Effectiveness of Percutaneous Adhesiolysis in Managing Chronic Central Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

Background: Symptomatic lumbar spinal stenosis is a condition affecting a growing numberof individuals resulting in significant disability and pain, leading to a multitude of interventionsranging from simple over the counter medication to opioids, and, finally, to complex surgicalfusions. After failure of conservative treatment with drug therapy, physical therapy, and otherconservative modalities including epidural injections, percutaneous adhesiolysis with targeteddelivery of drugs into the epidural space can be offered in lumbar central spinal stenosis prior tominimally invasive surgical options or complex surgical fusions. To date there has been only onesystematic review which has assessed the role of percutaneous adhesiolysis in treating centralspinal stenosis, compared to post lumbar surgery syndrome which has multiple systematic reviewsand randomized controlled trials (RCTs).Study Design: A systematic review of RCTs and observational studies assessing the role ofpercutaneous adhesiolysis in managing lumbar central spinal stenosis.Objective: To evaluate the effectiveness of percutaneous adhesiolysis in managing central lumbarspinal stenosis, utilizing currently available literature.Methods: This systematic review was performed utilizing Preferred Reporting Items for SystematicReviews and Meta-Analyses (PRISMA) for literature search, Cochrane review criteria, InterventionalPain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPMQRB), and Interventional Pain Management Techniques – Quality Appraisal of Reliability and Riskof Bias Assessment for Nonrandomized Studies (IPM-QRBNR) to assess methodologic qualityassessment and qualitative analysis utilizing best evidence synthesis principles, and meta-analysis.PubMed, Cochrane library, US National Guideline Clearinghouse, Google Scholar, and priorsystematic reviews and reference lists were utilized in the literature search from 1966 through June2019. The evidence was summarized utilizing principles of the best evidence synthesis on a scaleof 1 to 5.Outcome Measures: The primary outcome or hard endpoint was defined as the proportion ofpatients with 50% pain relief and improvement in functionality, whereas the secondary outcomemeasures or soft endpoints were pain relief and/or improvement in functionality. Short-termeffectiveness was defined as improvement of 6 months or less, whereas long-term effectivenesswas defined as more than 6 months.Results: Based on search criteria, 9 manuscripts were identified and considered for inclusionwith final inclusion of 2 RCTs and 4 observational studies in this systematic review and 5 studiesfor single arm meta-analysis. The results showed Level II evidence for short-term and long-termimprovement in pain and function with application of percutaneous adhesiolysis in managingcentral lumbar spinal stenosis.Limitations: There was a significant paucity of evidence assessing the role of percutaneousadhesiolysis in managing lumbar central spinal stenosis, leading to Level II or moderate evidence.Conclusion: Overall, the present analysis shows Level II (moderate) evidence for percutaneous adhesiolysis in managing lumbarcentral spinal stenosis based on relevant high quality RCTs and observational studies.Key Words: Lumbar central spinal stenosis, percutaneous adhesiolysis, randomized controlled trials, systematic reviews,neuroplasty