Clinical Effectiveness of Posterior Annular Targeted Ablative Decompression as an Alleviative Intervention for Lumbosacral Discogenic Pain: Systematic Review and Meta-analysis.

BACKGROUND: Various percutaneous intradiscal procedures have been implemented to manage lumbosacral discogenic pain. But most of these procedures simply end up manipulating the central nucleus pulposus or the inner annulus, instead of accessing the posterior outer annulus where the actual, major pain generators exist. Thus, more localized percutaneous techniques, specifically derived to address the pathologic tissues creeped between the torn, posterior annulus and hyperplastic sinuvertebral nerve, have been devised. However, the clinical effectiveness of these "more" accurate procedures is still skeptical.

OBJECTIVES: This study has investigated whether the posterior annular targeted decompression was a useful method to treat lumbosacral discogenic pain in terms of pain control or functional improvement.

STUDY DESIGN: A systematic review and meta-analysis.

SETTING: Primary clinic and tertiary referral center.

PATIENTS: Published past references that have dealt with the issue of clinical effectiveness after the posterior annular targeted decompression as a treatment of discogenic pain in terms of pain control and functional improvement.

METHODS: A literature search was performed using MEDLINE, EMBASE, Cochrane Review, and KoreaMed databases from the studies published until December 2022. After reviewing titles, abstracts, and full texts of 65 studies during the initial database search, 12 studies were included in a qualitative synthesis, and 9 trials from 8 studies were in quantitative meta-analysis. Data, including pain and functional scores, were extracted and were analyzed using a random effects model to obtain statistical significance of mean difference. Quality assessment and evidence level were established in accordance with the Grading of Recommendations Assessment, Development and Evaluation methodology.

RESULTS: Finally, 12 single-arm studies without the control group were included. All studies showed significant pain reduction and functional improvement from a 1-month to 1-year follow-up period. A meta-analysis showed significant reduction in pain scores at 1 month, 3 months, 6 months, and 1 year and functional scores at 1 month, 6 months, and 1 year. The level of evidence was very low because of the nonrandomized study design and inconsistency and imprecision across studies.

LIMITATIONS: Only single-arm studies comparing clinical results before and after treatment without the control group were analyzed. The statistical and clinical heterogeneity, due to different aspect of techniques across the studies and a relatively small number of patients, reduced the evidence level.

CONCLUSIONS: Comprehensive reviews of selected articles revealed posterior annular targeted decompression could be recommended as treatment option in the patients with discogenic pain who have failed in attaining clinical improvement after the conservative managements under weak evidential strength support.

KEY WORDS: Discogenic pain, minimal invasive technique, percutaneous targeted disc decompression, systematic review, meta-analysis.