treatments for post-surgical epidural scar tissue

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Have patient with previous L5-S1 diskectomy with persistent S1 radicular pain for 10 years. Has essentially dealt with pain but has become more bothersome over the last 2 yrs. Pain is burning, crampy pain in S1 distribution in left lower limb. No neurological deficits on exam. New MRI of L-spine with contrast show epidural scar in epidural space at L5-S1. No recurrent disk herniation. EMG of left lower limb demonstrates chronic S1 radiculopathy. Started him in PT with gabapentin 300 tid.

Wondering if any of you would employ epidural injection or other measures if above fails. Seems like lysis of adhensions with racz has fallen out of favor. Thanks.

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Have patient with previous L5-S1 diskectomy with persistent S1 radicular pain for 10 years. Has essentially dealt with pain but has become more bothersome over the last 2 yrs. Pain is burning, crampy pain in S1 distribution in left lower limb. No neurological deficits on exam. New MRI of L-spine with contrast show epidural scar in epidural space at L5-S1. No recurrent disk herniation. EMG of left lower limb demonstrates chronic S1 radiculopathy. Started him in PT with gabapentin 300 tid.

Wondering if any of you would employ epidural injection or other measures if above fails. Seems like lysis of adhensions with racz has fallen out of favor. Thanks.

For burning pain below the knee I do adhesiolysis, but not Racz's crap. I use a target cath through the sacral hiatus. If whole leg or N&T, SCS. I don't think steroids penetrate through scar tissue too well and I am unimpressed with repeat ESI for FBSS.
 
You can do ESI, just to prove it only helps a little or for a short time. Ultimately he'll end up with a SCS.
 
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For burning pain below the knee I do adhesiolysis, but not Racz's crap. I use a target cath through the sacral hiatus. If whole leg or N&T, SCS. I don't think steroids penetrate through scar tissue too well and I am unimpressed with repeat ESI for FBSS.

What's your adhesolysis technique? How is it better than a high volume caudal?
 
What's your adhesolysis technique? How is it better than a high volume caudal?

Target cath via 14-16g caudal Tuohy. Advance to region of scar. 5cc contrast, 3cc lido. Tease into scar with back and forth plus left/right sweeping motion. 150u Wydase then more wiggling of cath. 3-5cc contrast to see if increased flow. If yes the hypertonic saline. If no then steroids and done.
 
Have patient with previous L5-S1 diskectomy with persistent S1 radicular pain for 10 years. Has essentially dealt with pain but has become more bothersome over the last 2 yrs. Pain is burning, crampy pain in S1 distribution in left lower limb. No neurological deficits on exam. New MRI of L-spine with contrast show epidural scar in epidural space at L5-S1. No recurrent disk herniation. EMG of left lower limb demonstrates chronic S1 radiculopathy. Started him in PT with gabapentin 300 tid.

Wondering if any of you would employ epidural injection or other measures if above fails. Seems like lysis of adhensions with racz has fallen out of favor. Thanks.

Don't treat the imaging. SCS, Racz never was in vogue with orthodox practitioners.
 
Have patient with previous L5-S1 diskectomy with persistent S1 radicular pain for 10 years. Has essentially dealt with pain but has become more bothersome over the last 2 yrs. Pain is burning, crampy pain in S1 distribution in left lower limb. No neurological deficits on exam. New MRI of L-spine with contrast show epidural scar in epidural space at L5-S1. No recurrent disk herniation. EMG of left lower limb demonstrates chronic S1 radiculopathy. Started him in PT with gabapentin 300 tid.

Wondering if any of you would employ epidural injection or other measures if above fails. Seems like lysis of adhensions with racz has fallen out of favor. Thanks.
Have you tried a TFESI at L5/s1 or even through the S1 neuroforamen yet? This could be diagnostic , as well as therapeutic.

I've seen a few Racz procedures. Unfortunately, I never saw any 'opening up " of any foramen or the epidural space when I saw what these tguys were doing....
 
For burning pain below the knee I do adhesiolysis, but not Racz's crap. I use a target cath through the sacral hiatus. If whole leg or N&T, SCS. I don't think steroids penetrate through scar tissue too well and I am unimpressed with repeat ESI for FBSS.

So regular catheter. Any preference? I use an epimed kit. Introducer cath on a tuohy and a radio opaque 20g or so catheter that I can bend the otherwise floppy tip a little to help guide it.

Is it mostly manual lysis or are you injecting hyaluronate or hypertonic saline?
 
So regular catheter. Any preference? I use an epimed kit. Introducer cath on a tuohy and a radio opaque 20g or so catheter that I can bend the otherwise floppy tip a little to help guide it.

Is it mostly manual lysis or are you injecting hyaluronate or hypertonic saline?

Yeah Steve, what catheters are you using? I use the epimed tunnel- XL and brevi for cervicals. I think they're both rather flimsy and difficult to steer....
 
So regular catheter. Any preference? I use an epimed kit. Introducer cath on a tuohy and a radio opaque 20g or so catheter that I can bend the otherwise floppy tip a little to help guide it.

Is it mostly manual lysis or are you injecting hyaluronate or hypertonic saline?

1000Units Hyaluronidase, not hyaluronate.
RACZ work well in my opinion (compared to TFESI's with foraminal obstruction), just needs to be repeated in fusion patients.
 
For burning pain below the knee I do adhesiolysis, but not Racz's crap. I use a target cath through the sacral hiatus. If whole leg or N&T, SCS. I don't think steroids penetrate through scar tissue too well and I am unimpressed with repeat ESI for FBSS.

Adhesioilysis or Racz's - either one can work well..it's impressive how the contrast flow changes.

But in my experience, the scar reoccurs - and why wouldn't it - we probably are just recreating more inflammation in the area.

I know you would never do this since you can't get paid for it (sad that is how decision on how to treat patients are made), but try pulsing the DRG.
 
Adhesioilysis or Racz's - either one can work well..it's impressive how the contrast flow changes.

But in my experience, the scar reoccurs - and why wouldn't it - we probably are just recreating more inflammation in the area.

I know you would never do this since you can't get paid for it (sad that is how decision on how to treat patients are made), but try pulsing the DRG.[/QUOTE]

I do that along with injecting a little LA and steroid and bill as a lumbar tf
 
Adhesioilysis or Racz's - either one can work well..it's impressive how the contrast flow changes.

But in my experience, the scar reoccurs - and why wouldn't it - we probably are just recreating more inflammation in the area.

I know you would never do this since you can't get paid for it (sad that is how decision on how to treat patients are made), but try pulsing the DRG.[/QUOTE]

I do that along with injecting a little LA and steroid and bill as a lumbar tf
paper out of beth israel suggsting this works.


Whats your experience been w/ pulsing the DRG? Ithink over there, they were continuous RF'ing, but at a lower temp (60deg)
 
I can understand prf DRG if there is scar in the Foramen at the level of the actual DRG. What about more neuraxial scar? It seems the DRG would be peripheral to what is actually causing pain.
 
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