Treatment of chronic pain dates back as early as 1863. This is when we find the first reports of subcutaneous injections, being administered by Luton, to treat chronic pain.
Moving forward over 125 years, we find the origins of Lysis of Adhesions, sometimes referred to as the Racz Procedure. This interventional technique is unique in that it involves site-specific catheter placement and injectates of various medications intended to “open-up” the perineural space. These injected medications are intended to increase nerve root mobility and reduce inflammation associated with swollen and painful nerve roots exiting the spinal canal via the intervertebral foramen.
The first report of this procedure was by Dr. Racz and Holubec in 1989.The results were based on a survey of seventy-two patients who were randomly selected from approximately 200 patients who underwent caudal neuroplasty (lumbar Lysis). There were slight variations in the protocol, namely the volume of bupivacaine used (25 mL instead of 10 mL) and the omission of hyaluronidase. Approximately 72.2% of the patients reported pain relief on discharge, while 37.5% had pain relief of < 1 month, 30.0% reported pain relief of 1 to 3 months, and 12.5% had relief for 3 to 6 months.
When the technique of epidural neuroplasty (Lysis of Adhesions) was first developed, the catheter was inserted into the posterior epidural space. As more and more procedures were performed, it was noted that the posterior epidural space was difficult to access in some patients who had undergone surgical procedures for discogenic or radicular pain. This was most likely due to scar tissue formation from the previous surgery.
Choosing the Right Tool
Early developments in Lysis of Adhesions came in the form of the plastic-coated spring-tipped epidural catheter which provided a significant step forward in pain management. The catheter allows precision placement under fluoroscopy because of the x-ray visibility and it makes multiple passes through the same needle possible without fear of shearing the catheter. The soft tip of the spring-wire catheter also rules out injury to nerve roots within the epidural space and the spring-wire body rules out the possibility of kinking during prolonged use. Aspiration would therefore reveal catheter placement either into the subarachnoid space or into one of the numerous epidural vasculatures.
When the technique of epidural neuroplasty (lysis of epidural adhesions) was first developed, the catheter was inserted into the posterior epidural space. As more and more procedures were performed, it was noted that the posterior epidural space was difficult to access in some patients who had undergone surgical procedures for discogenic or radicular pain. This was most likely due to scar tissue from the previous surgery. In 1996, the technique for catheter insertion was changed to direct the catheter into the anterior-lateral epidural space. The catheter needed to be directed towards the anterior-lateral epidural space at the level of the L3 nerve root on the affected side for caudal neuroplasty. The lumbar epidural space is accessed via the sacral hiatus.
Pain is a symptom with many etiologies. Pain can persist well after the initial cause has been resolved, because this initial insult initiates a perpetuating cycle of biochemical events leading to longer lasting pain. This cycle can be extremely difficult to overcome, however therapeutic measures that effectively interrupt this cycle, even for 24 to 48 hours, may give protracted pain relief.
In the Evolution of Epidural Lysis of Adhesions article there is a section on ‘Drugs used for Neuroplasty’. We will have a full session in coming months specific to medications used and what has been learned over time.
The history and physical exam should be thorough and note failed conservative therapies and include neural tension tests, neurological changes, and maneuvers that provoke axial and radicular pain. The diagnostic workup should also include radiographic and physiologic exams.
Prior to an invasive procedure such as neuroplasty, other issues must be addressed. The patient must be willing to participate in a multidisciplinary rehabilitation program. Significant psychopathology must be ruled out with psychological testing and evaluation.
Lysis is typically indicated for:
Failed back surgery syndrome
Chronic back pain from excessive scarring in the anterior lateral epidural space
Radicular pain unresponsive to epidural steroid injections
Physical therapy is a critical component to further ensure improved, lasting recovery. Healthy nerves should move freely within the IVF to ensure proper blood supply, fluid exchange, and nutrition absorption. An effective method of this nerve root nourishment is routine stretching and exercise.
Many studies have been done to determine what procedures produce the greatest long-lasting effects in reducing chronic back pain. Only two have been identified as being efficacious, Neuroplasty (Lysis of Adhesions) and Neuromodulation.
As Lysis continues to be the superior modality for interventional pain, for being a cost effective and long-lasting treatment, much of this procedure has not changed. However, there are a few recent findings that have improved the already remarkable results versus other procedures, namely neuromodulation.
These new findings will be discussed in greater detail in the upcoming months. Here are a few of those topics we will discuss:
We didn’t know until recently, but there is a unique triangular space located medial to the L5 nerve root, lateral to the S1 nerve root, and above the L5-S1 disc. This space measures 0.9 – 1.1 mL, and is large enough to collect disc fragments which can cause L5 neuropathy.
There are stages in the formation of epidural adhesions where the scarring will not give you radiculopathy, but if you pull on the dura, it will cause severe pain. This is called the Dural Tug test. It can reproduce a collection of symptoms to determine the area of pain generation and site of pathology.
There is an issue that has not been talked about often enough which is call Spinal Cord Stimulation (SCS) Fade. This is when the benefits of neuromodulation become weaker and weaker working and eventually stop over time due to scar formation as the electrodes sticks to the dura and surrounding structures. This can be addressed with Lysis of Adhesions to break up this scar tissue and administer the needed medication to the needed locations around the electrodes.
The epidural lysis of adhesions procedure has provided significant relief for numerous individuals who cope with pain. The medical procedure performed by your doctor is just one step in the process towards pain relief.