Epidural Lysis of Adhesions

General

Interventional Pain Management involves the applications of different modalities designed to alleviate acute and chronic pain. It has become one of the fastest growing sub-specialties in medicine in recent years. Using epidural spring guide catheters, physicians are able to target the specific source of pain signals delivering medication and electrical stimulation for treatment. A common cause of chronic pain is excessive scarring in the epidural space. The epidural space is a thin area between the inside of the spine and the protective layer around the spinal cord. Scar tissue may restrict the natural movement of nerves causing inflammation and therefore creating pain. This is known as the loss of “glide”.

How does it work?

A new line of epidural catheters to be directed under fluoroscopy (x-ray) has been developed in which the physician inserts the epidural catheter into the epidural space at the nearest convenient area to the affected region. Due to common anatomy, this is usually the caudal canal via the sacral hiatus. The location can be anywhere an opening can be made into the epidural space. The sacral hiatus is a natural opening in the spine near the end of the tailbone. Aided by real-time X-ray imaging, the catheter can be seen on the monitor and directed precisely to the affected nerve root (Figure 1). Catheters have a soft, non-damaging tip to glide off sensitive areas and a strong body to steer through the epidural space. Once the tip of the catheter is in place, medication can be injected to relieve pain at the source and dissipate scar tissue.

Figure 1: Catheter Placement

What to expect during the procedure…

After the staff has prepared you for the case, you will be taken into the procedure room. This can be an operating room or a sterile environment with all necessary equipment and supplies. You will be placed on a table that is compatible with the C-arm (fluoroscopy machine).

The physician will inject local anesthetic in the skin where the catheter will be introduced. This may cause a very short pinching sensation. Mild sedation will also be administered to reduce potential discomfort. General anesthesia is usually not necessary as your participation in the procedure is helpful in assisting your physician. Once the local anesthetic sets in, an epidural needle will be inserted. Through this needle, the catheter is advanced to the injection site. During the procedure, you may be asked how a certain stimulus may feel or to move your toes, etc.

The movement of the catheter is continuously monitored with the C-arm to assure safe and effective positioning. The make-up of the epidural space is as unique as your fingerprints, so predicting the ease of the placement can be difficult. Your physician will inject contrast material to see an outline of the epidural space on the monitor (commonly referred to as an Epidurogram). The contrast material is simply a metallic fluid that shows up on x-ray and has no adverse effect on the human body in the quantities used in these procedures. Other fluids will also be injected to relieve pain, dissipate scar tissue and reduce inflammation. Common injectants are steroid, anesthetic agent, enzyme and hypertonic saline. The catheter may be left in place for further injections.

What happens next?

You will be observed in the patient recovery area for at least 30 minutes. If your physician decides to inject hypertonic saline (10% NaCl or hyaluronidase), there may be a 20-30 minute waiting period. This time period allows the medication time to permeate the epidural space.

It is important to remember that this procedure is only a part of your treatment. The injectants help to break up the scarring around the nerve root and reduce swelling. The anesthetic agent can temporarily provide pain relief. However, aggressive physical therapy may be necessary to free up the nerves completely (see figure 2). Your physician will instruct you on recommended exercises.

Overview

Chronic pain can be debilitating and may lead to depression. Often the body can heal itself of many ailments. However, there are many instances when a pain specialist may need to intervene for complete healing to occur. Take advantage of your physician’s knowledge and allow him or her to educate you on treatment options on the road to recovery. The Interventional Pain Medical Group is committed to being a proud and fortunate participant in the healing of people who suffer from chronic pain.

Figure 2: Section View of the Spine and exiting Nerve Routes.