Epidural Lysis of Adhesions: Percutaneous and Endoscopic Techniques
Epidural lysis of adhesions is an interventional technique that was initially described in 1989. It was designed to address refractory low back and leg pain due to epidural scarring by delivering high concentrations of injectable medication to targeted ar
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Timothy Y. Ko and Salim M. Hayek
Key Points
• The purpose of using the lysis of adhesion technique is to bypass scar tissue and improve delivery of high concentrations of injected medications to the targeted area. • The ideal patient would be one who may be suffering with more radicular symptoms from epidural fibrosis in close proximity to a nerve root. • Identifying filling deficits that correlate well with patient’s symptoms improves the likelihood of success. • Minimizing the amount of adjustments to the catheter in the needle reduces the risk of equipment malfunction and risk to the patient. • Resistance to the advancing catheter or epiduroscope should be respected as force may result in a complication.
Introduction Epidural lysis of adhesions is an interventional technique that was initially described in 1989 [1]. It was designed to address refractory low back and leg pain due to epidural scarring by delivering high concentrations of injectable medication to targeted areas. These areas of scar tissue develop due to many reasons including postsurgical resection and chemical
T.Y. Ko, M.D. (*) LakeHealth Department of Anesthesiology, Division of Pain Medicine, Pinnacle Interventional Pain and Spine Consultants, 7580 Auburn Road, Suite 102, Concord Township, OH 44077, USA e-mail: [email protected] S.M. Hayek, M.D., Ph.D. Department of Anesthesiology, Case Western Reserve University, Division of Pain Medicine University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106, USA e-mail: [email protected]
irritation from leaking nucleus pulposus. The contribution of epidural fibrosis to intractable low back pain and lumbosacral neuritis has been debated [2]. Kuslich and colleagues [3] performed an extensive evaluation on the origins of lumbar back pain throughout 193 operations under progressive local anesthesia delivered sequentially to different surgical planes. Back pain could be mostly reproduced by stimulation of the outer layer of the annulus fibrosis and the posterior longitudinal ligament. Sciatica could only be reproduced by stimulation of swollen, restricted, or compressed nerve roots. While epidural fibrosis itself was not painful, patients that had prior laminectomies were found to have perineural fibrosis that lead to painful and sensitive nerve roots [3]. The lysis of these adhesions has been reported to reduce pain in several prospective studies and systematic reviews [4–7]. The rate of lumbar spine surgery has grown exponentially in Western culture [8–10]. Studies like Weinstein and colleagues’ Spine Patient Outcomes Research Trial (SPORT) have suggested a central role for spinal surgeries [11]. In their 4-year combined as-treated analysis, patients who underwent spine surgery for a herniated disk achieved greater improvement than the nonoperative cohort in all primary and secondary outcomes except work status. With this growth in surgical intervention, the number of failed back surgery syndrome has become an increasingly common diagnosis [12] for the interventional pain ph
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