The failed back or postlaminectomy syndrome is obviously multidimensional. Failure of therapy may result from structural abnormalities in the back, psychosocial influences, or a combination of both. The causes of back pain are largely unknown. Correlations with diagnostic studies are uncertain. The lack of precise diagnoses is reflected in a multiplicity of nonspecific treatments, mostly of unproven value. Our current disability-litigation system adds greatly to the problem. Patients are rewarded for nonfunction. Some physicians become advocates for patients, others for insurance carriers and employers. Decisions concerning appropriate treatment are often made by patients, attorneys, the disability determination system, employers, and judges for extraneous reasons, which include financial gain or personal bias and often reflect lack of current information. Even when correct decisions are made, there is a lack of adequate programs for diagnosis and comprehensive treatment of these individuals. The failed back syndrome is not likely to disappear quickly. Large numbers of these patients require care. The best available evaluation includes thorough, but not overly minute investigation using the best current imaging techniques. These studies combined with the history and physical examination should provide a reasonably accurate assessment of the patient's condition. Concomitant evaluation of psychosocial issues is mandatory, and those who treat these patients without understanding the importance of the various comorbidities discussed are likely to be detrimental. Reparative surgery has real, but limited use. Nerve root compression and instability are the only two conditions demonstrated to be correctable at the present time. However, even when a potentially remediable lesion is found, these patients should undergo a reasonable attempt at physical rehabilitation with attention to both local factors and general function. The best data available today suggest that most of the patients suffering from failed back syndrome are incapacitated by psychiatric, psychologic, and social/vocational factors, which relate to the back complaint only indirectly. Those currently suffering from this problem can be best treated by comprehensive programs that address these complex psychosocial issues. New additions to this category can be reduced by rigorous attention to physical abnormalities, so that surgery is undertaken only for clear indications, and appreciation of the importance of the psychologic aspects of disability from low back pain. The smaller group suffering principally from physical abnormalities can be improved by reparative surgery or pain-relieving procedures if intensive conservative rehabilitation efforts fail. All surgical procedures fail occasionally, and as long as there is a need for reparative surgery, some patients will fail to benefit or be worsened by the procedures.(ABSTRACT TRUNCATED AT 400 WORDS)