epidural adhesiolysis/racz racz procedure

[TIVAndy]

none of the attendings did this in fellowship so i never had any exposure to this procedure.

for those of you who do it or don't do it what's your experience with this procedure?
is it worth it to add it to our armamentarium?

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[Ducttape]

Very few people do it because it doesn’t really work...

 

[Aether2000]

Essentially, you are poking holes in bands of scar tissue adhering the nerve to the dura and and ligamentum flavum. These bands of scar tissue are filamentous (as per my experience with epiduroscopy) and are not easily lysed. Most of the significant adhesions are anterolateral- a place that you usually do not target with lysis of adhesions due to difficulty entering the anterior epidural space. Placement of a spiral wound wire causes channels to form, can cause nerve damage, and can cause penetration of the dura. If hypertonic saline (part of the protocol for epidurolysis of adhesions) is injected subdural, it can cause severe pathology including paralysis. Receiving payment for this admittedly brutal procedure is difficult and the outcomes are not significantly better than a TFESI.

 

[NJPAIN]

Whenever I see a discussion about Racz catheters and lysis of adhesions it always brings to mind the vast Racz empire. Epimed, WIP, and the associated FIPP certification. At the very least he is a marketing genius. He has a cult like following and he is so so very confident and convincing that his techniques are incredibly effective. I honestly don’t know who/what to believe.


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[lobelsteve]

Whenever I see a discussion about Racz catheters and lysis of adhesions it always brings to mind the vast Racz empire. Epimed, WIP, and the associated FIPP certification. At the very least he is a marketing genius. He has a cult like following and he is so so very confident and convincing that his techniques are incredibly effective. I honestly don’t know who/what to believe.


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Tend not to believe the guy selling me something that only works in his hands.

 

[NJPAIN]

Good point


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[bronchospasm]

We did tons of this in fellowship. Most of the time. It did not work. Also not reimbursed in my state.

 

[Doctodd]

Tend not to believe the guy selling me something that only works in his hands.

May he RIP, but what did we know as fellows, especially since his book was full of mistakes. And we used wydase to "dissolve" the adhesions....in theory.

 

[TIVAndy]

Essentially, you are poking holes in bands of scar tissue adhering the nerve to the dura and and ligamentum flavum. These bands of scar tissue are filamentous (as per my experience with epiduroscopy) and are not easily lysed. Most of the significant adhesions are anterolateral- a place that you usually do not target with lysis of adhesions due to difficulty entering the anterior epidural space. Placement of a spiral wound wire causes channels to form, can cause nerve damage, and can cause penetration of the dura. If hypertonic saline (part of the protocol for epidurolysis of adhesions) is injected subdural, it can cause severe pathology including paralysis. Receiving payment for this admittedly brutal procedure is difficult and the outcomes are not significantly better than a TFESI.

thanks for your input. anyways can you shed me some light on epiduroscopy? i've heard of it and read about it here and there but never seen anyone do it.

 

[epidural man]

Adhesiolysis probably works if done correctly - but when we do them in my clinic, we don't do them correctly.

The question isn't if it works...the question is...is it worth it? And the answer is...no..if done correctly, the benefits don't outweigh the risks.

Same with epiduroscopy. There is definitely benefit - but benefits clearly don't outweigh risks with that.

 

[Aether2000]

There were a few options for epiduroscopy- a very small gauge scope through a rigid outer introducer with a flex tip or using a hysteroscope through a Cordis introducer placed through the sacrococcygeal ligament. The problem with the former is there was effectively no working channel within the scope. The latter did have a working channel and we tried several means of adhesiolysis- mechanical via the scope itself, using grasping forceps, small knife tips, and HoYAG lasers. Adhesions were sometimes very dense but most were filamentous fine lesions. The idea of poking holes through these fine lesions made no sense using a epidurolysis catheter since we could see nothing would happen with the epiduroscope. Lasering worked but caused thermal transfer to the nerve in spite of cool normal saline being used to irrigate, therefore lasering the adhesion had the same effect as lasering the nerve from a patient standpoint- very painful. We also tried injecting Adcon-L into the epidural space through a catheter placed through the working channel of the scope. Usually you had to dilute it down in order to get it injected, and this may have changed the ionic barrier properties of the substance. In any case, it was cool to see the adhesions, and it helped to understand the anatomy of nerves being tethered to dura and ligamentum flavum, but you really could not effectively treat the adhesions using the technology that was available in the 1990s and 2000s

 

[Ferrismonk]

I did a ton of LOEA procedures in fellowship and they were paid for on about half the insurances. They usually worked pretty well and it was a nice bridge between LESI/TFESI and surgery. I don't do them in my clinic though because I don't think the risk/reward is there. In fellowship I did them in the OR with laparotomy drape, gown/glove/mask/hat, antibiotic solution to soak catheter, and sedation including opiates. We would budget an hour or so and sometimes would go through 2-3 catheters if they became too kinked. I can't replicate those conditions in my office procedure suite very well and I think the risk/reward ratio is low. Especially when you consider the cost of supplies to in-office reimbursement.

 

[lobelsteve]

I did a ton of LOEA procedures in fellowship and they were paid for on about half the insurances. They usually worked pretty well and it was a nice bridge between LESI/TFESI and surgery. I don't do them in my clinic though because I don't think the risk/reward is there. In fellowship I did them in the OR with laparotomy drape, gown/glove/mask/hat, antibiotic solution to soak catheter, and sedation including opiates. We would budget an hour or so and sometimes would go through 2-3 catheters if they became too kinked. I can't replicate those conditions in my office procedure suite very well and I think the risk/reward ratio is low. Especially when you consider the cost of supplies to in-office reimbursement.

Worked well per recall. No data collected, no research protocol. Just background noise and bias. Placebo a deux. But no harm done. Read Algos post above. Procedure does not pass scientific plausibility.

 

[clubdeac]

I did these in fellowship. Once I didn’t wait long enough for the anesthetic to take effect prior to injecting hypertonic saline. The patient screamed bloody murder the entire time. It wasn’t until after the procedure that I read that hypertonic saline was extremely irritating and painful

 

[emd123]

May he RIP, but what did we know as fellows, especially since his book was full of mistakes. And we used wydase to "dissolve" the adhesions....in theory.

What were the mistakes?