Background: Speculated causes of post lumbar surgery syndrome include epidural fibrosis, acquired
stenosis, and facet joint pain among other causes. Even though fluoroscopically directed caudal
epidural injections and facet joint interventions are effective in some patients, others continue to suffer
with chronic persistent pain. Percutaneous adhesiolysis with target delivery of medications has been
demonstrated to be effective in these patients. However, the evidence for percutaneous adhesiolysis in
managing post surgery syndrome has been questioned, coupled with a paucity of controlled trials.
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 in post surgery syndrome and compare with
fluoroscopically directed caudal epidural steroid injections.
Methods: Patients were randomly assigned to one of 2 groups: Group I (60 patients) receiving
caudal epidural injections with catheterization up to S3 with local anesthetic, steroids, and
0.9% sodium chloride solution serving as the control group, and Group II (60 patients) receiving
percutaneous adhesiolysis with targeted delivery of lidocaine, 10% hypertonic sodium chloride
solution, and non-particulate Betamethasone serving as 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: Significant pain relief (≥ 50%) and functional status improvement was recorded in 73%
of patients in Group II versus 12% in Group I (P < 0.001). The average procedures per year were
3.5 with an average total relief of 42 out of 52 weeks in Group II and 2.2 procedures with total
relief per year of 13 weeks in Group I (P < 0.001).
Limitations: The results of this study are limited by potentially inadequate double blinding, by
the lack of a placebo group, and the preliminary report of one-year follow-up.
Conclusions: Percutaneous adhesiolysis in chronic function-limiting, recalcitrant low back pain
in post lumbar surgery syndrome demonstrated effectiveness in 73% of the patients.
Key words: Post lumbar surgery syndrome, post lumbar laminectomy syndrome, chronic low
back pain, epidural adhesions, epidural steroid injections, percutaneous adhesiolysis, epidural
fibrosis, spinal stenosis, randomized trial, comparative effectiveness
Establishing a common language for lumbar transforaminal epidural steroid injections