Dr. Gabor Racz is frequently asked about medications used when performing Lysis of Adhesions. With his many years of experience he has developed industry best practices that come from his deep and vast knowledge of performing interventional pain procedures.
A: No. It is shorter lasting, a little bit less painful, with a lower concentration than 10% hypertonic saline.
When I started working at Preston Surgery Center, I was used to working with 10% hypertonic saline. The only way I could get hypertonic saline was the supply generated for the vascular surgeons who were injecting it into veins as a corrosive. I found a study on mixing a very high concentration of lidocaine with the 23.4% hypertonic to maintain hypertonicity to corrode the varicose veins. I calculated the 10% value concentration and diluted it to meet the appropriate levels. This mixture is not neurolytic in the classical sense, but it’s corrosive. Interestingly, they maintained similar corrosive action with less pain.
A: I prefer Omnipaque 240 and always recommend selecting the safest option.
Yes, I prefer the Omnipaque 240. Anytime you use intra-spinal contrast, and, if you read the packet insert, they always talk about potential neurotoxic activities secondary to the iron content. The visibility is enhanced, but I have never needed to use the more potentially nephro-toxicity 300.
A: Even if you check the patient’s record, still be very aware of the possibility for allergic reaction when administering contrast or any penicillin-like substance.
Example Case: I once had a patient who told me that he had no anaphylactic reactions. He told the admitting nurse that he had no history of anaphylactic reactions, but he did have hives after being injected with penicillin. We did not read the nurses notes. The surgeon asked to add penicillin to the IV infusion and gradually the patient developed an anaphylactic reaction, as well as ventricular tachycardia. We gave the patient an intravenous slow injection of 1 in 10000 epinephrine, along with rapid volume expansion. To keep the circulation and blood pressure going, we did a few chest compressions. He rapidly recovered. We stopped the penicillin, but we rapidly noticed swelling around the eyes. Because of the patient’s age, there was a higher likelihood of myocardial infarction. Post operatively, the patient was told about the event, and we stressed to him: “You don’t just have hives, but YOU ARE ALLERGIC TO PENICILLIN!”
A: Neither. Nobody has determined how much Hylenex to give.
The first type of hyaluronidase that we had available was Wydase, which was an animal extract. The pharmacological action is the same as Hylenex. Both types were evaluated in two animal studies, and the data found was that both types INHIBITED NEUTROPHIL INFILTRATION AFTER PRE-TREATMENT OF HYDROGENASE (an under the skin air packet model.) Neutrophils are the first step in the inflammatory cascade, and typically cause pain through swelling of injection of local anesthetics and steroids. Therefore, we always use Hylenex for transforaminal injections with the blunt Coude needle technique. For transforaminal catheter injections, we gain access with an 18 gage RX-2™ Coudé® needle and VERSA-KATH® catheter to mid-canal. Next slowly inject and observe transforaminal runoff along the catheter, up and down the epidural space. You must have transforaminal runoff without compressing the spinal cord. We must document this runoff, and allow drainage of the venous plexus and gain significant space from decompressing the venous system, which becomes a space occupying lesion. This is due to the high venous pressures. Venous runoff can happen some distance away from the catheter, so pull the catheter back, advance it past the venous runoff, and try to open up a transforaminal runoff at another level. By using this technique, we have never (ever) had a problem causing a hematoma. The problem is not blood in the epidural space, but blood in the same space under pressure.
A: Absolutely, yes. I never worry about Triamcinolone because I do not use sharp needles.
The catheter is blunted and can’t enter a vein, but you realize this because you also cannot move laterally. Which is exactly what a sharp needle can do when it gets into a vein.
When using a catheter pull it back out, advance further up, place the stylet back into catheter, and advance into the nearest neural foramen. Next, take the stylet out and open up lateral runoff by doing flexion rotation. It solves any potential hematoma.
Flextion Rotation: Conducted during injection with the patient moving their chin to shoulder left then right. Follow this process with 5 cc hydrogenase, and watch for dispersal of the contrast through transforaminal runoff and somewhat to the other side. This is followed by 5 ml 0.25% Bupivacaine, or 0.2% Ropivicaine.
A: I used to prefer Ropivacaine because of the alleged, less toxic side effects. However, recent information suggests that they are equally toxic, it's just that Ropivacaine has fewer milligrams.
A: First, you must have the right diagnosis. The best therapy other than mild anaphylactoid reactions, which can be treated by antihistamines, is epinephrine.
The best way to deliver epinephrine, which is the specific therapy for cells allowing leaking fluid, is that it needs to be diluted. If you are where there is no intravenous lines available, transtrachial epinephrine can be an alternate route to stop a disaster.
*Remember, the mechanism of anaphylactic reaction is that the intercellular matrix pulls apart and leaks fluid leading to loss of circular volume.
Fun fact: Many years ago, we created a table: “How to manage Anaphylactic Reactions” for radiology departments. These multi-page descriptions were hanging in virtually every radiology procedure department in the United States.
A: Yes, it is possible, but the good outcome is measured in months. When incorporating the hypertonic injection sequence, good outcome can be measured in many months to many years.
I have used the Hylenex sequence in patients with severe post-traumatic sacral radiculopathy, getting such great outcomes that I told the patient: “In one month time we will place sacral electrodes for your intractable, severe pain,” only to have the patient tell me: “I have no pain!” I responded, “Come back when you have pain!” It was three years until he came back, with the area rescarred.
Remember: Hypertonic saline inhibits fibroblastic proliferation, re-scarring, while Hylenex does not. In cases of back pain, the hypertonic saline is virtually neurolytic as far as the non-myelinated c-fibers are concerned. Back pain relief extends to the area that the contrast indicates. This can include the posterior longitudinal ligament, which is innervated in the sinuvertebral system, leading to back pain relief.
A: The best improvement will be if we use a curved blunt needle with an introducing cannula and place the tip of the needle in the ventral epidural neural foramen. I then go just beyond the mid facet joint line and use 1 ml Omnipaque 240 with 4-5 ml Hylenex. I take 150 units of Hylenex and dilute it with 9 ml of preservative free saline. I inject into transforaminal levels, followed by 5 ml of 0.25% bupivacaine and 20 mg of triamcinolone. This gives you the best long-lasting effect, measured in months, because you can observe freeing up the dura from the posterior longitudinal ligament.
You get pain reduction from the neutrophil infiltration and avoidance of pain from the developing edema. Most importantly, for long lasting effect (months to 1 year+).
I do a two level transforaminal injections using a Double-Nelson extension set. Using this does away with connecting solid needles, and I can inject rapidly, one after the other with valves controlling backflow on the line. You can see the spread of the contrast along with the enzyme-local anesthetic-steroid solution.
The cost effectiveness comes from its long-lasting effect, with the safety coming from seeing the lateral transforaminal spread. What you lose is the long-lasting effect of the hypertonic saline disconnecting c-fibers which is the primary cause of back pain.
Please Note: I do not recommend hypertonic saline for transforaminal injections.
I am aware of one paper where they used the hypertonic sequence, but only waited 5 minutes between the local anesthetic and hypertonic transforaminal injection. Waiting time is designed to rule out epidural misplacement of injection by making sure there is no motor block. Motor block comes 15 -16 minutes later, therefore the 20-minute wait before application of hypertonic.
The recommended technique by the group doing the study did not use the pain free sequence. If you use a sharp needle, it is distinctly possible to do an intravenous, inter-atrial, inter-neural, or inter-dural injection. The incidence may be rare, but it is an unnecessary hazard.
A: Here’s an important rule: you start injections with the contrast. You can see the contrast spreading in the vicinity of the spinal cord and the patient reports pain. There is no escape of fluid through the neural foramen. This is volume dependent pain, where the pressure will be generated by the injected fluid. This is loculation. In case there is contrast spreading, not out of the spinal canal, but in a tortuous manner to the other side of a cervical injection, if there is escape on the other side, virtually no damage is done. This is because degenerative changes have not scarred down all the outlets.
Remember, we do use flexion-rotation during Cervical Lysis because of its assistance for transforaminal runoff. The initial rate of injection is governed by what you see in the dye spread, never in what you call “rapid.” If the dye spread is in the right area, but you are in dense scarring, the pressure requirements are absorbed by the force necessary to spread within the scar. The tissue damage is caused by ischemia of the tissues that are being compressed. Our goal is to open up tissue planes and avoid midline posterior catheter tip placement.
Legal Case: One of the cases where I was an expert witness, the patient had no intravenous runoff, but the path of least resistance was to the opposite side of the spinal canal, thus compressing both sides of the spinal cord. We did not know about flexion-rotation to enlarge the neural foramina, opening up escape routes within seconds.
Within two days, the patient became ventilator dependent quadriplegic, requesting after a few years to be taken off the ventilator. The dye spread was named Peri-Venous Counter Spread (PVCS), and since that time, has been featured in multiple publications.
A: I'm sorry, I do not. The only cost saving that I can provide is that when you inject two sites (i.e. two catheters) dilute the 150 units into two 5 cc saline injections.
I’m not aware of any specific indications as to how many units does it take to reduce neutrophil infiltration, but I know through large number of clinical experience, that these 75 units works very well. I have not tried diluting the 150 units into three 5 ml doses.
One possible way would be to do a study, measuring post-operative pain in double-blinded 3-4 or placebo arm, but it would take a center that does a lot of transforaminals or a multi-center study. It would be important to see a dose related response on post-operative pain. The only studies I am aware of was in carpal-tunnel surgery; they had less post-operative pain when hydrogenase was added.
Medication: Q&A
More Like This
Learn the key steps when performing Caudal Neuroplasty, also referred to as Lumbar Lysis of Adhesions.
A unique triangular space has been identified that is large enough to accept the average loose disc fragment and tends to collect leaky disc material. Discover how to open up this area called the Scarring Triangle.
Learn the key steps when performing Caudal Neuroplasty, also referred to as Lumbar Lysis of Adhesions.
