Clinical effectiveness of Percutaneous adhesiolysis using Navicath for the management of chronic pain due to lumbosacral disc herniation

Wooridul Spine Hospital, Seoul, Korea.
Pain physician (Impact Factor: 3.54). 05/2012; 15(3):213-21.
Source: PubMed


Epidural steroid injection has been frequently performed to treat chronic pain due to lumbosacral disc herniation (L-HIVD). However, a considerable number of patients do not achieve pain relief using this method because perineural or epidural adhesions prevent the spread of injectate into the epidural space. Percutaneous adhesiolysis (PA) is thought to be a useful method because it can eliminate the deleterious effects of adhesion.
This study aimed to evaluate the effectiveness of PA in managing chronic pain due to L-HIVD and the clinical and radiological predictive factors for the effectiveness of PA using NaviCath®.
Retrospective study
Spine hospital
From a group of patients diagnosed with L-HIVD, we selected the 86 patients who underwent PA with NaviCath® who had experienced chronic lower back or leg pain for at least 3 months and had failed to respond to anti-inflammatory medications or physical therapy of at least 1 month's duration and fluoroscopy guided transforaminal epidural injection. We recorded the Numeric Rating Scale for back pain (NRS back) and leg pain (NRS leg) and the Oswestry Disability Index (ODI) at pretreatment, 2 weeks, and 3 months after treatment. Clinical data and magnetic resonance imaging (MRI) findings were obtained to assess the possible predictive factors for PA efficacy.
Retrospective chart review without a control group.
At 2 weeks after PA, significant improvement was observed in NRS back, NRS leg, and ODI compared with pretreatment. This improvement was maintained until 3 months after treatment. Among 86 patients, 61 (70.9%), 53 (61.6%) and 61 patients (70.9%) showed successful outcomes in NRS back, NRS leg, and ODI at 2 weeks, respectively. Among 74 patients who were followed up at 3 months, 47 (63.5%), 44 patients (59.5%), and 50 patients (67.6%) showed successful results in NRS back, NRS leg, and ODI at 3 months, respectively. A significantly higher proportion of patients with a history of previous lumbar surgery showed unsuccessful results on NRS back, NRS leg, and ODI scores at 2 weeks and 3 months. Co-existence of spinal stenosis was associated with a significantly higher proportion of unsuccessful results in NRS back and ODI at 2 weeks and 3 months, as well as NRS leg at 3 months. Patients with spondylolisthesis also showed a significantly higher proportion of unsuccessful results in NRS and ODI at 2 weeks.
PA with NaviCath® showed clinical effectiveness in the treatment of chronic pain due to L-HIVD that was not responsive to transforaminal epidural injection. Previous surgery and the presence of spinal stenosis or spondylolisthesis were poor prognostic predictors. This procedure may enable the physician to place the catheter tip and deliver medicine more precisely.

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    • "In order to control the direction of the catheter during the procedure, other instruments have been developed. Among them, the NaviCath, which is more steerable and can be bent to only one side, has been reported to be clinically effective in the treatment of chronic lower back pain that is not responsive to transforaminal epidural injection [9]. However, this procedure has some limitations in patients with a severe degree of adhesion or severe spinal stenosis because of the difficulty in placing the catheter at the target area. "
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    ABSTRACT: Epidural adhesions cause pain by interfering with the free movement of the spinal nerves and increasing neural sensitivity as a consequence of neural compression. To remove adhesions and deliver injected drugs to target sites, percutaneous epidural adhesiolysis (PEA) is performed in patients who are unresponsive to conservative treatments. We describe four patients who were treated with a newly developed inflatable balloon catheter for more effective PEA and relief of stenosis. In the present patients, treatments with repetitive epidural steroid injection and/or PEA with the Racz catheter or the NaviCath did not yield long-lasting effects or functional improvements. However, PEA and decompression with the inflatable balloon catheter led to maintenance of pain relief for more than seven months and improvements in the functional status with increases in the walking distance. The present case series suggests that the inflatable balloon catheter may be an effective alternative to performing PEA when conventional methods fail to remove adhesions or sufficiently relieve stenosis.
    The Korean journal of pain 04/2014; 27(2):178-85. DOI:10.3344/kjp.2014.27.2.178
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    • "No benefit was noted for either the use of a reinforced navigable catheter or the addition of hyaluronidase. In two retrospective studies evaluating the effectiveness of percutaneous adhesiolysis by Lee et al., a poor outcome was more common in patients with previous surgery, spondylolisthesis, herniated disc, and lumbosacral and foraminal stenosis [64,65]. An observational study by Park et al. performed in 66 patients with clinical spinal stenosis found no association between LOA outcome and the anatomical degree of stenosis [45]. "
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    ABSTRACT: As our population ages and the rate of spine surgery continues to rise, the use epidural lysis of adhesions (LOA) has emerged as a popular treatment to treat spinal stenosis and failed back surgery syndrome. There is moderate evidence that percutaneous LOA is more effective than conventional ESI for both failed back surgery syndrome, spinal stenosis, and lumbar radiculopathy. For cervical HNP, cervical stenosis and mechanical pain not associated with nerve root involvement, the evidence is anecdotal. The benefits of LOA stem from a combination of factors to include the high volumes administered and the use of hypertonic saline. Hyaluronidase has been shown in most, but not all studies to improve treatment outcomes. Although infrequent, complications are more likely to occur after epidural LOA than after conventional epidural steroid injections.
    The Korean journal of pain 01/2014; 27(1):3-15. DOI:10.3344/kjp.2014.27.1.3
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    ABSTRACT: 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.
    Pain physician 08/2012; 15(4):E435-62.. · 3.54 Impact Factor
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