Efficacy of Percutaneous Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Laxmaiah Manchikanti; Nebojsa Nick Knezevic; Emilija Knezevic; Rachana Pasupuleti; Alan D Kaye; Mahendra R Sanapati; Joshua A Hirsch

doi:10.1007/s40122-023-00508-y

Efficacy of Percutaneous Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Pain Ther. 2023 Aug;12(4):903-937. doi: 10.1007/s40122-023-00508-y. Epub 2023 May 25.

Authors

Laxmaiah Manchikanti^{1

2}, Nebojsa Nick Knezevic³, Emilija Knezevic⁴, Rachana Pasupuleti⁵, Alan D Kaye⁶, Mahendra R Sanapati^{7

8}, Joshua A Hirsch⁹

Affiliations

¹ Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY, 42001, USA. drlm@thepainmd.com.
² Pain Management Centers of America, Evansville, IN, USA. drlm@thepainmd.com.
³ Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL, USA.
⁴ College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Champaign, IL, USA.
⁵ University of Kentucky, Lexington, KY, USA.
⁶ LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Interventional Pain Clinic Feist-Wieller Cancer Center, Shreveport, LA, USA.
⁷ Pain Management Centers of America, 67 Lakeview Drive, Paducah, KY, 42001, USA.
⁸ Pain Management Centers of America, Evansville, IN, USA.
⁹ Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Abstract

Introduction: Chronic refractory low back and lower extremity pain recalcitrant to conservative management and epidural injections secondary to postsurgery syndrome, spinal stenosis, and disc herniation are sometimes managed with percutaneous adhesiolysis. Consequently, this systematic review and meta-analysis was undertaken to assess the efficacy of percutaneous adhesiolysis in managing low back and lower extremity pain.

Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases from 1966 to July 2022, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included trials, meta-analysis, and best evidence synthesis was performed. The primary outcome measure was a significant reduction in pain (short term up to 6 months and long term more than 6 months).

Results: The search identified 26 publications, with 9 trials meeting the inclusion criteria. The results of dual-arm and single-arm analyses showed significant improvement in pain and function at 12 months. Opioid consumption was also significantly reduced at 6 months with dual-arm analysis, whereas single-arm analysis showed a significant decrease from baseline to treatment at the 3-, 6-, and 12-month analyses. At 1 year follow-up, seven of seven trials were positive for improvements in pain relief, function, and diminution of opioid use.

Discussion: Based on the present systematic review of nine RCTs, the evidence level is I to II, with moderate to strong recommendation for percutaneous adhesiolysis in managing low back and lower extremity pain. The limitations of the evidence include paucity of literature, lack of placebo-controlled trials, and the majority of the trials studying post lumbar surgery syndrome.

Conclusion: The evidence is level I to II or strong to moderate based on five high-quality and two moderate-quality RCTs, with 1 year follow-up that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain.

Keywords: Chronic low back pain; Epidural scarring; Lumbar disc herniation; Lumbar spinal stenosis; Percutaneous adhesiolysis; Post lumbar surgery syndrome; Radicular pain; Spinal pain.

Publication types

Review