1. 2009;12;419-435Effectiveness of Spinal Endoscopic Adhesiolysis in Post Lumbar Surgery Syndrome: A Systematic Review
   Systematic Review
   Salim M. Hayek, MD, PhD, Standiford Helm II, MD, Ramsin M. Benyamin, MD, Vijay Singh, MD, David A. Bryce, MD, and Howard S. Smith, MD.

BACKGROUND: Post lumbar surgery syndrome with persistent chronic low back and lower extremity pain is common in the United States. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS). Percutaneous adhesiolysis with a catheter or direct visualization of the spinal canal and the contents with an endoscope are techniques employed in resistant cases when patients fail to respond to conservative modalities of treatment, including fluoroscopically directed epidural injections. Some patients failing to respond to percutaneous adhesiolysis are candidates for spinal endoscopic adhesiolysis. However, literature evaluating the effectiveness of spinal endoscopic adhesiolysis is sparse and discussions continue about its effectiveness, utility, and complications.

STUDY DESIGN: A systematic review of the available literature.

OBJECTIVE: To evaluate the effectiveness and safety of spinal endoscopic adhesiolysis in the management of chronic low back and lower extremity pain in post surgical patients with chronic recalcitrant pain, non-responsive to conservative modalities of management and fluoroscopically directed epidural injections.

METHODS: A search of relevant resources (PubMed, EMBASE, and the Cochrane database) was accomplished and the resulting publications were examined based on the inclusion/exclusion criteria set forth. Randomized controlled trials and observational studies were included in the search. Two reviewers assessed the studies’ methodologies and outcomes. Randomized clinical trials were assessed and scored based on the criteria established by the Cochrane methodological assessment criteria of randomized clinical trials and the observational studies were assessed and scored based on the Agency for Healthcare Research and Quality (AHRQ) criteria.

Clinical relevance was evaluated utilizing Cochrane review criteria.

Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II.

OUTCOME MEASURES: The primary outcome measure was pain relief (>/= 50%) in follow-up for at least 6 months. Pain relief for longer than 6 months was considered long-term and 6 months or less was considered short-term. The secondary outcome measures were functional and psychological status, return to work, patient satisfaction, and opioid intake.

RESULTS: Of the 13 studies considered for inclusion, one randomized trial and 5 observational studies met inclusion criteria for evidence synthesis based on the inclusion criteria and methodologic quality scores of 50 or more.

The indicated level of evidence for endoscopic adhesiolysis is Level II-1 or II-2 evidence for short- and long-term relief based on the U.S. Preventive Services Task Force (USPSTF) criteria.

LIMITATIONS: There was a paucity of literature for randomized trials.

CONCLUSION: Spinal endoscopic adhesiolysis may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy that is related to epidural adhesions.