Join PainCast

Do you want to know more about Pain Medicine? Join PainCast to view hundreds of exclusive videos, and access to luminary physicians, forums, and more!

Scarring Triangle

Anonymous on February 28, 2021 at 12:46 am
  • Author
    • Anonymous

      Is the scarring triangle a better approach to treat L5 radiculopathy than caudal adhesiolysis? The adhesiolysis seems like an easier approach.

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

        It is a little bit like fool’s gold: what appears to be gold is not necessarily so. The common L5 radiculopathy is exactly just that. Typically, contralateral epidural catheter placement, so long as you have a curved tip, not going rapidly to the L5 nerve root, can navigate the catheter to the neural foramen exactly. Effectiveness of the technique is evidenced by significant transforaminal runoff. A provocative test is straight leg raising. Innervation of the facet joint may be from intraspinal canal scarring of the nerve root, giving off the medial branch. Very often, it becomes non-symptomatic after a neuroplasty if the main L5 nerve root is involved. Hypertonic saline disconnects C-fibers. You must verify spread of contrast on the lateral view, making sure that the dura and the posterior longitudinal ligament will be separated, and the multiple hypertonic saline injections will have a chance to disconnect said C-fibers. The scarring triangle location is ventral-lateral on the vertebral body, but above the L5-S1 Disk. It’s big enough to accept the average loose disk fragment, and small injection into scarring triangle goes a long way, as from the paper from Taske, et all. It is the common spot which is quite rare, but when it is present, a caudal epidural catheter cannot exit on the painful side. Tomikitchi Matsumoto identified the fact that when the scarring triangle is present, surgery fails, epiduroscopy fails, and neuroplasty fails. The provocative test for scarring triangle, because the dura moves 10-15 mm, the nerve root moves a fraction of dura movement (20-25%.) Matsumoto clearly identified that the 21 gauge Versa-Kath, when used with 18 gauge Rx2 coude needle, can be safely placed between the trans S1 placed needle in the appropriate tissue plane. This technique is remarkably easily learnt. To understand the technical aspects, a small 21 gauge Versa-Kath can be passed in the correct tissue plane, avoiding injuring L5, S1, S2, S3 nerve roots and, to large extent, successful reversal of post-operative spinal-stenosis surgery induced bladder dysfunction by opening up the fixed, scarred-down, above mentioned nerve roots. Bladder dysfunction reversal, IE: inability to void, 15-20x nighttime micturition, has been reversible with bilateral one-side treatment, followed, around three weeks later, with another transforaminal hypertonic saline technique to the scarring triangle. The bladder is unusual in that it has bilateral innervation, calling for the worse side treated first, followed by the less severe side.

        A precaution: Anytime you move the tip of the needle in the spinal canal, injury to nerves, veins, arteries can be prevented by the use of blunt needle, curved needle, or blunted by the second stylet protruding beyond the Rx2 coude needle tip.

        The volumes for the S1 injections are:
        • 10mm omnipaque240, followed by
        • 10mm 150 unit of hylenex (hyaluronidase),
        • 10ml of 0.25% bupivacaine,
        wait at least 20 minutes to rule out motor dysfunction,
        • 1.5ml of 1% lidocaine bolus,
        2-3 minutes later,
        • 10ml of 10% sodium chloride in 0.6% lidocaine,
        • flush with 1-2 cc saline,
        wait 4 hours,
        • 10ml of 0.25% bupivacaine,
        • 1.5ml of 1% lidocaine,
        waiting 2-3 minutes,
        • 10% sodium chloride in 0.6% lidocaine (10cc),
        • then finally flush with 1-2 cc saline,
        the following morning,
        • repeat the second injection.

        Post procedure, the Racz-Fitz dural flossing exercise:

        • Maximum flexion of torso (sitting position),
        • followed by chin to chest flexion,
        • repeat to left shoulder,
        • repeat to right shoulder,
        • if a painful side is identified,
        • that is repeated 10x to the painful side, hanging on the painful generator,
        • this is done 10x a day,

        Report back to your Epimed representative in the event you identify patients with leftover pain.

      Viewing 1 reply thread

      Join The Discussion

      Reply To: Scarring Triangle
      Your information:

      <a href="" title="" rel="" target=""> <blockquote cite=""> <code> <pre class=""> <em> <strong> <del datetime="" cite=""> <ins datetime="" cite=""> <ul> <ol start=""> <li> <img src="" border="" alt="" height="" width="">

      Comments are closed.