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The Racz Procedure: Lysis of Epidural Adhesions (Percutaneous Neuroplasty)

  • Gabor B. Racz
  • Miles R. Day
  • James E. Heavner
  • Jeffrey P. Smith
Chapter

Abstract

Back pain is an exceedingly common condition and is often treated with surgery when patients have failed traditional conservative treatment. Despite the best efforts of treating surgeons, these patients are often left with significant postoperative pain, and reoperation or chronic opiate therapy is frequently felt to be the only alternative. A large portion of pain in this patient population is directly attributable to epidural adhesions that prevent normal nerve root movement along with adhesions affecting the ventral epidural structures. Lysis of adhesions is a minimally invasive procedure that was initially developed to spare patients from an additional surgery. Since its inception, the procedure has proved effective for a variety of additional etiologies beyond postsurgical back pain. Through site-specific targeting, lysis of adhesions involves the placement of a catheter in the neuroforamen of the affected nerve root. A fluid foraminotomy is performed when hyaluronidase, local anesthetic, corticosteroid, and hypertonic sodium chloride are injected through the catheter. This releases the nerve root from epidural adhesions and increases neuroforaminal cross-sectional area. Additionally, adhesiolysis opens venous runoff and decompresses high-pressure epidural veins.

Keywords

Nerve Root Hypertonic Saline Epidural Space Spinal Cord Stimulation Posterior Longitudinal Ligament 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Kuslich S, Ulstrom C, Michael C. The tissue origin of low back pain and sciatica. Orthop Clin North Am. 1991;22:181–7.PubMedGoogle Scholar
  2. 2.
    Racz G, Noe C, Heavner J. Selective spinal injections for lower back pain. Curr Rev Pain. 1999;3:333–41.PubMedCrossRefGoogle Scholar
  3. 3.
    Manchikanti L, Staats P, Singh V. Evidence-based practice guidelines for interventional techniques in the management of chronic spinal pain. Pain Phys. 2003;6:3–81.Google Scholar
  4. 4.
    LaRocca H, Macnab I. The laminectomy membrane: studies in it evolution, characteristics, effects and prophylus in dogs. J Bone Joint Surg. 1974;5613:545–50.Google Scholar
  5. 5.
    Cooper R, Freemont A, Hoyland J, et al. Herniated intervertebral disc-associated periradicular fibrosis and vascular abnormalities occur without inflammatory cell infiltration. Spine. 1995;20:591–8.PubMedCrossRefGoogle Scholar
  6. 6.
    McCarron R, Wimpee M, Hudkins P, et al. The inflammatory effects of nucleus pulposus; a possible element in the pathogenesis of low back pain. Spine. 1987;12:760–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Parke W, Watanabe R. Adhesions of the ventral lumbar dura: an adjunct source of discogenic pain? Spine. 1990;13:300–3.CrossRefGoogle Scholar
  8. 8.
    Straus B. Chronic pain of spinal origin: the costs of intervention. Spine. 2002;27(22):2614–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Ross J, Robertson J, Frederickson R, et al. Association between peridural scar and recurrent radicular pain after lumbar discectomy; magnetic resonance evaluation. Neurosurgery. 1996;38:855–63.PubMedCrossRefGoogle Scholar
  10. 10.
    Heavner JE, Chokhavatia S, Kizelshteyn G. Percutaneous evaluation of the epidural and subarachnoid space with a flexible fiberscope. Reg Anesth. 1991;15(1S):85.Google Scholar
  11. 11.
    Bosscher HA, Heavner JE. Incidence and severity of epidural fibrosis after back surgery: an endoscopic study. Pain Pract. 2010;10(1):18–24.PubMedCrossRefGoogle Scholar
  12. 12.
    Manchikanti L, Pampati V, Bakhit CE, et al. Non-endoscopic and endoscopic adhesiolysis in post-lumbar laminectomy syndrome: a one-year outcome study and cost effectiveness analysis. Pain Phys. 1999;2(3):52–8.Google Scholar
  13. 13.
    Hatten Jr H. Lumbar epidurography with metrizamide. Radiology. 1980;137:129–36.PubMedCrossRefGoogle Scholar
  14. 14.
    Stewart H, Quinnell R, Dann N. Epidurography in the management of sciatics. Br J Rheumatol. 1987;26(6):424–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Devulder J, Bogaert L, Castille F, et al. Relevance of epidurography and epidural adhesiolysis in chronic failed back surgery patients. Clin J Pain. 1995;11:147–50.PubMedCrossRefGoogle Scholar
  16. 16.
    Manchikanti L, Bakhit C, Pampati V. Role of epidurography in caudal neuroplasty. Pain Dig. 1998;8:277–81.Google Scholar
  17. 17.
    Viesca C, Racz G, Day M. Special techniques in pain management: lysis of adhesions. Anesthesiol Clin North Am. 2003;21:745–66.CrossRefGoogle Scholar
  18. 18.
    Day M, Racz G. Technique of caudal neuroplasty. Pain Dig. 1999;9(4):255–7.Google Scholar
  19. 19.
    Horlocker T, Wedel D, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA consensus conference on neuraxial anesthesia and anticoagulation). Reg Anesth Pain Med. 2003;28:172–97.PubMedGoogle Scholar
  20. 20.
    Racz G, Day M, Heavner J, et al. Hyaluronidase: a review of approved formulations, indications and off-label use in chronic pain management. Expert Opin Biol Ther. 2010;10(1):127–31.PubMedCrossRefGoogle Scholar
  21. 21.
    Racz GB, Day MR, Heavner JE, et al. 2012. Epidural Lysis of Adhesions and Percutaneous Neuroplasty, Racz GB, Day MR, Heavner JE, Smith JP, Scott J, Noe CE, Nagy L, Ilner H (Ed.), http://www.intechopen.com/books/pain-management-current-issues-and-opinions/epidural-lysis-of-adhesions-and-percutaneous-neuroplasty
  22. 22.
    Larkin T, Carragee E, Cohen S: A novel technique for delivery of epidural steroids and diagnosing the level of nerve root pathology, J Spinal Disord Tech. 2003;16(2):186–192.PubMedCrossRefGoogle Scholar
  23. 23.
    Gerdesmeyer L, Lampe R, Veihelmann A, Burgkart R, Göbel M, Gollwitzer H, Wagner K. Chronic radiculopathy. Use of minimally invasive percutaneous epidural neurolysis according to Racz. Schmerz 2005;19:285–295.PubMedCrossRefGoogle Scholar
  24. 24.
    Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. A comparative effectiveness evaluation of percutaneous adhesiolysis and epidural steroid injections in managing lumbar post surgery syndrome: A randomized, equivalence controlled trial. Pain Physician 2009;12:E355–E368.Google Scholar
  25. 25.
    Manchikanti L, Cash KA, McManus CD, Pampati V, Singh V, Benyamin R. The preliminary results of a comparative effectiveness evaluation of adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis: A randomized, equivalence controlled trial. Pain Physician 2009;12:E341–E354.Google Scholar
  26. 26.
    Heavner JE, Racz GB, Raj P. Percutaneous epidural neuroplasty: Prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase. Reg Anesth Pain Med. 1999;24:202–207.Google Scholar
  27. 27.
    Matsumoto, Tomikichi. Percutaneous Epidural Neuroplasty Using the Epimed Spring Guide Catheter (100 cases of Failed Back and Neck Surgery Syndrome). Presented at the American Japanese Society.Google Scholar
  28. 28.
    Lecture, Racz GB. Therapeutic and neurolytic blocks for the management of facial pain. Ophthalmic Anesthesia Society 8th Scientific Meeting, San Antonio, Texas. (unpublished).Google Scholar

Copyright information

© American Academy of Pain Medicine 2015

Authors and Affiliations

  • Gabor B. Racz
    • 1
    • 2
    • 3
  • Miles R. Day
    • 2
    • 3
    • 4
  • James E. Heavner
    • 2
    • 5
  • Jeffrey P. Smith
    • 6
    • 7
  1. 1.LubbockUSA
  2. 2.Department of AnesthesiologyTexas Tech University School of MedicineLubbockUSA
  3. 3.International Pain CenterTexas Tech University Health Sciences CenterLubbockUSA
  4. 4.LubbockUSA
  5. 5.Department of AnesthesiaUniversity Medical CenterLubbockUSA
  6. 6.Department of Anesthesiology and Pain ManagementTexas Tech University School of MedicineLubbockUSA
  7. 7.LubbockUSA

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