Racz catheter epidural adhesiolysis

Dr Thomas E Smith MBBS(Hons) MD FRCA FFPMRCA

The aim of this information sheet is to help answer some of the questions you may have about having a Racz Catheter Epidural Adhesolysis Procedure to treat your pain.

Why has a Racz catheter epidural adhesiolysis procedure been recommended?

Chronic Spinal Pain is very common. Pain can come from many different sources –  joints, nerves, muscle tension, ligaments, and “wind-up” of the pain system can all contribute to pain (1-3).

Sometimes nerve irritation within the spine is a cause of pain. Nerve irritation can be due to fibrosis (scar tissue) around the nerve interfering with the nerve blood flow or even pulling on the nerve itself. This sort of scar tissue and nerve irritation can follow common “wear and tear” disc injuries, and can also follow back surgery (4).

Epidural steroid injections are common injection treatments for spinal nerve pain. These injections can be effective in a number of ways – there may be a direct flushing effect, and the steroid medicine may calm down inflammation and swelling of the nerve (6). But these injections don’t always help. Two reasons for this can be 1. The injected medicine may not always reach the exact troublesome spot because spread of the medicine in the epidural space is unreliable 2. Although there may be a flushing effect, epidural injections are unlikely to loosen fibrotic adhesions (mild scars) which may be the main problem.

Racz catheter epidural adhesiolysis treatment addresses these two issues. With this procedure a fine, flexible, catheter (injection-tube) is introduced in to the epidural space and steered under x-ray control to the target area. Saline and a medicine called hyaluronidase, are injected through the catheter to loosen fine adhesions (scar tissue). Contrast is injected to check the spread of medicine. Finally, steroid medicine is injected in the target area. This technique allows targeting of highly troublesome sites – such as past surgical levels – which often cannot be directly reached with simple epidural blocks.

Published papers support the use of the Racz catheter epidurolysis/adhesiolysis as a safe technique with improved outcomes compared to simple epidural injection techniques in patients with radicular pain and a history suggesting epidural fibrosis (5, 7-23)

A note about corticosteroids:

Corticosteroids medicines are not licensed to be given as an epidural injection, and their use is termed ‘unlicensed’. They have however been used this way worldwide for many years, and it is considered to be standard practice.

References:

1.Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzat M. Years lived with disability(YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2163-96.

2. Nikolai Boduk Management of chronic low back pain. Medical Journal of Australia 2004; 180: 79–83

3. Laxmaiah Manchikanti, MD, Standiford Helm, MD, Vijay Singh, MD, Ramsin M. Benyamin, MD4,Sukdeb Datta, MD, Salim M. Hayek, MD, PhD, Bert Fellows, MA and Mark V. Boswell, MD, PhD. An Algorithmic Approach for Clinical Management of Chronic Spinal.  PainPain Physician 2009; 12:E225-E264 • ISSN 2150-1149

4. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Helene M. Langevin, Karen J. Sherman Med Hypotheses. 2007;68(1):74-80. Epub 2006 Aug 21.

5. Percutaneous Adhesiolysis in the Managementof Chronic Low Back Pain in Post Lumbar Surgery Syndrome and Spinal Stenosis: A Systematic Review.  Pain Physician 2012; 15:E435-E462 • ISSN 2150-1149

6. Epidural Steroids: A Comprehensive, Evidence-Based Review Steven P. Cohen, MD,* Mark C. Bicket, MD,* David Jamison, MD, Indy Wilkinson, MD, and James P. Rathmell, MD Regional Anesthesia and Pain Medicine & Volume 38, Number 3, May-June 2013

7.Heavner J., Racz G., Raj P.: Percutaneous epidural neuroplasty: prospective evaluationof 0.9% saline versus 10% saline with or without hyaluronidase. Reg Anesth Pain Med 1999; 24:202-207.

8. Manchikanti L., Pakanati R., Bakhit C., et al: Role of adhesiolysis and hypertonic saline neurolysis in management of low back pain: evaluation of modification of the Racz protocol. Pain Digest 1999; 9:91-96.

9. Manchikanti L., Pampati V., Fellow B., et al: Role of one day epidural adhesiolysis in management of chronic low back pain: a randomized clinical trial. Pain Phys 2001; 4:153-166.

10. Manchikanti L., Rivera J., Pampati V., et al: One day lumbar adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: a randomized, doubleblinded trial. Pain Phys 2004; 7:177-186.

11. Manchikanti L., Cash K., McManus C., et al: The preliminary results of a comparative effectiveness of adhesiolysis and caudal epidural injections in managing chronic low back pain secondary to spinal stenosis. Pain Phys 2009; 12(6):E341-E354.

12. Manchikanti L., Singh V., Cash K., et al: A comparative effectiveness evaluation of percutaneous adhesiolysis and epidural steroid injections in managing lumbar post surgery syndrome. Pain Phys 2009; 12(6):E355-E368.

13. Veihelmann A., Devens C., Trouiller H., et al: Epidural neuroplasty versus

physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial. J Orthop Sci 2006; 11(4):365-369.

14.  Helm II S., Benyamin R., Chopra P., Deer T., Justiz R.: Percutaneous Adhesiolysis in the Management of Chronic Low Back Pain in Post Lumbar Surgery Syndrome and Spinal Stenosis: A Systematic Review. Pain Physician 2012; 15:E435-E62.

15.  Gerdesmeyer L., Lampe R., Veihelmann A., et al: Chronic radiculopathy: use of minimally invasive percutaneous epidural neurolysis according to Racz. Der Schmerz 2005; 19:285-295.

16. Gerdesmeyer L., Rechl H., Wagenpfeil S., et al: Minimally invasive epidural neurolysis in chronic radiculopathy: a prospective controlled study to prove effectiveness. Der Orthopaede 2003; 32:869-876.

17. Gerdesmeyer L., Wagenpfeil S., Birkenmaier C., Veihelmann A., Hauschild M., Wagner K., Al Muderis M., Gollwitzer H., Diehl P., Toepfer A.: Percutaneous Epidural Lysis of Adhesions in Chronic Lumbar Radicular Pain: A Randomized, Double-Blind, Placebo- Controlled Trial. Pain Physician 2013; 16:185-196.

18. Koh W.U., Choi S.S., Park S.Y., Joo E.Y., Kim S.H., Lee J.D., Shin J.Y., Leem J.G., Shin J.W.: Transforaminal Hypertonic Saline for the Treatment of Lumbar Lateral CanalStenosis: A Double-Blinded, Randomized, Active-Control Trial. Pain Physician 2013; 16:197-211.

19. Manchikanti L., Singh V., Cash K., Pampati V.: Assesment of effectiveness of percutaneous adhesiolysis and caudal epidural injection in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial. Journal of Pain Research2012; 5: 597-608.

20. Park C.H., Lee S.H.: Effectiveness of Percutaneous Transforaminal Adhesiolysis inPatients with Lumbar Neuroforaminal Spinal Stenosis. Pain Physician 2013; 16: E37-E43.

21. Park E.J., Park S.Y., Lee S.J., Kim N.S., Koh D.Y.: Clinical Outcomes of EpiduralNeuroplasty for Cervical Disc Herniation. Journal of Korean Medical Science 2013; 28:461-465.

22. Choi E., Nahm F., Lee P.B.: Evaluation of Prognostic Predictors of Percutaneous Adhesiolysis Using a Racz Catheter for Post Lumbar Surgery Syndrome or Spinal Stenosis. Pain Physician 2013; 16:E531-E536.

23. Manchikanti L., Helm II S., Pampati V., Racz G.B.: Cost Utility Analysis of

Percutaneous Adhesiolysis in Managing Pain of Post-Lumbar Surgery Syndrome and Lumbar Central Spinal Stenosis. Pain Practice 2014; doi:10.1111/papr.12195.

How is the procedure performed?

The procedure is performed in the theatre environment using x-rays guidance

  • You will be placed lying on your front
  • You will have sedation by an Anaesthetist – sedation medicine will be given through a small tube placed in a vein in your hand or arm
  • Antiseptic is used to clean the skin on your back/neck and a local anaesthetic injection is given to numb the needle site
  • An introducing needle passes through the numb skin, between the bones of your spine and into the epidural space under x-ray guidance
  • The Racz catheter is steered within the epidural space using xray control
  • Saline and hyaluronidase are injected to “free up” the epidural space
  • Contrast dye is injected into the epidural space and viewed by x-ray to show spread of medicine
  • Finally, at the target area, mixture of local anaesthetic and steroid is then injected through the epidural needle and then the needle is removed

What are the benefits – why should I have this procedure?

The aim of the procedure is to provide you with pain reduction. If successful, this may help you increase your physical activity and reduce your pain medication.

What are the risks?

No procedure is entirely risk free. This type of procedure carries a minimal risk of side effects or complications. These may include:

  • A headache – occurs in around one in every 200 cases.
  • Diabetics may experience a rise in blood sugar for a few days.
  • A skin infection where the needle was inserted, causing redness, swelling or discharge of pus – estimated to be one in every 1000 cases.
  • Bleeding and bruising at the injection site – this is usually mild.
  • Temporary numbness/weakness as a result of the local anaesthetic – this usually resolves in a few hours. Rarely, it may last longer
  • Allergy to injected drugs – estimated to be one in every 40,000 cases.
  • Nerve injury such as temporary numbness or weakness – one in every 1000 cases. This usually resolves in days to weeks. Permanent nerve injury is so rare it is hard to be exact but a figure of one case per 30,000 procedures is suggested.
  • Paralysis is very rare indeed, but cases have been described – usually connected to other risk factors

Are there any other alternatives?

By the time you consider a Racz catheter adhesiolysis procedure you should have already tried other more simple treatments. These could have included physiotherapy and pain-medicines.

Giving your consent

Dr Smith wants to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form that says you agree to have the treatment and you understand what it involves. But you can still ask questions after this.

What happens on the day of the procedure?

Please remember to bring with you:

  • dressing gown and slippers
    • any medication you normally would take (apart from blood thinners)
    • something to read and your mobile phone.

A nurse will admit you. You will be given a gown to change into. You can put your own dressing gown on over this gown while you wait.

Please note the time stated on your letter may not be the time of your actual procedure. This is a time set to make sure that you are prepared and ready for your procedure. Therefore, you may have to wait for a while in the preoperative area. A friend or relative will be able to stay with you while you wait.

All women of child-bearing age will be asked to provide a urine sample, for us to test to rule out pregnancy. You must tell us if you could be pregnant. X-rays are safe for adults, but may harm your developing baby, so they aren’t usually done during pregnancy.

It is important that you take all your medication as usual, apart from blood thinning drugs (for example warfarin, rivaroxaban, clopidogrel), or specific diabetes medication (for example insulin or metformin). If you take blood thinning drugs or diabetes medication, then please inform us at least two weeks before your injection, to help us manage these.

Will I feel any pain?

You will be sedated for the procedure. Local anaesthetic will be used but some pain afterwards at the injection site and possibly some nerve pain may be experienced for a few days.

What happens after the procedure?

You will need to stay in the Procedure Unit for at least 30 mins after your procedure so your recovery can be monitored and we are sure that it is safe for you to go home.

Please arrange for a responsible adult to drive you home or accompany you in a taxi. We do not recommend public transport because it is not safe if you feel unwell.

You will be able to leave as soon as your nurse is satisfied that you are well enough and that there is a responsible adult to accompany you.

What do I need to do after I go home?

After the procedure and for the rest of the day, it is important for your safety that you follow the advice below.

Although you might feel fine, your reasoning, reflexes, judgement and co-ordination skills can be affected for up to 24 hours after your procedure. Please rest at home for the remainder of the day and follow the advice and instructions that the doctors and nurses have given you.

For 24 hours after the procedure, do not:

  • drive any vehicle, including a bicycle
  • operate machinery
  • cook, use sharp utensils or pour hot liquids
  • drink alcohol
  • smoke  
  • make any important decisions or sign any contracts

It is important to mention that some people feel pain relief immediately after the procedure. Some people feel no immediate change but pain relief develops over subsequent days. Some people feel worse for a short period before pain relief develops. If you experience some initial soreness you should take your usual painkillers and do gentle stretches until it settles.

Will I have a follow-up appointment?

Yes. You will have either a clinic or a telephone follow-up appointment to assess the effectiveness of the procedure.