epidural adhesiolysis

[epidural man]

Who's doing it?

Old thread on the subject

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[epidural man]

New data on old subject. View attachment epi adhesiolysis for radicular pain RCT pain physician 2013.pdf

 

[epidural man]

And some more...

View attachment epi adhesiolysis for lumbar central stenosis IJOS 2013.pdf
View attachment epi adhesiolysis for cervical central stenosis pain physician 2013.pdf
View attachment epi adhesiolysis for lumbar central stenosis pain physician 2013.pdf

 

[jj337]

Did tons in fellowship (>50) and have been out for about 3 years.

Did my first two this week... See how it goes.

 

[clubdeac]

Did tons in fellowship (>50) and have been out for about 3 years.

Did my first two this week... See how it goes.

Did tons huh.... must've been at Texas Tech I assume. Can you give pointers for those of use who have done 10-20 and got ****ty results. Does it involve anything more than threading the catheter up to the site of fibrosis, mucking around back and forth, injecting local, waiting a bit, injecting hypertonic saline and then some steroid and pulling out?

 

[lobelsteve]

I'll do a few target cath's every year with good results for leg pain, nothing for back pain.

I don't get the 3 day catheter in the caudal space. Are they inpatient?

Infection risk?

 

[jj337]

Had 3-4 attendings who trained at Texas Tech... they loved to do it. I was at UT Southwestern and had 12-13 attendings so had a few different perspectives and opionions from different attendings but all had a strong Texas Tech slant. Never really thought I had great results but hard to follow up in fellowship.

No pointers. Although I did a bunch, I have avoided it since leaving fellowship mostly because I didn't feel it helped. One day LOA with Hylenex 300 units. I try not to muck around too much because I seemed to have vascular uptake when that occured too much. Texas Tech guys use (from what I remember) like 1200 units but I do have the cojones to do that and we used 300 units at UT Southwestern. Take pre and post images which "look better" but whether that translates to better results is questionable in my hands. Followed with depomedrol/lidocaine.

I am doing my first two in private practice on two ladies with radicular leg pain, unresponsive to virtually everything else. One had SCS trial and didn't like it. The other never had SCS trial. First LOA on Wed, second one today. N=2. Wait and see.

 

[epidural man]

Had 3-4 attendings who trained at Texas Tech... they loved to do it. I was at UT Southwestern and had 12-13 attendings so had a few different perspectives and opionions from different attendings but all had a strong Texas Tech slant. Never really thought I had great results but hard to follow up in fellowship.

No pointers. Although I did a bunch, I have avoided it since leaving fellowship mostly because I didn't feel it helped. One day LOA with Hylenex 300 units. I try not to muck around too much because I seemed to have vascular uptake when that occured too much. Texas Tech guys use (from what I remember) like 1200 units but I do have the cojones to do that and we used 300 units at UT Southwestern. Take pre and post images which "look better" but whether that translates to better results is questionable in my hands. Followed with depomedrol/lidocaine.

I am doing my first two in private practice on two ladies with radicular leg pain, unresponsive to virtually everything else. One had SCS trial and didn't like it. The other never had SCS trial. First LOA on Wed, second one today. N=2. Wait and see.

How did they do?

 

[clubdeac]

Had 3-4 attendings who trained at Texas Tech... they loved to do it. I was at UT Southwestern and had 12-13 attendings so had a few different perspectives and opionions from different attendings but all had a strong Texas Tech slant. Never really thought I had great results but hard to follow up in fellowship.

No pointers. Although I did a bunch, I have avoided it since leaving fellowship mostly because I didn't feel it helped. One day LOA with Hylenex 300 units. I try not to muck around too much because I seemed to have vascular uptake when that occured too much. Texas Tech guys use (from what I remember) like 1200 units but I do have the cojones to do that and we used 300 units at UT Southwestern. Take pre and post images which "look better" but whether that translates to better results is questionable in my hands. Followed with depomedrol/lidocaine.

I am doing my first two in private practice on two ladies with radicular leg pain, unresponsive to virtually everything else. One had SCS trial and didn't like it. The other never had SCS trial. First LOA on Wed, second one today. N=2. Wait and see.

You just injecting the hylenex or also hypertonic saline? steroid? anesthetic? Give me the recipe!! Only if it works of course

 

[jj337]

0 for 2. These patients already had about everything else done on them and weren't improving... Maybe weren't the best candidates.

Maybe I need a better recipe or need to scrap the whole idea.

Pre-adhesiolysis pictures (2-3 mL contrast)

300 units of Hylenex (2 mL) - Thinking either I need more like the Texas Tech guys or maybe dilute it in saline?

Post-Adehesiolysis picutes.

4 mL of 1% Lidocaine and 2 mL Depo-Medrol.

 

[clubdeac]

0 for 2. These patients already had about everything else done on them and weren't improving... Maybe weren't the best candidates.

Maybe I need a better recipe or need to scrap the whole idea.

Pre-adhesiolysis pictures (2-3 mL contrast)

300 units of Hylenex (2 mL) - Thinking either I need more like the Texas Tech guys or maybe dilute it in saline?

Post-Adehesiolysis picutes.

4 mL of 1% Lidocaine and 2 mL Depo-Medrol.

The recipe I was using from personal disscusion with Tibor Racz was this:

2-3cc contrast to see the filling defect
then 7cc 2% lidocaine, wait 20min to ensure no subdural injection
then 7cc hypertonic saline (muck around with catheter a bit too)
follow with 2cc 0.25% marcaine and 40mg kenalog
remove catheter and voila!

I got about a 30% response rate when doing these. The meta-analysis we reviewed in fellowship showed there was no beneift of adding hyaluronidase so I wasn't using it. I dunno...

 

[epidural man]

The recipe I was using from personal disscusion with Tibor Racz was this:

2-3cc contrast to see the filling defect
then 7cc 2% lidocaine, wait 20min to ensure no subdural injection
then 7cc hypertonic saline (muck around with catheter a bit too)
follow with 2cc 0.25% marcaine and 40mg kenalog
remove catheter and voila!

I got about a 30% response rate when doing these. The meta-analysis we reviewed in fellowship showed there was no beneift of adding hyaluronidase so I wasn't using it. I dunno...

Why not use more volume for some hyrdodissection/hydroadhesiolysis?

I don't do them, but some in my group inject a ton of solution (saline or contrast) for hydrodissection. It seems to open the space up nicely. But often they are not using hypertonic saline or hyaluronidase.

 

[jj337]

I think I will use more volume the next time I do it... Can't be much worse

 

[clubdeac]

Why not use more volume for some hyrdodissection/hydroadhesiolysis?

I don't do them, but some in my group inject a ton of solution (saline or contrast) for hydrodissection. It seems to open the space up nicely. But often they are not using hypertonic saline or hyaluronidase.

He said he used to do 10cc contrast, 10cc lidocaine and 10cc hypertonic saline but refined it down to a smaller volume as he felt like it was too much when all said and done, total volume of 30-35cc

 

[pjuer]

I would be cautious with the hypertonic saline. A patient of mine had this done by her previous pain physician. Went intrathecal, permanent nerve damage and big lawsuit underway

 

[nvrsumr]

30cc is a high volume. I remember a paper somewhere about retinal hemorrhage after high volume esi....

 

[clubdeac]

Yeah that's why they say to wait 20min to ensure that it's not just not intrathecal but also not subdural. And that's why he went to the smaller volume b/c he was concerned with even 30-35cc's. Now it's more like 20cc's and when doing it I only used 3% hypertonic, not 10% that they advocated. Anyway..... I don't do it anymore and probably won't now that i'm no longer under the protective umbrella of the VA

 

[bedrock]

I would be cautious with the hypertonic saline. A patient of mine had this done by her previous pain physician. Went intrathecal, permanent nerve damage and big lawsuit underway

Why are you seeing this patient? It's unfortunate what happened, but it is a known potential complication of the procedure.

I wouldn't treat this patient at all and just tell them I can't do anything for them.

Part of a doctor-patient relationship is the mutual understanding that the doctor is doing his/her best to treat you, and often is going out on a limb to help the patient. Part of informed consent is the patient also taking on responsibility that these .1% complications do occur. .1% means it happens to 1/1000 people. So it is EXPECTED that 1/1000 people will have this complication, although no one expect they will be that 1 out of 1000.

That doesn't mean the patient just gets to sue you if anything happens they don't like, and then assume after the lawsuit that a bunch of other doctors will just line up to put their neck on the line for the patient again after they broke the doctor-patient relationship by suing their doctor.

To those patients, I say F%@k you.

I refuse to treat any patient who has sued a physician, (outside of gross negligence like a drunk surgeon etc).

 

[deleted185747]

Do you drain the injectate thru the catheter after you do the adhesiolysis?

 

[pjuer]

Why are you seeing this patient? It's unfortunate what happened, but it is a known potential complication of the procedure.

I wouldn't treat this patient at all and just tell them I can't do anything for them.

Part of a doctor-patient relationship is the mutual understanding that the doctor is doing his/her best to treat you, and often is going out on a limb to help the patient. Part of informed consent is the patient also taking on responsibility that these .1% complications do occur. .1% means it happens to 1/1000 people. So it is EXPECTED that 1/1000 people will have this complication, although no one expect they will be that 1 out of 1000.

That doesn't mean the patient just gets to sue you if anything happens they don't like, and then assume after the lawsuit that a bunch of other doctors will just line up to put their neck on the line for the patient again after they broke the doctor-patient relationship by suing their doctor.

To those patients, I say F%@k you.

I refuse to treat any patient who has sued a physician, (outside of gross negligence like a drunk surgeon etc).

At the time I saw this patient over several months, I had no idea there was a lawsuit. The patient refused further treatment "after Dr X paralyzed me". Several months later a physician working with me informed me of the suit. He was one of the plaintiff experts.

Normally I side with the doc. But when you berate patients, run them thru procedures like cattle, do multiple procedures, and procedures in search of an indication (adhesiolysis), I have no sympathy.