Epidural Lysis of Adhesions

Performed by Top Pain Management Doctors in San Antonio, Texas


Epidural adhesions with chronic low back pain is a common entity in modern medicine (Hammer et al, 2001). Lysis of adhesions, also known as adhesiolysis or the Racz procedure after its creator Dr. Gabor Racz, is a minimally invasive, percutaneous procedure designed to dissolve scar tissue (adhesions) in the epidural space surrounding the spine.

Epidural adhesions often put pressure on nerve roots exiting the spine, resulting in continual back pain. The pain, which can originate in any region of the spine, is frequently described as radicular as it radiates down the limbs. While epidural adhesions most commonly develop following surgery on the spine, leakage of disc material into the epidural space following an annular tear, or an inflammatory response can also result in the formation of epidural adhesions (Manchikanti & Bakhit, 2000).

The epidural space is the same space in which women in labor receive “an epidural,” or a continuous infusion of anesthetic into the epidural space administered to numb the pain of childbirth. It is also the same space where epidural steroid injections (ESIs) are administered to treat chronic low back pain and radiculopathy. However, adhesions can physically prevent the therapeutic medications in ESIs from reaching painful tissues. The goal of epidural adhesiolysis is to eradicate these adhesions, freeing nerve roots and reopening the epidural space so that therapeutic medications can circulate freely (Trescot et al, 2007).

” We never set out to develop a technique — it just evolved from an obstetrical death from a plastic epidural catheter that migrated into a vein and kinked at the same time,” said Dr. Gabor Racz, inventor of the procedure. “We tried to solve the catheter problem, which resulted in an X-ray visible, steerable, soft-tipped catheter that I wanted to get to the dorsal root ganglion to inject phenol, only to find that often because of assumed scar formation it was hard to get to. However, once you got through the scar tissue and injected volumes of contrast and steroids one could get long pain relief.”

Epidural adhesions are common among patients with failed back surgery syndrome (FBSS, or post lumbar surgery syndrome) contributing to approximately 60% of symptom recurrence (Manchikanti et al, 2005). Percutaneous epidural lysis of adhesions can in many cases effectively manage chronic low back pain and lower extremity pain arising from scar tissue formation after back surgery (Epter et al, 2009; Manchikanti et al, 2010). A randomized, controlled equivalence trial found percutaneous adhesiolysis demonstrated effectiveness in 73% of FBSS patients with chronic, function-limiting, recalcitrant low back pain (Manchikanti et al, 2009).

In another study that demonstrates the efficacy and the feasibility of application of percutaneous lysis of epidural adhesions in FBSS (Chun-Jing et al, 2012), 92 patients with FBSS were randomly divided into two groups, the control group (treated by injection dexamethasone only) and percutaneous lysis of epidural adhesions group. Pain levels as measured by visual analog scale scores (VAS) and therapeutic evaluation were observed preoperatively, seven days postoperatively, and one month and six months postoperatively. The VAS scores were significantly higher in the control group at one month and six months than that in epidural adhesiolysis group. Further, patients who received adhesiolysis reported a clinical effectiveness rate of 50%, whereas patients in the control group reported an effectiveness rate of only 5.26%.

Also, a review of randomized controlled trials and observational studies found Level II-1 or Level II-2 evidence for the effectiveness of adhesiolysis in FBSS, leading the researchers to conclude that it may be used as an effective treatment modality for chronic refractory low back pain and radiculopathy related to epidural adhesions (Hayek et al, 2009).

Percutaneous epidural adhesiolysis has also been used successfully in patients with spinal stenosis, a condition that can also develop as a consequence of back surgery (Manchikanti et al, 2001 & 2009). Sixty-six patients with degenerative lumbar spinal stenosis underwent percutaneous adhesiolysis (Park et al, 2011). Improvement (including reports of slightly improved, much improved, and no pain) was observed in 49 participants (74.2%) at two weeks after the procedure, and 45 participants (66.7%) at six months after the procedure. Improvement (including reports of slightly improved, much improved, and no pain) was observed in 49 participants (74.2%) at two weeks, and 45 participants (66.7%) at six months after the procedure. The researchers concluded percutaneous adhesiolysis was shown to be effective for the treatment of lumbar spinal stenosis.

Anatomy

The spinal cord and brain are surrounded by three meninges, or protective membranes. From innermost to outermost, these include the pia mater, the arachnoid mater and the dura mater. External to the dura mater  is a fluid filled space called the epidural space. The epidural space contains lymphatics, spinal nerve roots, loose fatty tissue, arteries, and a network of large, thin-walled veins called the epidural venous plexus. The epidural space communicates freely with the space surrounding the vertebral column through the intervertebral foramina, or pairs of openings located between every vertebral body that allow for the passage of the spinal nerve roots.

The formation of scar tissue (adhesions) in the epidural space can compress nerve roots as they exit the spinal column. It can also inhibit the flow of therapeutic medications throughout the epidural space and its connecting areas. Adhesiolysis is a minimally invasive way to remove adhesions that obstruct the flow of medications throughout the epidural space.

Procedure

Diagnostic imaging is used to confirm the presence of adhesions and identify which spinal nerves are being made painful by encroaching scar tissue. Typically, the diagnosis of adhesions is achieved with an MRI. Another way is with an epidurogram, which involves injection of contrast dye into the epidural space under fluorscopic guidance to obtain a detailed picture of the spinal region (Manchikanti & Bakhit, 2000).

Initially, ESIs may be administered in an attempt to treat chronic back pain caused by epidural adhesions. However, epidural adhesions may prevent the medications contained in ESIs from reaching affected tissues. When ESIs fail to produce pain relief, and the presence of scar tissue is confirmed in a patient, adhesiolysis may be recommended.

In adhesiolysis, the patient first receives an injection of local anesthetic into the area where the catheter will be inserted. When the area is sufficiently numbed, the physician advances a catheter or guide wire through a hollow needle into the epidural space, using fluoroscopic guidance or an endoscope to ensure accuracy. Therapeutic medications are then injected through the catheter into the epidural space in order to  dissolve adhesions and reduce inflammation and irritation in affected tissues. These medication may include omnipaque, hypertonic saline, hyaluronidase, local anesthetics, and steroids.

The procedure typically takes one hour or less. After the procedure, some patients report sensory changes such as heaviness in the legs, but these sensations should be temporary. In addition, there may be transient, minor discomfort at the site of insertion when the anesthetic wears off.

Benefits

Percutaneous lysis of epidural scar tissue has been shown to be safe and cost effective in multiple studies (Manchikanti & Bakhit, 2000; Manchikanti et al, 2001). A retrospective case analysis of 14 patients who failed to respond to other conservative treatment modalities including ESIs found adhesiolysis with hypertonic saline to be safe and effective in managing chronic back pain. Transforaminal ventral epidural adhesiolysis was performed on an outpatient basis in all patients. The results showed 93% improvement initially, which decreased to 71% at one month, 57% at three months, 43% at six months and 21% at one year (Hammer et al, 2001).

Another study, a retrospective evaluation of 18 patients with refractory low back and lower extremity pain from spinal stenosis, showed significant improvement with reduction of pain, as well as improvement in physical health, mental health, and functional status (Manchikanti et al, 2001). Improvement in psychological status and a decrease in narcotic intake were also noted,. And a randomized, controlled trial found epidural adhesiolysis followed by injection of steroid and local anesthetic improved sensory nerve function, lowered pain, and improved functionality in patients with chronic sciatica, as tested with nerve stimulation and intensity of pain and disability questionnaire scores (Sakai et al, 2008).

Risks

Although the Racz procedure is minimally invasive, it is associated with remote risks. Although unlikely, the most common risks include infection, bleeding and damage to tissues. Some patients report heaviness in the legs and soreness around the insertion site after the anesthetic wears off. Another potential risk is re-adhesion, or reformation of scar tissue after the procedure, although re-adhesion may take years to occur (Takeshima et al, 2009).

Outcome

In general, adhesiolysis has been proven to be a minimally invasive, low-risk solution to chronic back and leg pain caused by compression of nerve roots by scar tissue.

A consortium from the American Society of Interventional Pain Physicians found strong evidence that the procedure brings short-term relief and moderate evidence that it results in long-term relief for chronic spinal pain (Boswell et al, 2007). Also, most practitioners report that patients who undergo adhesiolysis therapy are able to decrease use of pain medication and experience improvements in physical health, functional status, and psychological well-being.

Journal Articles/Resources

  1. Chun-Jing H, Hao-Xiong N, & Jia-Xiang N. (2012). The application of percutaneous lysis of epidural adhesions in patients with failed back surgery syndrome. Acta Cir Bras. 27(4):357-62.
  2. Epter RS, Helm S 2nd, Hayek SM, Benyamin RM, Smith HS, & Abdi S. (2009). Systematic review of percutaneous adhesiolysis and management of chronic low back pain in post lumbar surgery syndrome. Pain Physician. 12(2):361-78.
  3. Hammer M, Doleys DM, & Chung OY. (2001). Transforaminal ventral epidural adhesiolysis. Pain Physician. 4(3):273-9.
  4. Hayek SM, Helm S, Benyamin RM, Singh V, Bryce DA, & Smith HS. (2009). Effectiveness of spinal endoscopic adhesiolysis in post lumbar surgery syndrome: a systematic review. Pain Physician. 12(2):419-35.
  5. Manchikanti L, & Bakhit CE. (2000). Percutaneous lysis of epidural adhesions.  Pain Physician. 3(1):46-64.
  6. Manchikanti L, Boswell MV, Rivera JJ, Pampati VS, Damron KS, McManus CD, Brandon DE, & Wilson SR. (2005). [ISRCTN 16558617] A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesthesiol. 5:10.
  7. Manchikanti L, Datta S, Gupta S, Munglani R, Bryce DA, Ward SP, Benyamin RM, Sharma ML, Helm S 2nd, Fellows B, & Hirsch JA. (2010). A critical review of the American Pain Society clinical practice guidelines for interventional techniques: part 2. Therapeutic interventions. Pain Physician. 13(4):E215-64.
  8. Manchikanti L, Pampati V, Fellows B, Rivera JJ, Damron KS, Beyer C, & Cash KA. (2001). Effectiveness of percutaneous adhesiolysis with hypertonic saline neurolysis in refractory spinal stenosis. Pain Physician. 4(4):366-73.
  9. Manchikanti L, Singh V, Cash KA, Pampati V, & Datta S. (2009). A comparative effectiveness evaluation of percutaneous adhesiolysis and epidural steroid injections in managing lumbar post surgery syndrome: a randomized, equivalence controlled trial. Pain Physician. 12(6):E355-68.
  10. Park CH, Lee SH, & Jung JY. (2001). Dural sac cross-sectional area does not correlate with efficacy of percutaneous adhesiolysis in single level lumbar spinal stenosis. Pain Physician. 14(4):377-82.
  11. Sakai T, Aoki H, Hojo M, Takada M, Murata H, & Sumikawa K. (2008). Adhesiolysis and targeted steroid/local anesthetic injection during epiduroscopy alleviates pain and reduces sensory nerve dysfunction in patients with chronic sciatica. J Anesth. 22(3):242-7.
  12. Trescot AM, Chopra P, Abdi S, Datta S, & Schultz DM. (2007). Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update. Pain Physician. 10(1):129-46.