Epidural Lysis of Adhesions (article): is anyone doing this?

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I've done them before. Weird procedure with even weirder patients.
 
They were done where I did my residency in patients with FBSS, filling defects on caudal epidurogram and ideally signs of epidural fibrosis on MRI.

Pretty good results in general, typically a few years of significant (50%+ improvement). Often an intermediate step in these patients to see if it's possible to avoid a SCS.
 
When I trained more than 15 years ago, this was not impressive. How do you break up scar tissue with a piece of spaghetti?

I always thought if your device is rigid and abrasive enough to break up scar tissue, it is too dangerous to maneuver around fragile nerves.

Has anything changed?
 
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hyperalgesia said:
When I trained more than 15 years ago, this was not impressive. How do you break up scar tissue with a piece of spaghetti?

I always thought I'd your device is rigid and abrasive enough to break up scar tissue, it is too dangerous to maneuver around fragile nerves.

Has anything changed?
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It's the volume injected that breaks up the scar tissue. I'd have to find the article but the technique itself or what's injected doesn't really matter. The only parameter than was correlated with effectiveness was volume injected.
 
Did these in fellowship and awhile in practice. Never saw amazing results. Just make sure you numb 'em up good before injecting hypertonic saline. That stuff burns like a mother. Would also mix in some hyaluronic acid. Not sure if it did anything though
 
epidural scarring is like shoe leather. not really sure what injecting a little water is gonna do
 
I trained in Texas 17 years ago. At the time, Lysis of Adhesions was taught to all fellows. It's still a relatively niche service. In my practice, I do 1-2 caudal esi with LOA's per month. Some post-surgical patients who don't respond to much of anything will respond to this procedure. Typical response is 6 months. I use hylenex 150Units, along with 10-12mL volume of lidocaine 1% (3-4 mL) / NS 6mL/ Depo 20-40mg. In the right patient (PLIF, epidural scarring, prior lami, some foraminal stenosis at L45 or L5s1) it does quite well, and often much improvement over a typical caudal esi or tfesi. Do I have great data or studies on this--no. Most insurances do not cover this, so we have to charge for the Racz catheter and the hylenex. Not all patients respond to SCS, and many of these patients don't like the idea of an SCS implant, so most of them are repeat patients (every 6mo-1 year).
 
PainMD23 said:
I trained in Texas 17 years ago. At the time, Lysis of Adhesions was taught to all fellows. It's still a relatively niche service. In my practice, I do 1-2 caudal esi with LOA's per month. Some post-surgical patients who don't respond to much of anything will respond to this procedure. Typical response is 6 months. I use hylenex 150Units, along with 10-12mL volume of lidocaine 1% (3-4 mL) / NS 6mL/ Depo 20-40mg. In the right patient (PLIF, epidural scarring, prior lami, some foraminal stenosis at L45 or L5s1) it does quite well, and often much improvement over a typical caudal esi or tfesi. Do I have great data or studies on this--no. Most insurances do not cover this, so we have to charge for the Racz catheter and the hylenex. Not all patients respond to SCS, and many of these patients don't like the idea of an SCS implant, so most of them are repeat patients (every 6mo-1 year).
Click to expand...
I've heard stories about how Racz would go to town and do these quite aggressively in the cervical spine. Now that would freak me out!
 
PainMD23 said:
I trained in Texas 17 years ago. At the time, Lysis of Adhesions was taught to all fellows. It's still a relatively niche service. In my practice, I do 1-2 caudal esi with LOA's per month. Some post-surgical patients who don't respond to much of anything will respond to this procedure. Typical response is 6 months. I use hylenex 150Units, along with 10-12mL volume of lidocaine 1% (3-4 mL) / NS 6mL/ Depo 20-40mg. In the right patient (PLIF, epidural scarring, prior lami, some foraminal stenosis at L45 or L5s1) it does quite well, and often much improvement over a typical caudal esi or tfesi. Do I have great data or studies on this--no. Most insurances do not cover this, so we have to charge for the Racz catheter and the hylenex. Not all patients respond to SCS, and many of these patients don't like the idea of an SCS implant, so most of them are repeat patients (every 6mo-1 year).
Click to expand...
Theatrical placebo.

Lots of meds, lots of volume, strong belief. No different than moa for voodoo.
 
Not a proponent but I’d try it before a battery personally
 
How does high pressure, high volume fluid disrupt scar tissue, which is connective tissue, but doesn't disrupt fragile neurological tissue?

In ophtho, when a person develops symptomatic adhesions on the retina, they go in with a scope, stain the adhesions, and gently peel them off the retina. We should be more like that.

It constantly amazes me that the smartest people come up with the worst ideas. In all of medicine, not just in pain.
 
hyperalgesia said:
How does high pressure, high volume fluid disrupt scar tissue, which is connective tissue, but doesn't disrupt fragile neurological tissue?

In ophtho, when a person develops symptomatic adhesions on the retina, they go in with a scope, stain the adhesions, and gently peel them off the retina. We should be more like that.

It constantly amazes me that the smartest people come up with the worst ideas. In all of medicine, not just in pain.
Click to expand...

Having worked as a greenskeeper, this might do it....
 
SSdoc33 said:
did they let you get in any rounds for free?
Click to expand...
It was part of the job. Had to play at least once a week around the course and walk around with a clipboard to make sure you saw what the golfers were seeing and fix any problems before they were major.
 
lobelsteve said:
It was part of the job. Had to play at least once a week around the course and walk around with a clipboard to make sure you saw what the golfers were seeing and fix any problems before they were major.
Click to expand...
Is this position still available?
 
the above pics are from a patient with fbss. She has chronic right leg radicular pain mainly L5 distribution. She gets LOA with hyaluronidase every 6 months. I do a lot of these for patients who have FBSS. Usually once or twice a year for my fbss patients. I have lot who would rather do this than have someone put a SCS in them. I would rather do this on FBSS because most (not all) of the implanted scs for FBSS are waste of money.
 
jsaul said:
the above pics are from a patient with fbss. She has chronic right leg radicular pain mainly L5 distribution. She gets LOA with hyaluronidase every 6 months. I do a lot of these for patients who have FBSS. Usually once or twice a year for my fbss patients. I have lot who would rather do this than have someone put a SCS in them. I would rather do this on FBSS because most (not all) of the implanted scs for FBSS are waste of money.
Click to expand...
Your experience is not congruent with the literature.
 
hyperalgesia said:
How does high pressure, high volume fluid disrupt scar tissue, which is connective tissue, but doesn't disrupt fragile neurological tissue?

In ophtho, when a person develops symptomatic adhesions on the retina, they go in with a scope, stain the adhesions, and gently peel them off the retina. We should be more like that.

It constantly amazes me that the smartest people come up with the worst ideas. In all of medicine, not just in pain.
Click to expand...
I don't think it has anything to do with physically breaking and removing the scar tissue. What the procedure probably allows you to do is simply get cortisone and washout in the area of the "filling defects" where it can't get with a typical epidural injection, and the volume itself provides a great washout.
 
jsaul said:
the above pics are from a patient with fbss. She has chronic right leg radicular pain mainly L5 distribution. She gets LOA with hyaluronidase every 6 months. I do a lot of these for patients who have FBSS. Usually once or twice a year for my fbss patients. I have lot who would rather do this than have someone put a SCS in them. I would rather do this on FBSS because most (not all) of the implanted scs for FBSS are waste of money.
Click to expand...
does this have reasonable reimbursement my Medicare or other payors? Or is this out of pocket ?
 
For jsaul and PainMD23 and others:

You aren't using 62264? Or are payers just not covering this code?

How long does the procedure typically take you? Are you needing to use sedation? What can patient's expect during and shortly after the procedure in terms of discomfort?
 
1 Up said:
For jsaul and PainMD23 and others:

You aren't using 62264? Or are payers just not covering this code?

How long does the procedure typically take you? Are you needing to use sedation? What can patient's expect during and shortly after the procedure in terms of discomfort?
Click to expand...
It's a 14G or 17G through the caudal hiatus with a catheter steered cephalad. Normally, generous local is enough. The rest of the procedure is essentially the same as getting a DRG lead to the targeted foramen, but without the annoying loops to anchor it.
 
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