Lysis of Epidural Adhesions (also know as the Racz® Procedure) is a technique involving site-specific catheter placement and fluid injection intended to “open up” the perineural space with various therapeutic medications. The injected medications are designed to free the nerve root from restrictions and reduce inflammation associated with swollen, painful nerve roots exiting the spinal canal in the epidural space. A unique, proprietary, steerable, soft-tip Racz® Catheter is guided to the target site where medications are delivered directly to the painful nerve roots. These Racz® Catheters are introduced through a specially designed, shear-resistant epidural needle called the RX-2™ Coudé® or RX Coudé®. They are commonly introduced through the sacral hiatus. They can also be introduced transforaminally.
Also known as:
- Lysis of Epidural Adhesions
- Percutaneous Neuroplasty
- Racz® Procedure
- Adhesiolysis
Have the patient lie prone with a pillow placed beneath the lower abdomen to create slight flexion in the lumbar spine and reduce lumbar lordosis. Ask the patient to rotate their legs internally, i.e., toes touching. This internal rotation will relax the gluteal muscles to allow easier identification of the sacral hiatus. Start with the skin wheal needle technique to numb the entry point area of the introductory needle. The skin entry point for the introducer needle is midline and 2” caudal from the sacral hiatus.
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Tuohy and other epidural needles, including the conventional spinal cord stimulator needles, are oval-tipped which increase the chances of shearing as well as other complications. The recommended needle for this procedure is the RX-2™or RX Coudé®. Both needles have a wide open tip allowing for multiple passes of the catheter and are designed to reduce the chance of catheter shearing.Initial angle of entry through the notch is approximately 45° and then while advancing through the hiatus, this angle is lowered to about 30°. After confirming epidural placement fluoroscopically, rotate the needle 90° towards the target area. Injecting water soluble, non-ionic, radio-opaque contrast media in both A/P and lateral views confirm proper needle placement. Needle tip placement should be below the S3 neural foramen to avoid accidental dural puncture.
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The RX Coudé® needle allows for multiple passes of the catheter to achieve the optimal tip placement. This is possible because the RX Coudé® tip is completely round allowing for free passage of the catheter.The first injection during the lysis of adhesions procedure is an epidurogram. This is performed to outline the epidural filling defects. This also demonstrates fluid dissection and scar formation while outlining decompression of the affected nerve roots. The epidurogram will also aid in correct catheter tip placement. Use 5-10 mL of OMNIPAQUE™240 to outline the filling defect through the introducer needle. *Use non-ionic water-soluble dye. Some physicians also use 5-10 mL of ISOVUE-M 200.*
Make a one inch, 15°-20° bend in the catheter tip for optimum steerability. Direct the catheter to the anterior-lateral aspect of the affected nerve root by gently twisting the catheter as you advance. Avoid “propellering” the tip in circles, because it can create difficulty in directing the catheter. The target site for the catheter tip is the ventral-lateral epidural space. Most epidural scar formation is symptomatic and located in the ventral and lateral recess.
Once the catheter is placed, inject 4-5 mL of OMNIPAQUE™240 through the catheter to reveal runoff. Once runoff is visualized, inject Hylenex® 150-300 units diluted in 10 mL of preservative-free saline. Fluid injection under pressure opens up the perineural space. This process is called “compartmental filling”. Compartmental filling is where the fluid finds the weakest spot in the scar and overflows into the adjoining compartment. Hyaluronidase is used to facilitate spread.
The next step is to inject a bolus of steroid and local anesthetic. This bolus includes: 4 mg dexamethasone or 40 mg triamcinolone, local anesthetic, 10 mL of 0.2% ropivacaine or 10 mL of 0.25% bupivacaine.
Be aware of allergic and anaphylactic reactions, as any injected material can trigger such reactions. These reactions are very rare, but the physician must be able and ready to treat any and all reactions by having intravenous access, the necessary medications, and monitoring equipment available.
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Some Epimed catheters include Racz® Bend Marks (RBM) to indicate optimal bend location for lumbar or cervical procedures. For this procedure, use the distal marking (RBM) furthest from the tip of the catheter.
At this point, inject 2-3 mL of OMNIPAQUE™240 to verify filling defect. Inject contrast through the catheter under live fluoroscopic view to verify the absence of intravascular injection and to act as a marker for injection spread in the target area. If the ventral-lateral epidural space does not open up, a second catheter may need to be placed transforaminally.
After the injections have been completed, remove the needle. Next attach the catheter to the bacterial filter to the Stingray® connector, assuring its sterility. The patient should be taken to the recovery room in order to evaluate motor function. This is done with a voluntary straight leg raise. If the patient tests positive for a motor block (i.e. patient is unable to do the straight leg raise), STOP the procedure. This is an indication of a possible subdural spread.
Wait 20-30 minutes and if no motor block is present, place the patient with their painful side down and infuse 8-10 mL of hypertonic saline (10% NaCl) over 5-10 minutes. Most hypertonic saline injections should not be painful. (This volume should be the same or less than the local anesthetic volume previously injected. If pain is experienced during the injection, STOP and inject 2-3 mL of local anesthetic before proceeding with the injection). Hypertonic saline is used for osmotic reduction of edema and disconnection of C fibers (sinuvertebral system) function.
After injections have been completed, withdraw the catheter from the patient (introducer needle should have been previously removed). Start neural flossing exercises as soon as possible.
For more information on Neural Flossing, please visit this page.
For more information on Neural Flossing, please visit this page.- Diagnostic: 5-10 mL OMNIPAQUE™240* - outline filling defect and place catheter to target site
- To show runoff and absence of loculation, contrast 4-5 mL OMNIPAQUE™ 240* injected through the catheter
- 2-3 mL OMNIPAQUE™240* through catheter for verification of enzyme effectiveness
- Spreading Factor: Hylenex® 150-300 units (human recombinant) diluted in 10 mL of preservative-free saline
- Steroid Injection: 4 mg dexamethasone or 40 mg triamcinolone
- Local Anesthetic: 10 mL 0.2% ropivacaine or 10 mL of 0.25% bupivacaine
- Depending on the physician’s lysis technique, wait 20-30 min. Evaluate for motor block with a voluntary straight leg raise. If no motor block is present, with the patients painful side down, inject 8-10 mL of 10% hypertonic saline over 20-30 minutes. If the patient experiences pain, inject 2-3 mL of local anesthetic.
- Gerdesmeyer L, Wagenpfeil S, Birkenmaier C, Veihelmann A, Hauschild M, Wagner K, Al Muderis M, Gollwitzer, H, Diehl P, Toepfer A. Percutaneous Epidural Lysis of Adhesions in Chronic Lumbar Radicular Pain: A Randomized, Double-Blind, Placebo-Controlled Trial. Pain Physician 2013; 16: 185-196
- Racz G, Day M, Heavner J, Smith J. The Racz Procedure: Lysis of Epidural Adhesions (Percutaneous Neuroplasy). Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Integrative Approaches (Deer Ed.) 2013; Chapter 50: 521-534
- Manchikanti L, Cash KA, McManus CD, Pampati V. Assessment of Effectiveness of Percutaneous Adhesiolysis in Managing Chronic Low Back Pain Secondary to Lumbar Central Spinal Canal Stenosis. International Journal of Medical Sciences 2013; 10(1): 50-59
- Helm II S, Benyamin R, Chopra P, Deer T, Justiz R. Percutaneous Adhesiolysis in the Management of Chronic Low Back Pain in Post Lumbar Surgery Syndrome and Spinal Stenosis: A Systematic Review. Pain Physician 2012; 15: E435-E462
- Manchikanti L, Rivera J, Pampati V, Damron K, McManus C, Brandon D, Wilson S. One Day Lumbar Epidural Adhesiolysis and Hypertonic Saline Neurolysis in Treatment of Chronic Low Back Pain: A Randomized, Double-Blind Trial. Pain Physician 2004; 7: 177-186
- Helm S, Racz G, Gerdesmeyer L. Percutaneous and Endoscopic Ahesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis. Pain Physician 2016; 19: E245-E281
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