Lysis of Epidural Adhesions

Utilizing the Epidural Approach

 

Introduction

Bleeding into the epidural space following surgery or leakage of disc material following breakage or a tear of a disc most commonly causes epidural scarring.  Presumably, inflammation and compression of nerve roots by epidural scar (Adhesions) are the mechanism of persistent pain following back surgery, ruptured or herniated discs, or vertebral body fracture.  Epidural scar may also contribute to the pain of spinal column metastatic carcinoma, failed facet joint syndrome, and unexplained neck or low back pain.

 

Diagnosis

Conventional studies such as myelograms, computerized tomography (CT Scans), and magnetic resonance imaging (MRI), are usually inadequate to make the diagnosis.  Injection of contrast material (dye) into the epidural space yields an "epidurogram", which is diagnostic for the presence or absence of epidural scar tissue.

 

Procedure

Since further surgery would only produce more scar tissue, a different approach to the problem needs to be taken.  "Lysis of Epidural Adhesions suing the Epidural Approach"(Breakage of scar tissue) is an alternative to this problem.  The procedure consists of introducing an epidural catheter (thin plastic tube) into the epidural space (space between your spinal cord and the walls of the spinal canal, within your backbone).  Once in place, medications are injected through this tubing in order to break the scar tissue.  Although the catheter is placed within fifteen to twenty minutes, it is kept in the epidural space for approximately 3‑4 days.  During this time, the injection of medications through the tubing is performed on a daily basis, while at the same time the patient undergoes extensive physical therapy.  At the end of the 3rd‑4th day, the catheter is removed and the patient discharged to home.

 

Conditions Usually Treated with This Modality Conditions include, but are not limited to:

…       Failed Back Surgery Syndrome

…       Back and leg pain

…       Neck and arm pain

…       Leg pain

…       Disc disruption

…       Traumatic vertebral body compression fracture

…       Degenerative arthritis of the spine

…       Facet pain

…       Epidural scarring following infection

…       Occipital neuralgia

…       Others


Side Effects and Possible Complications

Everything in medicine is subject to side effects and possible complications.  No two patients are alike.  Side effects and complications are not the same or equivalent to malpractice.  Malpractice refers to an injury sustained by a patient, which occurs as a consequence of negligence in the practice of medicine.  Side effects and complications, on the other hand, are untoward events, which can occur and may injure a patient, in certain percentages of the population.  These events can, and do occur even if everything goes according to plan, and in the absence of negligence or malpractice.  Possible side effects and complications of this procedure include, but are not limited to.

…       Pain or worsening of symptoms

…       Infection (local = abscess; or generalized = sepsis), including meningitis and death. Infection due to a steroid‑induced immune system suppression.

…       Bleeding, including hematomas, which might compress the spinal cord, therefore causing paralysis.

…       Nerve damage, including sensory or motor weakness, and/or paralysis. Nerve damage, ranging from minor nerve irritation with pain, to major nerve damage with paralysis, impotence, urinary incontinence, and/or fecal incontinence.

…       Allergic reactions ranging from a minor rush to an anaphylactic reaction and death

…       Failure to relieve pain

…       Spinal cord compression leading to paralysis

…       Breakage of catheter (tubing)

…       Unforeseen events:

 

Guarantees That It Will Help

None. There are no guarantees in medicine.

 

Results of Treatment

93.9% of patients will experience some pain relief, which will be variable.  6.1% will experience no relief. 

 

Duration of Results

Only 12.3% will experience persistent pain relief beyond 12 months.  57.9% of male patients and 64.4% of female patients will experience between 0‑3 months of variable degrees of pain relief.

 

Frequently Asked Questions

 

What is the incidence of complications?

It is unknown.  Most complications occur sporadically and are reported as isolated case reports.

 

Can the procedure be repeated when and if my pain returns?

Yes.  The effectiveness of subsequent repeat procedures is also variable.  Some patients obtain longer duration of pain relief while others obtain shorter duration.

 

Does this require that I be hospitalized?

Yes.  On the average the procedure takes anywhere from 1 to 4 days to complete.

 

What should I expect to feel after the procedure?

If the procedure is successful, you should experience pain relief of variable degrees.

 

Will I obtain complete (100%) pain relief?

Although possible, it is our experience that patients suffering from chronic pain, the cause of the pain is multifactorial, and therefore, highly unlikely to completely address the problem with only one type of therapy.

 

What is an Epidurolysis (RACZ) Procedure?

Epidurolysis (RACZ) Procedure is used to dissolve some of the scar tissue from around entrapped nerves in the Epidural space of spine, so that medications such as cortisone can reach the affected areas. Dr. Gabor Racz pioneered this procedure.

 

What causes scarring (adhesions)?

Scarring is most commonly caused from bleeding into the Epidural space following back surgery and the subsequent healing process. It is a natural occurrence following surgical intervention. Sometimes scarring can also occur when a disk ruptures and its contents leak out.

 

What is the purpose of it?

To allow medications to reach affected nerves so that pain and other symptoms may be diminished.

 

How long does the procedure take?

The procedure requires a series of three injections. First, a catheter (a small tubing) inserted in the Epidural space up to the area of scarring. This is done in the procedure room under sterile conditions using fluoroscopy (x-ray vision). This catheter is secured to the skin with dressings and tapes. The first injection of medications is made via this catheter. The patients are then kept in the hospital overnight. The second injection is done the following day. On the third day, the catheter is injected and then removed. The actual injections only take a few minutes.

 

What is actually injected?

The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (triamcinolone ñ AristocortÆ or methylprednisolone ñ Depo-medrolÆ, as well as x-ray contrast dye to visualize scarred space and hyaluronidase ñ and concentrated sterile salt solution to soften scar tissue.

 

Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the RACZ needle. The patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

 

Will I be "put out" for this procedure?

No. This procedure is done under local anesthesia. The patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance. We like to communicate with the patients during the procedure to help assess the proper location of the catheter tip.

 

How is the procedure performed?

It is done with the patient lying on their stomach. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the back is cleaned with antiseptic solution and then the procedure is carried out. After the procedure, you are placed on your back or on your side. X-rays (fluoroscopy) is used to assist the placement of the catheter and perform the epidurogram.

 

What should I expect after the injection?

Immediately after the injection, you may feel your legs slightly heavy and may be numb. Also, you may notice that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours.

 

When can I return to work?

Unless there are complications, you should be able to return to your work the day after the catheter is removed. The most common thing you may feel is a sore back.

 

How long the effects of the medication last?

The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 5 to 7 days and its effect can last for several days to a few months. The benefits from the procedure may last as long as 6 month.

 

How many times do I need to have this procedure performed?

If the first procedure does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more procedure. After this, we recommend 6 months between procedures.

 

Will the Epidurolysis (RACZ) Procedure help me?

It is very difficult to predict if the procedure will indeed help you or not. Generally speaking, the patients who have recent scarring (e.g. following back surgery) respond better.

 

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain ñ which is temporary. The other risks involve spinal puncture with headaches, infection, bleeding inside the Epidural space with nerve damage, worsening of symptoms etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of bodyís own natural production of cortisone etc. Some of the patients may develop allergic reaction to hyaluronidase. Fortunately, the serious side effects and complications are uncommon.

 

Who should not have this procedure?

If you are allergic to any of the medications to be injected, if you are on a blood thinning medication (e.g. CoumadinÆ), or if you have an active infection going on, you should not have the injection.