Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial

Minimally Invasive Trans-sacral Canal Plasty for Lumbar Canal Stenosis

Objective The elderly population is increasing in Japan. Along with the increase in the elderly population, the number of patients with lumbar degenerative diseases is also on the rise. In general, elderly patients tend to have more complications and are at higher risk for surgery. Many elderly people suffer from lumbar degenerative disease. We reviewed our initial experience with trans-sacral canal plasty (TSCP) for patients with lumbar spinal canal stenosis and examined the pertinent literature for this report. Methods An analytical observational study was performed on 120 patients with lumbar spinal canal stenosis who underwent TSCP at our single institution from March 2019 to October 2021. These patients had leg pain and/or lower back pain due to degenerative lumbar disease. Patients who had coagulation abnormality, pregnancy, contrast allergy, pyogenic spondylitis, or spinal metastasis were excluded. Results Immediately after TSCP, the average Visual Analog Scale (VAS) score for back pain improved from 58.2 to 29.3, and for leg pain from 72.0 to 31.3. Two years after TSCP, the average VAS score for back pain increased slightly and the average score for leg pain remained almost the same. Additional surgery was performed in 37 of 120 (31%) patients who underwent TSCP. The additional surgery group had significantly worse back pain at one and three months postoperatively than the conservative treatment group. The additional surgery group had significantly worse leg pain immediately after TSCP and at one and three months postoperatively than the conservative treatment group. Logistic regression analysis demonstrated that a decreased spinal canal area (OR 0.986, p = 0.039) was associated with additional surgery. Conclusions We reviewed the outcomes of TSCP at our hospital. The average VAS score for back pain and leg pain improved. However, 31% of patients who underwent TSCP required additional surgery. It was found that the spinal canal area was a major factor in the need for additional surgery.

Minimal-invasive pain procedures are effective in different degenerative pain generators in CLBP: A prospective cohort study

BACKGROUND

It is estimated that a significant number of spinal surgeries are performed, but many patients do not often benefit.

OBJECTIVE

Our aim was to determine how effective minimally invasive pain procedures (MIP) are in chronic low back pain (CLBP) patients with proven degenerative causes (specific low back pain).

METHODS

386 eligible patients with CLBP/sciatica resistant to conservative therapy and scheduled for open surgery were screened, and 167 could be enrolled in this study. Indications for MIP in the remaining 150 individuals were made by one experienced spinal surgeon. Before and 6 months after the intervention, the numeric rating scale (NRS) and Oswestry Disability Index (ODI) were recorded. MIP was performed, such as radiofrequency of the facet and SI-joint, intradiscal electrothermal therapy in case of discogenic pain, as well as epidural neuroplasty in patients with disc herniation/epidural fibrosis.

RESULTS

There was a statistically significant decrease in NRS (p< 0.05), as well as a significant increase in ODI (p< 0.001) 6 months after the procedures. This was also true for the results of all different pain generators and subsequent performed procedures alone.

CONCLUSIONS

The indication of MIP should be routinely reviewed in patients with CLBP to avoid potentially open surgery and a burden on healthcare costs.

Evaluation of the Efficacy of Caudal Epidural Neuroplasty in Patients With Lumbar Epidural Fibrosis

Introduction Lumbar and leg pain can be caused by many factors, including scar tissue in the epidural space. Epidural fibrosis may cause chronic radicular low back pain. Adhesions in the epidural space may occur due to surgical or non-surgical reasons. Epidural adhesiolysis, i.e., neuroplasty, eliminates the pain-causing effects of scar tissue by releasing the nerve from the scar tissue or decompressing the nerve. In light of this information, this study was conducted to evaluate the effectiveness of percutaneous epidural neuroplasty interventions performed in the algology clinic in patients with lumbar epidural fibrosis who have and have not undergone lumbar surgery. Methods The sample of this retrospective study consisted of 72 patients with chronic radicular low back pain, finding fibrosis in the epidural region on contrast-enhanced magnetic resonance imaging (MRI), filling defect after epidurogram, and caudal epidural neuroplasty. Patients' visual analog scale (VAS) and Oswestry disability index (ODI) scores, pregabalin, duloxetine, and opioid doses were evaluated before and one month and six months after having neuroplasty. Results The VAS and ODI scores and pregabalin, duloxetine, and opioid doses decreased significantly in patients who had had caudal epidural neuroplasty at post-procedure endpoints compared to before the procedure (p<0.001). The paired temporal comparisons of the data of the patients who underwent epidural neuroplasty procedures before the procedure, one month after the procedure, and six months after the procedure revealed significant differences in the VAS and ODI scores (p<0.001). Additionally, the analysis of patients' VAS scores revealed that the pre-procedure VAS scores decreased significantly more one month after the procedure in patients without a history of lumbar surgery than in patients with a history of lumbar surgery. Conclusions The findings of our study demonstrated that fluoroscopy-guided percutaneous epidural neuroplasty alleviated pain and improved physical functions and quality of life. In conclusion, percutaneous epidural neuroplasty is a safe and effective treatment method for patients with lumbar epidural fibrosis.

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

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.

Interventional Pain Procedures: A Narrative Review Focusing On Safety and Complications. PART 2 Interventional Procedures For Back Pain

In patients where conservative approaches have failed to relieve from chronic pain, interventional procedures may be an option in well selected patients. In recent years there has been an increase in the use and development of invasive procedures. Concomitantly, there has also been an increase in the complications associated with these procedures. Taken this into consideration, it is important for healthcare providers to take a cautious and vigilant approach, with a focus on patient safety, in order to minimize the risk of adverse events and ensure the best possible outcome for the patient. This may include careful selection of patients for procedures, use of proper techniques and equipment, and close monitoring and follow-up after the procedure. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopy or ultrasound-guided) interventional procedures and provide strategies to reduce the risk of these complications. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.

Validity of outcome measures used in randomized clinical trials and observational studies in degenerative lumbar spinal stenosis

It is unclear whether outcome measures used in degenerative lumbar spinal stenosis (DLSS) have been validated for this condition. Cross-sectional analysis of studies for DLSS included in systematic reviews (SA) and meta-analyses (MA) indexed in the Cochrane Library. We extracted all outcome measures for pain and disability. We assessed whether the studies provided external references for the validity of the outcome measures and the quality of the validation studies. Out of 20 SA/MA, 95 primary studies used 242 outcome measures for pain and/or disability. Most commonly used were the VAS (n = 69), the Oswestry Disability Index (n = 53) and the Zurich Claudication Questionnaire (n = 22). Although validation references were provided in 45 (47.3%) primary studies, only 14 validation studies for 9 measures (disability n = 7, pain and disability combined n = 2) were specifically validated in a DLSS population. The quality of the validation studies was mainly poor. The Zurich Claudication Questionnaire was the only disease specific tool with adequate validation for assessing treatment response in DLSS. To compare results from clinical studies, outcome measures need to be validated in a disease specific population. The quality of validation studies need to be improved and the validity in studies adequately cited.

Trans-Sacral Epiduroscopic Ho:YAG Laser Ablation of the Ligamentum Flavum in a Live Pig

Introduction

For the aging population, surgery for lumbar spinal canal stenosis (LSCS) requires minimally invasive procedures. Recently, trans-sacral epiduroscopic laser decompression for lumbar disc herniation has been reported with good results. In this study, we devised a new method to perform trans-sacral epiduroscopic laser ablation of the ligamentum flavum (LF), known to be the major cause of LSCS. Using a live pig, this study aims to evaluate the efficacy, safety, and drawbacks of this procedure.

Methods

Using an epiduroscope, we observed intra-spinal canal structures and then examined the feasibility and problems of a decompression procedure to ablate the LF using holmium:YAG (Ho:YAG) laser. The pig was observed for behavioral changes and neurological deficits after the procedure. Histological analysis was performed to evaluate the amount of tissue ablation and damage to surrounding tissues.

Results

Although it was possible to partially ablate the LF using the Ho:YAG laser under epiduroscopy, it was difficult to maintain a clear field of view, and freely decompressing the target lesion has been a challenge. After the first two experiments, the pig neither showed abnormal behavior nor any signs of pain or paresis. However, in the third experiment, the pig died during the operation. On autopsy, no thermal or mechanical injury was noted around the ablated site, including the dura mater and nerve root. Histological analysis showed that the LF and lamina were deeply ablated as the laser power increased, and no damage was noted on surrounding tissues beyond a depth of 500 μm.

Conclusions

Although Ho:YAG laser could ablate the ligamentum and bone tissues without causing damage to surrounding tissues, it was difficult to completely decompress the LF under epiduroscopy. This method is a potentially highly invasive procedure that requires caution in its clinical application and needs further improvement in terms of the instruments and techniques used.

Efficacy of Minimally Invasive Trans-Sacral Canal Plasty between Patients with and without Failed Back Surgery Syndrome

Background and Objectives: Clinicians are required to manage a growing number of elderly patients with several medical comorbidities, and invasive surgical treatments are sometimes not advisable for these patients. The aim of this study was to evaluate the efficacy of minimally invasive intraspinal canal treatment, trans-sacral canal plasty (TSCP), for patients with and without failed back surgery syndrome (FBSS). Materials and Methods: A multicenter analysis was conducted. TSCP was performed in patients with chronic low back pain and leg pain due to lumbar spinal disorders. An adhesiolysis by TSCP was carried out, then a mixture of steroid and local anesthesia was injected. Visual Analog Scales (VAS) for low back pain and leg pain, and complications were evaluated. Results: A total of 271 patients with a minimum 6-month follow-up were enrolled. There were 80 patients who had a history of previous lumbar spinal surgery (F group), and 191 patients without previous lumbar spinal surgery (N group). There were no significant differences in sex and age between the two groups. VAS scores for low back pain (N group/F group) preoperatively, immediately postoperatively, and 1 month, 3 months and 6 months postoperatively, were 51/52 mm, 24/26 mm, 33/34 mm, 30/36 mm, and 30/36 mm, respectively. VAS scores for leg pain were 69/67 mm, 28/27 mm, 39/41 mm, 36/43 mm, and 32/40 mm, respectively. Both VAS scores for low back pain and leg pain were significantly decreased from baseline to final follow-up in both groups (p < 0.01). However, VAS scores for leg pain at 3 months and 6 months postoperatively were significantly higher in F group (p < 0.05). There were three catheter breakages (2/3 in F group), and one dural tear in F group. Conclusions: TSCP significantly reduced both VAS scores for low back and leg pain in patients with and without FBSS. However, co-existence of intractable epidural adhesion might be associated with less improvement in FBSS.

The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis

BACKGROUND

Recalcitrant disc herniation may result in chronic lumbar radiculopathy or sciatica. Fluoroscopically directed epidural injections and other conservative modalities may provide inadequate improvement in some patients. In these cases, percutaneous neurolysis with targeted delivery of medications is often the next step in pain management.

METHODS

An evidence-based system of methodologic assessment, namely, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. Multiple databases were searched from 1966 to January 2021. Principles of the best evidence synthesis were incorporated into qualitative evidence synthesis. The primary outcome measure was the proportion of patients with significant pain relief and functional improvement (≥ 50%). Duration of relief was categorized as short-term (< 6 months) and long-term (≥ 6 months).

RESULTS

This assessment identified one high-quality randomized controlled trial (RCT) and 5 moderate-quality non-randomized studies with an application of percutaneous neurolysis in disc herniation. Overall, the results were positive, with level II evidence.

CONCLUSIONS

Based on the present systematic review, with one RCT and 5 nonrandomized studies, the evidence level is II for percutaneous neurolysis in managing lumbar disc herniation.

Invasive Treatments for Low Back Disorders

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's Low Back Disorders guideline reviews the evidence and recommendations developed for invasive treatments used to manage low back disorders.

METHODS

Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 47 high-quality and 321 moderate-quality trials were identified for invasive management of low back disorders.

RESULTS

Guidance has been developed for the invasive management of acute, subacute, and chronic low back disorders and rehabilitation. This includes 49 specific recommendations.

CONCLUSION

Quality evidence should guide invasive treatment for all phases of managing low back disorders.

Patient-Reported Outcomes and Satisfaction after Cervical Epidural Steroid Injection for Cervical Radiculopathy

BACKGROUND

Cervical radiculopathy caused by disc herniation is a frequent public health issue with economical and socio-professional impacts. The objective of the present study is to evaluate the patient-reported outcomes and satisfaction from cervical epidural steroid injection during a 2-year follow-up.

MATERIALS AND METHODS

Results based on patients' reports from a previously performed intervention of cervical epidural steroid injection on patients with cervical radiculopathy due to cervical disc herniation are prospectively collected. Outcome measures are Neck Disability Index (NDI), numerical rating scale (NRS) for pain assessment, and 5-scale patient satisfaction questionnaire (PSQ) plus opioid medication for pain relief, additional injections, and progression to surgery.

RESULTS

Of total 37 cases, 34 were available for follow-up after 2-year postoperatively. The mean preoperative NDI was 21.17 and improved to 17.38, and the mean NRS was 7.7 and improved to 5.00; both were statistically significant. Mean patient satisfaction after 2 years was 3.17 out of 5. 11 cases needed additional injections, and 4 of patients proceeded to surgery.

CONCLUSION

We showed that transforaminal cervical epidural steroid injection for cervical radiculopathy is an effective non-surgical treatment option, providing significant pain relief and functional improvement during 2-years follow-up along with higher-than-average patient satisfaction in most of our patients.

Clinical Effectiveness of Percutaneous Epidural Neuroplasty According to the Type of Single-Level Lumbar Disc Herniation : A 12-Month Follow-Up Study

Objective

To determine whether the outcomes of percutaneous epidural neuroplasty (PEN) are influenced by the type of lumbar disc herniation (LDH) and evaluate the effectiveness of PEN in patients with single-level LDH.

Methods

This study included 430 consecutive patients with single-level LDH who underwent PEN. Before treatment, the LDH type was categorized as bulging, protrusion, extrusion, and sequestration, while Pfirrmann grades were assigned according to imaging findings. Visual analog scale (VAS) scores for back and leg pain and success rates (Odom’s criteria) were assessed at 1, 3, 6, and 12 months after treatment.

Results

The mean preoperative VAS scores for back and leg pain were 6.90 and 4.23, respectively; these decreased after PEN as follows : 2.25 and 1.45, respectively, at 1 month; 2.61 and 1.68, respectively, at 3 months; 2.28 and 1.48, respectively, at 6 months; and 2.88 and 1.48, respectively, at 12 months (p<0.001). The decrease in VAS scores for leg pain was significantly greater in the extrusion and sequestration groups than in the other two groups (p<0.05); there were no other significant differences among groups. More than 70% patients exhibited good or excellent 12-month outcomes according to Odom’s criteria. Subsequent surgery was required for 59 patients (13.7%), with a significantly higher rate in the extrusion (25.0%) and sequestration (30.0%) groups than in the bulging (7.3%) and protrusion (13.8%) groups (p<0.05). Nevertheless, subsequent surgery was not required for >70% patients with extrusion or sequestration. Patients with Pfirrmann grades 1–3 (14.0–21.5%) showed a significantly higher rate of subsequent surgery than those with Pfirrmann grade 0 (4.9%; p<0.05).

Conclusion

Our findings suggest that PEN is an effective treatment for back and leg pain caused by single-level LDH, with the outcomes remaining unaffected by the LDH type.

Clinical Efficacy and Safety of Trans-Sacral Epiduroscopic Laser Decompression Compared to Percutaneous Epidural Neuroplasty

Percutaneous epidural neuroplasty (PEN) is an effective and safe procedure for herniated lumbar disc (HLD). Although PEN has an advantage of adhesiolysis, this procedure cannot decompress the protruded disc. Recently, trans-sacral epiduroscopic laser decompression (SELD) for HLD has been introduced as a promising alternative methodology. This study evaluated the clinical efficacy and safety of SELD compared to PEN, as well as the change in protruded disc volume after SELD through pre- and postoperative magnetic resonance imaging (MRI), in patients with HLD. Thirty consecutive patients underwent SELD (SELD group), and 45 patients underwent PEN (PEN group). The Visual Analog Scale (VAS) for leg pain; Oswestry Disability Index (ODI); 12-Item Short-Form Health Survey (SF-12); preoperative and postoperative 4-, 12-, and 24-week Macnab criteria; and preoperative and 24-week postoperative lumbar spinal MRIs after SELD were obtained. There was no significant difference in age, sex, duration of symptoms, and the distributions of disc level between the two groups (all P > 0.05). Between the SELD and PEN groups, preoperative VAS, ODI, and SF-12 scores had no significant differences. However, the VAS, ODI, and SF-12 scores improved significantly after the procedures by postoperative week 24 in each group (all P < 0.05). Furthermore, improvements of VAS, ODI, SF-12, and success rate of Macnab criteria in the SELD group were better than those in the PEN group (all P < 0.05). The protruded disc volume after SELD decreased significantly (P=0.034). All clinical and functional outcomes of patients undergoing SELD and PEN for HLD improved following the procedures. Notably, SELD was superior to PEN regarding the degree of improvement in clinical and functional outcomes. Therefore, we suggest that SELD can be used as an effective alternative to PEN to provide improved clinical and functional outcomes in patients with HLD.

A review of the role of epidural percutaneous neuroplasty

Degeneration, whether from age or postsurgical, in the ventral and lateral epidural space can lead to irritation of both the nerve roots and of the nerves present in the epidural space, the peridural membrane and the posterior longitudinal ligament. This irritation is often accompanied by mild scarring. Neuroplasty is a specific procedure designed to relieve this irritation. The effectiveness of neuroplasty is not affected by the extent of spinal stenosis. Neuroplasty can be performed in the lumbar, thoracic and cervical spine, and using caudal, transforaminal and interlaminar approaches. Postprocedural home exercises are an integral part of the procedure. There are multiple high-grade studies positive for the effectiveness and safety of neuroplasty. Neuroplasty should be offered prior to surgery in patients with persistent back and/or extremity pain.

A novel technique for managing symptomatic spinal cysts using epiduroscopic neural laser decompression: technical note and preliminary results

BACKGROUND

Benign spinal cysts are relatively common, but can cause significant pain. However, consensus regarding the best method for treating these cysts has not been established. We aimed to examine the usefulness of epiduroscopic neural laser decompression (ENLD), a novel percutaneous treatment, for treating lumbo-sacral cysts.

METHODS

Ten patients (6 men, 4 women; mean age 45.5 years) with benign lumbo-sacral cysts underwent ENLD. The lumbo-sacral cysts were caused by multiple pathophysiologies and displayed different characteristics. Cysts were evaluated using a recorded epiduroscopic procedure video, magnetic resonance imaging (MRI), and electronic medical records. In all patients, MRI identified cysts with well-defined margins that were compressing the nerves in the lumbo-sacral region and were associated with the pain symptoms of the patients. Retrospectively, we reviewed a series of consecutive patients who underwent surgery (two with discal cysts, four with facet cysts, and four with Tarlov cysts). Low back/leg pain was evaluated using a 1-10 visual analog scale. Functional improvement was evaluated using Oswestry Disability Index scores. Outcomes were evaluated pre- and post-operatively and 1 year post-surgery.

RESULTS

Patients were examined between May 2016 and August 2017. Average pain scores improved from 4.7 pre-surgery to 1.8 post-surgery (low back; p < .001) and from 5.8 pre-surgery to 1.6 post-surgery (leg; p < .001). Disability scores decreased from 27.2% pre-surgery to 14.6% post-surgery.

CONCLUSION

Currently, no standard treatment strategy for symptomatic spinal cysts exists. These results show that ENLD using a Holmium: YAG laser can be useful in treating symptomatic benign spinal cysts.

TRIAL REGISTRATION

Not applicable as this is a retrospective chart review.

Clinical Significance of Epidurography Contrast Patterns after Adhesiolysis during Lumbar Percutaneous Epidural Neuroplasty

Background

The correlation between epidurography contrast patterns and the clinical outcomes of percutaneous epidural neuroplasty (PEN) remains unclear.

Objective

To analyze the correlation between postadhesiolysis epidurography contrast patterns and the clinical outcomes of patients who undergo lumbar PEN.

Design

This study is a retrospective analysis of 78 consecutive patients who underwent lumbar PEN between April 2012 and March 2013.

Setting

The analysis was done in the university hospital center.

Method

The clinical outcomes of all patients were assessed before and 1, 3, 6, and 12 months after undergoing lumbar PEN. Specifically, the intensity of back and leg pain, quality of life, and procedural outcomes were evaluated using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and the 12-Item Short-Form Health Survey (SF-12).

Results

The VAS scores for back and leg pain, ODI score, and SF-12 score exhibited a significant improvement during the follow-up period (P < 0.01 versus preprocedural scores). At most follow-up time points, patients exhibiting extraforaminal contrast distribution (n=22) on postadhesiolysis epidurograms exhibited a similar improvement in VAS scores and a significantly better improvement in ODI and SF-12 scores compared with patients exhibiting intracanal contrast distribution (n=56).

Conclusion

Extraforaminal contrast distribution during lumbar PEN may be associated with better functional outcomes.

Trans-sacral epiduroscopic laser decompression versus the microscopic open interlaminar approach for L5-S1 disc herniation

Context/Objective: Trans-sacral epiduroscopic laser decompression (SELD) is an alternative to microscopic open lumbar discectomy (OLD). SELD and OLD for L5-S1 lumbar disc herniation (LDH) have not been compared. We compared clinical results, including pain control, between SELD and OLD.Design: Retrospective analysis.Setting: Korean hospital.Participants: Eighty patients treated with SELD (n = 40) or microscopic OLD (n = 40) for L5-S1 LDH.Interventions: N/A.Outcome Measures: Clinical data were compared over 6 months. Functional status was evaluated using Oswestry Disability Index (ODI, 0-100%) and time to return to work. Preoperative and postoperative pain was measured using a visual analog scale (VAS, 0-10). Radiological assessment was performed preoperatively and postoperatively.Results: The ODI and VAS scores for leg and back pain significantly improved in both groups. At 6-months after the procedure, the average ODI decreased to 13.2 ± 11.2 from 54.5 ± 14.5 for SELD and 9.5 ± 10.4 from 57.5 ± 16.0 for OLD. The average leg VAS decreased to 1.9 ± 1.2 from 6.0 ± 1.4 for SELD and 2.3 ± 1.3 from 6.7 ± 1.6 for OLD. Back VAS reduced to 2.6 ± 1.3 from 7.2 ± 1.5 for OLD. Time to return to work was 1.1 ± 1.1 weeks for SELD and 5.4 ± 2.1 weeks for OLD. Clinical outcomes of SELD were non-inferior to those of OLD in terms of pain control.Conclusion: A scar-free procedure and early return to normal life are advantages of SELD.

Complications of lumbar disc herniations following trans-sacral epiduroscopic lumbar decompression: a single-center, retrospective study

Background

Trans-sacral epiduroscopic lumbar decompression (SELD) is an emerging procedure for the treatment of lumbar disc herniation (LDH), with favorable outcomes having been reported. However, the complications associated with SELD have not been comprehensively evaluated to date. Therefore, the aim of our study was to describe the incidence rate, types, and characteristics of complications following SELD and management outcomes.

Methods

Retrospective analysis of the surgical and clinical outcomes for 127 patients (average age, 42.2 ± 15.2 years) who underwent SELD for LDH at L2-3, L3-4, L4-5, and/or L5-S1, performed by a single experienced spine surgeon at a single center, between January 2015 and April 2017, was conducted.

Results

All procedures were successful, with a mean follow-up of 12.3 ± 2.3 months. Complications were identified in 8 patients (6.3%), including 3 cases of incomplete decompression (2.4%), 2 cases of recurrent disc herniation (1.6%), and one case each of hematoma, dural tearing, and subchondral osteonecrosis (0.8%). Among these cases with complications, only 2 cases with incomplete decompression and one case with recurrent LDH did not improve with conservative treatment and required re-operation using an open approach. The rate of complications decreased from 12.6% when considering only the first 50 cases to 2.6% for cases 51–127.

Conclusions

Incomplete decompression, recurrent herniation, epidural hematoma, dural tear, and subchondral osteonecrosis were identified as complications of SELD, although the overall rate of complications was low. Practice with the procedure and careful patient selection can lower the risk of complications.

Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review

OBJECTIVE

To evaluate the degree to which conservative care and failure were specifically defined in studies comparing nonoperative treatment versus surgery for low back pain (LBP) conditions in adults.

DATA SOURCES

A comprehensive literature search was conducted by an experienced librarian using MEDLINE (PubMed), Embase, Google Scholar, and CENTRAL from January 2003 to June 2014. Endnote bibliographic management application was used to remove duplicates and organize the citations.

STUDY SELECTION

Prospective, randomized, or cohort trials comparing surgery versus conservative intervention for patients with LBP conditions. Study selection was conducted by 2 independent reviewers.

DATA EXTRACTION

Three independent reviewers extracted data from each article using a structured data extraction form. Data extracted included type of study, participant characteristics, sample size, description, and duration of conservative care and whether failed conservative care criterion was defined.

DATA SYNTHESIS

A total of 852 unique records were screened for eligibility; of those, 72 articles were identified for further full-text review. Thirty-four full texts were excluded based on the exclusion criteria, and 38 articles, representing 20 unique studies, were included for qualitative synthesis. Fifteen of the 20 studies defined the duration of conservative care. Only 3 studies defined the dosage of physical therapy sessions, including total number of visits and visit duration. Two studies described medication usage, including the duration and type. No studies specifically defined what constituted failed conservative therapy.

CONCLUSIONS

This literature review suggests conservative care is poorly defined in randomized trials, which can lead to ambiguity of research procedures and unclear guidelines for clinicians. Future studies should increase transparency and explicitly define conservative care.

Low intensity laser and LED therapies associated with lateral decubitus position and flexion exercises of the lower limbs in patients with lumbar disk herniation: clinical randomized trial

The objective of this study is to evaluate the effectiveness of laser and LED therapies, associated with lateral decubitus position and flexion exercises of the lower limbs in patients with lumbar disk herniation (LDH). It is a randomized blinded clinical trial. Fifty-four subjects with LDH L4-L5 and L5-S1 were selected and randomly allocated into groups: laser 904 nm, placebo, and LED 945 nm. The numbers of subjects for each group that completed the treatment were 18, 13, and 18, respectively. Twelve points over the lumbar spine region (L2 to S1) and eight points on the injured thigh in the path of the lumbar roots L5 and S1 were irradiated. Irradiation parameters for each point were as follows: laser wavelength 904 ± 10 nm, average power 0.038 ± 20 % W, irradiated area 0.16 cm(2), energy per point 4 J, and treatment time per point 104 s; LED wavelength 945 ± 15 nm, power 0.1 W, irradiated area 1.0cm(2), energy per point 4 J, and treatment time per point 40 s. Lateral decubitus opposite to the side of the radicular was the standard position for all patients. After phototherapy and laser placebo sessions, the subjects performed sequences of flexion exercises of the lower limbs (ten per session) for 15 daily sessions.

VARIABLES STUDIED

pain intensity assessed by visual analog scale (VAS), degree of flexion of the affected hip measured by the universal goniometer and functional capacity assessed by the Oswestry Disability Index. The three groups had statistically significant improvement in lumbar and radicular pain, in hip mobility, and in the functional disability index (p ≤ 0.001). There was a statistically significant difference (p = 0.024) in radicular pain between the groups, gait claudication and Oswestry Disability Index. We can conclude that in the treatment of L4-L5 and L5-S1 LDH with radiculopathy, LED, associated with lateral decubitus position and flexion exercises of the lower limbs, showed better therapeutic performance for radicular pain, gait claudication, and functional disability.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

Efficacy of percutaneous epidural neuroplasty does not correlate with dural sac cross-sectional area in single level disc disease

PURPOSE

Percutaneous epidural neuroplasty (PEN) is a minimally invasive treatment. The efficacy of PEN has been relatively well investigated; however, the relationship between the clinical effectiveness of PEN and the severity of spinal canal stenosis by disc material has not yet been established. The purpose of this study was to compare clinical outcomes of PEN according to the dural sac cross-sectional area in single level disc disease.

MATERIALS AND METHODS

This study included 363 patients with back pain from single level disc disease with and without radiculopathy. Patients were categorized into groups according to spinal canal compromise by disc material: Category 1, less or more than 50%; and Category 2, three subgroups with lesser than a third, between a third and two thirds, and more than two thirds. Clinical outcomes were assessed according to the Visual Analog Scale (VAS) score for back pain and leg pain and Odom's criteria at 1, 3, 6, 12, and 24 months after treatment.

RESULTS

The demographic data showed no difference between groups according to spinal canal compromise by disc material except age (older age correlated with more spinal canal compromise). The dural sac cross-sectional area did not correlate with the VAS scores for back and leg pain after PEN in single level disc disease in Groups 1 and 2. Odom's criteria after PEN were also not different according to dural sac cross-sectional area by disc material.

CONCLUSION

PEN is an effective procedure in treating single level lumbar disc herniation without affecting dural sac cross-sectional area.

The efficacy of epiduroscopic neural decompression with Ho:YAG laser ablation in lumbar spinal stenosis

Although epiduroscopy is one of the popular interventions for the management of lumbar spinal stenosis (LSS), only a part of these patients show improvement in pain and functional level. Consequently, the authors thought that holmium:YAG (Ho:YAG) laser can be a reasonable alternative as an adjunct of epiduroscopic procedure, but has not been thoroughly determined yet which influence is resulted by it. This study was conducted to evaluate and compare the efficacy of epiduroscopic neural decompression (END) and END with Ho:YAG laser (ELND) in patients with LSS. Forty-seven patients with LSS were enrolled, all of whom underwent END or ELND and were followed up for 2 years or more. Clinical outcomes were evaluated using the visual analog scale (VAS) for back and leg pain and the Roland Morris Disability Questionnaire (RMDQ). Procedure-related complications, especially including laser-related complications, were also evaluated. The only laser-related complication that occurred was transient mild motor paralysis in one case (3.1 %). In the END group, clinical score is exhibiting V-shaped upward trend that ended after procedure with the almost similar score obtained with preoperative status. However, in the ELND group, it is exhibiting relatively consistent improvement after procedure. There was a statistically significant improvement in the VAS and RMDQ score after 6 months after ELND procedure compared with END procedure (p = 0.01, 0.03, respectively). ELND could produce significant improvement of low back pain (LBP) at the last follow-up time (p = 0.01), but radiating pain of leg could not be improved significantly (p = 0.09). In conclusion, the current study suggests that performing Ho:YAG laser ablation concurrently with END could produce more decreased intensity of pain and prolonged effect of pain relief compared with END in LSS patients. LSS patients with LBP would be an ideal candidate for ELND, but radiating pain of LSS might not be managed effectively with ELND.

Epidural lysis of adhesions

As our population ages and the rate of spine surgery continues to rise, the use epidural lysis of adhesions (LOA) has emerged as a popular treatment to treat spinal stenosis and failed back surgery syndrome. There is moderate evidence that percutaneous LOA is more effective than conventional ESI for both failed back surgery syndrome, spinal stenosis, and lumbar radiculopathy. For cervical HNP, cervical stenosis and mechanical pain not associated with nerve root involvement, the evidence is anecdotal. The benefits of LOA stem from a combination of factors to include the high volumes administered and the use of hypertonic saline. Hyaluronidase has been shown in most, but not all studies to improve treatment outcomes. Although infrequent, complications are more likely to occur after epidural LOA than after conventional epidural steroid injections.

Efficacy of epidural neuroplasty versus transforaminal epidural steroid injection for the radiating pain caused by a herniated lumbar disc

Objective

To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc.

Methods

Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment.

Results

In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00±1.52, 4.29±1.20, 2.64±0.93, 1.43±0.51 and those of FRI were 23.57±3.84, 16.50±3.48, 11.43±2.44, 7.00±2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22±2.05, 4.28±1.67, 2.56±1.04, 1.33±0.49 and those of FRI were 22.00±6.64, 16.22±5.07, 11.56±4.18, 8.06±1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically.

Conclusion

Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.

Interventional management of neuropathic pain: NeuPSIG recommendations

Neuropathic pain (NP) is often refractory to pharmacologic and noninterventional treatment. On behalf of the International Association for the Study of Pain Neuropathic Pain Special Interest Group, the authors evaluated systematic reviews, clinical trials, and existing guidelines for the interventional management of NP. Evidence is summarized and presented for neural blockade, spinal cord stimulation (SCS), intrathecal medication, and neurosurgical interventions in patients with the following peripheral and central NP conditions: herpes zoster and postherpetic neuralgia (PHN); painful diabetic and other peripheral neuropathies; spinal cord injury NP; central poststroke pain; radiculopathy and failed back surgery syndrome (FBSS); complex regional pain syndrome (CRPS); and trigeminal neuralgia and neuropathy. Due to the paucity of high-quality clinical trials, no strong recommendations can be made. Four weak recommendations based on the amount and consistency of evidence, including degree of efficacy and safety, are: 1) epidural injections for herpes zoster; 2) steroid injections for radiculopathy; 3) SCS for FBSS; and 4) SCS for CRPS type 1. Based on the available data, we recommend not to use sympathetic blocks for PHN nor radiofrequency lesions for radiculopathy. No other conclusive recommendations can be made due to the poor quality of available data. Whenever possible, these interventions should either be part of randomized clinical trials or documented in pain registries. Priorities for future research include randomized clinical trials, long-term studies, and head-to-head comparisons among different interventional and noninterventional treatments.

Clinical outcomes of epidural neuroplasty for cervical disc herniation

Cervical disc herniation is a common disorder characterized by neck pain radiating to the arm and fingers as determined by the affected dermatome. This condition has a favorable prognosis, but pain can have a serious detrimental impact on daily activities. Epidural neuroplasty has been applied as a treatment option for cervical disc herniation; however, no study has addressed the clinical outcomes. This retrospective study evaluated the clinical outcomes of epidural neuroplasty on 128 patients for the treatment of cervical disc herniation. To measure pain-related disabilities over time, the changes of pain scores in neck and arm were evaluated using a numerical rating scale (NRS) and the neck disability index (NDI). Compared with preprocedural values, the pain NRS of neck and arm demonstrated significant improvement at day 1, and 1, 3, 6, and 12 months after the procedure (P < 0.001). Likewise, the NDI was significantly reduced at 3, 6, and 12 months after the procedure (P < 0.001). There were no serious complications. Cervical epidural neuroplasty shows good clinical outcomes in the treatment of cervical disc herniation and can be considered a treatment modality for cervical disc herniation refractory to conservative treatment.

Assessment of effectiveness of percutaneous adhesiolysis in managing chronic low back pain secondary to lumbar central spinal canal stenosis

BACKGROUND

Chronic persistent low back and lower extremity pain secondary to central spinal stenosis is common and disabling. Lumbar surgical interventions with decompression or fusion are most commonly performed to manage severe spinal stenosis. However, epidural injections are also frequently performed in managing central spinal stenosis. After failure of epidural steroid injections, the next sequential step is percutaneous adhesiolysis and hypertonic saline neurolysis with a targeted delivery. The literature on the effectiveness of percutaneous adhesiolysis in managing central spinal stenosis after failure of epidural injections has not been widely studied.

STUDY DESIGN

A prospective evaluation.

SETTING

An interventional pain management practice, a specialty referral center, a private practice setting in the United States.

OBJECTIVE

To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis.

METHODS

Seventy patients were recruited. The initial phase of the study was randomized, double-blind with a comparison of percutaneous adhesiolysis with caudal epidural injections. The 25 patients from the adhesiolysis group continued with follow-up, along with 45 additional patients, leading to a total of 70 patients. All patients received percutaneous adhesiolysis and appropriate placement of the Racz catheter, followed by an injection of 5 mL of 2% preservative-free lidocaine with subsequent monitoring in the recovery room. In the recovery room, each patient also received 6 mL of 10% hypertonic sodium chloride solution, and 6 mg of non-particulate betamethasone, followed by an injection of 1 mL of sodium chloride solution and removal of the catheter.

OUTCOMES ASSESSMENT

Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12, 18 and 24 months post treatment. The primary outcome measure was 50% or more improvement in pain scores and ODI scores.

RESULTS

Overall, a primary outcome or significant pain relief and functional status improvement of 50% or more was seen in 71% of patients at the end of 2 years. The overall number of procedures over a period of 2 years were 5.7 ± 2.73.

LIMITATIONS

The lack of a control group and a prospective design.

CONCLUSIONS

Significant relief and functional status improvement as seen in 71% of the 70 patients with percutaneous adhesiolysis utilizing local anesthetic steroids and hypertonic sodium chloride solution may be an effective management strategy in patients with chronic function limiting low back and lower extremity pain with central spinal stenosis after failure of conservatie management and fluoroscopically directed epidural injections.

The application of percutaneous lysis of epidural adhesions in patients with failed back surgery syndrome

PURPOSE

To investigate the efficacy and the feasibility of application of percutaneous lysis of epidural adhesions in failed back surgery syndrome (FBSS) using a stiff type guide wire and 4F vascular catheter.

METHODS

Ninety two patients with FBSS were randomly divided into two groups, the control group (treated by injection dexamethasone only) and percutaneous lysis of epidural adhesions group. Visual analog scale scores (VAS) and therapeutic evaluation were observed in the preoperative, seven days postoperative, one month and six months postoperative.

RESULTS

VAS scores for pain were significantly reduced in both groups at seven days. The VAS scores were in controlled group at one month, six months was significantly higher than that in epidural lysis group. However, there was no statistical difference in VAS scores of one month and six months when respectively compared to that of before operation in controlled group. Patients on epidural lysis reported clinical effectiveness rate was 50%. Patients on control was 5.26%, there was a statistical difference between two groups.

CONCLUSION

Percutaneous lysis of epidural adhesions by using a stiff type guide wire and 4F vascular catheter is an effective method in the treatment of FBSS and it has a value in clinical application.

A review of the role of epidural percutaneous adhesiolysis

SUMMARY Low back and leg pain can arise for a variety reasons, including epidural scarring caused by post lumbar surgery syndrome, infection or bleeding. Treatment options for low back and/or leg pain caused by epidural scarring include conservative approaches, such as physical therapy and medication management, and procedures, such as epidural steroid injections. Despite appropriate treatment, pain can persist in these patients. Surgery is often not an option for patients whose pain is caused by scarring. Percutaneous adhesiolysis is a minimally invasive technique, which is effective in treating refractory low back and leg pain arising from epidural scarring. It involves the use of a spring-wound, shear-resistant catheter, ideally placed in the ventrolateral aspect of the epidural space for the lysis of adhesions, allowing medications to reach the involved nerve and removing compression of the nerve. After mechanical lysis of adhesions, relatively large volumes of local anesthetic, saline, steroid and radiopaque contrast material are injected. Either hypertonic or normal saline may be used, along with hyaluronidase. After the procedure, the patient should perform exercises to stretch the nerve roots. While this has been studied as a caudal procedure, thoracic and cervical procedures have also been described, using both transforaminal and interlaminar approaches. With trained practitioners, complications are minimal. The effectiveness of the procedure has been documented by high-quality randomized controlled trials and observational studies for both postlumbar surgery syndrome and spinal stenosis.

11. Lumbosacral radicular pain

Lumbosacral radicular pain is characterized by a radiating pain in one or more lumbar or sacral dermatomes; it may or may not be accompanied by other radicular irritation symptoms and/or symptoms of decreased function. The annual prevalence in the general population, described as low back pain with leg pain traveling below the knee, varied from 9.9% to 25%, which means that it is presumably the most commonly occurring form of neuropathic pain. The patient's history may give a suggestion of lumbosacral radicular pain. The best known clinical investigation is the straight-leg raising test. Final diagnosis is made based on a combination of clinical examination and potentially additional tests. Medical imaging studies are indicated to exclude possible serious pathologies and to confirm the affected level in patients suffering lumbosacral radicular pain for longer than 3 months. Magnetic resonance imaging is preferred. Selective diagnostic blocks help confirming the affected level. There is controversy concerning the effectiveness of conservative management (physical therapy, exercise) and pharmacological treatment. When conservative treatment fails, in subacute lumbosacral radicular pain under the level L3 as the result of a contained herniation, transforaminal corticosteroid administration is recommended (2 B+). In chronic lumbosacral radicular pain, (pulsed) radiofrequency treatment adjacent to the spinal ganglion (DRG) can be considered (2 C+). For refractory lumbosacral radicular pain, adhesiolysis and epiduroscopy can be considered (2 B+/-), preferentially study-related. In patients with a therapy-resistant radicular pain in the context of a Failed Back Surgery Syndrome, spinal cord stimulation is recommended (2 A+). This treatment should be performed in specialized centers.

Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review

STUDY DESIGN

A systematic review of randomized controlled trials.

OBJECTIVE

To determine the efficacy and adverse effects of conservative treatments for people who have lumbar disc herniation with associated radiculopathy (LDHR).

SUMMARY OF BACKGROUND DATA

Although conservative management is commonly used for people who have LDHR, the efficacy and adverse effects of conservative treatments for this condition are unclear.

METHODS

We searched 10 computer databases for trials published in English between 1971 and 2008. Trials focusing on people with referred leg symptoms and radiologic confirmation of a lumbar disc herniation were included if at least 1 group received a conservative and noninjection treatment.

RESULTS

Eighteen trials involving 1671 participants were included. Seven (39%) trials were considered of high quality. Meta-analysis on 2 high-quality trials revealed that advice is less effective than microdiscectomy surgery at short-term follow-up, but equally effective at long-term follow-up. Individual high-quality trials provided moderate evidence that stabilization exercises are more effective than no treatment, that manipulation is more effective than sham manipulation for people with acute symptoms and an intact anulus, and that no difference exists among traction, laser, and ultrasound. One trial showed some additional benefit from adding mechanical traction to medication and electrotherapy methods. Adverse events were associated with traction (pain, anxiety, lower limb weakness, and fainting) and ibuprofen (gastrointestinal events).

CONCLUSION

Advice is less effective than microdiscectomy in the short term but equally effective in the long term for people who have LDHR. Moderate evidence favors stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound. Adverse events were associated with traction and ibuprofen. Additional high-quality trials would allow firmer conclusions regarding adverse effects and efficacy.

Acute monoplegia after lysis of epidural adhesions: a case report

Lysis of epidural adhesions is an interventional procedure performed to treat refractory low back pain or radicular pain due to epidural scarring. A 39-year-old female with a diagnosis of failed back surgery syndrome underwent lysis of epidural adhesions using a Racz catheter. She developed acute monoplegia of her right lower extremity immediately after the procedure. Radiographic imaging did not reveal an epidural hematoma. Motor and sensory function in the right lower limb returned after 5 days. Large volumes of fluid injected during neuroplasty could have caused transient nerve injury from compression within loculated epidural compartments.