The Korean Journal of Pain

The Korean Pain Society (대한통증학회)
권호 표지
DOI QR코드

DOI QR Code

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

  • Manchikanti, Laxmaiah (Pain Management Centers of America) ;
  • Knezevic, Emilija (University of Illinois at Urbana-Champaign, College of Liberal Arts and Sciences) ;
  • Knezevic, Nebojsa Nick (Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois) ;
  • Sanapati, Mahendra R. (Pain Management Centers of America) ;
  • Kaye, Alan D. (LSU Health Sciences Center, Shreveport, Ochsner Shreveport Hospital and Pain Clinic Feist-Wieller Cancer Center) ;
  • Thota, Srinivasa (Pain Management Centers of America) ;
  • Hirsch, Joshua A. (Massachusetts General Hospital and Harvard Medical School)
  • Received : 2021.04.30
  • Accepted : 2021.05.28
  • Published : 2021.07.01
Download PDF
⟨ Previous Next ⟩

Abstract

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 non-randomized studies, the evidence level is II for percutaneous neurolysis in managing lumbar disc herniation.

Keywords

Acknowledgement

The authors wish to thank Bert Fellows, MA, Director Emeritus of Psychological Services at Pain Management Centers of America, for manuscript review, and Tonie M. Hatton and Diane E. Neihoff, transcriptionists, for their assistance in preparation of this manuscript.

References

  1. Manchikanti L, Knezevic NN, Navani A, Christo PJ, Limerick G, Calodney AK, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) comprehensive evidencebased guidelines. Pain Physician 2021; 24(S1): S27-208.
  2. Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 1934; 211: 210-5. https://doi.org/10.1056/NEJM193408022110506
  3. Andersson G. Epidemiology of spinal disorders. In: The adult spine: principles and practice. 2nd ed. Edited by Frymoyer JW, Ducker TB, Hadler NM, Kostuik JP, Weinstein JN, Whitecloud TS 3rd. New York, Raven Press. 1997, pp 93-141.
  4. Heliovaara M. Epidemiology of sciatica and herniated lumbar intervertebral disc. Helsinki, The Social Insurance Institution. 1988.
  5. Friberg S, Hirsch C. Anatomical and clinical studies on lumbar disc degeneration. Acta Orthop Scand 1949; 19: 222-42. https://doi.org/10.3109/17453674908991095
  6. Schultz A, Andersson G, Ortengren R, Haderspeck K, Nachemson A. Loads on the lumbar spine. Validation of a biomechanical analysis by measurements of intradiscal pressures and myoelectric signals. J Bone Joint Surg Am 1982; 64: 713-20. https://doi.org/10.2106/00004623-198264050-00008
  7. Zhong M, Liu JT, Jiang H, Mo W, Yu PF, Li XC, et al. Incidence of spontaneous resorption of lumbar disc herniation: a metaanalysis. Pain Physician 2017; 20: E45-52.
  8. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil 2015; 29: 184-95. https://doi.org/10.1177/0269215514540919
  9. Ahn SH, Ahn MW, Byun WM. Effect of the transligamentous extension of lumbar disc herniations on their regression and the clinical outcome of sciatica. Spine (Phila Pa 1976) 2000; 25: 475-80. https://doi.org/10.1097/00007632-200002150-00014
  10. Manchikanti L, Knezevic NN, Boswell MV, Kaye AD, Hirsch JA. Epidural injections for lumbar radiculopathy and spinal stenosis: a comparative systematic review and meta-analysis. Pain Physician 2016; 19: E365-410.
  11. Oster BA, Kikanloo SR, Levine NL, Lian J, Cho W. Systematic review of outcomes following 10-year mark of Spine Patient Outcomes Research Trial for intervertebral disc herniation. Spine (Phila Pa 1976) 2020; 45: 825-31. https://doi.org/10.1097/BRS.0000000000003400
  12. Helm S 2nd, Racz GB, Gerdesmeyer L, Justiz R, Hayek SM, Kaplan ED, et al. Percutaneous and endoscopic adhesiolysis in managing low back and lower extremity pain: a systematic review and meta-analysis. Pain Physician 2016; 19: E245-82. https://doi.org/10.36076/ppj/2016.19.E245
  13. Manchikanti L, Soin A, Boswell MV, Kaye AD, Sanapati M, Hirsch JA. Effectiveness of percutaneous adhesiolysis in post lumbar surgery syndrome: a systematic analysis of findings of systematic reviews. Pain Physician 2019; 22: 307-22.
  14. Manchikanti L, Knezevic NN, Sanapati MR, Boswell MV, Kaye AD, Hirsch JA. Effectiveness of percutaneous adhesiolysis in managing chronic central lumbar spinal stenosis: a systematic review and meta-analysis. Pain Physician 2019; 22: E523-50.
  15. Manchikanti L, Knezevic NN, Sanapati SP, Sanapati MR, Kaye AD, Hirsch JA. Is percutaneous adhesiolysis effective in managing chronic low back and lower extremity pain in post-surgery syndrome: a systematic review and metaanalysis. Curr Pain Headache Rep 2020; 24: 30. https://doi.org/10.1007/s11916-020-00862-y
  16. Cho JH, Lee JH, Song KS, Hong JY, Joo YS, Lee DH, et al. Treatment outcomes for patients with failed back surgery. Pain Physician 2017; 20: E29-43.
  17. Manchikanti L, Kosanovic R, Pampati V, Kaye AD. Declining utilization patterns of percutaneous adhesiolysis procedures in the fee-for-service (FFS) medicare population. Pain Physician 2021; 24: 17-29.
  18. Heavner JE, Racz GB, Raj P. Percutaneous epidural neuroplasty: prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase. Reg Anesth Pain Med 1999; 24: 202-7. https://doi.org/10.1016/S1098-7339(99)90128-1
  19. Racz GB, Racz GJ, Racz TA. Interventional pain management procedures. In: Pain management for clinicians: a guide to assessment and treatment. Edited by Noe C. Cham, Springer. 2020, pp 523-653.
  20. McCarron RF. Epidural fibrosis: experimental model and therapeutic alternatives. In: Techniques of neurolysis. Edited by Racz GB. Boston, Kluwer Academic Publishers. 1989, pp 87-94.
  21. Adams MA, Roughley PJ. What is intervertebral disc degeneration, and what causes it? Spine (Phila Pa 1976) 2006; 31: 2151-61. https://doi.org/10.1097/01.brs.0000231761.73859.2c
  22. Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am 1991; 22: 181-7. https://doi.org/10.1016/S0030-5898(20)31644-8
  23. Zhu L, Huang Y, Hu Y, Tang Q, Zhong Y. Toll-like receptor 4/nuclear factor-kappa B pathway is involved in radicular pain by encouraging spinal microglia activation and inflammatory response in a rat model of lumbar disc herniation. Korean J Pain 2021; 34: 47-57. https://doi.org/10.3344/kjp.2021.34.1.47
  24. Hazer DB, Acarbas A, Rosberg HE. The outcome of epiduroscopy treatment in patients with chronic low back pain and radicular pain, operated or non-operated for lumbar disc herniation: a retrospective study in 88 patients. Korean J Pain 2018; 31: 109-15. https://doi.org/10.3344/kjp.2018.31.2.109
  25. Gerdesmeyer L, Wagenpfeil S, Birkenmaier C, Veihelmann A, Hauschild M, Wagner K, et al. Percutaneous epidural lysis of adhesions in chronic lumbar radicular pain: a randomized, double-blind, placebo-controlled trial. Pain Physician 2013; 16: 185-96.
  26. Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) [Internet]. PRISMA; 2021. Available at: http://prisma-statement.org/.
  27. Furlan AD, Malmivaara A, Chou R, Maher CG, Deyo RA, Schoene M, et al.; Editorial Board of the Cochrane Back, Neck Group. 2015 updated method guideline for systematic reviews in the Cochrane Back and Neck Group. Spine (Phila Pa 1976) 2015; 40: 1660-73. https://doi.org/10.1097/BRS.0000000000001061
  28. Manchikanti L, Hirsch JA, Cohen SP, Heavner JE, Falco FJ, Diwan S, et al. Assessment of methodologic quality of randomized trials of interventional techniques: development of an interventional pain management specific instrument. Pain Physician 2014; 17: E263-90.
  29. Manchikanti L, Hirsch JA, Heavner JE, Cohen SP, Benyamin RM, Sehgal N, et al. Development of an interventional pain management specific instrument for methodologic quality assessment of nonrandomized studies of interventional techniques. Pain Physician 2014; 17: E291-317.
  30. Manchikanti L, Falco FJ, Benyamin RM, Kaye AD, Boswell MV, Hirsch JA. A modified approach to grading of evidence. Pain Physician 2014; 17: E319-25.
  31. Cho PG, Ji GY, Yoon YS, Shin DA. Clinical effectiveness of percutaneous epidural neuroplasty according to the type of single-level lumbar disc herniation: a 12-month follow-up study. J Korean Neurosurg Soc 2019; 62: 681-90. https://doi.org/10.3340/jkns.2019.0070
  32. Moon SH, Park JY, Cho SS, Cho HS, Lee JY, Kim YJ, et al. Comparative effectiveness of percutaneous epidural adhesiolysis for different sacrum types in patients with chronic pain due to lumbar disc herniation: a propensity score matching analysis. Medicine (Baltimore) 2016; 95: e4647. https://doi.org/10.1097/MD.0000000000004647
  33. Moon SH, Lee JI, Cho HS, Shin JW, Koh WU. Factors for predicting favorable outcome of percutaneous epidural adhesiolysis for lumbar disc herniation. Pain Res Manag 2017; 2017: 1494538. https://doi.org/10.1155/2017/1494538
  34. Taheri A, Khajenasiri AR, Nazemian Yazdi NA, Safari S, Sadeghi J, Hatami M. Clinical evaluation of percutaneous caudal epidural adhesiolysis with the Racz technique for low back pain due to contained disc herniation. Anesth Pain Med 2016; 6: e26749. https://doi.org/10.5812/aapm.26749
  35. Cho S, Park HS. Percutaneous epidural adhesiolysis with epidural steroid injection: a non-inferiority test of non-particulate steroids versus particulate steroids. Pain Med 2016; 17: 1612-9. https://doi.org/10.1093/pm/pnw021
  36. Kalagac Fabris L, Suput A, Gusic N, Mamontov P. Epidural adhesiolysis in the management of chronic low back pain in failed back surgery syndrome and in lumbar radicular pain: first year of experience at Pula General Hospital, Pula, Croatia - a randomized trial. Acta Med Croatica 2019; 73: 57-65.
  37. Park SH, Ji GY, Cho PG, Shin DA, Yoon YS, Kim KN, et al. Clinical significance of epidurography contrast patterns after adhesiolysis during lumbar percutaneous epidural neuroplasty. Pain Res Manag 2018; 2018: 6268045.
  38. Choi EJ, Yoo YJ, Lee PB, Kim YC, Lee SC, Moon JY. A retrospective study to evaluate the effect of concentration of hypertonic saline on efficacy and safety of epidural adhesiolysis. Anesth Analg 2017; 124: 2021-9. https://doi.org/10.1213/ANE.0000000000001925
  39. Lee JH, Lee SH. Clinical effectiveness of percutaneous adhesiolysis using Navicath for the management of chronic pain due to lumbosacral disc herniation. Pain Physician 2012; 15: 213-21.
  40. Ji GY, Oh CH, Moon B, Choi SH, Shin DA, Yoon YS, et al. Efficacy of percutaneous epidural neuroplasty does not correlate with dural sac cross-sectional area in single level disc disease. Yonsei Med J 2015; 56: 691-7. https://doi.org/10.3349/ymj.2015.56.3.691
  41. Veihelmann A, Devens C, Trouillier H, Birkenmaier C, Gerdesmeyer L, Refior HJ. Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial. J Orthop Sci 2006; 11: 365-9. https://doi.org/10.1007/s00776-006-1032-y
  42. Sicard MA. [Extradural drug injections by saracoccygiane route]. C R Seances Soc Biol Fil 1901; 53: 396-8. French.
  43. Ter Meulen BC, Weinstein H, Ostelo R, Koehler PJ. The epidural treatment of sciatica: its origin and evolution. Eur Neurol 2016; 75: 58-64. https://doi.org/10.1159/000443729
  44. Robecchi A, Capra R. [Hydrocortisone (compound F); first clinical experiments in the field of rheumatology]. Minerva Med 1952; 43: 1259-63. Italian.
  45. Lievre JA, Bloch-Mechel H, Pean G, Uro J. [Hydrocortisone in local injection]. Rev Rhum Mal Osteoartic 1953; 20: 310-1. French.
  46. Manchikanti L, Sanapati MR, Pampati V, Boswell MV, Kaye AD, Hirsch JA. Update on reversal and decline of growth of utilization of interventional techniques in managing chronic pain in the Medicare population from 2000 to 2018. Pain Physician 2019; 22: 521-36.
  47. Manchikanti L, Soin A, Mann DP, Bakshi S, Pampati V, Kaye AD, et al. Utilization patterns of facet joint interventions in managing spinal pain: a retrospective cohort study in the US fee-for-service Medicare population. Curr Pain Headache Rep 2019; 23: 73. https://doi.org/10.1007/s11916-019-0816-7
  48. Manchikanti L, Pampati V, Soin A, Sanapati MR, Kaye AD, Hirsch JA. Declining utilization and inflation-adjusted expenditures for epidural procedures in chronic spinal pain in the Medicare population. Pain Physician 2021; 24: 1-15.
  49. Manchikanti L, Pampati V, Parr Iii A, Manchikanti MV, Sanapati MR, Kaye AD, et al. Cervical interlaminar epidural injections in the treatment of cervical disc herniation, post surgery syndrome, or discogenic pain: cost utility analysis from randomized trials. Pain Physician 2019; 22: 421-31.
  50. Manchikanti L, Pampati V, Benyamin RM, Hirsch JA. Cost utility analysis of lumbar interlaminar epidural injections in the treatment of lumbar disc herniation, central spinal stenosis, and axial or discogenic low back pain. Pain Physician 2017; 20: 219-28.
  51. Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med 2015; 163: 373-81. https://doi.org/10.7326/M15-0934
  52. Manchikanti L, Kaye AD, Soin A, Albers SL, Beall D, Latchaw R, et al. Comprehensive evidence-based guidelines for facet joint interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) guidelines facet joint interventions 2020 guidelines. Pain Physician 2020; 23(3S): S1-127.

Cited by

  1. Comments on "The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis" vol.35, pp.1, 2021, https://doi.org/10.3344/kjp.2022.35.1.124
  2. Outcomes of epidural steroids following percutaneous transforaminal endoscopic discectomy: a meta-analysis and systematic review vol.35, pp.1, 2021, https://doi.org/10.3344/kjp.2022.35.1.97