Health Problem: Chronic low back pain (CLBP) is a common health condition that can cause substantive disability. There are many causes of CLBP, including spinal stenosis, disc disorders, and disc degeneration. Patients who have enduring low back pain even after surgery (e.g., laminectomy) are said to have failed back surgery syndrome (FBSS). Percutaneous epidural adhesiolysis was designed to lyse epidural scarring in patients with CLBP and leg pain due to lumbar FBSS. In the literature, percutaneous adhesiolysis (PA) has been more generally used for patients with CLBP with or without radiculopathy or sciatica that has not responded adequately to noninterventional and nonsurgical conservative modalities.
Technology Description: Percutaneous epidural adhesiolysis entails the use of an epidurogram and contrast media to identify filling defects that suggest epidural adhesions (fibrosis or scarring). Once adhesions are located, a catheter is inserted through the skin (percutaneous access) to inject hyaluronidase to break down the adhesions (adhesiolysis), followed by introduction of pressurized saline to hydraulically separate the adhesions and wash out proinflammatory cytokines. Anti-inflammatory and analgesic drugs, and sometimes steroids, are then also injected to treat pain, inflammation, and edema. Most patients are treated in an outpatient procedure and discharged the same day. When performed in a single session, the procedure takes < 1 hour. Most patients require > 1 adhesiolysis treatments to achieve durable relief of pain, and the procedure can be repeated at 4- to 6-week intervals
Controversy: Some research indicates that patients with epidural fibrosis, or adhesions, are more likely to have recurrent radicular pain after surgery; however, whether these epidural adhesions cause chronic spine or back pain has been questioned and debated. Some critics note that most patients who have had prior laminectomies have perineural fibrosis (but not necessarily pain) and that scar tissue itself is not painful.
Key Questions:
For adults with CLBP with epidural adhesions as a known or suspected cause:
- What is the evidence regarding the efficacy of percutaneous epidural adhesiolysis compared with sham treatment or active treatment with epidural steroid injections or physical therapy?
- What is the evidence regarding the safety of percutaneous epidural adhesiolysis?
- Have definitive patient selection criteria been identified for this technology?
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