adhesiolysis

[ParaVert]

What are people's opinions on epidural adhesiolysis?

I'm seeing tons of post-lami who have terrible contrast spread making targeted ESIs tough (even transforaminally). The technique seems easy. Before I jump to stim, should I consider trying this? Is anybody out there still doing this? Hypertonic saline and hyaluronidase?

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[Aether2000]

I abandoned hypertonic saline some time ago, but continue hyaluronidase when I only occasionally perform these procedures that seem to give short term relief.

 

[lobelsteve]

I believe Racz lysis is a scam to sell needles.

I believe strongly in Target adhesiolyis (EBI or Myelotec) is very effective for burning pain below the knee from epidural fibrosis at L5-S1. I use Wydase, hypertonic, lidocaine, Celestone, and Omnipaque to document how much "ground" I picked up.

Results are from 6 months to 2 years for the burning below the knee, much worse for axial or thigh pain.

 

[Mister Mxyzptlk]

I would suggest that anyone who embraces the concept of adhesiolysis scrub in on a few postlaminectomy backs and see what epidural fibrosis looks like. True fibrosis is like shoe leather.

Have you ever replaced a pump and found dense adhesions around the the connector and you have to spend forever teasing it apart without damaging the catheter (which always seems to be twisted around it in a knot that would make a sailor cross-eyed). That is what epidural scar tissue is like. Try taking down those pump adhesions with a catheter and some Wydase. Or better yet, do it percutaneously with fluoro.

And how does Wydase know what to dissolve and what not to dissolve? When did it become selective for scar tissue?

Back around 1997 I was at a meeting at MERI and Racz was talking about adhesiolysis. There was a neurosurgeon in the audience and he completely dismantled Racz.

What I would really like to see is before and after MRIs with contrast showing that the scar was dislodged or dissolved, not some picture of dye spread. Who knows what that actually signifies?

 

[spinal]

I see good results with lysis, if pt are selected carefully. Like with everything else patient selection is the key. We do a good number of these in our center.
FBSS and scarring- most of the scarring is outside epidural space-you can not cut this even with a knife. The epidural space contains mostly fat.
I have scrubed in in several laminotomy leads and have seen that there is still fat in epidural space. Fat does not scarr down does it?
Lysis of adhesions is good for ventral epidural scarring caused by a leaking discs and pt also has foraminal stenosis that you can not get enything in via TFESI.
So minimal scarring can be helped even in epidural space, but if it is severe forget it.
What do you guys do? Going for SCS right away or do something else.I am sure for stims you all select the right patients too. What if trial fails? What the pt is not a candidate for stim for whatever reason? What do you all do if the patients has no denaro to pay for the stim? Do you repeat the TFESI even if you can't get anything in there. TLESI- even when nothing spreads up. Or tell the pt-----sorry I can not help you.
Epiduroscopy? Any thoughts on this?
Share your thoughts and experience.

 

[drusso]

I think it is a procedure in search of an indication...you can't unboil an egg.

 

[Doctodd]

sorry to resurrect this thread, but i am in search of a supplier for hypertonic saline. PSS doesnt seem to carry it. Any suggestions?....wydase too. Im a little less afraid of the wydase. Here is the price im being quoted for wydase.

As for the price on the med, amphadase, it is - $216 for a box of 10 or $541 for a box of 25

 

[Mister Mxyzptlk]

I thought that hyaluronidase and hypertonic saline didn't add anything to the equation. I think Lax published something few years ago (2004?) where hypertonic saline was no better than w/o saline.

Agree with drusso. Anyone who's seen scar tissue in vivo at laminectomy knows that a flimsy little catheter isn't going to do much. I was at a lecture on this subject given by by Racz about 10 years ago and there was a neurosurgeon in the audience who ripped him a new rectal orifice.

Anything you can push out of the way and improve using epidural catheters is not true scar tissue. I've had plenty of patients where initial epidurography didn't look good but after further injection there was better spread, but I never tried to claim I "lysed" anything.

 

[Doctodd]

So what does the neurosurgeon think about pennies dissolving in coca-cola? Chemistry is chemistry. ALso, i dont think the catheter has much to do with it. Here is the wydase insert.

Clinical Pharmacology
Hyaluronidase is a spreading or diffusing substance which modifies the permeability of connective tissue through the hydrolysis of hyaluronic acid, a polysaccharide found in the intercellular ground substance of connective tissue, and of certain specialized tissues, such as the umbilical
cord and vitreous humor. Hyaluronic acid is also present in the capsules of type A and C hemolytic streptococci. Hyaluronidase hydrolyzes hyaluronic acid by splitting the glucosaminidic bond between C1 of the glucosamine moiety and C4 of glucuronic acid. This temporarily decreases the viscosity of the cellular cement and promotes diffusion of injected fluids or of
localized transudates or exudates, thus facilitating their absorption.
Hyaluronidase cleaves glycosidic bonds of hyaluronic acid and, to a variable degree, some other acid mucopolysaccharides of the connective tissue. The activity is measured in vitro by monitoring the decrease in the amount of an insoluble serum albumen-hyaluronic acid complex

 

[Tenesma]

let's do adhesiolysis with coca-cola -

 

[Doctodd]

if it helps the patients im all for it ;-)

 

[Mister Mxyzptlk]

So what does the neurosurgeon think about pennies dissolving in coca-cola? Chemistry is chemistry. ALso, i dont think the catheter has much to do with it. Here is the wydase insert.

Inject your skin with Wydase & see how much of it dissolves.

I asked a neurosurgeon about dissolving pennies in Coca Cola and he was 100% in favor of it.