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Dr. Racz’s Thoughts on Lysis of Adhesions

Guillermo Ortiz on January 31, 2017 at 2:41 pm

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    • Guillermo OrtizGuillermo Ortiz
      Member
      Joined: Jan 19, 2015
      Posts: 1
      #5277

      Dr Racz,
      I am Guillermo Ortiz, and I have a fellowship in Barcelona but I currently live in Colombia. I have a case I would like to get your opinion on. The subject is a 52 year old female, and because of a HPN, she underwent a laminectomy at T10-T12 level, complicated by dural rupture fixed with synthetic patch. After the surgery she complained of having neuropathic pain corresponding to T12 especially on the left side. I have made an epiurogram entering at L1, and the contrast doesn`t pass cephalad at the L1 level, it goes all caudal. I have scheduled her for a percutaneous adhesiolisys. Which do you think would be the most suitable route to enter?
      -Dr. Guillermo A Ortiz

      • Gabor B RaczGabor B Racz
        Participant
        Joined: Mar 28, 2016
        Posts: 30
        #5280

        Dear Guillermo,

        I have received your description of the 52 year old female patient following the thoracic laminectomy at T10-T12 level for HNP. She apparently developed a dural leak which was repaired with a synthetic patch.
        You left out a crucial piece of information, whether the dural leak was anterior or posterior? Hopefully it is posterior. Most of the pathology occurs in the ventral and in addition lateral recess areas. I note you did an epidurogram at L1 and your contrast spread would only go caudally. You should come in paramedian at L1 L2 from the right side approach entering at the midline with an RX2 Coude Needle. Make sure the bevel of the needle curves down when you enter the epidural space after getting loss of resistance, please introduce the second blunted stylet and gently interlock it into the hub. Rotate the needle tip towards the targeted site on the left side. Inject a half of a cc of contrast and thread the catheter toward the ventral lateral T12 nerve root in the lateral recess.

        Which needle and catheter should you use? The regular 18 RX2 Coude needle with a 21 gauge Versa-Kath or a 15/16 gauge RX2 Coude needle and a Tun-L-XL24 or a Brevi-XL catheter? I have found that in very densely tight scarred areas, the smaller 21 gauge Versa-Kath tends to find the tissue planes into the ventral epidural target site of the nerve root, whereas the bigger 19 gauge Brevi-Xl catheter sometimes will not.
        The most important step is to establish lateral runoff from the epidural space. Once this has been done you should inject the water soluble dye, followed by Hyaluronidase opening the T12 or T11 nerve roots….you can then inject the local anesthetic and steroids. If you see venous runoff, it will usually disappear when you do a fluid foraminotomy, which converts high pressure veins to low pressure by removing the venous obstruction.

        The ventral epidural adhesions are also the cause of pain. You can redirect the catheter to the worse pain level and repeat the injection of contrast, Hyaluronidase, local anesthetic and steroids….my favorite being triamcinolone followed by hypertonic saline at least 20 – 30 minutes later. The best inhibitors of scar formation are triamcinolone and hypertonic saline.
        None of this is possible if you do not have lateral runoff. Please review collegial communications in the Pain Practice 2013 article about Subdural spread and the role of flexion rotation to relieve accumulated fluid caused pressure of the blood supply on the spinal cord. Also review 2015 Pain and Treatment Intech publication chapter 10 which can be found in the articles section of Paincast, along with any of the lectures or cadaver training videos as well. I shall post the video presentation of a patient that developed a spinal fluid leak and foot drop during surgery from tethered cord. I was able to go in the ventral epidural space, because we knew the spinal leak was in the posterior epidural space and was able to reverse the foot drop without reopening the spinal fluid leak. I mainly used hyaluronidase following contrast and only a tiny dose of local anesthetic at the end to verify that we were not spreading into the subdural space.
        The injections must be done under continuous lateral view fluoroscopy, that way you know where the fluid is spreading.
        Please remember to let me know where the spinal fluid leak was in your patient?
        Gabor B. Racz, M.D, FIPP
        Grover E. Murry Professor,
        Professor Emeritus Chair TTUHSC
        Ex-President World Institute of Pain

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