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Adhesiolysis-does pt get worse?

A Kemal Erdemoglu on April 23, 2018 at 9:16 am
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    • A Kemal ErdemogluA Kemal Erdemoglu
      Participant
      Joined: Jan 25, 2017
      Posts: 5
      #44706

      I performed PRF, transforaminal injections and adesiolysis for spinal stenosis.
      I performed neuroplasty as contrast material has been injected caudally; then after the neuroplasty bolus consisting of hyaluronidase (1500 UI ) and non-particulate steroid (bethametasone 10 mg) was performed. I do not use hypertonic saline during the procedure.
      After 2 weeks, patient told me that he still has difficulty while walking and nothing has been changed after the procedure, even get worse especially on walking. As I told him that the procedure was carried out without any problems; it was perfect. I asked cardiologist to check his vessels and he reported me back vessels are ok. (I will check with angiography).

      I could not explain why patient got worse.
      Any opinion; will be appreciated
      A Kemal Erdemoglu, MD

      • Gabor B RaczGabor B Racz
        Participant
        Joined: Mar 28, 2016
        Posts: 30
        #44786

        You need to give me much more information. Such as the volumes injected, time allotted between injections and concentration levels. I suggest you read the introductory chapter regarding spinal stenosis in Techniques of Neurolysis 2nd Edition Book 2016, in a patient who had L3, L4, L5, three level surgery with good results for five years after a properly performed Lysis of Adhesions

        Upon return to pain one segment higher at L2 the patient developed sever spinal stenosis. I did a caudal catheter to the worse painful left side with 5ml’s Omnipaque, 5mls saline/hyaluronidase (150 units of hylenex) followed by 5mls of .25% bupivacaine and 40 mgs of triamcinolone. This was followed by placing a transforaminal L2-3 Tun-l-XL24 catheter to the mid-canal placed in the ventral epidural space. We waited 30 minutes to be sure of no motor block, waited 30 minutes and infused 10% of sodium chloride.

        On the same day 4-6 hours later, we reinjected the transforaminal catheter with 5ml .25% bupivacaine through the bacterial filter with 5ml’s of hyaluronidase, waited 30 minutes once again confirming no motor block and then infused 10% sodium chloride. We then observed the patient to be sure there was no motor block and similarly infused the caudal catheter with 10ml of 10% sodium chloride (hypertonic saline.) Please remember this procedure was done 8.5 years ago.

        Next day we injected the local .25% bupivacaine, followed by 5mls saline/ hyaluronidase and waited 30 minutes to make sure there was no motor block. Then we infused 5mls of 10% sodium chloride. 5.5 years later the patient returned and had developed spinal stenosis pain one level higher at L1-2 and we basically repeated the procedure as the day before the caudal and transforaminal catheter. This patient is an extremely successful athletic 78-79 year old with no complaints of any pain related to the previously treated areas. The MRI, at the time of the third injection, showed the L2-3 level to be wider open than the three surgical levels. The patient also continues to do twice daily neural flossing exercises (see Epimed hand out).

        The difference for the caudal injection was that by now we had learned about the scarring triangle. So we placed the caudal catheter through the S1 nerve root to access the scarring triangle to the ventral medial aspect of the epidural space with an 18g RX-2 Coude needle and a Versa-Kath. The placement must be between the L5-DRG and the S1 nerve Root. A regular 19 gauge spring catheter cannot be put in to the dense scar tissue, but the 21 gauge Versa-Kath has been proven to get there due to the smaller size of the catheter.

        You do not get medals for not using hypertonic saline as it is known to inhibit fibroblasts and slow down the regeneration of scar tissue. IT IS NOT A NEUROTOXIC AGENT. THE STUDIES PERFORMED BY OURSELVES AND OTHERS INDICATE THAT HYPERTONIC SALINE REDUCES COMPOUND ACTION POTENTIAL BUT IT IS REVERSABLE. HYPERTONIC SALINE INTERFERES WITH C-FIBERS, BUT NOT SENSORY AND/OR MOTOR FIBERS.
        *Techniques of Neurolysis,Gabor B. Racz, Chapter 7; 73-86, 1989 Kluwer Academic Publishers

        Hyaluronidase inhibits neutrophil cell infiltration along with preventing the likelihood of post procedure pain and swelling. This seems to be exactly what your patient is describing of his pain two weeks post procedure. The C-fibers are very much in play and the volumes that were used by you are unknown. Once again, I suggest you read the article recommended and look at the proper sequence of use of hypertonic saline before you use it. The best source is searching the published articles as listed in the publications; also view the many videos on PainCast. This is where you will see videos of the different procedures and injection volumes I have mentioned above.

        The new concepts are Painless Hypertonic Saline and reduction of the development of motor block after the second and third procedures. There is a brief video on PainCast describing the technique titled Hypertonic Saline.

        You cannot expect the same outcome if you change the technique that has developed over the last 35 years.

        Best,

        Gabor B. Racz, M.D, FIPP, DABIPP

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