Introduction

Epidural lysis of adhesions is a procedure used to treat axial and radicular spine pain. This chapter describes the caudal technique and steps to avoid complications.

Applied Anatomy

The spinal epidural space lies within the spinal canal from the foramen magnum to the sacral hiatus. The posterior epidural space is bounded by the ligament flavum posteriorly and the dura mater anteriorly. The epidural space contains veins and fat as well as segmental arteries. The epidural space extends laterally into the neural foramina. The epidural space may be compartmentalized by attachment of the dura mater to the ligamentum flavum lamina or other structures. A negative pressure is produced in the epidural space by the pressure gradient associated with inspiration.

The goal of the lysis of adhesions procedure is to separate the dura mater from the posterior longitudinal ligament and allow free dural and nerve root movement. The sliding motion between the posterior longitudinal ligament and the dura mater can become reduced from disc material leaking into the space and causing inflammation and scarring. The posterior longitudinal ligament is highly innervated and is a source of spine pain [1]. The procedures for caudal, sacral, lumbar transforaminal, and cervical lysis of adhesions have been described in detail elsewhere and much of the text and images are reproduced therein [2].

Indications

The epidural lysis of adhesions procedure is indicated for radicular pain syndromes that have not responded to conservative care including medications and physical therapy. A comprehensive list of established indications from previous studies is as follows:

• Chronic low back pain of 3–6 months duration and failed conservative treatment options
  
• Back pain with or without radiculopathy
  
• Radiating lower extremity pain with provocative straight leg raising test
  
• Failed back surgery syndrome
  
• Radiographic evidence of pathology such as spondylosis
  
• Spinal stenosis
  
• Osteophyte and radiculopathy
  
• Lateral recess stenosis and radiculopathy
  
• Disc herniation and radiculopathy
  
• Spondylosis and radiculopathy, (MRI, CT)
  
• Radiculopathy due to epidural fibrosis (on enhanced MRI)
  
• Discogenic back pain and back spasm
  
• Faded stimulation from neuromodulator (SCS, spinal narcotics)
  
• 18 years of age or older (no specific contraindication by age).

Contraindications

• Spinal instability
  
• Spinal cord syrinx
  
• Local infection, unresolved spinal infection
  
• Chronic infection
  
• History of gastrointestinal bleeding (GI) or ulcers
  
• Substance use disorder and/or uncontrolled major depression or psychiatric disorders
  
• Arachnoiditis
  
• Arterio-venous malformation
  
• History of adverse reaction to local anesthetic, steroids, contrast or other injected medications
  
• Uncontrolled or acute medical illnesses
  
• The use of anti-platelet medications or anticoagulants (laboratory measurements for bleeding and clotting to be in the normal range following discontinuation for appropriate duration)
  
• Pregnant or lactating women.

Technique

Informed consent is very important as these procedures have significant risk and are often of limited efficacy. This includes:

• Failure to reduce pain or worsening of pain
  
• Nerve damage including paralysis
  
• Epidural hematoma
  
• Infection
  
• Seizure
  
• Persistent leak of spinal fluid
  
• Breathing and/or heart problems including cardiac arrest
  
• Failure to reduce pain or worsen pain
  
• Bleeding
  
• Damage to nearby organ or structure seizure.

The sacral hiatus allows direct access to the sacral epidural space. The Rx™Coudé® epidural needle has a specialized tip to allow for catheter repositioning without shearing the catheter. The opening of the needle tip is completely round allowing free passage of the catheter, unlike the oval-tipped Touhy needles or conventional spinal cord stimulator needles. The needle tip and catheter bend must be positioned in the same direction. The Racz® catheters are radiopaque and can be steered in the epidural space to the level and side of pathology in the ventrolateral epidural space. The ventral lateral epidural space is unique in that fluid injected under pressure follows the path of least resistance and will spread into the scarred perineural space and “free up” the nerve roots. Subsequent treatment using the transforaminal approach for catheter placement and lysis can further reduce back pain and/or radiculopathy from involvement of the structures that are the most richly innervated by the sinu-vertebral nerve system. For one-day lysis procedures, the skin entry point for needle access may be close to the sacral hiatus in the midline for easier placement.

For the three-day technique and repeat injections or continuous infusion therapies, the skin entry is 2 inches inferior and 1 inch lateral of the gluteal cleft on the contralateral side to the pain. This second approach places the skin entry away from the sacral hiatus in order to reduce the chance of infection and allows easier catheter placement on the affected side. Palpation with the index finger is used to locate the sacral horns (cornua) of the sacral hiatus to locate the entry point for the 15G or 16G RX-2 Coudé needle. The anterior-posterior C-arm position may be used to confirm the location of the sacral hiatus.

The finger is rolled medially and laterally to confirm the location and the finger is maintained at the sacral hiatus as a guide. A lateral fluoroscopic view should be obtained after skin penetration to avoid needle advancement too anteriorly into the bowel. After confirming epidural placement, rotate the needle 90° degrees toward the target area. AP and lateral view and injection of contrast confirm good needle placement. The lateral fluoroscopic image should be used to check for circumferential contrast spread. Needle-tip placement should be below the S3 neural foramen to avoid the thecal sac. Midline catheter placement in the sacrum can result in subdural placement by penetrating the inferior dural sac at the S3 level.

This is avoided by catheter placement off the midline when using the caudal approach. It is important to make a bend at the Racz bend marker on the catheter one inch (second marker on the catheter) proximal to the catheter tip at a 15–20° angle for optimum steering. With the XL tip catheter, the stylet needs to be close to the tip for enhanced steering. The C-arm is rotated to the AP position. In order to direct the catheter to the ventral lateral epidural space, the catheter advancement should be slow, keeping the catheter near the midline and the point on the bend medial to the tip. This allows the catheter to be steered anteriorly in the epidural space. The tip of the RX-Coudé needle should be oriented toward the target (Figure 39.1).

The technique is described in more detail elsewhere [3]. Cases with long-term outcomes are also reported [4]. The technique for securing the catheter is shown.

1. Make a full twist in the catheter to form a loop.
   
2. Place loop over the neck of the connector.
   
3. Pull catheter until securely around the connector body.
   
4. Use tape to secure the device.
   
5. Attach a bacterial 0.2-micron filter to maintain sterility.

The connector is attached to the catheter for connection to a syringe. The C-arm is rotated to the lateral view. Contrast injection is performed, showing contrast in the ventrolateral epidural space. Subsequent injections result in the lysis of epidural adhesions. AP shows contrast in the epidural space and contrast that has flowed out of the epidural space through the neural foramen. Epimed’s Stingray™ Connector design allows for a fastening technique that changes pulling force direction to prevent disconnects [5]. Bacterial filters are recommended in all instances when more than one injection is used or the catheter is left in place for a prolonged period. Anytime there is a disconnection of the catheter and the connector, the system should be removed from the patient. After the catheter tip is placed in the proper location (ventral/lateral), attach the Stingray Connector to inject the target site.

Table 39.1 summarizes medications and doses for the procedures. Discharge criteria include ambulation and voiding. If patients have difficulty, they should be observed until recovery is complete. Spine surgery patients may have dural tears and need to be monitored for subdural blocks. Also, patients with a dense scar may develop recurrent scarring within 3 months and lysis can be repeated in one month to prevent this from occurring. A variation of the series of three injections is the one-day, single injection period and technique.

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