Percutaneous and Endoscopic Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis

Background: Chronic refractory low back and lower extremity pain is frustrating to treat.Percutaneous adhesiolysis and spinal endoscopy are techniques which can treat chronic refractorylow back and lower extremity pain.Percutaneous adhesiolysis is performed by placing the catheterinto the tissue plane at the ventrolateral aspect of the foramen so that medications can be injected.Adhesiolysis is used both for pain caused by scarring which is not resistant to catheter placementand other sources of pain, including inflammation in the absence of scarring.Mechanical lysis ofscars with a catheter may or may not be necessary for percutaneous adhesiolysis to be effective.Spinal endoscopy allows direct visualization of the epidural space and has the possibility to uselaser energy to treat pathology.Study Design: A systematic review of the effectiveness of percutaneous adhesiolysis and spinalendoscopic adhesiolysis to treat chronic refractory low back and lower extremity painObjective: To evaluate and update the effectiveness of percutaneous adhesiolysis and spinalendoscopic adhesiolysis to treat chronic refractory low back and lower extremity painMethods: The available literature on percutaneous adhesiolysis and spinal endoscopic adhesiolysisin treating persistent low back and leg pain was reviewed. The quality of each article used in thisanalysis was assessed.The level of evidence was classified on a 5-point scale from strong, based upon multiple randomizedcontrolled trials to weak, based upon consensus, as developed by the U.S. Preventive Services TaskForce (USPSTF) and modified by ASIPP.Data sources included relevant literature identified through searches of PubMed and EMBASEfrom 1966 to September 2015, and manual searches of the bibliographies of known primary andreview articles.Outcome Measures: Pain relief of at least 50% and functional improvement of at least 40%were the primary outcome measures.Short-term efficacy was defined as improvement of 6 months or less; whereas, long-term efficacywas defined more than 6 months.Results: For this systematic review, 45 studies were identified. Of these, for percutaneousadhesiolysis there were 7 randomized controlled trials and 3 observational studies which metthe inclusion criteria. For spinal endoscopy, there was one randomized controlled trial and 3observational studies.Based upon 7 randomized controlled trials showing efficacy, with no negative trials, there isLevel I or strong evidence of the efficacy of percutaneous adhesiolysis in the treatment of chronicrefractory low back and lower extremity pain.Based upon one high-quality randomized controlled trial, there is Level II to III evidence supportingthe use of spinal endoscopy in treating chronic refractory low back and lower extremity pain. Conclusion: The evidence is Level I or strong that percutaneous adhesiolysis is efficaciousin the treatment of chronic refractory low back and lower extremity pain. Percutaneousadhesiolysis may be considered as a first-line treatment for chronic refractory low backand lower extremity pain.The evidence is Level II to III that spinal endoscopy is effective in the treatment of chronicrefractory low back and lower extremity pain.Key words: Spinal pain, chronic low back pain, post lumbar surgery syndrome, epiduralscarring, adhesiolysis, endoscopy, radicular pain: