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Adhesiolysis, also commonly known as Lysis of Adhesions (LoA), refers to the process of cutting away internal scar tissue (adhesions) that commonly form after trauma, infection, inflammation or surgical procedures (Shannon, 2010). Surgery is perhaps the most common cause of adhesions, which form adjacent to affected tissue as part of the healing process. Adhesiolysis is performed to restore normal function of affected tissues and relieve any pain associated with the development of adhesions.
Adhesions are commonly seen in patients with complaints of low back pain, such as spinal stenosis (narrowing of the spinal canal), as a result of local inflammation that induces scar tissue formation (Igarashi, et al., 2004). Adhesions are also found in as many as 1/3 of Failed Back Surgery Syndrome (FBSS) cases, in which pain persists after the spinal surgery that was intended to treat it (Epter, et al., 2009). These adhesions are thought to affect the mobility of spinal nerve root, contribute to pain, and can also act as obstacles to injection therapy. Adhesiolysis can also be performed in conjunction with epidural injections and other treatment modalities to help relieve lower back pain associated with spinal stenosis and related pathology, while simultaneously making therapeutic injections possible.
Adhesiolysis is also a common procedure for the treatment of small bowel obstruction and uterine pathology. Small bowel obstructions are a condition in which the small intestines become mechanically or functionally unable to pass digested material (Berger, et al., 2007). The majority of these obstructions are caused by post-surgical adhesions of the small intestines; one study estimated the risk of developing an obstruction from adhesions to be as high as 42% following an abdominal surgical procedure (Hodin & Bordeianou, 2011). Adhesions can also develop within the uterus, and may be asymptomatic or can cause issues such as infertility, menstrual irregularity, pelvic pain, or loss of pregnancy (Shelly & Cedars, 2010). They typically occur after traumatic injury to the uterus, but can manifest following curettage (scooping) procedures within the uterus or as a complication of infection such as tuberculosis.
The spinal column consists of several bones, called vertebrae, which are stacked atop one another from the pelvis to the base of the skull, forming a protective channel for the spinal cord24. There are 33 of these vertebrae divided into five regions: (1) cervical, which are found in the neck closest to the skull (identified as C1-C7), (2) thoracic, found along the upper back (identified as T1-T12), (3) lumbar, found along the lower back (identified as L1-L5), (4) sacral, which are contiguous with the pelvis or hip (identified as S1-S5), and (5) coccygeal, which are fused as the tailbone (Leonard, 1995).
Vertebrae are connected to one another by two facet, or zygapophyseal, joints located on either side of the bone.Facet joints assist with spinal weight bearing, prevent the sliding of vertebral bones on top of one another, and limit spinal extension and rotation. Facet joints also create a space through which nerve roots exit the spine to the rest of the body. When adhesions develop near these nerve roots, they can constrict the roots causing irritation and reducing the flow of critical nutrients, which is interpreted by the body as pain (Trescot, et al., 2007). Pain due to compression of nerve roots is termed a radiculopathy.
For chronic back and neck pain, over 1.7 million epidural adhesiolysis procedures were performed in the United States in 2006 to treat radiculopathies (Racz, et al., 2008).
Adhesiolysis of adhesions seen in low back pathology is typically performed via a procedure using fluoroscopically-guided (real-time x-ray) catheters in conjunction with epidural injection (Igarashi & al., 2004). Prior to an adhesiolysis procedure, the physician will discuss potential risks and complications of the procedure, recommend any imaging and blood tests that should be performed, adjust current medications and discuss details of the procedure (ExitCare, 2012). A pain specialist will often order and review an MRI to help isolate nerve roots affected by adhesions which are contributing to pain, however conventional imaging techniques such as CT or MRI may not be able to identify the epidural fibrosis of which adhesions are composed (Hayek, et al., 2009).
During adhesiolysis for back and neck pain, the patient is properly draped and positioned on a procedure table, while the site of insertion is sterilized and numbed with a local anesthetic. A large needle catheter is then inserted into the area under fluoroscopic guidance, a type of real-time x-ray, to the location of an adhesion. Once located, a variety of medications are injected into the adhesion designed to dissolve the adhesions while preventing inflammation and blocking subsequent pain. Adhesiolysis is an outpatient procedure, thus it’s typically complete in under an hour and the patient may return home after a brief observation period for adverse reactions. The procedure may need to be performed twice on consecutive days to ensure that the adhesions have been properly dissolved.
Adhesiolysis for bowel obstruction and uterine pathology is generally more invasive requiring generally anesthesia. Intra-abdominal adhesiolysis can be performed with sharp scissors or a scalpel after openly and surgically exposing the tissue (referred to as a laparotomy), or it can be performed much less invasively with a technique known as laparoscopy (Shannon, 2010). With laparoscopy, cameras and instruments are inserted through smaller openings into internal tissues, and adhesions can be grasped and cut with scissor or cauterization attachments to the instruments (Hodin & Bordeianou, 2011). By avoiding large surgical incisions, laparoscopy can lower the potential for future post-surgical adhesions.
Intra-uterine adhesiolysis is generally done after cervical dilation provides direct visualization of the adhesions (Shelly & Cedars, 2010). Adhesions are usually banded and excised with surgical scissors, with special care taken to restore normal uterine anatomy without perforating the uterus. Re-formation of intra-uterine adhesions can be prevented after adhesiolysis via temporary hormone therapy and catheter placement.
Following an adhesiolysis procedure, it is important for all patients to adhere to instructions provided by the pain specialist, take all prescribed medications, and properly clean and care for the injection site (ExitCare, 2012). Physical activity should be gradually increased as the pain subsides following treatment.
Adhesiolysis is considered a safe and effective procedure to reduce the effect of painful internal scarring following spinal surgery. A successful procedure can also open additional treatment options for chronic back and neck pain, once the adhesions are no longer blocking or irritating nerve roots.
Adhesiolysis is employed by interventional pain specialists to manage chronic pain that is unresponsive to conservative treatments, with the purpose of eliminating scar tissue. The evidence for the use of adhesiolysis to treat FBSS has been shown to be moderate to strong (Epter, et al, 2009). In a systematic review of several randomized controlled trials, adhesiolysis was shown to be superior to epidural steroid injections for the treatment of adhesion-related chronic back pain.
Adhesiolysis for low back pain is a surgical procedure, and thus not without risk. Serious complications are rare, but occasionally include internal organ injury, dural puncture, worsening of adhesions or development of new adhesions, bleeding and infection (Shannon, 2010) Potential complications, such as increased intracranial fluid pressure from high fluid volume administration have been theorized but not reported (Epter & al, 2009). The most common adverse event associated with adhesiolysis was mild to moderate pain at the injection site following the procedure. All procedural risks are reduced by the use of fluoroscopy to guide catheter placement, proper sterilization and performance of the procedure by an experienced, well trained pain specialist. Additionally, appropriate monitoring and observation following the procedure allow for timely interventions for potential complications before they become serious (Racz, et al., 2008). Rarely, adhesions will reoccur following an adhesiolysis procedure.
To help avoid any potential complications with the procedure, patients should let their physician know about any allergies, medications being used, and any history of bleeding problems, blood clots or other medical problems, as well as any prior surgeries the patient may have undergone (ExitCare, 2012). After undergoing the procedure, patients should also be vigilant and seek medical care for any onset of fever, increase in pain, redness, discharge or swelling at the injection site, or persistent shortness of breath, nausea or vomiting.
At least two systematic reviews and associated published data have provided strong evidence and solidified adhesiolysis as an effective treatment option for the short term treatment of lower back pain and radiculopathy (Racz, et al., 2008). The evidence for long-term pain relief of these conditions is moderate. In one large study, 100% of participants reported pain relief after three months, while over 50% of those participants continued to have pain relief after one year (Boswell, et al., 2007).
References/ Journal Articles
- Adhesiolysis – PainDoctor.com
- Berger, D., et al. (2007). Gastrointestinal Surgery. Retrieved from Townsend: Sabiston Textbook of Surgery, 18th Ed. MD Consult.
- Boswell, M., et al. (2007). Percutaneous lysis of epidural adhesions. Pain Physician, 7-111.
- Epter, R., et al. (2009). Systematic Review of Percutaneous Adhesiolysis and Management of Chronic Low Back Pain in Post Lumbar Surgery Syndrome. Pain Physician, 361-78.
- ExitCare. (2012). Lysis of Adhesions. Retrieved April 15, 2012, from MD Consult: http://www.mdconsult.com.ezproxy2.library.arizona.edu/das/patient/body/331569112-5/1302315112/10089/57112.html
- Hayek, S., et al. (2009). Effectiveness of Spinal Endoscopic Adhesiolysis. Pain Physician, 419-35.
- Hodin, R., & Bordeianou, L. (2011). Small bowel obstruction: Causes and management. Retrieved from UpToDate.
- Igarashi, T., et al. (2004). Lysis of adhesions and epidural injection of steroid/local anaesthetic during epiduroscopy potentially alleviate low back and leg pain in elderly patients with lumbar spinal stenosis. Br J Anaesth, 181-87.
- Leonard, R. (1995). Human Gross Anatomy: An Outline Text. Oxford University Press USA.
- Racz, G., et al. (2008). Percutaneous Lysis of Epidural Adhesions—Evidence for Safety and Efficacy. Pain Practice, 277-286.
- Shannon, D. (2010). Lysis of Adhesions. Retrieved April 15, 2012, from Baptist Health Systems: http://mbhs.org/healthgate/GetHGContent.aspx?token=9c315661-83b7-472d-a7ab-bc8582171f86&chunkiid=100928
- Shelly, W., & Cedars, M. (2010). Intrauterine adhesions. Retrieved from UpToDate.
- Trescot, A., et al. (2007). Systematic Review of Effectiveness and Complications of Adhesiolysis in the Management of Chronic Spinal Pain: An Update. Pain Physician, 129-146.