Efficacy of Percutaneous Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Abstract Introduction Chronic refractory low back and lower extremity pain recalcitrant to conservative management and epidural injections secondary to postsurgery syndrome, spinal stenosis, and disc herniation are sometimes managed with percutaneous adhesiolysis. Consequently, this systematic review and meta-analysis was undertaken to assess the efficacy of percutaneous adhesiolysis in managing low back and lower extremity pain. Methods A systematic review and meta-analysis of randomized controlled trials (RCTs) utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases from 1966 to July 2022, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included trials, meta-analysis, and best evidence synthesis was performed. The primary outcome measure was a significant reduction in pain (short term up to 6 months and long term more than 6 months). Results The search identified 26 publications, with 9 trials meeting the inclusion criteria. The results of dual-arm and single-arm analyses showed significant improvement in pain and function at 12 months. Opioid consumption was also significantly reduced at 6 months with dual-arm analysis, whereas single-arm analysis showed a significant decrease from baseline to treatment at the 3-, 6-, and 12-month analyses. At 1 year follow-up, seven of seven trials were positive for improvements in pain relief, function, and diminution of opioid use. Discussion Based on the present systematic review of nine RCTs, the evidence level is I to II, with moderate to strong recommendation for percutaneous adhesiolysis in managing low back and lower extremity pain. The limitations of the evidence include paucity of literature, lack of placebo-controlled trials, and the majority of the trials studying post lumbar surgery syndrome. Conclusion The evidence is level I to II or strong to moderate based on five high-quality and two moderate-quality RCTs, with 1 year follow-up that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain

Systematic review and meta-analysis of effectiveness of therapeutic sacroiliac joint injections

Background:The sacroiliac joint is one of the proven causes of low back and lower extremity pain, ranging from 10% to 25% in patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis. Despite the difficulty of diagnosis, multiple therapeutic modalities including surgical and nonsurgical interventions have been utilized. Among the interventional modalities, intraarticular injections are commonly utilized. Objective:To evaluate the therapeutic effectiveness of intraarticular injections in the sacroiliac joint. Study design:A systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies of the therapeutic effectiveness of intraarticular injections of the sacroiliac joint utilizing the Preferred Reporting Items For Systematic Reviews And Meta-Analyses (PRISMA) checklist. Methods:The available literature on therapeutic sacroiliac joint intraarticular injections was reviewed. The quality assessment criteria utilized were the Cochrane review criteria to assess risk of bias, the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB) for randomized therapeutic trials, and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) for nonrandomized studies. The level of evidence was based on best evidence synthesis with modified grading of qualitative evidence from Level I to Level V. Data collection was performed including literature published from 1966 through December 2022, as well as manual searches of the bibliographies of known articles. Outcome measures:Primary outcome measures include pain relief and improvement in functional status at 3 months for a single intervention. Only the studies performed under fluoroscopic guidance, with at least 3 months of follow-up were included. Duration of relief was categorized as short-term (\u3c 6 months) and long-term (\u3e 6 months). Results:Based on the qualitative and quantitative analyses with a single-arm meta-analysis and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system of appraisal, and the inclusion of 11 RCTs (5 positive, 6 negative) and 3 observational studies (2 positive, one negative), the evidence was Level III or fair in managing low back pain of sacroiliac joint origin with sacroiliac joint injections. Limitations:This systematic review and meta-analysis are limited by lack of eligible studies, inconsistencies among the available studies, variations in techniques, variable diagnostic standards for inclusion criteria, and finally, the inability to correlate the results and perform an optimal systematic review and meta-analysis. Conclusion:The present systematic review and meta-analysis show an inability to perform conventional dual-arm analysis, whereas a single-arm meta-analysis demonstrated a difference of approximately 3 points on the Numeric Rating Scale (NRS) and 8 points on the Oswestry Disability Index (ODI). However, there were no studies that considered \u3e= 50% relief as the criterion standard. Overall, the qualitative and quantitative evidence combined shows Level III or fair evidence for therapeutic sacroiliac joint injections for managing low back pain of sacroiliac joint origin

Medial branch blocks and the effectiveness of radiofrequency neurotomy in managing chronic thoracic pain: A systematic review and meta-analysis

Background:Extensive research into potential sources of thoracic pain with or without referred pain into the chest wall has demonstrated that thoracic facet joints can be a potential source of pain confirmed by precise, diagnostic blocks.The objective of this systematic review and meta-analysis is to evaluate the effectiveness of medial branch blocks and radiofrequency neurotomy as a therapeutic thoracic facet joint intervention. Methods:Systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies of medial branch blocks and the radiofrequency neurotomy in managing thoracic pain utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases of RCTs and observational studies of medial branch blocks and radiofrequency neurotomy in managing chronic thoracic pain were identified from 1996 to December 2022 with inclusion of manual searches of the bibliography of known review articles and multiple databases. Methodologic quality and risk of bias assessment was also conducted. Evidence was synthesized utilizing principles of quality assessment and best evidence synthesis, with conventional and single meta-analysis. The primary outcome measure of success was 3 months of pain reduction for medial branch blocks and 6 months for radiofrequency thermoneurolysis for a single treatment. Short-term success was defined as up to 6 months and long-term was more than 6 months. Results:This literature search yielded 11 studies meeting the inclusion criteria, of which 3 were RCTs and 8 were observational studies. Of the 3 RCTs, 2 of them assessed medial branch blocks and one trial assessed radiofrequency for thoracic pain. The evidence for managing thoracic pain with qualitative analysis and single-arm meta-analysis and GRADE system of appraisal, with the inclusion of 2 RCTs and 3 observational studies for medial branch blocks was Level II. For radiofrequency neurotomy, with the inclusion of one RCT of 20 patients in the treatment group and 5 observational studies, the evidence was Level III in managing thoracic pain. Limitations:There was a paucity of literature with RCTs and real-world pragmatic controlled trials. Even observational studies had small sample sizes providing inadequate clinically applicable results. In addition, there was heterogeneity of the available studies in terms of their inclusion and exclusion criteria, defining their endpoints and the effectiveness of the procedures. Conclusion:This systematic review and meta-analysis show Level II evidence of medial branch blocks and Level III evidence for radiofrequency neurotomy on a long-term basis in managing chronic thoracic pain