1. 2005;8;87-100Role of Adhesiolysis in the Management of Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications
   A Systematic Review
   Pradeep Chopra, MD, Howard S. Smith, MD, Timothy R. Deer, MD, and Richard C. Bowman, MD.

Background: Percutaneous epidural adhesiolysis and spinal endoscopic adhesiolysis are interventional pain management techniques that play an active role in managing chronic intractable low back pain.  There have not been any systematic reviews performed on this subject.

Objective: To evaluate the effect of percutaneous adhesiolysis and spinal endoscopic adhesiolysis in managing chronic low back and lower extremity pain. 

Study Design: A systematic review utilizing the methodologic quality criteria of the Cochrane Musculoskeletal Review Group for randomized trials and the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials. 

Methods: Search identified the relevant literature, through searches of MEDLINE and EMBASE (January 1966 to November 2004), BioMed Central and Cochrane Review database.  Manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years, in English language.  Randomized and non-randomized studies were included in the review based on the criteria established.

Three reviewers independently assessed the trials for the quality of their methods.  Percutaneous adhesiolysis and endoscopic adhesiolysis were analyzed separately.

Outcome Measures: Primary outcome measure was significant pain relief (50% or greater).  Other outcome measures were functional improvement, improvement of psychological status, and return to work.  Short-term relief was defined as less than 3 months, and long-term relief was defined as 3 months or longer.

Results: There was strong evidence to indicate effectiveness of percutaneous epidural adhesiolysis with administration of epidural steroids for short term and long term in chronic, refractory low back pain and radicular pain.  There was moderate evidence of effectiveness of addition of hypertonic saline.  The evidence of effectiveness of hyaluronidase was negative.

There was strong evidence to indicate effectiveness of spinal endoscopic adhesiolysis and epidural steroid administration for short-term improvement, and moderate evidence for long-term improvement in managing chronic, refractory, low back and lower extremity pain.

Conclusion: The evidence of effectiveness of percutaneous adhesiolysis with administration of hypertonic sodium chloride administration, and spinal endoscopic adhesiolysis with epidural steroid administration in managing chronic, refractory low back and lower extremity pain of post lumbar laminectomy syndrome or epidural fibrosis was moderate to strong.

Keywords: Spinal pain, chronic low back pain, percutaneous adhesiolysis, spinal endoscopic adhesiolysis, spinal stenosis, post lumbar laminectomy syndrome, epidural fibrosis