. In persistent spinal pain syndrome the problem has moved from a compressed structure to the way signals are being processed — and that is precisely the problem neuromodulation is designed to address.
Individual results vary. This case is presented for education and does not predict the outcome of any therapy in any other patient.
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