Five RCTs and 9 observational studies were included in the review (893 participants). There were 4 RCTs (n=278) and 4 observational studies (n=275) of percutaneous adhesiolysis and 1 RCT (n=83) and 5 observational studies (n=257) of spinal endoscopic adhesiolysis.
The quality scores for the included studies were not reported.
All 4 RCTs reported positive results for percutaneous adhesiolysis compared with catheterisation without adhesiolysis, physical therapy, exercise and medication, or patients acting as their own control. All 4 observational studies reported short-term improvements; three also reported long-term improvements. Overall, there was strong evidence for short- and long-term relief of chronic pain secondary to post-lumbar laminectomy syndrome or lumbar epidural fibrosis, and moderate evidence for short- and long-term improvement in patients with monoradiculopathy secondary to disk herniation.
Percutaneous adhesiolysis was superior to epidural steroid injection (anaesthetic, steroid and saline via catheterisation without adhesiolysis) in both the short term and long term in 1 RCT. Another RCT and 2 observational studies in patients who had all failed with epidural steroid injections reported improvements with adhesiolysis. Overall, there was strong evidence that percutaneous adhesiolysis was superior to epidural steroid injections for short- and long-term improvement.
Two RCTs found no significant difference between the addition of hypertonic and isotonic saline, or hypertonic saline and percutaneous adhesiolysis alone. Nevertheless, the evidence for the addition of hypertonic sodium chloride to improve the efficacy of percutaneous adhesiolysis was classified as moderate.
One RCT found no significant difference between the addition of hyaluronidase plus saline (isotonic and hypertonic) compared with saline (limited evidence).
One RCT reported no adverse effects. Adverse effects reported in other studies included subarachnoid block (6 out of 204 patients), subarachnoid puncture (in 4 of 178 procedures) and serious infection (1 out of 129).
Spinal endoscopic adhesiolysis.
No new studies that met the inclusion criteria were identified, hence the findings remained unchanged from the previous review (see Other Publications of Related Interest).
The RCT scored 10 out of 10 for quality using the AHRQ and the Cochrane validity criteria. The observational studies scored 4 or 6 out of 8 against the AHRQ criteria.
The RCT reported significant improvements in pain relief and return to work in patients who were treated with spinal endoscopic adhesiolysis compared with endoscopy without adhesiolysis. The 5 observational studies showed improvement or reported positive short- and long-term results. Spinal endoscopy was superior to epidural steroid injections in the RCT. Overall, for spinal endoscopy, and spinal endoscopic adhesiolysis compared with epidural steroid injections, there was strong evidence for short-term relief and moderate evidence for long-term improvement.
Reported complications were said to be minor and to include back soreness and dural puncture, but no infections.