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Urits I, Schwartz RH, Brinkman J, Foster L, Miro P, Berger AA, Kassem H, Kaye AD, Manchikanti L, Viswanath O. An Evidence Based Review of Epidurolysis for the Management of Epidural Adhesions. PSYCHOPHARMACOLOGY BULLETIN 2020; 50:74-90. [PMID: 33633419 PMCID: PMC7901122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE OF REVIEW This review presents epidurolysis as a procedure to alleviate pain and disability from epidural adhesions. It reviews novel and groundbreaking evidence, describing the background, indications, benefits and adverse events from this procedure in an effort to provide healthcare experts with the data required to decide on an intervention for their patients. RECENT FINDINGS Epidural adhesions (EA) or epidural fibrosis (EF) is defined as non-physiologic scar formation secondary to a local inflammatory reaction provoked by tissue trauma in the epidural space. Often, it is a sequelae of surgical spine intervention or instrumentation. The cost associated with chronic post-operative back pain has been reported to be up to nearly $12,500 dollars per year; this, coupled with the increasing prevalence of chronic lower back pain and the subsequent increase in surgical management of back pain, renders EF a significant cost and morbidity in the U.S. Though risk factors leading to the development of EA are not well established, epidural fibrosis has been reported to be the culprit in up to 46% of cases of Failed Back Surgery Syndrome (FBSS), a chronic pain condition found in up to 20-54% of patients who receive back surgery. Moreover, EF has also been associated with lumbar radiculopathy after lumbar disc surgery. Epidurolysis is defined as the mechanical dissolution of epidural fibrotic scar tissue for persistent axial spine or radicular pain due to epidural fibrosis that is refractory to conservative therapy Endoscopic lysis of adhesions is a procedural technique which has been shown to improve chronic back pain in one-third to one-half of patients with clinically symptomatic fibrous adhesions. Here we review some of the novel evidence that supports this procedure in EA and FBSS. SUMMARY The literature concerning epidurolysis in the management of epidural adhesions is insufficient. Prospective studies, including randomized controlled trials and observational studies, have suggested epidurolysis to be effective in terms of pain reduction, functional improvement, and patient satisfaction scores. Observational studies report epidurolysis as a well-tolerated, safe procedure. Current evidence suggests that epidurolysis may be used as an effective treatment modality for epidural adhesions. Nonetheless, further high quality randomized controlled studies assessing the safety and efficacy of epidurolysis in the management of epidural adhesions is needed.
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Affiliation(s)
- Ivan Urits
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Ruben H Schwartz
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Joseph Brinkman
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Lukas Foster
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Paulo Miro
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Amnon A Berger
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Hisham Kassem
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Alan D Kaye
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Laxmaiah Manchikanti
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
| | - Omar Viswanath
- Urits, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. Berger, MD, PhD, Beth Israel Deaconess Medical Center, Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA. Schwartz, DO, Kassem, MD, Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL. Brinkman, BS, Foster, BS, Miro, BS, University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ. Kaye, MD, PhD, Departments of Anesthesiology and Pharmacology, Toxicology and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA. Manchikanti, MD, Pain Management Centers of America, Paducah, KY. Viswanath, MD, Department of Anesthesiology, Louisiana State University School of Medicine, Shreveport, LA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE
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