1 Educational center, National Cheng Kung University Hospital, Tainan city, Taiwan.
2 Department of Anesthesiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Taiwan
Failed back surgery syndrome (FBSS) defined as back pain not resolving to a satisfying level or a new back pain after spinal surgery. The scarring and adhesion in epidural space was considered lead to inflammation then this persisted inflammatory process may rise to more adhesion around nerve roots. So this vicious cycle is hard to break even after another surgery. Epidural injection or another surgery may be considered for those who suffered from persisted pain
after conservative treatments. Except the above treatments, percutaneous epidural adhesiolysis (PEA) is one of the well-known options nowadays. By using Racz
catheter to mechanically lysis adhesion and/or injecting medications such as steroids, saline, local anesthetics or hyaluronidase into epidural space to reduce inflammatory process, PEA can be an effective procedure to relief low back pain with low complication rate. Three randomized controlled trials and 1 observational study were included in this systemic review of PEA in treating low back pain due to FBSS. All of them showed positive results for pain relief and life quality improvement to 6 months after PEA. Besides, the complication rate was low and those complications were mostly self-limited. This review provides good evidence on effectiveness and safety of PEA in dealing with chronic low back pain due to FBSS.
percutaneous epidural, adhesiolysis, failed back, surgery syndrome, low back pain, outcome
Meucci RD, Fassa AG, Faria NM.
Prevalence of chronic low back pain: systematic review.
Rev Saude Publica. 2015;49.
The epidemiology of low back pain in the rest of the world. A review of surveys in low- and middle-income countries.
Spine (Phila Pa 1976). 1997;22(15):1747-54.
Chou R, Qaseem A, Snow V, Casey D, Cross JT, Jr., Shekelle P, et al.
Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
Ann Intern Med. 2007;147(7):478-91.
Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, et al.
Spinal stenosis prevalence and association with symptoms: the Framingham Study.
Spine J. 2009;9(7):545-50.
Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ.
Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population.
Spine (Phila Pa 1976). 1993;18(11):1463-70.
Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI.
United States trends in lumbar fusion surgery for degenerative conditions.
Spine (Phila Pa 1976). 2005;30(12):1441-5; discussion 6-7.
Chopko B, Caraway DL.
MiDAS I (mild Decompression Alternative to Open Surgery): a preliminary report of a prospective, multi-center clinical study.
Pain Physician. 2010;13(4):369-78.
Kobayashi S, Baba H, Uchida K, Kokubo Y, Yayama T, Takeno K, et al.
Blood circulation of cauda equina and nerve root.
Clin Calcium. 2005;15(3):63-72.
North RB, Campbell JN, James CS, Conover- Walker MK, Wang H, Piantadosi S, et al.
Failed back surgery syndrome: 5-year follow-up in 102 patients undergoing repeated operation.
Neurosurgery. 1991;28(5):685-90; discussion 90-1.
Failed back surgery syndrome-definition, epidemiology and demographics.
Br J Pain. 2013;7(1):56-9.
Helm Ii S, Benyamin RM, Chopra P, Deer TR, Justiz R.
Percutaneous adhesiolysis in the management of chronic low back pain in post lumbar surgery syndrome and spinal stenosis: a systematic review.
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(6):E523-E50.
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(4):307-22.
Inoue S, Kamiya M, Nishihara M, Arai YP, Ikemoto T, Ushida T.
Prevalence, characteristics, and burden of failed back surgery syndrome: the influence of various residual symptoms on patient satisfaction and quality of life as assessed by a nationwide Internet survey in Japan.
J Pain Res. 2017;10:811-23.
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(2):E245-82.
Manchikanti L, Pakanati RR, Bakhit CE, Pampati V.
Role of adhesiolysis and hypertonic saline neurolysis in management of low back pain: evaluation of modification of the Racz protocol.
Pain Digest. 1999;9:91-6.
Kim JH, Jung HJ, Nahm FS, Lee PB.
Does improvement in epidurography following percutaneous epidural neuroplasty correspond to patient outcome?
Pain Pract. 2015;15(5):407-13.
Furlan AD, Pennick V, Bombardier C, van Tulder M, Editorial Board CBRG.
2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group.
Spine (Phila Pa 1976). 2009;34(18):1929-41.
Peterson J, Welch V, Losos M, Tugwell P.
The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.
Ottawa: Ottawa Hospital Research Institute. 2011.
Chun-jing H, Hao-xiong N, jia-xiang N.
The application of percutaneous lysis of epidural adhesions in patients with failed back surgery syndrome.
Acta Cir Bras. 2012;27(4):357-62.
Manchikanti L, Singh V, Cash KA, Pampati V.
Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial.
J Pain Res. 2012;5:597-608.
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(3):185-96.
Akbas M, Elawamy AR, Salem HH, Fouad AZ, Abbas NA, Dagistan G.
Comparison of 3 Approaches to Percutaneous Epidural Adhesiolysis and Neuroplasty in Post Lumbar Surgery Syndrome.
Pain Physician. 2018;21(5):E501-E8.
Gerdesmeyer L, Rechl H, Wagenpfeil S, Ulmer M, Lampe R, Wagner K.
Minimally invasive percutaneous epidural neurolysis in chronic radiculopathy. A prospective controlled pilot study to prove effectiveness
Veihelmann A, Devens C, Trouillier H, Birkenmaier &*HUGHVPH\HU/5H¿RU+-
Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial.
J Orthop Sci. 2006;11(4):365-9.
Manchikanti L, Singh V, Derby R, Schultz DM, Benyamin RM, Prager JP, et al.
Reassessment of evidence synthesis of occupational medicine practice guidelines for interventional pain management.
Pain Physician. 2008;11(4):393-482.
Goebert HW, Jr., Jallo SJ, Gardner WJ, Wasmuth CE, Bitte EM.
Sciatica: treatment with epidural injections of procaine and hydrocortisone.
Cleve Clin Q. 1960;27:191-7.
Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, et al.
Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus.
N Engl J Med. 1997;336(23):1634-40.
Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, et al.
A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study.
Rheumatology (Oxford). 2005;44(11):1399- 406.
Ng L, Chaudhary N, Sell P.
The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double- blind, controlled trial.
Spine (Phila Pa 1976). 2005;30(8):857-62.
Davidson JT, Robin GC.
Epidural injections in the lumbosciatic syndrome.
Br J Anaesth. 1961;33:595-8.
Devor M, Wall PD, Catalan N.
Systemic lidocaine silences ectopic neuroma and DRG discharge without blocking nerve conduction.
Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP.
Epidural steroids: a comprehensive, evidence-based review.
Reg Anesth Pain Med. 2013;38(3):175-200.
Bicket MC, Horowitz JM, Benzon HT, Cohen SP.
Epidural injections in prevention of surgery for spinal pain: systematic review and meta- analysis of randomized controlled trials.
Spine J. 2015;15(2):348-62.
McGrath JM, Schaefer MP, Malkamaki DM.
Incidence and characteristics of complications from epidural steroid injections.
Pain Med. 2011;12(5):726-31.
Manchikanti L, Bakhit CE.
Removal of a torn Racz catheter from lumbar epidural space.
Reg Anesth. 1997;22(6):579-81.
Talu GK, Erdine S.
Complications of epidural neuroplasty: a retrospective evaluation.
Neuromodulation: Technology at the Neural Interface. 2003;6(4):237-47.
Trescot AM, Chopra P, Abdi S, Datta S, Schultz Figure 1. Flow diagram of study selection DM.
Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update.
Pain Physician. 2007;10(1):129-46.
Chopra P, Smith HS, Deer TR, Bowman RC.
Role of adhesiolysis in the management of chronic spinal pain: a systematic review of effectiveness and complications.
Pain Physician. 2005;8(1):87- 100.
Viesca CO, Racz GB, Day MR.
Special techniques in pain management: lysis of adhesions.
Anesthesiology Clinics of North America. 2003;21(4):745-66.
Heavner JE, Racz GB, Raj P.
Percutaneous epidural neuroplasty: prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase.
Regional Anesthesia and Pain Medicine. 1999;24(3):202-7.
The efficacy of solutions used in caudal neuroplasty
Pain Digest. 1997;7:323-30.