Forum

Forum Replies Created

Viewing 25 posts - 1 through 25 (of 33 total)
  • Author
    Posts
  • Gabor B RaczGabor B Racz
    Participant
    Joined: Mar 28, 2016
    Posts: 30
    #72856

    Similar to the case described above, an improvement to the standard of care is moving forward regarding the types of needles used for injections. There is overwhelming evidence where the FDA should not only be involved with drugs, but also in the use of sharp vs blunt needles. Our animal data clearly shows that blunt needles do not perforate nerves or arteries. In anesthetized dogs the incidence of problems is somewhere around 10,000+ cases, but it is randomly occurring which means you could have 2 in 2 weeks, 2 months, 2 years or never. I have defended a doctor who had 2 intravertebral artery injections and some very serious complications. Many transforaminal, stellate ganglion, subdural and intra-cord injection related complications. The neurosurgeons gave up over 50 years ago on the use of sharp needles for brain related injections.

    Recently the likely consequence of an intraneural injection was the development of a Brown-Sequard Cord Infarction (ipsilateral weakness and contralateral numbness). To date still have not heard of a blunt needle causing distant injuries or infarction nor have I heard of intra-arterial injections caused by blunt needle.

      in reply to: Scarring Triangle
      Gabor B RaczGabor B Racz
      Participant
      Joined: Mar 28, 2016
      Posts: 30
      #67069

      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.

        Gabor B RaczGabor B Racz
        Participant
        Joined: Mar 28, 2016
        Posts: 30
        #65544

        Hell Yes! Why do I say it, because of our studies on large numbers of patients. We published the first study on Hyaluronidase at the IASP World Congress in Paris, we looked at 50 patients where we did not use Hyaluronidase and allowed them paralleled to 50 patients doing Lysis of Adhesions vs. the other 50 patients similarly followed for 12 months. We looked at the difference of the outright failures. When we did not use hyaluronidase the outright failures were 18%, we did use the animal extract Hyaluronidase 1500 units, we chose this amount because that was how much was in the bottle. The failure rate dropped to 6.1 percent. In the beginning we were terrified, because of the concern of anaphylactic reactions. It was recommended that you had to do a skin test, but it added half to one hour to get it accomplished……. we never saw a reaction and eventually after a number of years I stopped. Meanwhile, I was invited by the American Society of Ophthalmic Anesthesiology to lecture and I asked 500 clinicians how many use Hyaluronidase….everyone raised their hand. Then I asked how many do skin tests …….Nobody. How many have seen an anaphylactic reaction…..Nobody. No longer is it recommended anywhere that the skin test is required, before it was mentioned in the PDR. Animal studies have shown that animal extract and the synthetic recombinant Hyaluronidase have similar actions of inhibiting neutrophil infiltration. Neutrophil infiltration will lead to edema triggering the inflammatory cascade, swelling and pain.

        Hypertonic Saline disconnects non-myelinated C fibers which inevitably causes back pain. Hypertonic saline inhibits fibroblast regeneration which softens and disconnects the scar tissue and inhibits more on the side where you injecting it previously. It has been proven that the 3 times hypertonic injections, which we developed were proven to be more effective and longer lasting than the 1 time injection.

        Hypertonic Saline has been known to be very painful during the injections, now we have developed a pain free hypertonic injection mixture with a local anesthetic. The first publication was 3 times hypertonic on a patient which was a multi level degenerative patient with a post traumatic tear and leaky disk, leading to severe radiculopathy because of scarring. The patient had 22 years improvement after the 3 time hypertonic injection followed by a discogram and infusion of the L5 S1 leaky disc space . He re-scarred the same area 22 years later in 2008 and we repeated and published the identical scarring that originally developed in 1986. The patient was not happy because we did not know at the time about the Scarring triangle pain or the provocative testing and he only received a few months of pain relief. Most physicians pay no attention today about new developments like provocative testing and neural flossing. I was once asked: “Why do I not get the same results as you Dr. Racz?” My response: ” Because you don’t listen and you are not doing the procedure correctly which includes provocative testing to name one!”

        There has been better understanding over the years, which has led to the improvement of long term outcomes and functional recovery to patients after having the Lysis of Adhesions procedure. Some of these improvements include the Dural Tug, Dural Flossing, Lumbar and Cervical Neural Flossing, Scarring Triangle Lysis, Pain Free Hypertonic and the fear of Hypertonic Saline in the Sub-Dural space.

        I do hope this has answered your question and I wish you the best of luck.

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

          Gabor B RaczGabor B Racz
          Participant
          Joined: Mar 28, 2016
          Posts: 30
          #59406

          Feedback requested: do you like this format of response and engagement? Some might find it not to your liking, please let me know if you do prefer it.

          Thank you,
          GBR

            Gabor B RaczGabor B Racz
            Participant
            Joined: Mar 28, 2016
            Posts: 30
            #59405

            Thank you, Lisa. Don’t forget to call, not necessarily me, but anyone you trust and are friendly with. I’d be happy to take your call anytime.

              Gabor B RaczGabor B Racz
              Participant
              Joined: Mar 28, 2016
              Posts: 30
              #59404

              To answer your question, yes. Five cc in the lumbar area. I strongly recommend you read the Collegial Communication article, not to be confused with my recent post:
              https://onlinelibrary.wiley.com/doi/abs/10.1111/papr.12057

              It was a trap; you have to be extra careful when you do a procedure between two fusions, above and below. A perfect epidural dye spread was followed by, in trying to place an epidural catheter with a subdural contrast reaching the sub-dural space. The patient developed pain, numbness, and weakness of one leg. This triggered my friend to call me, reaching me while the patient was still on the operating room table. He was able to text me X-Ray images taken of epidural followed by subdural spread. Persistent pain and weakness were some symptoms. Upon seeing the X-rays, I recognized that the pain, numbness, weakness was the result of compression of blood supply to the cord, and I recommended the patient to do a sit-up, and flex and rotate the torso. This enhanced the spread of the contrast in the subdural space, thus reducing the developed loculation pressure. By the time they reached the emergency room, the pain was less severe and started to move soon thereafter. The formerly weak, less and less responsive, foot drop. Subsequently recommended continuous movement; the MRI that was taken ASAP did not show any surgical lesion. The patient was kept in the hospital overnight. About the only thing you could do is to administer some intravenous steroids, but he already had steroids administered to the subdural space. He made a complete recovery, and we reported the event with some artist’s drawings and copies of the texted fluoroscopy pictures.

              This scenario was enacted many times, where one patient that had loculation, severe pain, and more injection of high concentration of local anesthetic did not help, but made matters worse. Following the phone call, within the few minutes of my recommendation of flexion rotation, the doctor responded in a few minutes with one word “Fantastic.” During the first medical legal case for following cervical neuroplasty, after surgical cutting of the greater occipital nerve, the patient in the recovery room started to complain of more severe pain, numbness, weakness. They were held back in the recovery room, hoping to manage the severe consequences of worsening pain. We did not have collegial communication, so the patient was discharged home. Overnight, they developed ipsilateral upper extremity paralysis. The following day, patient ended up with weakness, paralysis looking picture of the whole side of his body. The first group of lawyers withdrew from the case. After I prepared for the defense, five to six months post onset of hemipleygia, for the first time I was asked to write a chapter on medical legal cases involving neuroplasty/lysis of adhesion. I had to call Jim Rathmell whether he could give me a couple of weeks about what to do in such events. I have seen the need to distribute loculation, firmly etched in my mind that you simply have to do the flexion rotation in order to do what, eventually we understood, can best be described as duroplasty. After explaining the concept, he says “Yes! Hell, that is the only new thing in the book!” In the first publication on the flexion rotation, we mention the flexion of the torso enlarges the neural foramina, where fluid may escape. We also published a couple of cases that even hematomas can get better with the flexion rotation. The dural flossing, where at the flexion of the torso is followed by rotation of the head and neck, and flexing of the chin to shoulder left and right, moves the dural eight to twelve mm.

              Forgive me for the complexity of this case, but to understand we are talking about completely reversible to a major disaster. The spinal cord does not tolerate ischemia. Going back to hemipleygia look alike picture, which came before we understood how to reverse this condition; we had the dat documented when the patient developed the post procedure pain in the recovery room, and was managed with narcotics. The patient recovered the lower extremity weakness about five months later, with no residual deficit. A second group of lawyers picked up the case, and I was asked to continue the defense. My documentation of the flexion rotation, which we developed during the years of doing cervical neuroplasties. It became part of the cervical neuroplasty large series, with numerous publications on the topic. By the time we went to court, the patient virtually full recovered the upper extremity function/use, with possible weakness on pronation/supination. The explanation to the jury was that we just did not know exactly how to diagnose and treat cervical spinal loculation. The flexion rotation, leading to the exercise that we ended up naming as duroplasty, came through the recognition with the help of one of my patients who continued doing the repetitive flexion rotation and movement of dural until it separates the dural adhesions. The jury dismissed the case.

              There are few things that changed, for example, cord injury following transforaminal sharp needle interneural/interarterial injection leading to cord infarction. Since the publication by Scanlon, where the discussion of what to do in case of cord injury, he was the first one to report, “Use blunt needles!” Several other times mentioned, there have no been a single cord injury publication where curved blunt needles, with a second need used for delivery.

              The why, and what can happen, is a bit longer as you can tell. What is new: a rat injury model with lots of edema, hyaluronidase leads to rapid resolution of the edema. It prevents and reduced edema. Make sure you flex and rotate. Don’t forget Dural flossing!

              GBR

                Gabor B RaczGabor B Racz
                Participant
                Joined: Mar 28, 2016
                Posts: 30
                #59236

                Dear Lisa,

                The FDA does not allow differentiation of the products containing Hyaluronidase. However, we have written a couple of reviews, and I remember the royal pain of Hyaluronidase used sub-arachnoid used for the treatment of arachnoiditis, from a couple of Indian papers. These used skin testing of an animal extract. Compared to the purity of other proteinaceous animal extract hyaluronidases, the only alternative to me has been Hyalgan, which is a human recombinant synthetic Hyaluronidase. I usually take the 150 IU Hyalgan: for 1ml I dilute it in 10ml, preservative free, saline. I can use 5ml at two transforaminal injection with a curved blunt needle. I have never seen or heard of any complication for around 15 years of administration. The selection regarding anaphylactic reactions: Danny Moore, in 1957, published a study implicating Hyaluronidase in anaphylactic reaction to be 3%, but this has never been duplicated. I lectured to four to five hundred ophthalmic anesthesiologists, and asked how many used Hyaluronidase (all of them), how many does skin tests (none), how many have seen anaphylactic reactions (none.) Less than sufficiently scientific, but all of them, I believe, are significant. Currently, no publications recommends skin testing for anaphylactic reaction. Cost effectiveness is more convincing, especially in multiple blunt needle injections and multiple site injections such as codo or trans S1 catheter site for the scarring triangle. Plus, transforaminal, mid-canal epidural injections such as multi-level pathology, where it is simply the best outcome technique. The spreading impact of Hyaluronidase enhances transforaminal spread up and down the spinal canal.

                  Gabor B RaczGabor B Racz
                  Participant
                  Joined: Mar 28, 2016
                  Posts: 30
                  #59235

                  Dear Robert,

                  Thank you for the information. I’m not at all surprised. I still remember Bartfa and how beautiful the town is. That Queen Elizabeth chose it for repeated annual visits is obvious once you have been there. I have spoken to couple people about you, saying what a fine doctor you have become. Just for your information, we are on a New Mexican lake, seven thousand feet altitude, looking at twelve thousand foot snow capped mountains. Our county only has 1 confirmed case of coronavirus. You probably will say that the county of Bartov has 0, but hammer has been thrown down for you.

                  Feel free to call me, great to hear from you.

                  Gabor

                  PS: Reviewing the record, it shows that you are now up to three deaths in the great state of Slovakia/Northern Hungary.

                    in reply to: Prolotherapy
                    Gabor B RaczGabor B Racz
                    Participant
                    Joined: Mar 28, 2016
                    Posts: 30
                    #58117

                    Hello Frank, sorry for just noticing your question. I have been using Cryo for around 35 years now. Cryoneurolysis and injection of steroids is followed by pain usually overnight. One newly realized particular injectate in entrapment cases is hyaluronidase which reduces edema and pain. I think it would be of interest to collect your series and focus on the post procedure pain. Pretreat half of the patients with betamethasone, although I prefer triamcinolone, and the other half with a small diluted dose of hylenex (human recombinant hyaluronidase). More specific safety and pain treatment studies I’ve had favorable outcomes with the spinal canal use of hyaluronidase. Good luck!

                      in reply to: Prolotherapy
                      Gabor B RaczGabor B Racz
                      Participant
                      Joined: Mar 28, 2016
                      Posts: 30
                      #48246

                      I don’t think so. I would recommend first examining the patient with gentle palpation comparing the left and right side. The painful side likely will have painful dysesthesia and is very likely related to a iliohypogastric nerve injury. You will find the nerve when you go from anterior medial to the anterior superior iliac spine. I use Cryo lesioning to treat this type of painful condition. First we usually do a nerve block, but you have done that. I have the patient for the Cryo therapy tense the abdomen, I then perforate the external oblique muscle going parallel to the iliac crest with sensory stimulation until I find the painful nerve. Once I have located the painful nerve, I perform a double Cryo lesion for 3 minutes followed by defrosting and refreezing for 3 minutes. Important to note is that the second lesion should not be painful. Defrost and advance the probe in the same space with sensory stimulation and find the second part of the nerve which should respond with a familiar pain. I then repeat the double lesioning as was done on the first part of the nerve. Otherwise, if it is not the iliohypogastric nerve you have to identify the painful nerve that is coming around between the muscle layers. Cryo lesioning for neuromas has also been very helpful. What you may have faced is likely to be a direct entrapment or actual nerve injury. Please let me know. If you do a google search you will find a couple of articles on iliohypogastric nerve Cryo lesioning. The advantage of Cryo lesioning is it is more cost effective and does not create neuritis.

                      Best of luck,

                      Dr. Gabor B. Racz

                        in reply to: Multilevel neuroplasty
                        Gabor B RaczGabor B Racz
                        Participant
                        Joined: Mar 28, 2016
                        Posts: 30
                        #46834

                        Jamal,

                        Make sure you do a dural tug examination! If that is positive it means the dura is adherent to the posterior longitudinal ligament. The target for leaving the catheter will be different.

                        The examination needs to be done and your first procedure will need to be to the ventral lateral epidural space on the worst side of the patient’s pain. After you do the 3 times hypertonic technique the patient may report pain from the other side or a different level months or even years later.

                        Not uncommonly, I will place a second catheter transforaminally to the ventral mid canal in cases of spinal stenosis. Read the introductory chapter and Lysis Neuroplasty Chapter 8 in the 2nd Edition of Techniques of Neurolysis.

                        Best,

                        Dr. Gabor B. Racz

                          Gabor B RaczGabor B Racz
                          Participant
                          Joined: Mar 28, 2016
                          Posts: 30
                          #45430

                          Yes Normal Saline is pain free in the epidural space.

                          However it does not make the Hypertonic Saline pain free.

                          Distilled or Non-ionic water on the other hand is quite painful in the the epidural space, believed to irritate the small C Fibers.

                          In the subarachnoid space it is not painful. When I was a boy we used distilled water for the loss of resistance technique and gave it up because of the pain it caused to the patient.

                          Being pain free is important!

                          Dr. Gabor B. Racz

                            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

                              Gabor B RaczGabor B Racz
                              Participant
                              Joined: Mar 28, 2016
                              Posts: 30
                              #44471

                              Thank you for your continued interest.

                              The dural tug is explained below:

                              To appreciate the dural movement, I suggest you review the Cervical Neuroplasty video on Paincast in a patient that had three electrode placed at the C2 Level for Nucleus Caudalis stimulation. Electrodes adhere to the dura and indicate dural mobility. The dura is inserted to the foramen magnum and during the flexion rotation of the patients head and neck, the dura moves from 1 – 1.5 vertebral body lengths. The most richly innovated structure is the posterior longitudinal ligament. Therefore the Dural Tug is performed with the patient sitting up and then bending forward as much as possible and you flex and push the head down. This movement of the dura causes the patient to identify the exact location where the pain is coming from which is were the dura is adhered to the posterior longitudinal ligament. The picture of the lady pointing was taken the day before her procedure and the skin is marked with a pen. The next day the right picture has the patient were the Dural Tug is initiated and she points to the left side at the L2 Neural Foramen which is where the pain spiked during the TUG. This was confirmed by flouroscopy with a pointer to the left L2 Neural Foramen. Inter-laminar catheter mapping and Neuroplasty was performed on this patient and she had 3 years of complete pain relief I hope this helps and I will attach a video where I have one of my patient’s doing a Dural Tug” soon.

                              With regards to mapping:

                              Mapping is identifying painful nerve roots in the epidural space by sensory rate (50hz) stimulation with usual epidural catheter placement preferably with the RX2 coude needle for safety and ability to direct the catheter towards the target site. 

                              CATHETER – Needs to have an exposed stainless steel spring tip (Brevi-Kath or Tun-L-XL™/24 Epimed Int.) which is used as the active negative electrode by alligator clipping onto the metal stylet. The positive electrode is either an alligator clip to a ground pad or onto a needle that has been placed under the patient’s skin to complete the circuit. Once you are close to or touching the nerve root, just contact can elicit pain. The mapping is the process of slowly increasing voltage in the 0.345 volt range. The patient is instructed to report any sensation of stimulation (i.e, paresthesia) and then the patient is asked “DO YOU FEEL IT” or tell as soon as you feel it. Followed by “IS THIS YOUR PAIN”. 

                              The stimulating catheter now moved to the next level and the same process is repeated, followed by the next level. Once the painful nerve root is identified, you verify by repeat stimulation by patient recognition. 

                              The patient will be able to identify the painful nerve roots without causing pain by just reaching the sensory threshold and recognizing the pain pathways.

                                Gabor B RaczGabor B Racz
                                Participant
                                Joined: Mar 28, 2016
                                Posts: 30
                                #44439

                                This is a very rare problem with two possible etiologies. I was called by Mohammed Tariq, M.D. recently to look at a patient from Pakistan with many years duration of severe loin, flank, umbilical pain and Allodynia. The patient could not stand any contact and he already had three DRG electrodes and two more to the T9 nerve root. The patient following this had almost no allodynia, still some pain and was able to sit up and touch his toes. I recognized the condition to be similar to a couple of others I had seen in London were Adnan Alkaisy, M.D. had placed two 8 contact electrodes. One of them was posterior to the nerve roots covering T9 10 and 11 and a T8 and down to T9, 10, 11 just towards the painful side dorsal column stimulation with excellent results. There is a name for this condition……”Nutcracker Syndrome” and Loin Pain with Micro-Hematuria and Macro-Hematuria. The supposed mechanism is the innervation of the kidney, where the artery and the vein or a split in the artery compresses the nerves. The name of surgery is “Switch Operation”, sometimes utilized with apparently a loss of the Kidney. I called Dr. Alkaisy last night and he is reporting a large series of this condition. He recommends that there should be epidural nerve root mapping published by Larkin, Carragee and Cohen a prospective randomized double blind trial. The second diagnostic option is described in the Second Edition of Techniques of Neurolysis, a 13 year old girl had abdominal wall pain T 10 pain and was unable to sit up and bend forward to touch her toes. She had her gall bladder taken out and the appendix as well in a prolonged hospitalization. The pain remained unchanged; I did a mapping in the area of T9, 10, 11 and found her epidural space densely scarred down from what appeared to be a leaky disk. Not significantly deformed, but thinner, Did Thoracic Neuroplasty and a 5 day infusion of Local Anesthetic and Fentanyl that resulted in several months pain relief and repeated the infusion procedure two more times. The last visit was a rather long drive to report that she had no more pain and was happy. The etiology is either a renal artery innervation issue with compression of the nerve or discogenic scarred nerve root.
                                Can the patient touch his toes?
                                Have you done a Dural Tug?
                                Has there been a Thoracic MRI report?

                                  in reply to: Arachnoiditis
                                  Gabor B RaczGabor B Racz
                                  Participant
                                  Joined: Mar 28, 2016
                                  Posts: 30
                                  #44433

                                  To appreciate the dural movement, I suggest you review the Cervical Neuroplasty video on Paincast in a patient that had three electrode placed at the C2 Level for Nucleus Caudalis stimulation. Electrodes adhere to the dura and indicate dural mobility. The dura is inserted to the foramen magnum and during the flexion rotation of the patients head and neck, the dura moves from 1 – 1.5 vertebral body lengths. The most richly innovated structure is the posterior longitudinal ligament. Therefore the Dural Tug is performed with the patient sitting up and then bending forward as much as possible and you flex and push the head down. This movement of the dura causes the patient to identify the exact location where the pain is coming from which is were the dura is adhered to the posterior longitudinal ligament. The picture of the lady pointing was taken the day before her procedure and the skin is marked with a pen. The next day the right picture has the patient were the Dural Tug is initiated and she points to the left side at the L2 Neural Foramen which is where the pain spiked during the TUG. This was confirmed by flouroscopy with a pointer to the left L2 Neural Foramen. Inter-laminar catheter mapping and Neuroplasty was performed on this patient and she had 3 years of complete pain relief I hope this helps and I will attach a video where I have one of my patient’s doing a Dural Tug” soon.

                                    in reply to: Arachnoiditis
                                    Gabor B RaczGabor B Racz
                                    Participant
                                    Joined: Mar 28, 2016
                                    Posts: 30
                                    #44392

                                    Sorry to hear, but this is a tricky case and seems to be missing some information. I do not read any reference of bladder function? A patient with Arachnoiditis, I would expect some bladder function issues. I would suggest you do a ‘Dural Tug’ on the patient, to see if there are adhesions between the dura and the posterior longitudinal ligament. If the patient experiences pain from the tug, it most likely will be localized and highlight the site of the painful condition. Please look at the 2nd edition of Techniques of Neurolysis, GB Racz, MD and Carl Noe, MD. Dr. Hitchcock has described that subarachnoid hypertonic saline injection in Cancer Pain caused great results and I have done the same in one patient under general endotracheal anesthesia. Usually there is improvement in motor function. The patient may also have improved bladder function. My patient did very well by having no pain post-procedure after the previous metastatic pelvic pain.
                                    Was the Arachnoiditis present with this patient before the procedure? After subarachnoid hypertonic saline, usually there is twitching for a few days followed by improved bladder function. At this stage, consider scarring triangle if the Dural tug is positive, through S1 or repeat hyaluronidase subarachnoid into the Caudal and Transforaminal Neuroplasty with ziconotide pump as motor function and pain relief are important. SCS? Please check for foot drop or weakness. Best Wishes!

                                    Warning: I do not advocate Lysis of Adhesions on patients with Arachnoiditis. The above case, I was going for a loose catheter fragment in the subarachnoid space. Injection under pressure into the arachnoiditis can cause ischemic loculation and injury to the cauda equina.

                                    ADDENDUM:
                                    I had one patient who had failed back surgery syndrome, secondary to arachnoiditis. The patient was wheelchair bound and paralyzed for several years from progressive arachnoiditis. Attempt was made to remove the loose catheter segment using epiduroscopy with normal saline injections to help with the visualization, after 2 hours, unsuccessful – terminated procedure. Later replaced the morphine sylastic line and patient recovered with full motor and bladder function. Hydro dissection with normal saline of the scarred -nerve root through the L5-S1 epidurascope (plus 1500 units of hyaluronidase was used.) the patient is walking, voiding normally.
                                    To this day the patient is under the care of my formal fellow TTUHSC Pain Program Director & Friend Miles Day, MD FIPP, Trawick-Racz Professor.

                                      Gabor B RaczGabor B Racz
                                      Participant
                                      Joined: Mar 28, 2016
                                      Posts: 30
                                      #43713

                                      Dear Dr.

                                      Thank you for opening this case up to open discussion. I suspected from the beginning some of the injected materials that went into unplanned locations. Iopamidol* is not an agent that I have ever been exposed to, looking up the attached Google abstract describes a patient who had seizures, tonic-clonic movement which is a rather unique hallmark of ionized contrast, but no contrast is immune from it. Very commonly tiny amount is fatal if injected into the subarachnoid space. The only remedy at the time of this occurring is twenty to forty minutes after the injection, but the subarachnoid space must be washed and rinsed out with preservative free normal saline. I had one of these patients were I used to think injecting through the surgical scar will free up the scar tissue. On that day, I watched the contrast dissect and burst into a chimney like structure which later, I understand, was subarachnoid contrast. The patient was seizuring, a moving target, but I was able to get a needle, extension tubing, 3-way stop cock and a liter of preservative-free normal saline and rinse the subarachnoid space out. The patient had a stormy recovery with 2-3 days in the intensive care unit, but survived. This was approximately in 1982-1983 . I believe this comes closest to the mechanism of action in your patient. Especially in view of the repositioned, possibly subdural catheter, where the fluid entered through the foramen magnum, intracranial space and drained through the foramen of Luschka and Magendi to the ventricular system.

                                      1. If you get the catheter to the wrong space, I would remove it and cancel the case and reschedule for 3-4 weeks. Patients understand caution.
                                      2. The Lydocaine vs. Ropivacaine should be to rule out subdural spread. It may not be induced during the procedure, but spreads through a surgical tear. In the presence of arachnoiditis and tight spinal stenosis you need to know if the spread occurred and there are no shortcuts. A fully trained ACLS certified nurse in the holding area can respond if there is a motor block.
                                      3. A small volume of contrast can tell you which space you have injected into which will prevent a bigger problem.

                                      Just as you can see I have been through problems over the last 38 years, my technique has improved through very careful selection of the safest approach and equipment. I do not feel the pressure, neither do I have the complications as I did at the beginning. Remember the incidence of complication is somewhere in 8 – 12000 and you may go a lifetime without any or you may have 2 in 2 weeks.

                                      My best regards,

                                      Gabor B. Racz, M.D.

                                      *Iopamidol, a water-soluble contrast agent, has been rarely associated with seizures. We describe a case of generalized tonic-clonic seizure after cervical myelography with iopamidol in a previously healthy young man. In patients presenting with seizures, a history of recent myelography should be considered as an etiology. Iopamidol myelography may be associated with a risk of seizures. Clinicians need to be aware of this complication and inform their patients about such risk. 

                                        Gabor B RaczGabor B Racz
                                        Participant
                                        Joined: Mar 28, 2016
                                        Posts: 30
                                        #43649

                                        Dear Dr.

                                        The examples used are from rather vivid memories just like your case shall remain with you for a very long time. The number one recognition when I looked at similar cases, makes one realize that these are extremely rare and secondly that we do not understand everything. A lot of the cases are beyond anyone physician’s potential experience because of the rarity, but because many of these cases have gone on to medical/ legal status. I have been an expert witness with information whatever was available to any party, was available to me.

                                        My first analysis of what has been done on this patient in terms of volumes of injected material, you have indicated 2 ml of 2% Lidocaine and 1 ml betamethasone, plus an unknown quantity of unknown hyaluronidase. In your discussion, you are talking about 2 boluses of an unknown quantity of contrast without being specific that it is safe for spinal administration. To be sure, please understand that I have never recommended 2% Lidocaine as the initial local anesthetic. The purpose of the local anesthetic, which should not by itself give a motor block, it is to indicate the appropriate tissue plane injection.

                                        Recommended Local Anesthetics are .2% Ropivacaine or 0.25% Bupivacaine. Either of these local anesthetics, if injected in the subdural space will develop a motor block usually in 14 or so minutes, but will not produce a motor block in the epidural space. Whereas, Lidocaine will give a motor block every time in the subdural and epidural space.

                                        The catheter virtually should never go through the dura to the subdural space, but you must remember to put a 2.5 cm 15 degree bend near the tip and slow-down in advancing and make sure you navigate to the target which is the ventral lateral epidural space. The subarachnoid space on aspiration inevitably gives cerebrospinal fluid and to review other points regarding dealing with technical issues recommend the chapter 9 in Techniques of Neurolysis 2nd edition, editors G.B. Racz: Carl Noe.

                                        Answering your questions:
                                        Every single one of what you have injected except possibly betamethasone can have disastrous consequences. Anaphylaxis is usually followed by edema and circulatory cardiovascular consequences. Most of the medications are drawn up by the nursing staff and the physician does not always check every medication given. A prime example is ionized versus non-ionized contrast material. A very small volume of ionized contrast can be lethal in the spinal canal.
                                        A male in his 50’s after multiple back surgeries with significant arachnoiditis causing lower extremity weakness, bowel/bladder dysfunction and pain. The patient was being evaluated for a morphine pump and was scheduled for a myelogram. 30 – 45 minutes later developed tonic-clonic movements with circulatory collapse. He was rapidly resuscitated but remained in a coma. Several hours later he had a repeat circulatory arrest and died. It had taken two years later to discover the explanation which was the substitution of the contrast to an ionized contrast. No catheter was used, the hyaluronidase was of bovine extract. Dani Moore published some 1200 epidural use of hyaluronidase in the 1950’s and suggested a high incidence of anaphylactic reactions, including death. His findings have not been substantiated. Recommended reading – Hyaluronidase: a review of approved formulations, indications and off-label use in chronic pain management. Dunn AL1, Heavner JE, Racz G, Day M.

                                        Example 1:
                                        Cervical epidural single shot steroid: Uneventful single shot epidural steroid injection was done initial 2 ml’s Omnipaque 240 2ml’s local anesthetic and 1ml 40mg Depomedrol. After observation 15 – 20 minutes post procedure the patient was getting dressed when it was noted that he lost consciousness and stopped breathing. The nursing staff called the patients physician who was talking to the family about how good the procedure went. Following resuscitation and intubation, the MRI showed a subdural and intracranial spread of the injected fluids. The following days CAT Scan showed contrast still visible in the cerebral ventricular system and lighting up the central canal of the spinal cord showing the draining of intracranial contents. Touhy needles have a long bevel and can easily cut through the dura to be in multiple spaces at the same time, such as subdural and epidural. The subdural space communicates with intracranial structures. The local anesthetic used was .25 Bupivacaine and it will not give motor block in the epidural space but will give motor block in 14 minutes or so in the subdural space. The patients must be closely observed especially the first 30 minutes.

                                        Example 2:
                                        A young patient with non-specific back pain had a lumbar single shot epidural steroid injection. The procedure went very well having an injection of contrast followed by local anesthetic .25% bupivacaine steroid 40 ml’s Depomedrol. The patient was observed to be sitting in the recovery area eating an orange. Attention for further recovery was relaxed, 15 minutes or so after this he was found to be in respiratory and cardiovascular arrest. Resuscitation failed. All patients need to be intently observed and monitored especially in the first 30 minutes. Once again the Touhy needle was used, the total volume injected was 8 ml’s.

                                        Example 3:
                                        An Elderly patient had failed back surgery, lower extremity and back pain, bowel/bladder dysfunction and significant arachnoiditis. The catheter entered the subdural space and following the injection of contrast, 10 ml’s of .25% bupivacaine and 1 ml of triamcinolone. The patient developed a post-procedure motor block that recovered in a few hours but had a loss of rectal tone function and ended up with a permanent colostomy. The urinary bladder sphincter control remained intact. The patient reported excellent recovery of severe pain. This is the reason we must not go into patients with arachnoiditis and the subdural space with any kind of volume injection as it loculates and interferes with blood flow. The patient was so pleased with the pain relief they never filed a lawsuit.

                                        Example 4:
                                        Single Shot Epidural Steroid severe C6 Radiculopathy. Previous fusion at C4-5 and C6-7. The first epidural steroid for this patient gives two weeks pain relief, three weeks later second injection 1ml contrast 3 ml’s local steroid consisting of .25% bupivacaine and 40mg triamcinolone. The procedure performed under propofol anesthesia. The intra-operative epiduragram shows a posterior left sided near midline dye spread to the C6 level. Post-procedure, the patient develops pain of the left arm and continues on to numbness and weakness along with loss of function. Three weeks later the patient was seen by his physician who immediately ordered an MRI that showed a syrinx in the C6 area of the spinal cord. The lesson is that the patient noting pain, numbness progressive weakness should notify their physician or designate. But equally important, the emergency room or rehab facility staff need to know that the patient has had an injection procedure which could be causing pressure, vascular compression and secondary ischemia and numbness. This could be reversed by flexion rotation exercises.

                                        Almost every single one of the reasons I listed above could have caused some of the problems to your patient. I would most certainly not give up on Hypertonic Saline, but would give up on 2% Lidocaine. Single shot epidural steroids because of the Touhy needle can cause respiratory arrest if it spreads into the subdural space. Interesting to note that at one time the primary neurotoxic insult was one-sided which implies that the injected material is the primary potential explanation and it may very well be the wrong type of contrast or absolutely any other liquid believing it was contrast unless you drew it up yourself.

                                        There have been well over 2 million Lysis cases done worldwide and even if it was a low-frequency occurrence, I would have heard about it. My deepest sympathies for the moment and wishing you a bright future ahead of you.

                                        Dr. Gabor B. Racz

                                          Gabor B RaczGabor B Racz
                                          Participant
                                          Joined: Mar 28, 2016
                                          Posts: 30
                                          #41913

                                          1. Peri-venous spread means that the high pressure fluids do not completely exit through the ipsilateral foramina, but also crosses the canal to exit through the contralateral side. This lateral spread normally allows pressure to return to normal. However, if this lateral spread is not allowed, pressure can increase on both sides of the spinal canal, exceeding the capillary perfusion pressure, causing ischemic pain. This can also cause numbness, weakness, secondary paralysis, and necrosis of neural structures. I have seen this in syrinx formation in three weeks’ time. A major warning sign can be pain from an injection, and you will also see accumulation in the lateral recesses as well as the contrast spreading across the spinal canal in form of peri-venous counter spread (PVCS). Weakness and numbness can occur rapidly. The overall incidence of cord injury is rare, and it is easily prevented by cervical motion and “Neural Flossing.” Flexion with rotation increases the size of neural IVF via the inferior pars sliding over the superior pars. Specific stretching force (Neural Flossing) on the involved nerve enhances nerve root mobility within the IVF. Without adequate runoff, even small injectate volumes can be deleterious. Extra space can be obtained by a fluid foraminotomy. This is easily performed by advancing a catheter into the IVF. Contrast in injected to observe proper placement, followed by hyaluronidase, and the anesthetic/steroid mixture. This will enhance venous drainage and runoff

                                          2. Reference PainCast neural flossing, and Techniques of Neurolysis 2nd Edition.
                                          Patients with severe cervical spinal stenosis should never be inject midline. The MRI report should be examined. Spinal fluid needs to be visible around the entire cord. The site of injection must be lateral to the dura, in the lateral recess. A small volume injection is started with ½ to 1cc of contrast followed by 1-2cc hyaluronidase, and the fluid spread needs to be observed. If the fluid spread follows the peri-venous route to the other side, the patient may complain of pain. Again, if there is pain, have the patient perform flexion with rotation (chin to shoulder). This will open the IVF and lower the pressure on the spinal cord.

                                          Epidural hematomas are relatively common from needle sticks. Therefore avoid the higher venous density areas of the upper C-spine (T1-T3). The transitional area (C7-T1) is where the cervical, ventral venous plexus converts to dorsal, thoracic venous plexus.

                                          Answer: Cervical neuroplasty is one of the most effective and safe procedures, even in severe cases of spinal stenosis. However, there is a challenging learning curve for the procedure, and the patient follow up is extremely important. Patients must keep in contact with the treating physician and must understand the importance of flexion-rotation as a mechanism of reducing intra-spinal canal pressure as well as Neural Flossing as their physical therapy. Therefore the physician must demonstrate these modalities in the office while explaining the importance of continuing the physical therapy at home (frequency and duration are case dependent).

                                          Attached are both images of the contrast accumulation and flexion rotation.

                                          Attachments:
                                          You must be logged in to view attached files.
                                            Gabor B RaczGabor B Racz
                                            Participant
                                            Joined: Mar 28, 2016
                                            Posts: 30
                                            #40858

                                            Yes, for facet. The primary use for larger active tip is splanchnic, lumbar sympathetic, but double lesioning for lumbar facets will cover any anatomical variations without jeopardizing the nerve root. Cervical posterior approach, one lesion is usually adequate diagonally without rotation.

                                            Particularly anterior lateral approach is where we see undesirable lesioning with a very large lesion, and I do not ever see the need for a very large lesion in the neck.

                                            Peripheral nerves, I very much prefer cryolysis over a very large radiofrequency lesion. No neuritis with cryolysis. Large lesions in proximity to motor nerves can give motor deficit. Must use motor nerve stimulation preferably to 2V. Costs do matter, especially when you can get the same or better result for very much less.

                                              Gabor B RaczGabor B Racz
                                              Participant
                                              Joined: Mar 28, 2016
                                              Posts: 30
                                              #40773

                                              I regret for the delay, but I’m on vacation. Here is the 16g 10mm RF coudé compared to the 17g Cooled RF. The measurements on different needle sizes with and without 180° rotation are also available if you’re interested.

                                              Attachments:
                                              You must be logged in to view attached files.
                                                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

                                                  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
                                                    #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

                                                    Attachments:
                                                    You must be logged in to view attached files.
                                                    Viewing 25 posts - 1 through 25 (of 33 total)