What Is Lysis Of Adhesions?

Lysis of adhesions, also known as adhesiolysis, percutaneous adhesiolysis, or the Racz procedure, is a procedure that has been developed to address conditions mostly associated with scar tissue around the spine. This may include failed back surgery syndrome, in which chronic pain is a complication of interventions to correct unrelated problems with muscles or nerves in the spinal region. This may be related to scar tissue, which is thought to occur in up to 25% of all spinal surgeries. Scar tissue may be located in the area between the spinal cord (a thick cord of nervous tissue which sends information from all parts of the body to the brain) and the bones that surround and support it. This is known as the epidural space.

Foreign or potentially harmful matter (including scar tissue) in this region may pose a threat to the normal sensory or motor functions dependent on the spinal cord. Scar tissue may also affect the spinal nerves that connect the spine with the rest of the body. It may physically compress or impinge nervous tissue (which is known as spinal stenosis) or damage it chemically by causing the release of inflammatory molecules into the epidural space. Lysis of adhesions treats this by reducing or removing this scar tissue. This procedure has demonstrably improved chronic pain conditions such as failed back surgery and spinal stenosis.

Lysis of adhesion procedures are an increasingly popular option in cases of chronic pain to which they are applicable. Over 1.7 million of these were carried out in the U.S. by 2006. Their use increased by 47% in 11 years among the Medicare fee-for-service population.

How Is Lysis Of Adhesions Performed?

Lysis of adhesions involves the administration of drugs or other applications that will break up (or lyse) the scar tissue in an affected area. The procedure will begin with the injection of local anesthetic medications into the area to inhibit any pain during the procedure. The scar tissue, and the nervous tissue in its immediate vicinity, may be visualized using techniques such as fluoroscopy or magnetic resonance imaging (MRI) for enhanced accuracy and effective lysis of the scar tissue. Alternatively, a thin probe with a small camera may be inserted through the skin above the area to do the same.

Left: S2 dye spread during procedure. Right: Caudal Lysis with epidurogram showing absence of S2 prior to procedure.
S2 Dye Spread During Procedure

Visualization results in the identification of appropriate insertion and administration sites for the catheters that deliver compounds to lyse scar tissue. These may include saline and hyaluronidase, which break up the adhesions when injected into their proximity. Drugs that inhibit pain and inflammation, such as steroids or local anesthetics, may also be administered in the course of a lysis of adhesions procedure.
These procedures are safe and successful in many cases, but are also associated with some risks and complications. These are mainly related to inaccurate needle and catheter placement, which may result in the puncture of the membrane surrounding the spine, causing the disruption of sensory or motor functions. Additional complications include temporary headache and discomfort in the injection area following the procedure. This discomfort may result from damage to skin, muscles, or minor nerves sustained during the procedure.

The drugs used in lysis of adhesion procedures may also produce adverse effects in some patients. These include the side effects of steroids, which may range from abnormal emotional or behavioral responses, weight gain, immune system suppression, and gastrointestinal disorders. The use of local anesthetics may be associated with chest discomfort, headaches, and sensory disturbances. However, these procedures have been shown to be more effective than other similar techniques (e.g. stand-alone steroid injections) to treat the pain of failed back surgery syndrome, particularly in cases for which these conventional treatments have not elicited adequate pain relief.

Conditions Related To Lysis of Adhesions

Lysis of adhesions is applied to cases of often-chronic pain related to the accumulation of scar tissue near the spine or spinal nerves, as outlined above. Regions of the spine that may be affected by this may include the sacroiliac joint, or the junction at which the spine meets the pelvis. Scar tissue arising from spinal surgery or other types of damage may result in new-onset pain, as mentioned previously.

Other conditions related to spinal scar tissue include stenosis, in which nervous tissue is mechanically impinged upon or compressed by the accumulation of this tissue around it. Stenosis may result in pain, sensory disorders, or even the loss of motor control. The removal of these adhesions through lysis may result in a return to normal function and relief from pain for patients affected by these conditions. These results may last up to 12 weeks after treatment.

Lysis of adhesion procedures are mostly performed on the lower back. However, cases in which spinal stenosis affects the neck (cervical spine) are also possible. This may result in chronic pain in the neck or upper limbs. A recent trial demonstrated promising results in the application of adhesiolysis to this condition. This study showed that approximately 72% of the patients included had moderate to zero pain six months following their lysis of adhesion procedure.

Conclusion

Lysis of adhesions is a procedure carried out with the goal of breaking up scar tissue that has built up around the spinal cord or spinal nerve(s). Scar tissue may result in mechanical or chemical damage to these structures. This may result in chronic pain or other neurological disorders. Lysis of adhesion involves the injection of compounds into the area to break up (or lyse) the scar tissue. Medications such as local anesthetics and steroids may also be administered during the procedure. This may effectively treat pain and tissue damage in the relevant areas.

This technique may be associated with complications. However, the use of imaging techniques such as MRI reduce the risk of these by ensuring adequate visualization of the injection site and nerves in the region. Lysis of adhesions is most often used to address pain originating from the lower part of the spine, but may also be used in some cases of chronic neck pain. This technique is effective and safe in the majority of cases, and offers short- to medium-term relief from pain.

References

  1. Manchikanti L, Helm S, Pampati V, Racz GB. Cost Utility Analysis of Percutaneous Adhesiolysis in Managing Pain of Post-lumbar Surgery Syndrome and Lumbar Central Spinal Stenosis. Pain Pract. 2014.
  2. Manchikanti L, Singh V, Cash KA, Pampati V. Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial. J Pain Res. 2012;5:597-608.
  3. Pereira P, Severo M, Monteiro P, et al. Results of Lumbar Endoscopic Adhesiolysis Using a Radiofrequency Catheter in Patients with Postoperative Fibrosis and Persistent or Recurrent Symptoms After Discectomy. Pain Pract. 2014.
  4. Racz GB, Heavner JE, Trescot A. Percutaneous lysis of epidural adhesions–evidence for safety and efficacy. Pain Pract. 2008;8(4):277-286.
  5. Manchikanti L, Helm S, Pampati V, Racz GB. Percutaneous adhesiolysis procedures in the medicare population: analysis of utilization and growth patterns from 2000 to 2011. Pain Physician. 2014;17(2):E129-139.
  6. Kallewaard JW, Vanelderen P, Richardson J, Van Zundert J, Heavner J, Groen GJ. Epiduroscopy for patients with lumbosacral radicular pain. Pain Pract. 2014;14(4):365-377.
  7. Jamison DE, Hsu E, Cohen SP. Epidural adhesiolysis: an evidence-based review. J Neurosurg Sci. 2014;58(2):65-76.
  8. Lee JH, Lee S-H. Clinical effectiveness of percutaneous adhesiolysis versus transforaminal epidural steroid injection in patients with postlumbar surgery syndrome. Reg Anesth Pain Med. 2014;39(3):214-218.
  9. Park CH, Lee SH, Lee SC. Preliminary results of the clinical effectiveness of percutaneous adhesiolysis using a Racz catheter in the management of chronic pain due to cervical central stenosis. Pain Physician. 2013;16(4):353-358.