Adhesiolysis procedures
(Racz Procedures)

After surgery or aging, scars can occur in the epidural space. Without scarring the nerve roots can move in their openings of the spine as the body moves. With scarring, the nerve roots can become tethered or entrapped, so that when they move, they cause pain. Alternatively, the scar can decrease blood supply to the nerve, causing pain. Finally, scarring can prevent medications, such as steroids, from reaching the nerves, thereby stopping the efficacy of steroids.

This problem can effectively be treated with adhesiolysis procedures, of which there are two types.

The Racz procedure, named after Gabor Racz, M.D., who developed it, and formally called Percutaneous Adhesiolysis of Epidural Scarring with Hypertonic Saline, involves placing a catheter at the painful area in the spine. Because of the nature of the procedure, we can only treat one level at one side. We use the catheter to attempt to break up adhesions and inject medications to attempt to prevent scar reformation. The real difference with the Racz procedure, however, comes with the injection of hypertonic saline in the recovery room. Hypertonic saline will, because of the basic laws of chemistry, expand. This increase in volume, coupled with some simple physical therapy exercises which we will give you, helps to break up the scarring and free up the nerve root.

Hypertonic saline is very powerful and has some specific risks. If we inject it into the cerebral spinal fluid, rather than just into the epidural space, it can cause nerve damage. We are therefore very careful in how we do these procedures and wait to make sure that we are only in the epidural space.

Picture of Racz procedure, with both a caudal and a transforaminal approach.

A second approach to adhesiolysis is epiduroscopy, in which we place a scope into the epidural space and actually look at the epidural space using a camera and a monitor screen. Directly looking at the scarring and other pathology allows us to directly treat it.

Epiduroscopy is a powerful and useful tool. When doing epiduroscopy, we slowly inject saline to open up the epidural space, so that we see it. One potential risk stems from injecting too much saline, which can cause problems with too much pressure around the brain, including headache, difficulty seeing or even blindness. At PCPMC, we strictly limit the amount of saline use to avoid these problems.

Endoscopic view of the epidural space