Epidural Lysis of adhesions...

[Jcm800]

How do you guys do these, if you do them...i do them in primarily post-lam patients...

In my fellowship, the guys used to do them basically no different then a caudal epidural ESI with a RACZ catheter, and some minimal "mechanical" manipulation.

I have never injected any of that crazy suff Racz talked about, and i have never left a catheter in for that stuff...

Now i just put the needle in for caudal space, shoot in quite a biit of contrast 5-10 ccs (usually 6-7) find a filling defect, throw a catheter in till i meet resistance or get near my target, muck around a bit, shoot a fair amount a saline, 5-10 cc, throw some more contrast in see if there is a "blush" or improvement in the filling defect, muck around a bit more. repeat contrast...
pull catheter back a touch, throw some steroid in, and some local (i usually do them in a facility) and take the needle out first make sure i dont leave any plastic in them, and take the catherter out...

also, anyone doing this in the office. That Racz stuff is sooooo expensive, doing the math, it pays almost the same as the in the office as the facility when all is said and done...

discuss please.

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[lobelsteve]

Target from EBI > Myelotec > Racz

Cost is in the same order.
The reimbursement is about $20 and there is no catheter for adhesiolyis that makes this better than cost neutral.

I do this no more than 10 times per year because I become highly selective for patients that I can help and not make the practice lose money on.
As long as they get better with the procedure, they can send a friend or relative to me that needs more bread and better injections.

I sleep better knowing I did the right thing.
Just don't ask me to run your practice.....

 

[drusso]

I just do higher-than-usual-volume caudal esi's for the post-lami codgers. I'm convinced that I'm getting some kind of "lysis of adhesions" in the process, but who knows... 😀

 

[Ligament]

I just do higher-than-usual-volume caudal esi's for the post-lami codgers. I'm convinced that I'm getting some kind of "lysis of adhesions" in the process, but who knows... 😀

Racz' argument is that there is "hydraulic" lysis of adhesions and THAT is what helps the patient, NOT the catheter tip shearing (watch his latest technique video from Epimed where he states this). So you may be doing just that Dave.

I think we beat up on Racz too much here, I give him credit for developing new things, regardless of whether they stand the test of time...

 

[Mister Mxyzptlk]

I think we beat up on Racz too much here, I give him credit for developing new things, regardless of whether they stand the test of time...

Sort of like having our very own monkey on the typewriter randomly typing out Shakespeare?

Did anyone see Hammer's lecture on lysis at the ISIS meeting? He pretty much shredded it.

 

[Tenesma]

he shredded it - but I was surprised because he supposedly does do adhesiolysis...

 

[Mister Mxyzptlk]

He does, but he does a balloon dilation of the anterior epidural space. I think he uses a fogarty catheter. He has no supportive data for that technique, so pick which unproven procedure you want to do.

I still think lysis is BS. Maybe you can shove a few little wisps around but scar is like shoe leather and no little plastic tube and a few ccs of liquid is going to touch it, anecdotal evidence to the contrary notwithstanding.

 

[Tenesma]

having scrubbed into a few spine surgeries (purely as a learning experience to touch and feel), I have seen how difficult it is to SURGICALLY move/remove adhesions/scar tissue - it is nasty...

If it is hard with real tools, then the idea of being able to do it with a catheter (that is relatively flimsy) - blindly - makes no sense...

now, having seen before and after epidurograms where there is clearly better flow, it may be that a TINY hole is created that allows for contrast to flow around the obstacle - but that does not in any way imply that the scar tissue is GONE - nor does it correlate with pain improvement.

not only is it BS, it is a bunch of BS in my book... his balloon idea is interesting but i would think the last thing you'd want to do is compress neurologic tissue!!! no matter how short the duration of compression is...

 

[Disciple]

having scrubbed into a few spine surgeries (purely as a learning experience to touch and feel), I have seen how difficult it is to SURGICALLY move/remove adhesions/scar tissue - it is nasty...

Is this common? None of the surgeons I know attempt that sort of thing.

I don't try to remove scar tissue with adhesiolysis procedures, but have found that you can get better epidurograms when things seem to be "stuck together".

Maybe the best use is to do these procedures only if you've attempted a regular ESI and visualized a filling defect at your target nerve root.

 

[Tenesma]

they do if they go into re-explore and release a nerve root...

 

[Spinedude]

Regarding epidurography, pretty pictures do not equal science. After 20 years lysis continues and complications are buried in litigation. There is no proof that filling defects represent painful lesions.

Studies have failed to demonstrate beneficial effects of hyaluronidase and hypertonic saline. There is no evidence that any purported mechanism (catheter poking, chemicals, etc.) of lysis in the Racz procedure is effective.

I like Gabor yet absence of disclosure is seriously problematic.

If anyone has any data to support efficacy of this procedure please send the reference.

Thanks!

 

[lobelsteve]

Regarding epidurography, pretty pictures do not equal science. After 20 years lysis continues and complications are buried in litigation. There is no proof that filling defects represent painful lesions.

Studies have failed to demonstrate beneficial effects of hyaluronidase and hypertonic saline. There is no evidence that any purported mechanism (catheter poking, chemicals, etc.) of lysis in the Racz procedure is effective.

I like Gabor yet absence of disclosure is seriously problematic.

If anyone has any data to support efficacy of this procedure please send the reference.

Thanks!

Percutaneous Lysis of Epidural AdhesionsLaxmaiah Manchikanti, MD*, and Cyrus E. Bakhit, MD
Pain Physician 2000

Role of Adhesiolysis in the Management of Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications Pain Physician 2005 (Chopra, Smith, Deer)

 

[Spinedude]

Percutaneous Lysis of Epidural AdhesionsLaxmaiah Manchikanti, MD*, and Cyrus E. Bakhit, MD
Pain Physician 2000

Role of Adhesiolysis in the Management of Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications Pain Physician 2005 (Chopra, Smith, Deer)

Thanks.

Unfortunately neither provides the consumer with useful information other than copycat instructions or "this is how I do it". It's the same repetitive stuff which they hope will stick if they bombard the reader enough. ASIPP systematic reviews offer limited credible substance.

SD