The results patients see and feel from the Lysis procedure are not only from the procedure alone, but also from the rigorous steps taken before and after the procedure.Aside from a thorough history and physical exam performed by the physician, each patient is screened via an extensive inclusion and exclusion criteria to be considered a candidate for the procedure.
A patient may present as a good candidate for Lysis given the chief complaint and other symptomology, but he or she may also present with some underlying conditions that will exclude them. This is why pain physicians are so meticulous at reviewing medical records and medications taken.
There are also important steps that need to be taken after the procedure to ensure maximal safety and efficacy. These include observation of the patient, physical therapy (to target involved nerve roots), and a follow up exam.
It is these pre- and post-procedural steps that allow the Lysis procedure to be so effective.
Patient Preparation
Before epidural adhesiolysis has been deemed an appropriate treatment modality, the risks and benefits of the procedure should be discussed with the patient and informed consent obtained.
The benefits are analgesia, improved physical function, and possible reversal of neurologic systems. Risks include, but are not limited to, bruising, bleeding, infection, reaction to medications used (i.e., hyaluronidase, local anesthetic, corticosteroids, hypertonic saline), damage to nerves or blood vessels, no or little pain relief, bowel/bladder incontinence, worsening of pain, postdural puncture headache, seizure, and paralysis. Patients with a history of urinary retention of incontinence should have a urodynamic evaluation by a urologist before the procedure to document the preexisting urodynamic etiology and pathology.
Anticoagulant Medications & Supplements
Medications, supplements, and foods that prolong bleeding and clotting parameters should be withheld before performing epidural adhesiolysis. The length of time varies depending on the medication taken.
A consultation with the patient’s primary physician should be obtained before stopping any other these medications, particularly in patients who require chronic anticoagulation such as those with drug-eluting heart stents or prosthetic heart valves.
Recommended Medication Elimination
Prior to Lysis of Adhesions
nonsteroidal anti-inflammatory drugs.. withhold 4 days before procedure
aspirin………………………………… withhold 7-10 days before procedure
clopidogrel (Plavix)………………… withhold 7 days before procedure
ticlopidine (Ticlid)…………………….. withhold 10 - 14 days before procedure
warfarin (Coumadin) ………………… withhold 5 days before procedure
subcutaneous Heparin ……………… minimum of 12 hours before procedure
molecular – weight Heparin………… minimum of 24 hours before procedure
Over-the-counter homeopathic medications that prolong bleeding parameters should be withheld. These include fish oil, vitamin E, gingko biloba, garlic, ginseng, and St. John’s Wart.
Adequate coagulation status can be confirmed by the history, INR, prothrombin time, partial thromboplastin time, and a platelet function assay or bleeding time. The tests should be performed as close to the day of the procedure as possible. Tests performed only a few days after stopping the anticoagulant medication may come back elevated because not enough time has elapsed to allow the anticoagulant effects of the medication to resolve.
The benefits of the procedure must be weighed against the potential sequelae of stopping the anticoagulant medication and this should be discussed thoroughly with the patient.
Blood Test & Urinalysis
Before the procedure, a complete blood count and a clean-catch urinalysis are obtained to check for any undiagnosed infections. An elevated white count and/or a positive urinalysis should prompt the physician to postpone the procedure and refer the patient to the primary care physician for further workup and treatment. In addition, history of bleeding, abnormalities a prothrombin time, partial thromboplastin time, and platelet function assay or bleeding time, are obtained to check for coagulation abnormalities. Any elevated value warrants further investigation and postponement of the procedure until those studies are complete.
Removal of the Needle and Observation Period
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 test 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 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.
One-Month Follow-up
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.
Neural Flossing Exercises
Physical therapy is the next critical component to further ensure improved lasting recovery following medical intervention.
Healthy nerves should move freely within the body to ensure proper blood supply, fluid exchange, and nutrition. A healthful and effective method of renourishment is routine stretching and exercise.
Although results may not occur immediately, continued practice of these stretching exercises produces the best long-term outcome. Increased flexibility ad strength may emerge after one month. It is important that patients perform each individual exercise, or stretch, with increasing duration from 20-30 seconds. The exercises should be carried out two to three or more times a day with each session lasting no longer than three to five minutes. For chronic pain suffers, these exercises should be continued indefinitely to prevent the restriction of affected nerve roots and the resulting return of pain.
It's important to note that during the exercises, the patient's head should be flat on the floor without a pillow. Raising the head draws the spinal cord and attached nerves upward and can place a slight resistance inside the spinal canal. This resistance can further prevent the nerves from moving freely. Therefore, the three exercises are carried out in the fully flat, supine position.
Exercise 1
Lay down with your face up (supine) on the exercise mat without a pillow. Slowly, bring both knees close to the chest with bent legs and hold this position for 20-30 seconds. Release and assume a neutral position to rest briefly.
Exercise 2
Again, in the supine position, both legs are raised to a 90° straight-up position, with knees straight while laying flat on the firm surface. This position is held for 20-30 seconds. Assume a neutral position and rest briefly before the third and final stretching exercise.
Exercise 3
Similar to exercise 2, both legs are brought straight-up to a 90° position, while lying supine. Slowly spread the legs in a “V” shape, as much as is comfortably possible, and hold this position for 20-30 seconds. This exercise is extremely important because it reduces stress on the sciatic nerve.
*Repeat 3 Times Daily
One-Month Follow-up
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.
Neural Flossing Exercises
Physical therapy is the next critical component to further ensure improved lasting recovery following medical intervention.
Healthy nerves should move freely within the body to ensure proper blood supply, fluid exchange, and nutrition. A healthful and effective method of renourishment is routine stretching and exercise.
Although results may not occur immediately, continued practice of these stretching exercises produces the best long-term outcome. Increased flexibility ad strength may emerge after one month. It is important that patients perform each individual exercise, or stretch, with increasing duration from 20-30 seconds. The exercises should be carried out two to three or more times a day with each session lasting no longer than three to five minutes. For chronic pain suffers, these exercises should be continued indefinitely to prevent the restriction of affected nerve roots and the resulting return of pain.
It's important to note that during the exercises, the patient's head should be flat on the floor without a pillow. Raising the head draws the spinal cord and attached nerves upward and can place a slight resistance inside the spinal canal. This resistance can further prevent the nerves from moving freely. Therefore, the three exercises are carried out in the fully flat, supine position.
Exercise 1
Lay down with your face up (supine) on the exercise mat without a pillow. Slowly, bring both knees close to the chest with bent legs and hold this position for 20-30 seconds. Release and assume a neutral position to rest briefly.
Exercise 2
Again, in the supine position, both legs are raised to a 90° straight-up position, with knees straight while laying flat on the firm surface. This position is held for 20-30 seconds. Assume a neutral position and rest briefly before the third and final stretching exercise.
Exercise 3
Similar to exercise 2, both legs are brought straight-up to a 90° position, while lying supine. Slowly spread the legs in a “V” shape, as much as is comfortably possible, and hold this position for 20-30 seconds. This exercise is extremely important because it reduces stress on the sciatic nerve.
*Repeat 3 Times DailyAdditional endurance exercises (such as walking) are beneficial. Over time, extended exercise (brisk walking with increased distance) will help maintain muscle tone and enhance cardiovascular status.
Patients with leg pain in the upper thigh, particularly in the front, are more likely to have physical abnormalities in the upper lumbar nerve roots. This type of pain should be addressed with additional exercises focused on the femoral nerve, which involves pathological processes similar to the sciatic nerves.
It is not uncommon for patients with disc or facet joint-related back pain to require additional procedures which are focused on those affected areas. Typically, disc-generated pain will be mainly identifiable in the midline area. Facet pain is reproduced when learning backwards, to the left or right side.
References
- Gabor B. Racz M.D., DABPM, FIPP, DABIPP A Step-By-Step Guide On Racz Catheter-Based Procedure Via Caudal Approach: A White Paper Series
- Racz G, . Heavner J, Smith J., Noe C., Al-Kaisey A., Matsumoto T., Lee S., Nagy L. Epidural Lysis of Adhesions and Percutaneous Neuriplasty. Intech-Pain and Treatment 2015,
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