Epidural Neurolysis

The word Adhesion refers to scar tissue, and the word Lysis means to disintegrate or dissolve. Dr. Gabor Racz created The epidural neurolysis procedure in the late 1980s; it is a minimally invasive procedure. The therapy has shown to be successful in treating persistent neck and back pain brought on by the accumulation of scar tissue. Around nerve roots, scar tissue can develop, producing excruciating agony all the time. Adhesions frequently develop as a result of irritation and inflammation in the epidural space. These adhesions may aggravate neighboring nerve roots, resulting in excruciating agony. Pain that radiates from the low back into the legs due to irritated and inflamed nerves caused by scar tissue is common. People who experience neck or back pain from scar tissue formation typically have a history of previous surgeries or chronic back or neck discomfort. Adhesions form after spinal surgery and are assumed to be the source of ongoing pain.

 

What is Epidural Neurolysis?

Epidural neurolysis operation is utilized (sometimes referred to as epidural adhesiolysis or neuroplasty) to release nerves from scar tissue in the spine. The doctor Gabor Racz who invented the procedure received its name. He discovered that it works well for reducing scar tissue caused by back discomfort. This scar tissue (also known as adhesions) may form as a result of irritation, chronic inflammation (ongoing swelling), or after surgery. Scar tissue can then aggravate neighboring spinal nerve roots, resulting in pain that travels down the legs from the back. By releasing the nerves, one may reduce the pain and enable the delivery of drugs to irritated nerves.

 

Epidemiology

The two main indications for epidural neurolysis are failed back surgery syndrome (FBSS) and spinal stenosis (SS). The term FBSS refers to back and/or leg pain that persists or returns after an anatomically successful back operation. The prevalence statistics of FBSS, which range from 10% to over 40%, are frequently mentioned in earlier research on different groups. The prevalence of FBSS is likely to rise, particularly in the United States, if the volume of spine surgeries continues to rise at a rate similar to that of the previous two decades. Being defined as anatomical constriction of the central canal, lateral recesses, or foramina, the diagnosis of SS is less confusing than FBSS. Despite being rather arbitrary, several earlier research defined lumbar SS in image-based approaches as 12 mm for relative stenosis and 10 mm for absolute stenosis. Congenitally short pedicles, excessive growth of bone (such as osteophytes), hypertrophic arthritic abnormalities in the facet joints, spondylolisthesis, and bulging or herniated discs are a few non-cancerous causes of SS. However, the absence of widely accepted diagnostic criteria has made it difficult to determine the prevalence of SS. Prevalence estimates in the general population are frequently stated and typically range from 1.5% to 13%. The prevalence rates significantly rise among the elderly. According to a Framingham Study ancillary study, the prevalence of acquired SS in people aged 60 to 69 ranged from 19 to 47%.

 

Epidural Neurolysis History

When conservative therapy has failed to relieve axial spine or radicular pain, epidural neurolysis, sometimes referred to as epidural neuroplasty and epidural adhesiolysis is a minimally invasive procedure used to treat the pain. Even though there are numerous variations of this process, the majority of neurolysis procedures carried out today are based on a method created at the Texas Tech Health Sciences Pain Center and published in 1989. The procedure normally entails using a large gauge needle to enter the sacral hiatus and introducing a catheter into the epidural region. The adhesions are then marked using epidurography, and adhesiolysis is carried out by administering saline and medications in high volumes to the region of the adhesions. The original treatment called for the catheter to stay in the epidural area for three days while various drugs were injected each day. Later, the method was altered to become an outpatient procedure that is comparable to a traditional epidural steroid injection but uses a catheter that is removed right away after being injected with a steroid, local anesthetic, and occasionally hyaluronidase and hypertonic saline.

 

Epidural Neurolysis Benefits

Surgery with epidural neurolysis entirely prevents soft tissue harm. It enters the epidural space through the spine's natural openings. It is therefore the least invasive type of surgical pain treatment currently available. This treatment is especially beneficial following poor microsurgical results (open spine surgery). Depending on the situation, up to 50% of patients who have microsurgery do not experience enough pain relief, even if the underlying issue should have been resolved.

Due to the great density of nerve tissue in this region, surgery can be very dangerous. After open spinal surgery (microsurgical spine surgery), scarring can cause chronic discomfort and function loss, which causes a secondary issue. In these situations, the damaged nerve root can be locally treated with a scar-dissolving enzyme to eliminate the resultant scar tissue.

 

Epidural Neurolysis Indications

• Nerve compression and chemical irritation of the nerve roots are caused by disc herniation.
• Protruding spinal discs causing nerve compression
• Radiculopathy is a painful inflammation of a spinal cord nerve root.
• Chronic pain is brought on by scar tissue that forms around a nerve following an injury or spinal surgery.

 

Epidural Neurolysis Preparation

You must show up at the operation facility at least one hour before your planned procedure. You might be taking medications that could make it difficult for you to drive, so bring a competent adult driver with you. Do not eat anything for 6 hours before your procedure, unless you are positive you won't be sedated. You may, however, drink small amounts of clear liquids up to 4 hours before. Continue to take your long-acting narcotic and nerve pain drugs as usual with sips of water along with your previously scheduled blood pressure, heart, asthma, and other prescriptions. Take half of your usual dose if you have diabetes, and carry your insulin with you. Make sure to stop using aspirin and other blood thinners as directed.

You will be required to sign in and submit any necessary papers as soon as you arrive. After that, you'll be brought to the preoperative area. A nurse will next have you sign your consent documents after asking you a few medical-related questions. It is crucial that you, the patient, let the assistant know if your history or physical has changed, such as if you just had the flu or have other health issues that could affect your treatment. If you have any allergies, especially to betadine or iodine, let the staff know.

Some drugs may need to be stopped several days before the surgery. Let the doctor know about all of your prescription, over-the-counter, herbal, and vitamin supplement usage. The doctor will advise you on when and if it's necessary to stop taking the medications.

If you have asthma or have ever experienced an allergic reaction to an injection of dye during a radiological exam (CT scan, angiogram, etc.), you must inform the doctor right away. Symptoms of an allergic reaction include hives, itching, difficulty breathing, and any treatment that necessitated a hospital stay.

Before your scheduled appointment, if you get a cold, fever, or flu-like symptoms, or if you've started taking antibiotics for an infection, let the doctor know.

You may be asked to change into a gown.  An assistant will take your vital signs and an IV may be started to provide pain relief and relaxation.

The physician and nurse will talk to you before your procedure.  In certain cases, an anesthesiologist may also be utilized.  You will then be positioned and the injection sites will be prepped.  Your pain management physician will perform the procedure. Medications may be administered before and during your procedure to help you relax and provide pain relief. You may doze off during this time.  Afterward, bandages will be applied as needed.

You will be taken to the recovery area, where you will spend the next 30 to 60 minutes being monitored. You will be given some crackers and beverages. After that, someone will remove your IV and, if necessary, help you in getting dressed. Last but not least, discharge recommendations for your care at home will be given to your caregiver.

 

Epidural Neurolysis Procedure

An outpatient operation room with a fluoroscope (a specialized x-ray machine) is used to carry out the procedure. An IV line will be inserted in the pre-procedure area by the nurse or physician. This is employed for sedation and fluids.

• You will be placed on your belly in the operation room and attached to monitoring equipment (an ECG monitor, a blood pressure cuff, and a blood oxygen monitoring device) for your comfort and safety.
• After washing your back and buttocks with antiseptic soap, the doctor will shoot numbing medication into your skin, which will briefly make you feel like you are burning.
• The physician will find a little opening near the tailbone's base (sacrum). This opening is used to insert a needle. Injections of contrast dye will highlight the areas where scar tissue is present.
• After that, the Racz catheter is inserted through the needle and positioned over the scarring area. Then, a combination of steroid and anesthetic is administered.

 

Epidural Neurolysis Recovery

After the procedure, patients are watched over for a little while before being sent home. Repeated injections may be necessary for some patients; thus, the catheter may be left in place. The catheter is taken out after each injection has been given.

Following the surgery, patients could feel a slight heaviness or numbness in their legs, but this normally goes away quickly. The treatment is very good at releasing adhesions and minimizing pain. Effects may begin to manifest right away following the treatment and may continue for a few months.

Risks are quite rare. Mild headaches, bruising at the injection site, and, very infrequently, nerve injury that results in paralysis are possible side effects for patients. An allergic reaction to the medications is a serious adverse effect, but they are incredibly rare. Patients who are known to be allergic to these medications, have bleeding disorders, and are taking blood thinners should ideally avoid the treatment.

 

Epidural Neurolysis Risks

The risks don't happen often. They include:

• Medication-induced allergic response
• Nerve injury (spinal cord and nerve roots)
• Bruising and bleeding where the injection was given
• Discomfort during the injection or at the injection location
• Infection
• Puncture of the spinal cord's protective sac (dura mater)
• Medication injection into a spinal fluid or blood vessel
• In certain circumstances, there will be no improvement or a deterioration of your pain
• Steroid injections, especially in diabetics, may temporarily raise blood sugar levels.

 

Epidural Neurolysis Outcomes

A comprehensive evidence-based treatment guideline for the interventional care of chronic spinal pain was created by the American Society of Interventional Pain Physicians. According to the recommendations, adhesiolysis combined with epidural steroids is successful for both short- and long-term pain control in cases of refractory pain and radiculopathy. One of the large retrospective investigations revealed that 100% of the treated patients experienced pain alleviation in less than three months. Additional long-term observation revealed the following outcomes: Patients who reported feeling pain reduction for less than 3 months were 100%, 3 months 90%, 6 months 72%, and 12 months 52%, respectively. Another study found that patients who underwent the epidural neurolysis procedure experienced a marked improvement in their general health status. After having adhesiolysis therapy, patients said that their pain and use of painkillers had decreased and that their physical wellness, mental health, functional ability, and psychological status had all improved.

 

Conclusion

Epidural neurolysis's supporting evidence is still debatable. Even though randomized trials tend to favor epidural neurolysis over traditional epidural steroid injection (ESI) and conservative therapy, many of these studies were carried out by the same research teams and have serious methodological flaws. No randomized studies contrasting percutaneous and endoscopic epidural neurolysis have been done, although studies support ambulatory epidural neurolysis for failed back surgery syndrome (FBSS), spinal stenosis (SS), and radiculopathy resistant to less invasive procedures.

The anatomical link between scar tissue and pain symptoms is unclear; some studies have established an association, but not all of them. This is a potential complicating factor. The removal of scar tissue, the elimination of inflammatory cytokines by high volume injectates, and the inhibition of ectopic discharge from damaged nerves are likely the mechanisms of action for epidural neurolysis.

Research on the variables influencing epidural neurolysis results is limited. Currently, weaker, contradictory evidence supports hyaluronidase, whereas the literature points to adhesion-targeting by high-volume injections and hypertonic saline as potential contributors to the positive effect of adhesiolysis. Since larger, more methodically sound studies that compare neurolysis to placebo and other therapies are required to more accurately determine effectiveness, it is crucial to identify the ideal individuals and method for epidural neurolysis.