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.
In earlier Racz EDU sessions we addressed the Lumbar region and Scarring Triangle. While there are many similarities with the Cervical region, a higher level of skill is needed when performing procedures in this region.
Below you will find the step-by-step guide for Cervical Lysis of Adhesions. We've also included serval videos covering:
- Cervicogenic Headaches Walkthrough with Dr. Gabor Racz
- Cervical Lysis and Suboccipital Decompression with Dr. Gabor Racz on a live patient
- Cervical Interlaminar Lysis with Dr. Raul Mishra on a Cadaver
- Cervical Spine Pain lecture with Dr. Vikram Patel
The recommended needle for this technique is the 18g RX-2™ Coudé® Needle which has a second interlocking stylet that protrudes past the needle tip. This atraumatic tip functions to push the dura away while the needle is being rotated. Place the patient in the prone position with a C-arm rotated slightly cephalad to compensate for the kyphosis. Start with the skin wheal needle technique to numb the entry point of the introducer needle. The skin entry point is paramedial (0.5” off the midline) and one and a half interlaminar spaces below the target interlaminar space of C7-T1 or T1-T2, which can be confirmed fluoroscopically.
While still using the A/P view with the tip facing anterior medially, advance and direct the needle towards the midpoint of the chosen interlaminar space. Once the needle engages the deeper tissue planes, rotate the C-arm to the lateral view to confirm needle depth. (It is important that the tip of the needle is parallel to the ligamentum flavum). Continue to advance towards the epidural space and obtain an A/P view to recheck the direction of the needle before furthur advance. If the tip of the needle crosses the midline, withdraw the needle to allow redirection.
Using the loss-of-resistance technique, advance the needle to identify the epidural space. The tip of the RX-2™ Coudé® Needle must be pointed caudally.A. Remove the LOR syringe and insert the second interlocking stylet. It is extremely dangerous to rotate the needle tip without the atraumatic stylet fully inserted, as the dura can be easily cut.
B. Rotate the tip cephalad, then remove the stylet. Next, inject 1-2 mL of contrast to confirm entry and to check for filling defects. If there is no evidence of contrast runoff, then flexion with rotation of the head and neck should be performed to open up the foramen to intitate runoff.
B. Rotate the tip cephalad, then remove the stylet. Next, inject 1-2 mL of contrast to confirm entry and to check for filling defects. If there is no evidence of contrast runoff, then flexion with rotation of the head and neck should be performed to open up the foramen to intitate runoff.
Make a one inch, 15°- 20° bend in the catheter tip for optimum steerability and insert it through the needle. The opening of the needle should be directed towards the target site. Slowly advance the catheter and once the target level has been reached, rotate the tip of the catheter towards the foramen inject another 0.5-1 mL of contrast to visualize the targeted nerve root and
to ensure runoff.
Slowly inject 150 units of Hylenex® dissolved in 5 mL of preservative-free normal saline. Follow this with an additional 1-2 mL of contrast and observe for “opening up” of the “scarred in” nerve root. Next, give a 2 mL test dose of a 6 mL solution of local anesthetic and steroid (5 mL of 0.2% ropivacaine and 1 mL of 4mg of dexamethsaone). After five minutes, if there is no evidence of intrathecal or intravascular spread, inject the remaining 4 mL of the LA/S solution. Fluid injection under gentle presssure 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 the spread.1,5,7
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 the necessary medications and monitoring equipment available.
The RX Coudé® Needle should always point in the direction of the target. Catheter tip is placed towards the C6 ventral-lateral epidural space. Bacterial filters are recommended in all instances when more then one time injection is used or the catheter is left in place for a prolonged period of time. Anytime there is a disconnect of the catheter and the connector, the system should be removed from the patient. This is an essential precaution to prevent infection.
After the injections have been completed, remove the needle. Next attach 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. If the patient tests positive for a motor block, 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 5 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.3
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 (shown on next page).
During the one-month follow up visit, it is common to see patients with pain-related facet joint arthropathy. These patients may need a diagnostic block followed by a cryoanalgesia or radiofrequency denervation of the facet joint.
Begin Neural Flossing Exercises
After the procedure, have the patient perform the neural flossing exercises as soon as possible. Click here for more details.
- Diagnostic: 1-2 mL OMNIPAQUE™240* - outline filling defect and place catheter to target site
- To show runoff and absence of loculation, contrast 0.5-1 mL OMNIPAQUE™ 240* injected through the catheter
- 1-2 mL OMNIPAQUE™240* through catheter for verification of enzyme effectiveness
- Spreading Factor: Hylenex® 150-300 units (human recombinant) diluted in 5 mL of preservative-free saline
- Steroid Injection: 4 mg dexamethasone or 40 mg triamcinolone
- Local Anesthetic: 6 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. If no motor block is present, with the patients painful side down, inject 5 mL of 10% hypertonic saline over 5-10 minutes. If the patient experiences pain, inject 2-3 mL of local anesthetic.
One Day Cervical Lysis of Adhesions Step by Step: Poster Presentation, 4th Croatian Congress on the Treatment of Pain, Osijek, Croatia, May 2018
- 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, Heavner J, Smith J, Noe C, Al-Kaisy A, Matsumoto T, Lee S, Nagy L. Epidural Lysis of Adhesions and Percutaneous Neuroplasty Racz Procedure. Intech - Pain and Treatment; Chapter 10: 289-333
- 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
- Park E, Park S, Lee S, Kim N, Koh D. Clinical Outcomes of Epidural Neuroplasty for Cervical Disc Herniation. Journal Korean Medical Science 2013; 28: 461-465
- Dunn A, Heavner J, Racz G, Day M. Hyaluronidase: a review of approved formulations, indications and off-label use in chronic pain management. Expert Opinion on Biological Therapy 2010; 10(1): 127-131
- Veihelmann A, Devens C, Trouillier H, Birkenmaier C, Gerdesmeyer L, Refior H. Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial. Journal of Orthopaedic Science 2006; 11: 365-369
- Heavner J, Racz G, Raj P. Percutaneous Epidural Neuroplasty: Prospective Evaluation of 0.9% NaCl Versus 10% NaCl With or Without Hyaluronidase. Regional Anesthesia and Pain Medicine 1999; 24(3): 202-207
- Racz G, Heavner J. Complications Associated with Lysis of Epidural Adhesions and Epiduroscopy. Complications in Regional Anesthesia and Pain Medicine, 2nd Edition; Chapter 33: 373-384
- Moon DE, Park HJ, Kim YH. Assessment of Clinical Outcomes of Cervical Epidural Neuroplasty Using a Racz-Catheter and Predictive Factors of Efficacy in Patients with Cervical Spinal Pain. Pain Physician 2015; 18:E163-E170
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Cervical Lysis
Cervicogenic Headaches
Cervical Interlaminar Lysis
Cervical Spine Pain
Cervical Lysis and Sub Occipital Decompressure
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