Diagnostic Epidurography and Therapeutic Epidurolysis

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K. Dean Willis

Since its introduction in 1985, the Racz procedure (also known as epidurolysis, lysis of adhesions, adhesiolysis, epidural neurolysis, and epidural neuroplasty) has gained widespread acceptance in the pain management community. Early promotion of this technique for delivery of a percutaneous, epidurally administered, lesion-specific dose of steroid for the treatment of low back pain and radiculopathy met with reluctant acceptance at best. Soon published studies verifying the safety and effectiveness of this approach resulted in expanded use and a Current Procedural Terminology (CPT) code paving the way for insurance reimbursement.

The therapeutic benefit of a lesion-specific epidural steroid was demonstrated by Winnie et al. in 1972.1 Prior to this, confusion existed over the inconsistent results of the blind epidural (nonradio-logically directed) approach. All too often repeat epidural steroid injection (ESI) procedures performed without fluoroscopic guidance resulted in profoundly different outcomes. To address this issue, Mc-Carron proposed a pathological mechanism by which epidural fi-brosis could be generated by disc disruption resulting in low back pain and radiculopathy.2,3 This epidural fibrosis responsible for the generation of pain,4,5 produces a space-occupying lesion (SOL) that can inhibit an undirected steroid injection from reaching the painful lesion. Racz and Holubec in 1989 demonstrated that the fluoroscop-ically directed technique of epidurolysis is superior to the blind technique because it guides the steroid injectate more specifically to the target lesion.6 Since that time many investigators at multiple centers have published studies demonstrating the advantages of this technique over its predecessor.715

Kuslich and others have independently demonstrated that ventral structures of the epidural space (posterior annulus, posterior longitudinal ligament) producing low back pain and traction of the lateral nerve roots secondary to adhesions within the neuroforamen are the primary sources of nociception in the epidural space.4,5,1619

A review article by Anderson cites prospective studies demonstrating improved clinical outcomes and cost-effectiveness with this ventral epidural approach.20 Therefore, a ventrolateral catheter placement is preferable to a midline or posterior catheter position.9,10,21

The fluoroscopically directed epidurogram and epidurolysis treatment offers five distinct advantages over nonvisualized epidural steroid injection:

1. Epidurography provides diagnostic evidence of the suspect pain generator(s).

2. Catheter-guided, lesion-specific administration of epidural steroid has therapeutic advantages over the blind technique.

3. Documentation of the injection site (epidural vs subdural vs sub-arachnoid) provides important medicolegal information.

4. Having radiographic confirmation of injectate spread and having the needle entry distant from the site of pain pathology provide greater physiological safety.

5. Lysis of adhesions by both mechanical catheter placement and injection sequence treats the cause of pain (epidural adhesions) rather than merely providing symptomatic reduction of annular inflammation and/or radiculitis.

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Back Pain Revealed

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