Percutaneous Adhesiolysis in the Management of Chronic Low Back Pain in Post Lumbar Surgery Syndrome and Spinal Stenosis: A Systematic Review

Background: Low back pain after either post lumbar surgery syndrome or spinal stenosis in theabsence of surgery is a vexing problem. Post lumbar surgery syndrome can occur in any age group,while low back and radicular pain from spinal stenosis is a disease of aging. As the population ages,the incidence of symptomatic spinal stenosis will increase. There are currently limited treatmentoptions for either group. Further surgery is not uniformly effective in relieving pain after previoussurgery. While therapies are being developed to treat pain due to spinal stenosis, no therapy otherthan adhesiolysis will treat pain due to scarring.Adhesiolysis was developed as a means of removing epidural scarring leading directly or indirectly tocompression, inflammation, swelling, or a decreased nutritional supply of nerve roots. Adhesiolysisutilizes a number of modalities in the effort to break up epidural scarring, including the use of a wirebound catheter for mechanical adhesiolysis, placement of the catheter in the ventro-lateral aspectof the epidural space at the site of the exiting nerve root, and the use of high volumes of injectate,including local anesthetics and saline, either hypertonic or isotonic, along with steroids.Study Design: A systematic review of percutaneous adhesiolysis in the treatment of refractorylow back and leg pain due to post lumbar surgery syndrome or spinal stenosis.Objective: To evaluate the effectiveness of percutaneous adhesiolysis in the treatment of refractorylow back and leg pain due to post lumbar surgery syndrome or spinal stenosis. The severity of risksand adverse events associated with percutaneous adhesiolysis were also evaluated.Methods: The available literature on percutaneous adhesiolysis for the treatment of refractory lowback and leg pain due to post lumbar surgery syndrome or spinal stenosis was reviewed. The qualityassessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Groupcriteria as utilized for interventional techniques for randomized trials and the criteria developed bythe Newcastle-Ottawa Scale criteria for observational studies.The level of evidence was classified as good, fair, and limited (or poor) based on the quality ofevidence developed by the U.S. Preventive Services Task Force (USPSTF).Data sources included relevant literature identified through searches of PubMed and EMBASE from1966 to June 2012, and manual searches of the bibliographies of known primary and review articles.Outcome Measures:The primary outcome measure was pain relief of at least 6 months. Secondary outcome measureswere improvement in functional status, change in psychological status, return to work, and reductionin opioid use or interventions.Results: For this systematic review, 15 studies were identified and selected for review. Of these, 5randomized controlled trials and 2 observational studies met the inclusion criteria.Applying the USPSTF criteria, these studies indicate that there is fair evidence that percutaneousadhesiolysis is effective in relieving low back and/or leg pain caused by post lumbar surgery syndromeand that there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain caused by spinal stenosis The incidence of complications from percutaneous adhesiolysis is low and the complications are generally minimal and self-limited.The procedure should be considered to be low risk for serious adverse events when performed by well-trained physicians.Limitations: The limitations of this systematic review include the paucity of literature.Conclusion: In summary, there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg paindue to post lumbar surgery syndrome or spinal stenosis.Key words: Spinal pain, chronic low back pain, leg pain, adhesiolysis, Racz procedure, post lumbar surgery syndrome, spinalstenosis