Objective To investigate the clinical efficacy of combining small needle knife scar release based on fasciology theory with lumbar and back muscle functional exercises for treating failed back surgery syndrome (FBSS). Methods From January 2024 to June 2025, patients who were hospitalized in the Department of Spinal Surgery of Luoyang Orthopedic Hospital (Henan Provincial Orthopedic Hospital) after lumbar surgery and met the FBSS diagnosis were selected as the research objects. one hundred and fifty qualified subjects were randomly assigned to the control group (oral celecoxib capsules), the needle-knife group and the needle-knife plus exercise group (back muscle functional exercise) according to the ratio of 1∶1∶1, with 50 cases in each group. The lumbar function scores of visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) of the three groups were recorded on the 1st day, 5th day and 10th day after treatment, respectively, and the Young""s modulus (E) of bilateral multifidus was measured on the 10th day after treatment, at the same time, the clinical total effective rate was evaluated. Results Starting from day 5 post-treatment, both the needle-knife group and the needle-knife plus exercise group demonstrated significantly superior VAS scores and JOA scores compared to the control group (all P＜0.05). By day 10 post-treatment, the VAS score in the needle-knife plus exercise group (2.00±0.36) was significantly lower than that in the needle-knife group (2.80±0.45) (P＜0.05), while the JOA score (25.00 ± 0.71) was significantly higher than that of the needle-knife group (23.20±0.45) (P＜0.05). By day 10 post-treatment, the bilateral multifidus muscle E values in the control group were higher than those in both the needle-knife group and the needle-knife plus exercise group (all P＜0.05). The bilateral multifidus muscle Young""s modulus values in the needle-knife group were also higher than those in the needle-knife plus exercise group (P＜0.05). The total effective rate in the needle-knife plus exercise group (96%) was significantly higher than that in the needle-knife group (84%) and the control group (62%) (all P＜0.05). Conclusion Small needle knife scar release can rapidly alleviate FBSS pain and enhance muscle elasticity. Combined with lumbar and back muscle functional exercises, it further strengthens myofascial chain stability and neuromuscular control, improves muscle function, and significantly enhances short-term (10 d) therapeutic efficacy. This sequential treatment model of "mechanical release-functional strengthening" offers a novel approach for developing clinical treatment protocols for FBSS.