PAIN+ CPN

BACKGROUND: Lumbar radicular pain (LRP) and/or lower back pain is a challenging condition, particularly in cases refractory to conservative treatments like epidural steroid injections (ESI). Pulsed radiofrequency (PRF) to the dorsal root ganglion and epidural neuroplasty techniques are emerging as alternative interventional treatments. However, there are no direct comparison studies between PRF and epidural neuroplasty, leading to uncertainty in optimal treatment selection.

OBJECTIVE: This network meta-analysis (NMA) aims to indirectly compare the efficacy of PRF and epidural neuroplasty techniques in managing LRP.

EVIDENCE REVIEW: We conducted a systematic review and NMA of randomized controlled trials (RCTs) comparing PRF, epidural neuroplasty, and conservative treatments, including ESI and sham procedures. Data sources included PubMed, Cochrane Central, Embase, and Web of Science up to December 31, 2024. Inclusion criteria comprised RCTs evaluating adult patients with lumbar radicular pain from disc herniation, spinal stenosis, or failed back surgery syndrome. Two reviewers independently extracted data on study design, interventions, outcomes, and risk of bias. The primary outcome was pain reduction at 1, 3, 6, and 12 months post-treatment. The secondary outcome was disability reduction, measured by the Oswestry Disability Index (ODI). A frequentist random-effects model was used for data synthesis, and the certainty of evidence was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach. Prediction intervals were not calculated due to data limitations, which is acknowledged as a limitation.

FINDINGS: 14 RCTs comprising 1229 patients were included. At 1 month, there was no significant difference between PRF and epidural neuroplasty. At 3 months, epidural neuroplasty showed significant advantages over PRF (mean difference: -1.47, 95% CI -2.73 to -0.46); however, the certainty of evidence for this comparison was rated low. Similar trends were observed at 6 and 12 months, but the confidence in these estimates remained low to very low. For ODI, no significant differences were found at time points, and the certainty of evidence was moderate to very low across comparisons.

CONCLUSION: PRF and epidural neuroplasty may offer comparable long-term pain and disability outcomes for patients with lumbar radicular pain, but the overall certainty of evidence was low to very low, limiting confident clinical recommendations. These findings highlight the need for high-quality, head-to-head trials to better inform interventional treatment strategies for LRP.

Physician rater

This meta-analysis showed no difference between pulsed radiofrequency of lumbar dorsal root ganglion and epidural neuroplasty. This lack of difference occurred due to the poor studies included. This review confirms that a meta-analysis cannot correct poorly conducted studies.

Physician rater

This network meta-analysis investigated different interventions for chronic radicular lumbar pain and found a non-clinically significant difference in pain intensity at 3 months in favour of epidural neuroplasty versus pulsed radiofrequency, and no difference in ODI scores. The methodology is rigorous and the findings are clearly reported. The population in this meta-analysis is defined as “adult patients diagnosed with lumbar radicular pain caused by spinal stenosis, lumbar disc herniation, or FBSS.” The included studies defined their patients mostly by the duration of pain, location of pain, and aetiology. Is this "radiculopathy" a nerve trunk pain by nociception of the nerve sheath, a chemical radiculitis, or an established neuropathic pain? So it begs the question: are these patients truly affected by the same chronic pain? A more precise phenotyping of actual pain mechanisms will provide better evidence to guide our clinical decisions.

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