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Adhesiolysis hyaluronidase and hypertonic solution

A Kemal Erdemoglu on March 4, 2017 at 3:27 pm
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    • A Kemal ErdemogluA Kemal Erdemoglu
      Participant
      Joined: Jan 25, 2017
      Posts: 5
      #24251

      Is there any protocol for Adhesiolysis hyaluronidase and hypertonic solution irrigation? Is there any difference for cervical and lumbar area?

      • Gabor B RaczGabor B Racz
        Participant
        Joined: Mar 28, 2016
        Posts: 30
        #26042

        Adhesiolysis or neuroplasty is a procedure where primarily fluid is injected into the correct tissue plane-where the fluid is able to find the weakest point to separate the entrapped nerves. This allows a rapid increase of blood flow and you may see rapid motor function recovery.
        Injected materials include water soluble contrast (viscous), hyaluronidase that has a spreading factor-like effect. It also allows for filling up a compartment within the tissue plane and by finding the weakest spot, dissects into an adjoining compartment and so on and so on… Meanwhile by pushing the contrast, one can judge the extent of “lysising”!
        Hyaluronidase has no harmful effect on human fiberblast cell culture! A newly discovered therapeutic effect is the injected Hyaluronidase inhibits
        Neutrophil infiltration – thus preventing an inflammatory response and therefore preventing swelling and pain.
        There are animal extract products as well as synthetic human recombinant Hyalaronidase. They both have the same neutrophil inhibitory function. Hylaronidase does not inhibit fiber blast regeneration in the human fiberblast cell culture.
        The usual dose is 1500 or 750 units diluted in 10 ml of preservative-free saline OR Hylenex (synthetic) 150 units diluted the same way. There is no danger from intravenous or subarachnoid injection. However, anaphylactic reaction incidents are extremely hard to measure but is possible to have an occurrence therefore, you must be prepared to treat. Personally, in over 30 years of use, have not seen a single occurrence. Survey of reported group of ophthalmic anesthesiologists that frequently use animal extract Vitrase have not observed any anaphylactic reactions. It is not customary nor within the standard of practice to do skin testing to rule out anaphylactic reaction possibility prior to use.
        These agents are not NEUROLYTICS, so long as the recommended concentrations are not exceeded. Hypertonic saline used by vascular surgeons for thrombosing varicose veins is a corrosing agent at 23.4% that MUST NOT BE USED IN THE SPINAL CANAL.
        YOU MUST MAKE SURE THAT THEY DO NOT LOCULATE in the spinal canal that can, by exerting pressure on vessels, lead to ischemic changes if location occurs. Usual volumes of injection in caudal epidural-10mls. Transforaminally by catheter in mid canal is 5ml on lateral view continuous fluoroscopic observation.
        Cervical injection volume is only safe in the presence of lateral runoff, therefore, catheter placement must be ventral lateral and fluid lateral spread is enhanced by flexion rotation.
        Subarachnoid injection may be followed by twitching of the legs for a couple of days with improvements in preexisting symptoms. Subarachnoid Hypertonic saline was introduced by Professor Hitchcock, 1967, is painful, can cause twitching and hypertension was done under general and tracheal that may last for a couple of days with improvement of preexisting symptoms, almost never done this day in age. Hypertonic saline inhibits fiber blasts and scar formation inhibition can have many years duration of action. (Reference – Techniques of Neurolysis 2nd edition).
        Invitro studies show inhibition of action potentials in nerve conduction in a reversible manner. Also inhibit C-fibers therefore the long lasting back pain relief. During the neuroplasty procedure hypertonic saline injection was found to be very painful by itself. You must follow the injected local anesthetic because it is very painful by itself.
        Pain Free Hypertonic Epidural, recent unpublished discovery by myself is the incredibly obvious yet overlooked finding of diluting a 23.4% hypertonic saline by the use of
        1% lidocaine. Just prior to the injection, precede with 1-1/2 to 2 ml of 1% lidocaine that will be injected ahead of the hypertonic solution of 10% NaCl 2ml at 0.6% Lidocaine.
        On completion of the injection flush, the bacterial filter and catheter with 1-1/2 ml of 1% lidocaine – so that the next injection will not be the
        earlier left over potentially painful experience.
        The biggest danger with hypertonic injection is if you place the catheter midline into the SUBDURAL space and the osmotic effect of hyperemic expand from 10% to 0.9% or an 11X increase in volume(!!!) in a confined space.
        The patient will complain of pain , numbness, weakness, almost mimicking paralysis. You should read the introductory chapter and the Lysis chapter of Techniques of Nerolysis Racz/Noe editors by Springer publishers.
        If the contrast is still in place it is easy to be aspirated with an inter laminar needle placement
        Contraindications- arachnoidits with failed surgery, Syrinx formation in cord. There are good studies with very good outcomes in cervical and lumbar spinal stenosis patients.

        Caudal volumes: 10ml Omnipaque-240, 10ml saline Hyaluronidase, 10 ml 0.2% Ropivacaine or Bupivacaine and WAIT 20-30 MINUTES TO BE SURE THAT THERE IS NO MOTOR BLOCK! The 10% sodium chloride, if diluted by 1% Lidocaine can be almost pain free. For many years we have used an infusion pump, but we have found it is possible to inject the 10ml more rapidly. The patient must have ACLS certified personnel
        immediately available if complications are experienced. At the end of injection, flush the system with 1-1/2 ml of % Lidocaine.
        Cervical, Thoracic and Transforaminal volumes: Usually are 5 ml and if there is pain from the volume of injection, a flexion rotation maneuver is carried out to allow the escape of fluid pressure to the spinal canal or to vertically spread it in case of subdural loculation.
        POST INJECTION IS NOT NORMAL TO HAVE PAIN, NUMBNESS OR PARALYSIS!
        Emergency doctors , neurologists, neurosurgeons , and rehab doctors do not always understand the mechanisms involved in volume expanding loculation. EPIDURAL BLEEDING CAN TAKE 2-3 DAYS TO CAUSE PARALYSIS. SIMILARLY with SUBDURAL VOLUME EXPANSION!

        A motor block most likely comes as a result of a SUBDURAL INJECTION OR SPREAD.

        This circumstance is why there should be an ACLS trained group readily available, because the patient may look like a total spinal and must have immediate resuscitation.
        It is extremely rare but THE DELAYED ONSET OF A SUBDURAL BLOCK OR A SUBDURAL/EPIDURAL HEMATOMA MUST BE PART OF THE PHYSICIAN AND PATIENT EDUCATION PROTOCOL.

        FLUID LOCULATION MAY BE SOLVED BY ASPIRATION OR BY REPEATED FLEXION ROTATION.

        Gabor B. Racz, M.D, FIPP

        • A Kemal ErdemogluA Kemal Erdemoglu
          Participant
          Joined: Jan 25, 2017
          Posts: 5
          #32924

          Thank you for your detailed explanation ands sharing your experince. Which hyaluronidase do you choose? Hydase Vitrase or Amphadase or any other that you would recommend or use in your practice?

          • Gabor B RaczGabor B Racz
            Participant
            Joined: Mar 28, 2016
            Posts: 30
            #32947

            Hylenex – human recombinant – synthetic is the cleanest. Interestingly the animal extract and the Hylenex pretreatment had the same effect of inhibiting neutrophilic infiltration therefore the inflammatory processes. The best news is the PAIN FREE hypertonic saline just by diluting with 1% lidocaine. Even the one day lysis gives you great result for 12 months – recent publications. I prefer the 3 series of injections resulting in multi-year positive outcomes. CRIMINAL to do single shot ESI before and operate at the wrong level causing one disaster after another. ESI works for 2-3 weeks. If you spread it through the neural foramina with catheter placement – works for years!!!!

            Hylenex comes 150 units in 1mL. Usually dilute Hylenex in 10mL normal saline (.9% sodium chloride), and inject it following the contrast. Then the local anesthetic along with steroid. Each of them at the same volume. 10mL, 10mL, 10mL, in the lumbar area, after waiting 20-30 minutes to be sure there is no motor block. Then inject 1-1.5 to 2mL of 1% lidocaine prior to the 10ml of 10% sodium chloride diluted in 1% lidocaine.

            The commercial hypertonic saline comes as 23.4% (see picture) and we aspirate 4.3ml of the hypertonic and 5.7ml of the 1% lidocaine to end up with very close to 10% solution of NaCl-2mL at 0.6% Lidocaine.

            The 169 patient study on cervical neuroplasty in Pain Physician had 46 patients recommended neck surgery and only 3 went to surgery after having a lysis!! The best outcomes come from the latest technique.

            You must know facts, not what you feel – need to learn new things

            Best wishes,

            Gabor

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            • Gabor RaczGabor Racz
              Keymaster
              Joined: Mar 31, 2016
              Posts: 1
              #34258

              How and when did you come up with this new formulation of Hypertonic Saline mixed with the local anesthetic. Do you still do a test dosage with the local before injecting Hypertonic Saline?

              • Gabor B RaczGabor B Racz
                Participant
                Joined: Mar 28, 2016
                Posts: 30
                #35586

                FIRST IN MY COMMENTS ABOVE I MENTIONED THE DILUTION WITH !% LIDOCAINE – WE END UP WITH A 10% SOLUTION ( HYPERTONIC SALINE ), BUT ALSO A 0.57% LIDOCAINE- FOR SIMPLICITY I CALL IT 0.6% LIDOCAINE or 60mg -predosing to prevent the pain from the hypertonic saline for when the 10 ml volume is injected. When doing a transforaminal, I usually use 5ml through the mid ventral canal with a second catheter- therefore less milligrams. YOU MUST COUNT THE MILLIGRAMS !!

                SECOND TO YOUR QUESTION:

                THE CAUDAL CATHETER APPROACH I use is 10ML of OMNOPAQUE 240 + 10ML HYALURONIDASE (HYLENEX ) 150 UNITS IN NORMAL 0.9%SALINE +10 ML’s of 02% ROPIVACAINE OR 0.25% BUPIVACAINE WITH 40MG TRIAMCINOLONE AND WAIT FOR 20-30 minutes to be sure that you do not have a motor block. Happens very rarely but when it does you must have somebody present that can resuscitate and ventilate the patient from a possible SUBDURAL INJECTION…….you will get a motor block including respiratory arrest that takes 14-16 minutes and this easy to manage for a physician or nurse with ACLS training.
                The pre-treatment with the 1 1/2 to 2ml of 1% Lidocaine while following the usual volume of injections. The reference for this is in my latest book in 2016. The 2nd editionof “Techniques Neurorlysis” Racz/Noe Springer publishers. Read the introductory chapter and the Lysis chapter- to be safer and better!!!!
                The COMPLICATIONS LISTED IN THE BOOK ARE EXTREMELY RARE – YOU MUST OBSERVE THE PATIENT POST PROCEDURE AND ASSIST THEM POSSIBLY IF THEY NEED HELP TO AMBULATE FOR 3-4 HOURS.

                IF THERE IS SUBDURAL FLUID SPREAD THROUGH A SURGICAL TEAR OR FROM CATHETER PLACEMENT, (I HAVE NEVER SEEN A CATHETER DELAYED MIGRATION) YOU MAY NEED TO ASPIRATE THE SUBDURAL SPACE, THEREFORE MY RECOMMENDATION FOR YOU IS TO READ THE BOOK.
                The outcomes in your patient will exceed your expectations.

                Third point: For many years I used the bovine extract of Hyaluronidase 750-1000 units in preservative free normal 0.9% saline and
                NEVER HAD AN ANAPHYLACTIC REACTION!!!

                NOW I USE HYLENEX 150 units in 10ml normal saline plus half dose transforaminally –either with a catheter or for single shots using a blunt needle.
                The Whittacker needle is designed to perforate – the only needle that has been studied is the blunt needle for safety to avoid intra-neural and intra- arterial injections.

                • Gabor B RaczGabor B Racz
                  Participant
                  Joined: Mar 28, 2016
                  Posts: 30
                  #35611

                  The big difference in the Cervical and thoracic area from the lumbar is the presence of the spinal cord.
                  You must place the catheter in the lateral epidural space and establish lateral run off.
                  LATERAL RUN OFF CAN BE GREATLY ENHANCED BY FLEXION ROTATION OF THE HEAD AND NECK
                  The lexicon enlarges the neural foramina by the superior pars sliding up on the inferior pars. Read reference in Pain Practice: Collegial communication article- Racz, Apicelli…..where unintended compression of the cord from saline steroid injection caused tingling and weakness of one foot and leg and responded to flexion rotation and 12 months follow up-full recovery.
                  Next time I was in court defending inter laminar single shot cervical epidural steroid injection where the patient goes home-developes pain and weakness of the neck and arm fails to make contact with the physician and 3 weeks later has a left sided syrinx in the spinal cord. FLEXION ROTATION MAY HAVE PREVENTED THIS
                  REMEMBER: WARN THE PATIENT FOR DELAYED PAIN , WEAKNESS- PARALYSIS – YOU MUST CONSIDER WHILE YOU ARE WAITING FOR THE MRI PICTURES AND REPORT OR YOU THINK THE PATIENT HAS A EPIDURAL VENOUS BLEED LEADING TO HEMATOMA THE DEVELOPMENT OF PRESSURE LEADING TO ISCHEMIC CORD INJURY MAY TAKE SEVERAL DAYS-IN ONE OF THESE MEDICOLEGAL CESES
                  CORD INJURY TOOK 4 DAYS TO DEVELOP AFTER SINGLE SHOT ESI !! CASE SETTLED SO WAS NOT REPORTABLE.
                  MOET OF THE CASES HAPPENED AFTER SINGLE SHOT ESI’S
                  THE SYSTEMATIC REVIEW BY STAN HELM ET OF EPIDURAL NEURLYSIS FOR SPINAL STENOSIS MAKES THE NOTE THAT NOT A SINGLE CASE OF HEMATOMA HAS BEEN REPORTED- BECAUSE FLUID FORAMINOTOMY CONVERTS THE HIGH PRESSURE VEINS TO LOW PRESSURE thus remove the danger from venous bleeding.
                  LOOK AT THE PAIN CAST VIDEO ABOUT FLEXION ROTATION WHILE YOU ARE WORKING DURING CERVICAL NEUROPLASTY-
                  THE CATHETER KEEPS THE DURA AWAY FROM THE NEEDLE TIP!
                  FLUID FORAMINOTOMY IS FOR REAL. PREVENTS HIGH PRESSURE BLEEDS .
                  BLOOD IN THE EPIDURAL SPACE IS NOT THE PROBLEM- THINK OF THE EBP’s Blood under pressure can be relieved by the flexion rotation!.
                  This is covered in the in The techniques of neuroplasty 2nd edition book Racz/Noe Springer 2016
                  need to read the introductory chapter as well to be safer. Plus the Paincast videos
                  The best outcomes come from cervical neuroplasty but only if you open up LATERAL RUN OFFS-
                  BEST WISHES
                  GABOR
                  Ps
                  Look at the great Korean series of Han, Lee, Cho et al. 169 cervical neuroplasty where 46 patients were recommended surgery and 3 of them needed it. Found the outcome was better when there was trans foraminal run off in Pain Physician 2016-
                  Almost never see run off with CESI at the painful segment. CESI has been great for some but also used as a very poor excuse for far too many surgeries regardless of costs and complications
                  Pain Physician

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