Chapter 40: Epidural Lysis of Adhesions

INTRODUCTION

Epidural lysis of adhesions refers to a percutaneous spinal procedure for pain relief (Racz procedure). Pain may occur due to epidural inflammation, nerve root compression, venous engorgement, and scar tissue. Under contrast-enhanced fluoroscopy, a steerable radiopaque catheter is used to deliver several drugs to the target “pain generator”; these include local anesthetics, hyaluronidase, hypertonic saline, and steroids. Contrast epidurography identifies correct placement and permits early detection of subarachnoid, subdural, or intravascular placement. Local anesthetics reduce intraoperative and postprocedural pain. An enzymatic agent (hyaluronidase) or mechanical motions (moving the catheter back and forth) are used to “loosen” peridural scar tissue. Hypertonic saline (10%) is used to reduce intraneural edema. Steroids modulate inflammation. This procedure was initially developed for patients with symptomatic epidural scarring, ie, post-laminectomy syndrome. Published studies report safe and efficacious outcomes following epidural lysis of adhesions for several spinal pain etiologies: failed back surgery syndrome, post-laminectomy syndrome, spinal stenosis, lumbar radiculopathy, and cervicalgia.

INDICATIONS

• Back/neck pain and sciatica (with or without surgery)

• Chronic low back pain

• Radiculopathy (mono- or polysegmental)

• Failed back surgery syndrome

• Lumbar spinal stenosis

• Post-laminectomy syndrome

• Spinal stenosis

• Neurogenic claudication

• Degenerative disc disease

• Herniated/prolapsed intervertebral disc

• Epidural scarring

• Sympathetically independent pain

RELEVANT ANATOMY

• The epidural space is a potential space that surrounds the dural sac and is contained within the bony spinal canal.

• Ventrally, the epidural space is bounded by the vertebral body, intervertebral disc, and longitudinal ligament.

• Dorsally, the epidural space is bounded by the ligamentum flavum, lamina, and spinous processes.

• Laterally, the epidural space is bounded by the pedicles, facet joints, articular processes, and “foramina.”

• The bony spinal canal is contiguous from the foramen magnum to the sacral hiatus.

• Epidural needle access should be attempted at the sacral hiatus, interlaminar space, and only rarely, at the intervertebral foramen.

• The sacral hiatus is dorsally covered by the sacrococcygeal ligament and is laterally bounded by the sacral cornua. In thin patients, the hiatus is palpable.

• For the cervical, thoracic, and lumbar levels, a paramedian approach to the interlaminar space is advised.

• The interlaminar window may be optimally visualized when utilizing cephalocaudal angulation, during fluoroscopy.

• Optimal patient positioning helps with access.

• The lumbar lordosis should be reduced; the cervical or thoracic kyphosis should be accentuated. This “opens up” the interlaminar space and facilitates needle entry.

PREOPERATIVE CONSIDERATIONS

Patient selection and choice of this technique depend on an individualized risk/benefit analysis and a review of prior therapies. For instance, epidural lysis of adhesions may be the index procedure in a patient with failed back surgery syndrome. On the other hand, this procedure may be used late in the treatment algorithm for patients with spinal stenosis.

Contraindications (relative or absolute) and indications for procedure termination include:

• Infection, systemic or localized

• Coagulopathy

• Distorted or complicated anatomy

• Progressive neurological deficit

• Allergy to ...