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L Manchikanti - One of the best experts on this subject based on the ideXlab platform.
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is percutaneous Adhesiolysis effective in managing chronic low back and lower extremity pain in post surgery syndrome a systematic review and meta analysis
Current Pain and Headache Reports, 2020Co-Authors: L Manchikanti, Nebojsa Nick Knezevic, Mahendra R Sanapati, Alan D Kaye, Satya P Sanapati, Joshua A HirschAbstract:The growing prevalence of spinal pain in the USA continues to produce substantial economic impact and strain on health-related quality of life. Percutaneous Adhesiolysis is utilized for recalcitrant, resistant conditions involving spinal pain when epidural injections have failed to provide adequate improvement, especially low back and lower extremity pain, specifically in post-lumbar surgery syndrome. Despite multiple publications and systematic reviews, the debate continues in reference to effectiveness, safety, appropriate utilization, and medical necessity of percutaneous Adhesiolysis in chronic pain. This systematic review, therefore, was undertaken to evaluate and to update effectiveness of percutaneous Adhesiolysis to treat chronic refractory low back and lower extremity pain, post-surgical patients of the lumbar spine. From 2009 to 2016, there was a decline of 53.2% utilization of percutaneous Adhesiolysis with an annual decline of 10.3% per 100,000 fee-for-service (FFS) Medicare population. Multiple insurers, including Medicare, with Medicare area contractors of Noridian and Palmetto have issued noncoverage policies for percutaneous Adhesiolysis resulting in these steep declines and continued noncoverage by Medicare Advantage plans, Managed Care plans of Medicaid, and other insurers. Since 2005, 4 systematic reviews of percutaneous Adhesiolysis were published with 3 of them showing proper methodology and appropriate results with effectiveness of Adhesiolysis, whereas one poorly performed systematic review showed negative results. In addition, there were only 4 randomized controlled trials (RCTs) to be included in the previous systematic reviews of post-surgery syndrome, whereas now, the RCTs and other studies have increased. This systematic review shows level I or strong evidence for the effectiveness of percutaneous Adhesiolysis in managing chronic low back and lower extremity pain related to post-lumbar surgery syndrome.
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effectiveness of percutaneous Adhesiolysis in managing chronic central lumbar spinal stenosis a systematic review and meta analysis
Pain Physician, 2019Co-Authors: L Manchikanti, Nebojsa Nick Knezevic, Mahendra R Sanapati, Mark V Boswell, Alan D Kaye, Joshua A HirschAbstract:Background Symptomatic lumbar spinal stenosis is a condition affecting a growing number of individuals resulting in significant disability and pain, leading to a multitude of interventions ranging from simple over the counter medication to opioids, and, finally, to complex surgical fusions. After failure of conservative treatment with drug therapy, physical therapy, and other conservative modalities including epidural injections, percutaneous Adhesiolysis with targeted delivery of drugs into the epidural space can be offered in lumbar central spinal stenosis prior to minimally invasive surgical options or complex surgical fusions. To date there has been only one systematic review which has assessed the role of percutaneous Adhesiolysis in treating central spinal stenosis, compared to post lumbar surgery syndrome which has multiple systematic reviews and randomized controlled trials (RCTs). Study design A systematic review of RCTs and observational studies assessing the role of percutaneous Adhesiolysis in managing lumbar central spinal stenosis. Objective To evaluate the effectiveness of percutaneous Adhesiolysis in managing central lumbar spinal stenosis, utilizing currently available literature. Methods This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for literature search, Cochrane review criteria, Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB), and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) to assess methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and meta-analysis.PubMed, Cochrane library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through June 2019. The evidence was summarized utilizing principles of the best evidence synthesis on a scale of 1 to 5. Outcome measures The primary outcome or hard endpoint was defined as the proportion of patients with 50% pain relief and improvement in functionality, whereas the secondary outcome measures or soft endpoints were pain relief and/or improvement in functionality. Short-term effectiveness was defined as improvement of 6 months or less, whereas long-term effectiveness was defined as more than 6 months. Results Based on search criteria, 9 manuscripts were identified and considered for inclusion with final inclusion of 2 RCTs and 4 observational studies in this systematic review and 5 studies for single arm meta-analysis. The results showed Level II evidence for short-term and long-term improvement in pain and function with application of percutaneous Adhesiolysis in managing central lumbar spinal stenosis. Limitations There was a significant paucity of evidence assessing the role of percutaneous Adhesiolysis in managing lumbar central spinal stenosis, leading to Level II or strong evidence. Conclusion Overall, the present analysis shows Level II (moderate) evidence for percutaneous Adhesiolysis in managing lumbar central spinal stenosis based on relevant high quality RCTs and observational studies. Key words Lumbar central spinal stenosis, percutaneous Adhesiolysis, randomized controlled trials, systematic reviews, neuroplasty.
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effectiveness of percutaneous Adhesiolysis in post lumbar surgery syndrome a systematic analysis of findings of systematic reviews
Pain Physician, 2019Co-Authors: L Manchikanti, Mahendra R Sanapati, Mark V Boswell, Alan D Kaye, Amol Soin, Joshua A HirschAbstract:Background Post lumbar surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous Adhesiolysis are often contemplated in managing post lumbar surgery syndrome. Multiple previous systematic reviews have reached discordant conclusions about the level of evidence for the effectiveness of percutaneous Adhesiolysis in managing post lumbar surgery syndrome and other conditions. Study design A systematic review of previously published systematic reviews assessing efficacy of percutaneous Adhesiolysis in managing post lumbar surgery syndrome. Objective To evaluate the value and validity of previous systematic reviews performed after 2015 on effectiveness of percutaneous Adhesiolysis in managing chronic refractory low back and lower extremity pain secondary to post lumbar surgery syndrome. Methods Previous systematic reviews on percutaneous Adhesiolysis were evaluated. The quality of each systematic review was assessed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and A Measurement Tool to Assess Systematic Reviews (AMSTAR).The randomized trials included in the available systematic reviews were assessed by Cochrane review criteria and Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for methodologic quality.Data sources included relevant systematic reviews and the randomized trials included in those systematic reviews published since 2015 with searches of PubMed, Cochrane reviews, and Google Scholar through February 2019. Outcome measures Outcome measures were significant improvement defined as 50% pain relief and improvement in functional status. Short-term efficacy was defined as improvement of 6 months or less, whereas long-term efficacy was defined as more than 6 months. Results Three systematic reviews and 4 randomized controlled trials (RCTs) of post lumbar surgery syndrome with chronic refractory low back and lower extremity pain showed notable evidence of significant pain relief. Only one systematic review, which was of low quality with inappropriate analysis, showed lack of evidence. Conclusion Overall, the present analysis shows Level I evidence for percutaneous Adhesiolysis based on significant evidence from published RCTs and 3 of the 4 systematic reviews. Key words Post lumbar surgery syndrome, epidural fibrosis, percutaneous Adhesiolysis, systematic reviews, randomized controlled trials.
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efficacy of percutaneous Adhesiolysis in the treatment of lumbar post surgery syndrome
Anesthesiology and Pain Medicine, 2015Co-Authors: L Manchikanti, Kavita N Manchikanti, Christopher Gharibo, Alan D KayeAbstract:Context: Lumbar post-surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous Adhesiolysis is often contemplated in managing lumbar post surgery syndrome. Recent guidelines and systematic reviews have reached different conclusions about the level of evidence for the efficacy of epidural injections and percutaneous Adhesiolysis in managing lumbar post surgery syndrome. The objective of this systematic review was to determine the efficacy of all 3 percutaneous Adhesiolysis anatomical approaches (caudal, interlaminar, and transforaminal) in treating lumbar post-surgery syndrome. Evidence Acquisition: Data Sources: A literature search was performed from 1966 through October 2014 utilizing multiple databases. Study Selection: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and percutaneous Adhesiolysis in managing lumbar post-surgery syndrome was performed including methodological quality assessment utilizing Cochrane review criteria, Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment (IPM–QRB), and grading of evidence using 5 levels of evidence ranging from Level I to Level V. Data Extraction: The search strategy emphasized post-surgery syndrome and related pathologies treated with percutaneous Adhesiolysis procedures. Results: The search criteria yielded 16 manuscripts on percutaneous Adhesiolysis assessing post-surgery syndrome. Of these, only 4 randomized trials met inclusion criteria for methodological quality assessment, 3 of them were of high quality; and the fourth manuscript was of low quality. Based on these 3 randomized controlled trials, 2 of them with one-day procedure and one with a 3-day procedure, the level of evidence for the efficacy of percutaneous Adhesiolysis is Level II based on best evidence synthesis. Conclusions: Based on this systematic review, percutaneous Adhesiolysis is effective in managing patients with lumbar post-surgery syndrome after the failure of conservative management including fluoroscopically directed epidural injections.
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assessment of effectiveness of percutaneous Adhesiolysis in managing chronic low back pain secondary to lumbar central spinal canal stenosis
International Journal of Medical Sciences, 2013Co-Authors: L Manchikanti, Carla D Mcmanus, Kimberly A Cash, Vidyasagar PampatiAbstract:Background: Chronic persistent low back and lower extremity pain secondary to central spinal stenosis is common and disabling. Lumbar surgical interventions with decompression or fusion are most commonly performed to manage severe spinal stenosis. However, epidural injections are also frequently performed in managing central spinal stenosis. After failure of epidural steroid injections, the next sequential step is percutaneous Adhesiolysis and hypertonic saline neurolysis with a targeted delivery. The literature on the effectiveness of percutaneous Adhesiolysis in managing central spinal stenosis after failure of epidural injections has not been widely studied. Study Design: A prospective evaluation. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To evaluate the effectiveness of percutaneous epidural Adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis. Methods: Seventy patients were recruited. The initial phase of the study was randomized, double-blind with a comparison of percutaneous Adhesiolysis with caudal epidural injections. The 25 patients from the Adhesiolysis group continued with follow-up, along with 45 additional patients, leading to a total of 70 patients. All patients received percutaneous Adhesiolysis and appropriate placement of the Racz catheter, followed by an injection of 5 mL of 2% preservative-free lidocaine with subsequent monitoring in the recovery room. In the recovery room, each patient also received 6 mL of 10% hypertonic sodium chloride solution, and 6 mg of non-particulate betamethasone, followed by an injection of 1 mL of sodium chloride solution and removal of the catheter. Outcomes Assessment: Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12, 18 and 24 months post treatment. The primary outcome measure was 50% or more improvement in pain scores and ODI scores. Results: Overall, a primary outcome or significant pain relief and functional status improvement of 50% or more was seen in 71% of patients at the end of 2 years. The overall number of procedures over a period of 2 years were 5.7 ± 2.73. Limitations: The lack of a control group and a prospective design. Conclusions: Significant relief and functional status improvement as seen in 71% of the 70 patients with percutaneous Adhesiolysis utilizing local anesthetic steroids and hypertonic sodium chloride solution may be an effective management strategy in patients with chronic function limiting low back and lower extremity pain with central spinal stenosis after failure of conservatie management and fluoroscopically directed epidural injections.
Vidyasagar Pampati - One of the best experts on this subject based on the ideXlab platform.
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Cost Utility Analysis of Percutaneous Adhesiolysis in Managing Pain of Post-lumbar Surgery Syndrome and Lumbar Central Spinal Stenosis
Pain Practice, 2014Co-Authors: Standiford Helm, Vidyasagar Pampati, Gabor B. RaczAbstract:Background The increase in the number of interventions for the management of chronic pain and associated escalation of healthcare costs has captured the attention of health policymakers, in no small part due to the lack of documentation of efficacy, cost-effectiveness, or cost utility analysis. A recent cost utility analysis of caudal epidural injections in managing chronic low back pain of various pathologies showed a high cost utility with improvement in quality of life years, competitive with various other modalities of treatments. However, there are no analyses derived from high-quality controlled studies related to the cost utility of percutaneous Adhesiolysis in the treatment of post-lumbar surgery syndrome or lumbar central spinal stenosis. Study Design This analysis is based on 2 previously published controlled studies. Objective To assess the cost utility of percutaneous Adhesiolysis procedures in managing chronic low back and lower extremity pain secondary to post-lumbar surgery syndrome and lumbar central spinal stenosis. Setting A private, specialty referral interventional pain management center in the United States. Methods Two controlled studies were conducted assessing the clinical effectiveness of percutaneous Adhesiolysis for post-lumbar surgery syndrome and lumbar central spinal stenosis in an interventional pain management setting utilizing contemporary interventional pain management practices. A cost utility analysis was performed with direct payment data for a total of 130 patients in treatment groups over a 2-year period. Various outcome measures were included with significant improvement, defined as at least 50% improvement with reduction in pain and disability status. Results The results of 2 controlled studies of low back pain with 60 and 70 patients and a 2-year follow-up with the actual reimbursement data showed cost utility for 1 year of quality-adjusted life year (QALY) of USD $2,652 for post-lumbar surgery syndrome and USD $2,649 for lumbar central spinal stenosis. The results of this assessment show that the cost utility of managing chronic, intractable low back pain with percutaneous Adhesiolysis at a QALY that is similar or lower in price than medical therapy only, physical therapy, manipulation, spinal cord stimulation, and surgery. Limitations The limitations of this cost utility analysis are that it is a single-center evaluation, with the inclusion of costs of Adhesiolysis procedures in an ambulatory surgery center and physician visits, rather than all related costs including drug therapy and costs of disability in multiple settings. Conclusion This cost utility analysis of percutaneous Adhesiolysis in the treatment of post-lumbar surgery syndrome and lumbar central spinal stenosis shows the clinical effectiveness and cost utility of these procedures at USD $2,650 per one year of QALY when performed in an ambulatory surgery center.
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assessment of effectiveness of percutaneous Adhesiolysis in managing chronic low back pain secondary to lumbar central spinal canal stenosis
International Journal of Medical Sciences, 2013Co-Authors: L Manchikanti, Carla D Mcmanus, Kimberly A Cash, Vidyasagar PampatiAbstract:Background: Chronic persistent low back and lower extremity pain secondary to central spinal stenosis is common and disabling. Lumbar surgical interventions with decompression or fusion are most commonly performed to manage severe spinal stenosis. However, epidural injections are also frequently performed in managing central spinal stenosis. After failure of epidural steroid injections, the next sequential step is percutaneous Adhesiolysis and hypertonic saline neurolysis with a targeted delivery. The literature on the effectiveness of percutaneous Adhesiolysis in managing central spinal stenosis after failure of epidural injections has not been widely studied. Study Design: A prospective evaluation. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To evaluate the effectiveness of percutaneous epidural Adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis. Methods: Seventy patients were recruited. The initial phase of the study was randomized, double-blind with a comparison of percutaneous Adhesiolysis with caudal epidural injections. The 25 patients from the Adhesiolysis group continued with follow-up, along with 45 additional patients, leading to a total of 70 patients. All patients received percutaneous Adhesiolysis and appropriate placement of the Racz catheter, followed by an injection of 5 mL of 2% preservative-free lidocaine with subsequent monitoring in the recovery room. In the recovery room, each patient also received 6 mL of 10% hypertonic sodium chloride solution, and 6 mg of non-particulate betamethasone, followed by an injection of 1 mL of sodium chloride solution and removal of the catheter. Outcomes Assessment: Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12, 18 and 24 months post treatment. The primary outcome measure was 50% or more improvement in pain scores and ODI scores. Results: Overall, a primary outcome or significant pain relief and functional status improvement of 50% or more was seen in 71% of patients at the end of 2 years. The overall number of procedures over a period of 2 years were 5.7 ± 2.73. Limitations: The lack of a control group and a prospective design. Conclusions: Significant relief and functional status improvement as seen in 71% of the 70 patients with percutaneous Adhesiolysis utilizing local anesthetic steroids and hypertonic sodium chloride solution may be an effective management strategy in patients with chronic function limiting low back and lower extremity pain with central spinal stenosis after failure of conservatie management and fluoroscopically directed epidural injections.
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the preliminary results of a comparative effectiveness evaluation of Adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis a randomized equivalence controlled trial
Pain Physician, 2009Co-Authors: L Manchikanti, Vidyasagar Pampati, Carla D Mcmanus, Kimberly A Cash, Vijay P Singh, Ramsin M BenyaminAbstract:Background Lumbar surgery and epidural injections for spinal stenosis are the most commonly performed interventions in the United States. However, there is only moderate evidence to the effectiveness of surgery and caudal epidural injections. The next sequential step is Adhesiolysis and hypertonic neurolysis with targeted delivery. There have not been any randomized trials evaluating the effectiveness of percutaneous Adhesiolysis and targeted delivery of local anesthetic, steroid and hypertonic sodium chloride solution in lumbar spinal stenosis. Study design A randomized, equivalence, controlled trial. Setting An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives To evaluate the effectiveness of percutaneous epidural Adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis and compare with fluoroscopically directed caudal epidural injections. Methods Patients were randomly assigned to one of 2 groups with 25 patients in each group. Group I patients received caudal epidural injections with catheterization up to S3 with local anesthetic, 0.9% sodium chloride solution, non-particulate betamethasone and served as the control group. Group II patients received percutaneous Adhesiolysis with targeted delivery and injection of lidocaine, 10% hypertonic sodium chloride solution, and non-particulate Betamethasone and formed the intervention group. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes assessment Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12 months post treatment. Significant pain relief was described as 50% or more, whereas significant improvement in the disability score was defined as a reduction of 40% or more. Results This evaluation showed significant pain relief (>or= 50%) in 76% of the patients at one year follow-up in the Adhesiolysis group compared to 4% of the patients in the control group. Limitations The results of this study are limited by the lack of a placebo group, the fact that it is a preliminary report, and there are only 25 patients in each group. Conclusions With significant pain relief in 76% of patients, percutaneous Adhesiolysis utilizing local anesthetic, steroids and hypertonic sodium chloride solution may be effective in patients with chronic function-limiting low back and lower extremity pain with spinal stenosis.
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a randomized controlled trial of spinal endoscopic Adhesiolysis in chronic refractory low back and lower extremity pain isrctn 16558617
BMC Anesthesiology, 2005Co-Authors: L Manchikanti, Vidyasagar Pampati, Mark V Boswell, J J Rivera, K S Damron, Carla D Mcmanus, Doris E Brandon, Sue R WilsonAbstract:Postoperative epidural fibrosis may contribute to between 5% to 60% of the poor surgical outcomes following decompressive surgery. Correlations have been reported between epidural scarring and radicular pain, poor surgical outcomes, and a lack of any form of surgical treatment. The use of spinal endoscopic Adhesiolysis in recent years in the management of chronic refractory low back and lower extremity pain has been described. A prospective, randomized, double-blind trial was conducted to determine the outcome of spinal endoscopic Adhesiolysis to reduce pain and improve function and psychological status in patients with chronic refractory low back and lower extremity pain. A total of 83 patients were evaluated, with 33 patients in Group I and 50 patients in Group II. Group I served as the control, with endoscopy into the sacral level without Adhesiolysis, followed by injection of local anesthetic and steroid. Group II received spinal endoscopic Adhesiolysis, followed by injection of local anesthetic and steroid. Among the 50 patients in the treatment group receiving spinal endoscopic Adhesiolysis, significant improvement without adverse effects was shown in 80% at 3 months, 56% at 6 months, and 48% at 12 months. The control group showed improvement in 33% of the patients at one month and none thereafter. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain, functional status, and psychological status. Spinal endoscopic Adhesiolysis with targeted delivery of local anesthetic and steroid is an effective treatment in a significant number of patients with chronic low back and lower extremity pain without major adverse effects.
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effectiveness of percutaneous Adhesiolysis with hypertonic saline neurolysis in refractory spinal stenosis
Pain Physician, 2001Co-Authors: L Manchikanti, Vidyasagar Pampati, J J Rivera, K S Damron, Carla Beyer, Bert Fellows, Kim A CashAbstract:The increasing proportion of elderly patients, coupled with increasing longevity, causes the problem of lumbosacral pain secondary to spinal stenosis of the lumbar spine to be an important issue. Symptoms of spinal stenosis are caused by entrapment and compression of intraspinal vascular and nervous structures; which may lead to inactivity, loss of productivity, and potential loss of independence, particularly in the elderly. Surgical decompression is considered as the natural treatment. However, the results of surgical treatments have been mixed. Results of conservative treatment are also not encouraging. While the effectiveness of caudal epidural blocks for lumbar canal stenosis was positive, the effectiveness of interlaminar epidural steroid injections showed no beneficial effects on symptomatology of spinal stenosis. Percutaneous epidural Adhesiolysis with hypertonic saline neurolysis has been studied in patients with refractory low back pain secondary to post lumbar laminectomy syndrome, as well as spinal stenosis. The specific role of Adhesiolysis and hypertonic saline neurolysis in the management of refractory low back and lower extremity pain secondary to spinal stenosis has not been studied. This retrospective evaluation included 18 patients derived from a total sample of 239 patients undergoing Adhesiolysis and hypertonic saline neurolysis over a period of 3 years. The results showed significant improvement with reduction of pain; with improvement of physical health, mental health, and functional status. Improvement in psychological status was also noted, with decrease in narcotic intake. Epidural Adhesiolysis with hypertonic saline neurolysis is a safe and probably effective modality of treatment in managing symptomatic moderate to severe lumbar spinal canal stenosis.
Joshua A Hirsch - One of the best experts on this subject based on the ideXlab platform.
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is percutaneous Adhesiolysis effective in managing chronic low back and lower extremity pain in post surgery syndrome a systematic review and meta analysis
Current Pain and Headache Reports, 2020Co-Authors: L Manchikanti, Nebojsa Nick Knezevic, Mahendra R Sanapati, Alan D Kaye, Satya P Sanapati, Joshua A HirschAbstract:The growing prevalence of spinal pain in the USA continues to produce substantial economic impact and strain on health-related quality of life. Percutaneous Adhesiolysis is utilized for recalcitrant, resistant conditions involving spinal pain when epidural injections have failed to provide adequate improvement, especially low back and lower extremity pain, specifically in post-lumbar surgery syndrome. Despite multiple publications and systematic reviews, the debate continues in reference to effectiveness, safety, appropriate utilization, and medical necessity of percutaneous Adhesiolysis in chronic pain. This systematic review, therefore, was undertaken to evaluate and to update effectiveness of percutaneous Adhesiolysis to treat chronic refractory low back and lower extremity pain, post-surgical patients of the lumbar spine. From 2009 to 2016, there was a decline of 53.2% utilization of percutaneous Adhesiolysis with an annual decline of 10.3% per 100,000 fee-for-service (FFS) Medicare population. Multiple insurers, including Medicare, with Medicare area contractors of Noridian and Palmetto have issued noncoverage policies for percutaneous Adhesiolysis resulting in these steep declines and continued noncoverage by Medicare Advantage plans, Managed Care plans of Medicaid, and other insurers. Since 2005, 4 systematic reviews of percutaneous Adhesiolysis were published with 3 of them showing proper methodology and appropriate results with effectiveness of Adhesiolysis, whereas one poorly performed systematic review showed negative results. In addition, there were only 4 randomized controlled trials (RCTs) to be included in the previous systematic reviews of post-surgery syndrome, whereas now, the RCTs and other studies have increased. This systematic review shows level I or strong evidence for the effectiveness of percutaneous Adhesiolysis in managing chronic low back and lower extremity pain related to post-lumbar surgery syndrome.
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effectiveness of percutaneous Adhesiolysis in managing chronic central lumbar spinal stenosis a systematic review and meta analysis
Pain Physician, 2019Co-Authors: L Manchikanti, Nebojsa Nick Knezevic, Mahendra R Sanapati, Mark V Boswell, Alan D Kaye, Joshua A HirschAbstract:Background Symptomatic lumbar spinal stenosis is a condition affecting a growing number of individuals resulting in significant disability and pain, leading to a multitude of interventions ranging from simple over the counter medication to opioids, and, finally, to complex surgical fusions. After failure of conservative treatment with drug therapy, physical therapy, and other conservative modalities including epidural injections, percutaneous Adhesiolysis with targeted delivery of drugs into the epidural space can be offered in lumbar central spinal stenosis prior to minimally invasive surgical options or complex surgical fusions. To date there has been only one systematic review which has assessed the role of percutaneous Adhesiolysis in treating central spinal stenosis, compared to post lumbar surgery syndrome which has multiple systematic reviews and randomized controlled trials (RCTs). Study design A systematic review of RCTs and observational studies assessing the role of percutaneous Adhesiolysis in managing lumbar central spinal stenosis. Objective To evaluate the effectiveness of percutaneous Adhesiolysis in managing central lumbar spinal stenosis, utilizing currently available literature. Methods This systematic review was performed utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for literature search, Cochrane review criteria, Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB), and Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) to assess methodologic quality assessment and qualitative analysis utilizing best evidence synthesis principles, and meta-analysis.PubMed, Cochrane library, US National Guideline Clearinghouse, Google Scholar, and prior systematic reviews and reference lists were utilized in the literature search from 1966 through June 2019. The evidence was summarized utilizing principles of the best evidence synthesis on a scale of 1 to 5. Outcome measures The primary outcome or hard endpoint was defined as the proportion of patients with 50% pain relief and improvement in functionality, whereas the secondary outcome measures or soft endpoints were pain relief and/or improvement in functionality. Short-term effectiveness was defined as improvement of 6 months or less, whereas long-term effectiveness was defined as more than 6 months. Results Based on search criteria, 9 manuscripts were identified and considered for inclusion with final inclusion of 2 RCTs and 4 observational studies in this systematic review and 5 studies for single arm meta-analysis. The results showed Level II evidence for short-term and long-term improvement in pain and function with application of percutaneous Adhesiolysis in managing central lumbar spinal stenosis. Limitations There was a significant paucity of evidence assessing the role of percutaneous Adhesiolysis in managing lumbar central spinal stenosis, leading to Level II or strong evidence. Conclusion Overall, the present analysis shows Level II (moderate) evidence for percutaneous Adhesiolysis in managing lumbar central spinal stenosis based on relevant high quality RCTs and observational studies. Key words Lumbar central spinal stenosis, percutaneous Adhesiolysis, randomized controlled trials, systematic reviews, neuroplasty.
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effectiveness of percutaneous Adhesiolysis in post lumbar surgery syndrome a systematic analysis of findings of systematic reviews
Pain Physician, 2019Co-Authors: L Manchikanti, Mahendra R Sanapati, Mark V Boswell, Alan D Kaye, Amol Soin, Joshua A HirschAbstract:Background Post lumbar surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous Adhesiolysis are often contemplated in managing post lumbar surgery syndrome. Multiple previous systematic reviews have reached discordant conclusions about the level of evidence for the effectiveness of percutaneous Adhesiolysis in managing post lumbar surgery syndrome and other conditions. Study design A systematic review of previously published systematic reviews assessing efficacy of percutaneous Adhesiolysis in managing post lumbar surgery syndrome. Objective To evaluate the value and validity of previous systematic reviews performed after 2015 on effectiveness of percutaneous Adhesiolysis in managing chronic refractory low back and lower extremity pain secondary to post lumbar surgery syndrome. Methods Previous systematic reviews on percutaneous Adhesiolysis were evaluated. The quality of each systematic review was assessed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and A Measurement Tool to Assess Systematic Reviews (AMSTAR).The randomized trials included in the available systematic reviews were assessed by Cochrane review criteria and Interventional Pain Management techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for methodologic quality.Data sources included relevant systematic reviews and the randomized trials included in those systematic reviews published since 2015 with searches of PubMed, Cochrane reviews, and Google Scholar through February 2019. Outcome measures Outcome measures were significant improvement defined as 50% pain relief and improvement in functional status. Short-term efficacy was defined as improvement of 6 months or less, whereas long-term efficacy was defined as more than 6 months. Results Three systematic reviews and 4 randomized controlled trials (RCTs) of post lumbar surgery syndrome with chronic refractory low back and lower extremity pain showed notable evidence of significant pain relief. Only one systematic review, which was of low quality with inappropriate analysis, showed lack of evidence. Conclusion Overall, the present analysis shows Level I evidence for percutaneous Adhesiolysis based on significant evidence from published RCTs and 3 of the 4 systematic reviews. Key words Post lumbar surgery syndrome, epidural fibrosis, percutaneous Adhesiolysis, systematic reviews, randomized controlled trials.
Howard S Smith - One of the best experts on this subject based on the ideXlab platform.
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systematic review of percutaneous Adhesiolysis and management of chronic low back pain in post lumbar surgery syndrome
Pain Physician, 2009Co-Authors: Richard S Epter, Standiford Helm, Howard S Smith, Salim M Hayek, Ramsin M Benjamin, Salahadin AbdiAbstract:Background: Post lumbar surgery syndrome or failed back surgery syndrome with persistent pain continues to increase over the years. The speculated causes of post lumbar laminectomy syndrome include acquired stenosis, epidural fibrosis, arachnoiditis, radiculopathy, and recurrent disc herniation. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome. Percutaneous epidural Adhesiolysis has been employed in interventional pain management in the treatment of chronic, refractory low back and lower extremity pain after back surgery. Study Design: A systematic review of randomized trials and observational studies. Objective: To evaluate the effectiveness of percutaneous Adhesiolysis in managing chronic low back and lower extremity pain due to post lumbar surgery syndrome.
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effectiveness of spinal endoscopic Adhesiolysis in post lumbar surgery syndrome a systematic review
Pain Physician, 2009Co-Authors: S M Hayek, Standiford Helm, Ramsin M Benyamin, David A Bryce, Howard S SmithAbstract:Background: Post lumbar surgery syndrome with persistent chronic low back and lower extremity pain is common in the United States. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS). Percutaneous Adhesiolysis with a catheter or direct visualization of the spinal canal and the contents with an endoscope are techniques employed in resistant cases when patients fail to respond to conservative modalities of treatment, including fluoroscopically directed epidural injections. Some patients failing to respond to percutaneous Adhesiolysis are candidates for spinal endoscopic Adhesiolysis. However, literature evaluating the effectiveness of spinal endoscopic Adhesiolysis is sparse and discussions continue about its effectiveness, utility, and complications. Study Design: A systematic review of the available literature. Objective: To evaluate the effectiveness and safety of spinal endoscopic Adhesiolysis in the management of chronic low back and lower extremity pain in post surgical patients with chronic recalcitrant pain, non-responsive to conservative modalities of management and fluoroscopically directed epidural injections. Methods: A search of relevant resources (PubMed, EMBASE, and the Cochrane database) was accomplished and the resulting publications were examined based on the inclusion/exclusion criteria set forth. Randomized controlled trials and observational studies were included in the search. Two reviewers assessed the studies’ methodologies and outcomes. Randomized clinical trials were assessed and scored based on the criteria established by the Cochrane methodological assessment criteria of randomized clinical trials and the observational studies were assessed and scored based on the Agency for Healthcare Research and Quality (AHRQ) criteria. Clinical relevance was evaluated utilizing Cochrane review criteria. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. Outcome Measures: The primary outcome measure was pain relief (≥ 50%) in follow-up for at least 6 months. Pain relief for longer than 6 months was considered long-term and 6 months or less was considered short-term. The secondary outcome measures were functional and psychological status, return to work, patient satisfaction, and opioid intake. Results: Of the 13 studies considered for inclusion, one randomized trial and 5 observational studies met inclusion criteria for evidence synthesis based on the inclusion criteria and methodologic quality scores of 50 or more. The indicated level of evidence for endoscopic Adhesiolysis is Level II-1 or II-2 evidence for shortand long-term relief based on the U.S. Preventive Services Task Force (USPSTF) criteria. Limitations: There was a paucity of literature for randomized trials. Conclusion: Spinal endoscopic Adhesiolysis may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy that is related to epidural adhesions.
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role of Adhesiolysis in the management of chronic spinal pain a systematic review of effectiveness and complications
Pain Physician, 2006Co-Authors: Pradeep Chopra, Howard S Smith, Timothy R Deer, Richard C BowmanAbstract:BACKGROUND Percutaneous epidural Adhesiolysis and spinal endoscopic Adhesiolysis are interventional pain management techniques that play an active role in managing chronic intractable low back pain. There have not been any systematic reviews performed on this subject. OBJECTIVE To evaluate the effect of percutaneous Adhesiolysis and spinal endoscopic Adhesiolysis in managing chronic low back and lower extremity pain. STUDY DESIGN A systematic review utilizing the methodologic quality criteria of the Cochrane Musculoskeletal Review Group for randomized trials and the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials. METHODS Search identified the relevant literature, through searches of MEDLINE and EMBASE (January 1966 to November 2004), BioMed Central and Cochrane Review database. Manual searches of bibliographies of known primary and review articles, and abstracts from scientific meetings within the last 2 years, in English language. Randomized and non-randomized studies were included in the review based on the criteria established. Three reviewers independently assessed the trials for the quality of their methods. Percutaneous Adhesiolysis and endoscopic Adhesiolysis were analyzed separately. OUTCOME MEASURES Primary outcome measure was significant pain relief (50% or greater). Other outcome measures were functional improvement, improvement of psychological status, and return to work. Short-term relief was defined as less than 3 months, and long-term relief was defined as 3 months or longer. RESULTS There was strong evidence to indicate effectiveness of percutaneous epidural Adhesiolysis with administration of epidural steroids for short term and long term in chronic, refractory low back pain and radicular pain. There was moderate evidence of effectiveness of addition of hypertonic saline. The evidence of effectiveness of hyaluronidase was negative. There was strong evidence to indicate effectiveness of spinal endoscopic Adhesiolysis and epidural steroid administration for short-term improvement, and moderate evidence for long-term improvement in managing chronic, refractory, low back and lower extremity pain. CONCLUSION The evidence of effectiveness of percutaneous Adhesiolysis with administration of hypertonic sodium chloride administration, and spinal endoscopic Adhesiolysis with epidural steroid administration in managing chronic, refractory low back and lower extremity pain of post lumbar laminectomy syndrome or epidural fibrosis was moderate to strong.
Ramsin M Benyamin - One of the best experts on this subject based on the ideXlab platform.
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percutaneous Adhesiolysis in the management of chronic low back pain in post lumbar surgery syndrome and spinal stenosis a systematic review
Pain Physician, 2012Co-Authors: Helm Ii S, Timothy R Deer, Pradeep Chopra, Ramsin M Benyamin, Rafael JustizAbstract:BACKGROUND Low back pain after either post lumbar surgery syndrome or spinal stenosis in the absence of surgery is a vexing problem. Post lumbar surgery syndrome can occur in any age group, while low back and radicular pain from spinal stenosis is a disease of aging. As the population ages, the incidence of symptomatic spinal stenosis will increase. There are currently limited treatment options for either group. Further surgery is not uniformly effective in relieving pain after previous surgery. While therapies are being developed to treat pain due to spinal stenosis, no therapy other than Adhesiolysis will treat pain due to scarring. Adhesiolysis was developed as a means of removing epidural scarring leading directly or indirectly to compression, inflammation, swelling, or a decreased nutritional supply of nerve roots. Adhesiolysis utilizes a number of modalities in the effort to break up epidural scarring, including the use of a wire-bound catheter for mechanical Adhesiolysis, placement of the catheter in the ventro-lateral aspect of the epidural space at the site of the exiting nerve root, and the use of high volumes of injectate, including local anesthetics and saline, either hypertonic or isotonic, along with steroids. STUDY DESIGN A systematic review of percutaneous Adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. OBJECTIVE To evaluate the effectiveness of percutaneous Adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. The severity of risks and adverse advents associated with percutaneous Adhesiolysis were also evaluated. METHODS The available literature on percutaneous Adhesiolysis for the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. OUTCOME MEASURES The primary outcome measure was pain relief of at least 6 months. Secondary outcome measures were improvement in functional status, change in psychological status, return to work, and reduction in opioid use or interventions. RESULTS For this systematic review, 15 studies were identified and selected for review. Of these, 5 randomized controlled trials and 2 observational studies met the inclusion criteria. Applying the USPSTF criteria, these studies indicate that there is fair evidence that percutaneous Adhesiolysis is effective in relieving low back and/or leg pain caused by post lumbar surgery syndrome and that there is fair evidence that percutaneous Adhesiolysis is effective in relieving low back and/or leg pain caused by spinal stenosis.The incidence of complications from percutaneous Adhesiolysis is low and the complications are generally minimal and self-limited. The procedure should be considered to be low risk for serious adverse events when performed by well-trained physicians. LIMITATIONS The limitations of this systematic review include the paucity of literature. CONCLUSION In summary, there is fair evidence that percutaneous Adhesiolysis is effective in relieving low back and/or leg pain due to post lumbar surgery syndrome or spinal stenosis.
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the preliminary results of a comparative effectiveness evaluation of Adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis a randomized equivalence controlled trial
Pain Physician, 2009Co-Authors: L Manchikanti, Vidyasagar Pampati, Carla D Mcmanus, Kimberly A Cash, Vijay P Singh, Ramsin M BenyaminAbstract:Background Lumbar surgery and epidural injections for spinal stenosis are the most commonly performed interventions in the United States. However, there is only moderate evidence to the effectiveness of surgery and caudal epidural injections. The next sequential step is Adhesiolysis and hypertonic neurolysis with targeted delivery. There have not been any randomized trials evaluating the effectiveness of percutaneous Adhesiolysis and targeted delivery of local anesthetic, steroid and hypertonic sodium chloride solution in lumbar spinal stenosis. Study design A randomized, equivalence, controlled trial. Setting An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives To evaluate the effectiveness of percutaneous epidural Adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis and compare with fluoroscopically directed caudal epidural injections. Methods Patients were randomly assigned to one of 2 groups with 25 patients in each group. Group I patients received caudal epidural injections with catheterization up to S3 with local anesthetic, 0.9% sodium chloride solution, non-particulate betamethasone and served as the control group. Group II patients received percutaneous Adhesiolysis with targeted delivery and injection of lidocaine, 10% hypertonic sodium chloride solution, and non-particulate Betamethasone and formed the intervention group. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes assessment Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12 months post treatment. Significant pain relief was described as 50% or more, whereas significant improvement in the disability score was defined as a reduction of 40% or more. Results This evaluation showed significant pain relief (>or= 50%) in 76% of the patients at one year follow-up in the Adhesiolysis group compared to 4% of the patients in the control group. Limitations The results of this study are limited by the lack of a placebo group, the fact that it is a preliminary report, and there are only 25 patients in each group. Conclusions With significant pain relief in 76% of patients, percutaneous Adhesiolysis utilizing local anesthetic, steroids and hypertonic sodium chloride solution may be effective in patients with chronic function-limiting low back and lower extremity pain with spinal stenosis.
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effectiveness of spinal endoscopic Adhesiolysis in post lumbar surgery syndrome a systematic review
Pain Physician, 2009Co-Authors: S M Hayek, Standiford Helm, Ramsin M Benyamin, David A Bryce, Howard S SmithAbstract:Background: Post lumbar surgery syndrome with persistent chronic low back and lower extremity pain is common in the United States. Epidural fibrosis may account for as much as 20% to 36% of all cases of failed back surgery syndrome (FBSS). Percutaneous Adhesiolysis with a catheter or direct visualization of the spinal canal and the contents with an endoscope are techniques employed in resistant cases when patients fail to respond to conservative modalities of treatment, including fluoroscopically directed epidural injections. Some patients failing to respond to percutaneous Adhesiolysis are candidates for spinal endoscopic Adhesiolysis. However, literature evaluating the effectiveness of spinal endoscopic Adhesiolysis is sparse and discussions continue about its effectiveness, utility, and complications. Study Design: A systematic review of the available literature. Objective: To evaluate the effectiveness and safety of spinal endoscopic Adhesiolysis in the management of chronic low back and lower extremity pain in post surgical patients with chronic recalcitrant pain, non-responsive to conservative modalities of management and fluoroscopically directed epidural injections. Methods: A search of relevant resources (PubMed, EMBASE, and the Cochrane database) was accomplished and the resulting publications were examined based on the inclusion/exclusion criteria set forth. Randomized controlled trials and observational studies were included in the search. Two reviewers assessed the studies’ methodologies and outcomes. Randomized clinical trials were assessed and scored based on the criteria established by the Cochrane methodological assessment criteria of randomized clinical trials and the observational studies were assessed and scored based on the Agency for Healthcare Research and Quality (AHRQ) criteria. Clinical relevance was evaluated utilizing Cochrane review criteria. Analysis was conducted using 5 levels of evidence, ranging from Level I to III, with 3 subcategories in Level II. Outcome Measures: The primary outcome measure was pain relief (≥ 50%) in follow-up for at least 6 months. Pain relief for longer than 6 months was considered long-term and 6 months or less was considered short-term. The secondary outcome measures were functional and psychological status, return to work, patient satisfaction, and opioid intake. Results: Of the 13 studies considered for inclusion, one randomized trial and 5 observational studies met inclusion criteria for evidence synthesis based on the inclusion criteria and methodologic quality scores of 50 or more. The indicated level of evidence for endoscopic Adhesiolysis is Level II-1 or II-2 evidence for shortand long-term relief based on the U.S. Preventive Services Task Force (USPSTF) criteria. Limitations: There was a paucity of literature for randomized trials. Conclusion: Spinal endoscopic Adhesiolysis may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy that is related to epidural adhesions.