Systematic Review of Effectiveness and Complications of Adhesiolysis in the Management of Chronic Spinal Pain: An Update

Background: Percutaneous epidural adhesiolysis and spinal endoscopic adhesiolysis are interventional pain management techniques used to treat patients with refractory low back pain dueto epidural scarring. Standard epidural steroid injections are often ineffective, especially in patients with prior back surgery. Adhesions in the epidural space can prevent the flow of medicineto the target area; lysis of these adhesions can improve the delivery of medication to the affected areas, potentially improving the therapeutic efficacy of the injected medications.Study Design: A systematic review utilizing the methodologic quality criteria of the CochraneMusculoskeletal Review Group for randomized trials and the criteria established by the Agency forHealthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials.Objective: To evaluate and update the effectiveness of percutaneous adhesiolysis and spinal endoscopic adhesiolysis in managing chronic low back and lower extremity pain due toradiculopathy, with or without prior lumbar surgery, since the 2005 systematic review.Methods: Basic search identified the relevant literature, in the MEDLINE, EMBASE, and BioMeddatabases (November 2004 to September 2006). Manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years were reviewed. Randomized and non-randomized studies are included in the review based on criteria established. Percutaneous adhesiolysis and endoscopic adhesiolysis are analyzed separately.Outcome Measures: The primary outcome measure was significant pain relief (50% or greater). Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term relief was defined as less than 3 months, and long-term relief was defined as 3 months or longer.Results: Studies regarding the treatment of epidural adhesions for the treatment of low backand lower extremity pain were sought and reviewed. The evidence from the previous systematic review was combined with new studies since November 2004. There is strong evidence forshort term and moderate evidence for long term effectiveness of percutaneous adhesiolysis andspinal endoscopy.Conclusion: Percutaneous adhesiolysis and spinal endoscopy may be effective interventions totreat low back and lower extremity pain caused by epidural adhesions.Key Words: Spinal pain, chronic low back pain, percutaneous adhesiolysis, spinal endoscopicadhesiolysis, spinal stenosis, post lumbar laminectomy syndrome, epidural fibrosis, epidural adhesions, caudal neuroplasty.