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This procedure, which is also called percutaneous adhesiolysis, epidural lysis of adhesions, epidural neurolysis, epidural neuroplasty or Racz procedure, consists of destroying the fibrosis tissue (scarring) that forms in the epidural space of the spinal canal after herniated disc surgery, thus reducing the pain produced by compression of the nerves.
The main purpose of epidurolysis is to provide pain relief by eliminating the epidural adhesions. This fibrous scar tissue causes radicular pain by the mechanical effect of the nerve roots being stretched and compressed against these scars.
With this procedure it is possible to apply medication (local anesthetic steroids, hypertonic saline, hyaluronidase, ozone, etc.) exactly at the site of the injury on the affected roots, and also apply radiofrequency on the affected spinal ganglia.
It is indicated in the following cases:
When there is no improvement, or insufficient improvement, after conservative therapy and repeated treatments with epidural infiltration.
Lumbar pain subsequent to multiple back surgeries.
As in all surgery, before proceeding the patient will be informed of the possible risks and will be asked to sign a consent form.
In the event that it is decided to sedate the patient, it will be light sedation because the patient must be able to collaborate during the procedure in order ensure that administering the medications does not cause any compression on the spinal cord.
This procedure must always be carried out with fluoroscopic guidance and following the usual recommendations for radiation protection.
The steps are as follows:
The steps are as follows:
1) 1. The patient is positioned face down with the head to one side, with a pillow under the abdomen to reduce the spinal curve, and the feet turned outward to facilitate access to the peridural space.
2) Patient’s vital signs are monitored.
3) The point of entry is sterilized.
4) Local anesthesia is administered at the point of entry. It can be delivered by inserting a needle deeply through the muscles until it reaches the bone.
5) Confirmation through x-rays of the correct position of the needle, in both anteroposterior and lateral views. After negative aspiration for blood or CSF, the contrast substance is injected.
6) The catheter is introduced through the needle. Bending the tip of the catheter approximately 15º, can make it easier to reach the target area. Sometimes various attempts are required before the catheter reaches the fibrous tissue.
7) Once the target is reached, negative aspiration is performed and 5-10 ml of contrast is administered through the catheter. This allows us to see where the contrast extends and where it does not, so that we can detect which part of the epidural space has the highest degree of fibrosis and which roots are most affected.
8) At this point, it is also possible to perform pulsed radiofrequency on the dorsal node of the affected root through the epidural space. For this, the Racz catheter is connected by means of a crocodile clip to the radiofrequency apparatus and the usual procedure is followed of sensory stimulation at 50 Hz and motor stimulation at 2 Hz with an adequate impedance. Pulsed lesion is performed for between 4 to 8 minutes.
9) At this time, 1,500 IU of hyaluronidase dissolved in 4-10 ml of sterile isotonic saline is administered, followed by a slow, fragmented injection of 10 ml of ropivacaine 0.2% or levobupivacaine 0.25%, along with the corticosteroid, preferably 40 mg triamcinolone acetate.
In the immediate postoperative period, the patient’s basic functions are monitored and once bladder and motor function have been verified, the patient will be discharged. The operated area should be kept dry for at least 48 hours. After this period, showers are allowed, but no immersion baths until at least 7-10 days later.
This procedure usually produces a significant improvement in pain and motor function. We recommend beginning physical therapy as soon as possible to improve muscle tone and promote stretching of the spine. We recommend this practice twice a day for about 5 minutes per session. If it is necessary to repeat the therapy, you should wait about 3 months between performing one technique and another.
If the patient should note any persistent sensory or motor deficit, a nuclear magnetic resonance (MRI) should be considered to rule out possible severe complications, especially spinal compression, hematoma, abscess, etc.
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