Chronic spinal pain is the greatest overall cause of disability in our society1. It can be caused by a number of issues with joints, nerves, muscles, ligaments, and central pain processing, all contributing factors2,3,4. To maximise therapy outcomes, it’s important to identify contributing factors and target them with appropriate treatments.
One factor which may contribute to chronic spinal pain is epidural fibrosis (the formation of scarring near the nerve root). This can impact nerves and obstruct blood flow, thereby causing radicular pattern nerve pain5. There are many causes of epidural fibrosis.
The most common are post-surgical scarring, and fibrosis following common disc-degeneration events (i.e. tears, extrusions, sequestrations, prolapses)5. Less common causes include infection, hematoma, or intrathecal contrast material (contrast dyes used in imaging procedures)5.
Treatment For Radicular Nerve Pain
Epidural steroid injections — (caudal, translaminar, and transforaminal) are common interventional treatments for radicular nerve pain. They can also be tried as a conservative treatment for spinal stenosis (narrowed spinal canal) pain6.
These injections can be effective by:
assisting with the removal of stimuli that cause inflammation
reducing the inflammation response and pain pathways
reducing nerve swelling.
Although these injections are often beneficial, there are times when they are not. This may be due to:
The injectate may not always reach the area being targeted
The injections are unlikely to loosen fibrotic adhesions which may be the main cause of the pain in some cases.
Racz catheter epidural adhesiolysis treatment addresses these two issues. With this procedure a fine, flexible, steerable catheter is placed in to the epidural space and directed under (guided x-ray to the target area. Saline and contrast, and hyaluronidase (a substance to increase the absorption of these ingredients), are injected to facilitate the passage of the catheter and loosen epidural adhesions (scar tissue)5. Once the desired flow of injectate is seen at the target site, steroid may be injected for additional therapeutic benefit.
Very often, with this technique, initial obstruction to catheter passage and injectate flow is overcome with the procedure and the physician can be more confident that the target area is treated, compared with the simpler epidural techniques. This technique allows targeting of highly pathological sites — such as past surgical levels — which often cannot be accessed with simple epidural techniques.
A Racz catheter is also the preferred technique when targeting specific cervical spine (neck area) epidural sites. The catheter can be introduced safely and easily via the upper thoracic spine and steered upwards towards the head to the desired sites. Simple epidural injection at a cervical level and transforaminal epidural injection (injection of a long-acting steroid) at cervical levels have a higher risk of complication6 and offer less flexibility with targeting of injectate.
A number of papers support the use of the Racz catheter epidurolysis/adhesiolysis as a safe technique with improved outcomes compared with simple epidural injection techniques in patients with radicular pain and a history suggesting epidural fibrosis5, 7-23.
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.
Nikolai Boduk Management of chronic low back pain. Medical Journal of Australia 2004; 180: 79–83
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. Pain Physician 2009; 12:E225-E264 ISSN 2150-1149
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.
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
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
Heavner J., Racz G., Raj P.: Percutaneous epidural neuroplasty: prospective evaluation of 0.9% saline versus 10% saline with or without hyaluronidase. Reg Anesth Pain Med 1999; 24:202-207.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Park C.H., Lee S.H.: Effectiveness of Percutaneous Transforaminal Adhesiolysis inPatients with Lumbar Neuroforaminal Spinal Stenosis. Pain Physician 2013; 16: E37-E43.
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.
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.
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.
Disclaimer Please note the contents contained in this Patient Fact Sheet are not intended as a substitute for your own independent health professional’s advice, diagnosis or treatment. At Metro Pain Group, we assess every patient’s condition individually. As leaders in pain intervention, we aim to provide advanced, innovative, and evidence-based treatments tailored to suit each patient. As such, recommended treatments and their outcomes will vary from patient to patient. If you would like to find out whether our treatments are suitable for your specific condition, please speak to one of our doctors at the time of your consultation.