Aspects of the failed back syndrome: role of litigation

A review that attempts to identify the mechanism and causation of persistent or recurring low back pain.

A personal assessment of clinical features with a selective review of the literature.

Thirty to forty per cent of our population aged 10-65 years report that back trouble occurs on a monthly basis and in 1% to 8% this interferes with work. A definite patho-anatomical cause for the pain is demonstrable in only a minority. It can be deduced that psychosocial factors, including insurance benefits are of importance for this variation.

Neither non-operative nor surgical procedures have a major impact on the capacity for work in this substantial minority of backache sufferers. The main risk factors identified are: Wrong diagnosis, repeated medical certificates for sickness benefits, failed surgery, symptoms incongruous with signs or imaging, multiple spinal procedures, poor social support and poor motivation, psychological illness, clinical depression before or after injury or operation. Pending compensation and delays in settlement are important additional features in claimants for compensation. For patients with unproven diagnostic labels such as 'pain-behaviour', no evidence exists that any type of surgery is cost effective.