June 7, 2013

Percutaneous Adhesiolysis

Low back pain and leg pain are common.  They often respond to simple actions, such as keeping up your normal activities, over-the-counter pain medications and exercise. Physical therapy and chiropractic therapy are very important for pain that does not respond to simpler measures.    Pain that does not go away often responds to simple interventional pain management techniques, such as epidural injections.  A number of diseases respond to epidural injections, including disc herniations (also known as disc bulges, ruptured discs or slipped discs), spinal stenosis, post lumbar surgery syndrome and degenerative disc disease (also known as spondylosis and sometimes simply called arthritis of the spine).  Epidural injections offer a quick, safe (all injections have some risk, just like driving a car does) and economical way of treating persistent pain.

What do we do when back and leg pain does not go away with epidural injections?  Surgery is often not an option.  Your problem may not lend itself to surgery.  You may not want surgery.  You may be concerned about the risks of surgery or the possibility that surgery may not work.  You may be concerned about the cost of surgery.

Percutaneous adhesiolysis, also known as the Racz procedure, provides relief to patients who have not responded to epidural injections.  We have seven high quality randomized studies showing that it is safe and effective.  Percutaneous adhesiolysis treats scarring in the epidural space.  Scarring occurs after surgery, infection, bleeding and simply because we get older.

Scar causes a number of problems which can lead to pain.  Nerves in your spine need to move freely, just like the pistons in an engine, so that as you move, the nerves move.  Scarring can tether the nerves, preventing this movement.  Scars can also block epidural veins, causing them to become swollen and engorged.  The swollen veins can then press on the nerves, causing the nerves to become inflamed and painful.  Scarring can also prevent injections, like epidural injections, to work because the medication cannot get to the nerve.

Percutaneous adhesiolysis works because it can break up scarring.  The procedure can be done in any part of the spine, from the neck to the tailbone, but is usually done in the low back or lumbar region.  Most commonly, the needle is placed into the epidural space at the tailbone, or coccyx.

There several necessary things that are done that make percutaneous adhesiolysis different from an epidural injection.  A spring-wound catheter is essential.  A spring-wound catheter has a wire in it so that the catheter will not be cut off or sheared while the catheter is being properly positioned in the epidural space.  After the catheter is in position, we confirm that the scarring is present by looking at the flow of dye under fluoroscopy.  We will mechanically break up scars with the catheter.  We will then inject a large volume of local anesthetic and some medicine, hyaluronidase, to help the medications spread.  We may use steroids.  After making sure everything is safe, we will inject saline.  The saline may be either normal saline, the same concentration as we have in our body, or it may be concentrated.

After the procedure, you should do some stretching exercises, to stretch the nerve roots, to help free them up.  An example would be to lie on your back and bring your knees up to your chest.

About 95% of the time, the procedure is done on an outpatient, one-day basis.  It can also be done as a 3-day procedure.

Percutaneous adhesiolysis is a simple, effective technique to treat persistent back and leg pain.  Despite the strong evidence in its favor, we are having trouble getting some insurers to cover it.  Despite this, it is an important option that you should be aware of.