Table. 2.

Characteristics of included studies of percutaneous adhesiolysis/neurolysis in lumbar disc herniation

Study Study characteristics Methodological quality
scoring
Participants and interventions Outcome
measures
Pain relief and function Results Comment(s)
3 mo 6 mo 12 mo Short-term Long-term
≤ 3 mo > 6 mo ≥ 12 mo
Gerdesmeyer et al., 2013 [25] RA, PC, DB Quality scores:Cochrane: 13/13IPM-QRB 41/48 The authors screened 90 patients from 381 patients with chronic radicular pain lasting longer than 4 months over a period of 4 years. Primary outcome measure: ODI at 3, 6, and 12 months Placebo group = 17%(7/42)
Lysis group = 58%(26/45)
Placebo group = 11%(4/37)
Lysis group = 74%(31/42)
Placebo group = 35%(9/26)
Lysis group = 90%(28/31)
P P P This is the first true placebo controlled trial, injecting and inert substance into an inert structure, yet it showed positive response in some patients. Overall, there were significant differences in the active treatment group and lysis group compared to placebo group. Ten-year follow-up also showed significant improvement and surgery was avoided in majority of the patients. Surgery was avoided in 85% of the patients.
Chronic lumbar radicular pain lasting longer than 4 months Randomization:
Placebo control group = 44
VAS: At least 50% reduction in ODI scores and VAS scores at 3, 6, and 12 months after treatment Lysis group = 58%(26/45) Lysis group = 74%(31/42) Lysis group = 90%(28/31)

In the placebo group, a needle and catheter was inserted through caudal approach and the needle was intentionally inserted without entering the spinal canal and the catheter was inserted into the subcutaneous tissue overlying the afflicted level.

10 mL of preservative-free sodium chloride solution was injected for 3 days and the catheter was removed.

Neurolysis group = 46

The catheter was placed through sacral canal with injection of 10 mL of contrast with identification of filling defects. Subsequently a Tun-L catheter was inserted through the epidural needle and advanced to the anterolateral area of the filling defect.

Local anesthetic, 10 mL, 0.25% bupivacaine was injected through the catheter, followed by 10 mL of preservative free sodium chloride solution containing 150 units per mL of hyaluronidase.

Sodium chloride solution, 10 mL, 10%, containing 40 mg of triamcinolone was then injected slowly, along with 2 mL of 0.25% bupivacaine.

On the 2nd and 3rd days, 10 mL of 0.25% bupivacaine was injected through the catheter, followed by slow injection of 10 mL of 10% sodium chloride solution and 2 mL, 0.25% bupivacaine.

The catheter was removed on the third day in both groups.
Ji et al., 2015 [40] Retrospective Quality Scores:IPM-QRBNR 30/48 Authors studied correlation of dural sac cross sectional area with a single-level disc disease and effectiveness of percutaneous epiduroplasty. VAS for back pain and leg pain, Odom’s criteria SI in VAS SI in VAS SI in VAS SI in VAS SI in VAS SI in VAS This study looking at dural cross sectional area in single level disc disease showed no significant difference based on dural sac cross sectional area. The results show that percutaneous epidural neuroplasty is an effective procedure in treating single-level lumbar disc herniation without affecting dural sac cross sectional area.
Lumbar disc herniation Number of patients = 363 Assessment intervals: 3, 6, 12, and 24 months
Categorization to spinal canal compromiseCategory 1 – less or more than 50%Category 2 – lesser than one-third, between a third and two-thirds, and more than two-thirds with subcategories

Catheterization was performed with a caudal approach. After final positioning of the Racz catheter, 6 mL of 0.2% preservative free ropivacaine containing 1,500 units of hyaluronidase and 4 mL of 40% triamcinolone acetate was injected.

One-hour after the procedure, 6 mL of 8% sodium chloride solution was infused over 30 minutes in the recovery room under monitoring.

Epidural catheter was removed.

Moon et al., 2017 [33] Retrospective Quality Scores:IPM-QRBNR 30/48

407 patients were evaluated retrospectively to predict the outcome of percutaneous epidural adhesiolysis in patients with lumbar disc herniation.

All patients underwent percutaneous adhesiolysis with an RK needle and Racz catheter through caudal approach. After final positioning of the catheter in the anterior epidural space of the target site, 3-5 mL of 1% lidocaine was administered as a test dose. This was followed by 10 mL of 0.9% sodium chloride solution, followed by injection of 0.125% bupivacaine mixed with 5 mg of dexamethasone.

After 5 minutes, 10 mL of 10% sodium chloride solution was slowly injected under real-time fluoroscopic guidance.

Catheter was removed and insertion site was sutured.

The primary outcome measure was substantial response of 4 or more points or 50% of pain relief in the numerical rate scaling pain score, 12 months after treatment. NA NA SI in 72.2% of patients NA NA P This is a positive study with long-term follow-up assessing factors predicting favorable outcome of percutaneous epidural adhesiolysis. The presence of high intensity zone on magnetic resonance imaging was a predictor of substantial response to percutaneous epidural adhesiolysis for 12 months.
Lumbar disc herniation Repeat procedure was performed if needed at 3 months. Six-months not available.
Cho et al., 2019 [31] Retrospective Quality Scores:IPM-QRBNR 30/48

This study included 430 consecutive patients with a single-level disc herniation undergoing percutaneous epidural neuroplasty. Authors categories LDH type as bulging, protrusion, extrusion, and sequestration. LDH type inclusion: bulging 124, protrusion 240, extrusion 56, sequestration 10, total 430.

All patients were treated with percutaneous adhesiolysis or neuroplasty through a caudal approach with placement of the catheter ventrally and laterally. Following the satisfactory positioning of the catheter and injection of contrast, 6 mL of 0.2% preservative free ropivacaine containing 1,500 units of hyaluronidase and 4 mL of betamethasone sodium phosphate was injected.

One hour after the procedure, 6 mL of 8% sodium chloride solution was infused over a period of 30 minutes under monitoring in the recovery room. Epidural catheter was removed.

VAS for back pain and leg pain, Odom’s criteria with classification of outcomes as excellent, good, fair or poor. Significant decrease in VAS scores for back and leg pain Significant decrease in VAS scores for back and leg pain Significant decrease in VAS scores for back and leg pain Good or excellent outcome = 73.1 Good or excellent outcome = 74.8 Good or excellent outcome = 71.7 Overall, this is a positive study with positive results with a single treatment of one-day percutaneous adhesiolysis providing improvement in VAS of back and leg pain lasting for one-year. Surgery was avoided in more than 70% of the patients with extrusion or sequestration. Patients with Pfirrmann’s Grades 1 to 3, shows a significantly higher rate of subsequent surgery than with Pfirrmann Grade 0.
Lumbar disc herniation Outcomes were recorded at 1, 3, 6, and 12 months
Park et al., 2018 [37] Retrospective Quality Scores:IPM-QRBNR 29/48 Authors sought to evaluate clinical significance of epidurography contrast patterns after adhesiolysis. VAS, ODI, 12-item short-form health survey (SF-32) SI SI SI P P P In this study assessing clinical significance of epidurography contrast patterns, authors reported positive results and authors also showed that when there is extraforaminal contrast spread, outcomes were superior.
Lumbar disc herniation and/or spinal stenosis Number of patients = 78

Both spinal stenosis and disc herniation patients were included without separating the data.

Procedure was performed with caudal entry. After appropriate positioning of the catheter, a mixture of 10 mL of 0.9% sodium chloride solution and 300 units of hyaluronidase was injected. Following this, another epidurogram was carried out. After epidurogram a mixture of 0.2% ropivacaine 8 mL and 40 mg of triamcinolone was slowly injected.

Significant improvement in VAS scores, back pain and leg pain

Significant improvement in ODI scores

Extraforaminal leakage of the contrast was associated with a tendency for decreased pain and significant better quality of life.

Outcomes assessed at 1, 3, 6, and 12 months
Choi et al., 2017 [38] Retrospective Quality Scores:IPM-QRBNR 30/48

This study included 543 patients assessing 5% or 10% hypertonic sodium chloride solution injection.

5% group = 333

10% group = 210

Procedure was performed with a caudal entry and catheterization after final catheter position was achieved. 5 mL of 0.25% ropivacaine containing 1,500 units of hyaluronidase was injected. After confirming the absence of any complications, 6 mL of 10% or 5% sodium chloride solution was injected at a rate of 1 mL every 15 minutes for 1.5 hours. This was followed by injection of 2 mL of 0.9% sodium chloride solution containing 40 mg of triamcinolone.

Epidural catheter was removed before discharging the patients

NRS No significant differences between the groups. No significant differences between the groups. NA P P NA Short-term follow-up with positive outcomes showing no significant difference between 5% or 10% sodium chloride solution.
Lumbar disc herniation and/or spinal stenosis Both groups showed significant improvement in pain rating. Both groups showed significant improvement in pain rating.

RA: randomized, PC: placebo control, DB: double-blind, ODI: Oswestry Disability Index, VAS: visual analog scale, SI: significant improvement, NA: not applicable, P: positive, IPM-QRB: Interventional Pain Management techniques – Quality Appraisal of Reliability and Risk of Bias Assessment, IPM-QRBNR: Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies, NRS: numeric rating scale, LDH: lumbar disc herniation.

Korean J Pain 2021;34:346~368 https://doi.org/10.3344/kjp.2021.34.3.346
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