Epidurolysis

 Lysis of epidural adhesions, also called the Racz procedure, involves passage of a catheter (Racz catheter) endoscopically or percutaneously under fluoroscopic guidance into the epidural space under general anesthetic or conscious sedation. Various protocols for breaking up adhesions and reducing pain and inflammation have been described. The catheter may then be manipulated to mechanically break up adhesions, and various agents that may include anesthetics, corticosteroids, hyaluronidase, and hypertonic saline, are injected. In some early protocols, the catheter was left in place and injections repeated over several days.

Background

Epidural fibrosis with or without adhesive arachnoiditis most commonly occurs as a complication of spinal surgery and may be included under the diagnosis of “failed back surgery syndrome.” Both result from manipulation of the supporting structures of the spine. Epidural fibrosis can occur in isolation, but adhesive arachnoiditis is rarely present without associated epidural fibrosis. Arachnoiditis is most frequently seen in patients who have undergone multiple surgical procedures.

Both conditions are related to inflammatory reactions that result in the entrapment of nerves within dense scar tissue, increasing the susceptibility of the nerve root to compression or tension. The condition most frequently involves the nerves within the lumbar spine and cauda equina. Signs and symptoms indicate the involvement of multiple nerve roots and include low back pain, radicular pain, tenderness, sphincter disturbances, limited trunk mobility, muscular spasm or contracture, and motor sensory and reflex changes. Typically, the pain is characterized as constant and burning. In some cases, the pain and disability are severe, leading to analgesic dependence and chronic invalidism.

Lysis of epidural adhesions, using fluoroscopic guidance, with epidural injections of hypertonic saline in conjunction with corticosteroids and analgesics, has been investigated as a treatment option. Theoretically, the use of hypertonic saline results in a mechanical disruption of the adhesions. It may also function to reduce edema within previously scarred and/or inflamed nerves. Finally, manipulating the catheter at the time of the injection may disrupt adhesions. Spinal endoscopy has been used to guide the lysis procedure. Prior to the use of endoscopy, adhesions could be identified as nonfilling lesions on fluoroscopy. Using endoscopy guidance, a flexible fiberoptic catheter is inserted into the sacral hiatus, providing 3-D visualization to steer the catheter toward the adhesions, to more precisely place the injectate in the epidural space and onto the nerve root. Various protocols for lysis have been described; in some situations, the catheter may remain in place for several days for serial treatment sessions.

What is an Epidurolysis (RACZ) Procedure?

Epidurolysis (RACZ) is a procedure used to dissolve scar tissue (adhesions) that has built up in the epidural space. Dr. Gabor Racz pioneered this procedure.

What causes scarring (adhesions)?

Scarring can be caused by any kind of irritation in the body. This can be from surgery, blood, hardware, or disc material. It is a natural reaction of your body trying to heal itself.

What is the purpose of it?

The purpose of epidurolyisis is to reduce scar tissue so that medication can reach the irritated nerves.

How long does the injection take?

The procedure is actually a series of three injections over a period of three days. On the first day, a catheter (small plastic tubing) is placed in the epidural space through a needle to the area of scarring. This is done in the operating room using fluoroscopy (x-ray) in a clean environment to reduce the chance of infection. The first injection into the catheter will be made at this time and then secured to your back with tape and dressing. The second injection is done the following day through the epidural catheter. On the third day, the catheter is injected and then removed. The actual injections only take a few minutes.

What is injected?

The injection consists of a mixture of local anesthetic (numbing medicine,) corticosteroid to reduce inflammation, contrast dye to visualize the scarred space, and a mixture of hyaluronidase and saline to soften the scar tissue.

Will the injection hurt?

Most patients tolerate the injection very well. Numbing medicine is placed under the skin that feels like a poke and a burn. After that, you most likely will only feel pressure. If you feel any pain during the injection, more numbing medicine can be given. If you choose, you may have intravenous sedation to help you relax.

Will I be “put out” for this procedure?

No. The safest way to do this procedure is under local anesthesia. You may choose to have intravenous sedation, which will help you relax, but you will always be awake during the procedure to minimize the chance of any nerve damage.

How is the injection performed?

You will be lying on your stomach on an x-ray table. We will monitor your blood pressure, heart rhythm, and blood oxygen. Your skin will be cleansed with an antiseptic. After the injection, you will be placed on a bed and moved to the recovery area.

What should I expect after the injection?

You may or may not feel better immediately after the injection and your legs or arms may feel slightly heavy or numb. The numbing medicine injected can wear off after several hours. You may have a sore back or neck for several days after the injection. This is due to the needle insertion as well as the chemically irritating effect of the steroid. The steroid is a long and slow acting medication that can take up to 5 days before starting to work and up to 2 weeks before taking full effect.

Can I go to work to work the next day?

You should be able to return to work the next day unless otherwise directed by your physician. Some patients will feel soreness in the neck at the injection site.

How long the effect of the medication last?

The effect of the steroid can last anywhere from several days to several months. The purpose of the injection is to decrease swelling and inflammation to decrease pain. Over time, your body may heal itself.

How many injections do I need?

If the first procedure does not relieve your symptoms after two weeks, a second procedure may be recommended. If the second procedure doesn't relieve your symptoms after an additional two weeks, a third procedure may be recommended. The effects of the injections are additive if spaced at these time intervals. We generally would not perform more than 3 steroid injections in a 6-month time period. More than this may increase the steroid load in your body increasing the likelihood of suffering from side effects. If 3 injections did not provide a lasting benefit, it is unlikely that any further steroid injections would provide further benefit.

What are the risks and side effects?

Overall, the procedure is very safe. As with any procedure, there are risks. The most common side effect is pain, which is temporary. Any time a needle is punctured through the skin, there is a chance of bleeding or infection that is very rare. Other rare side effects include spinal headache, nerve damage, worsening of pain, etc., which are extremely unlikely.

Who should not have these injections?

If you are allergic to specific local anesthetics or ionic contrast, please notify your physician. Also, if you are taking any blood thinners (Coumadin, Plavix, Warfarin, Lovenox, Aspirin, etc,) please let your physician know ahead of time to help devise a safe plan for the injection.