ADHESIOLYSIS

Adhesiolysis is the dissolution of epidural adhesions, or scar tissue. This minimally invasive surgery was developed in the mid-1980s by Dr. Gabor Racz (Boswell et all, 2007) and continues to be an effective way to eliminate the chronic, intense scar-tissue related pain that often radiates from the lower spine to the legs (Machikanti et all, 2000).

Scar tissue causes inflammation when nerve roots are compressed. This results in chronic injury and incredible pain for many patients. Typically, the scar tissue forms after spinal surgery or even injury and can block pain medications from reaching the area of pain. For this reason, adhesiolysis, is an excellent corrective treatment for this troublesome and painful issue. It directly dissolves the tissue that interferes with traditional pain management treatments.

Spinal scar tissue can result from:

Spinal Surgery

Most patients who undergo spinal surgery develop scar tissue that adheres to the nerve roots. This fixes the nerve into a certain position, often causing tension and nerve compression. In other cases, the scar tissue causes inflammation, which results in the same compression and pain (Belozer et al, 2004).

Annular Tears

An annular tear is a tear in the outer-most portion of the intervertebral discs, where cartilage cushions the joint and acts as a ligament to hold the joint in place. A tear in this location will cause mechanical or chemical irritation (Cooper, 2011). Mechanical irritation caused by an annular tear occurs when the axial load of the center of the disc compresses the nerve endings. A chemical irritation happens when the glutamate from the intervertebral disc material causes inflammation around the nerve root, which results in swelling that can pin the nerve roots. This will cause the adhesions to remain after the inflammation disappears (Trescot et al, 2007). Annular tears are often caused by collagen genetics, trauma, or disc degeneration (Cooper 2011) and can be a continuous source of pain.

In addition to spinal surgery and annular tears, trauma is also a known cause of scar tissue along the spine (Hammer et al, 2007).

Procedure:

An MRI of the patient’s spine is the first step in step in determining if scar tissue is the cause of chronic pain. Once, the source and site of injury have been determined, the patient’s pain will be addressed with a series of epidural steroid injections. If these treatments fail, as they sometimes do when scar tissue blocks the medication from reaching the nerve roots-the source of the pain, an adhesiolysis procedure will be the best option.

The patient is first given an injection of local anesthetic, using a very small needle. Once the injection site is numb, a larger needle is inserted. This needle contains a catheter/guide wire and is fluoroscopically (with a camera) guided to prevent nerve damage (Boswell et al, 2007). Once the catheter is in the right place, a series of medications (omnipaque, hypertonic saline, hyaluronidase, local anesthetics and steroids) are injected near the nerve root. These medications help to eliminate the inflammation and dissolve scar tissue. Usually, an adhesiolysis treatment is completed in less than an hour. However, it can also be performed over a two-day period if a second immediate injection is needed. After a brief recovery period, the patient is allowed to return home. Patients who undergo this procedure may feel some discomfort as the numbing anesthetic wears off near the injection site, and even fewer, experience a heavy feeling in their legs which wears off within a couple of hours.

Benefits:

The scar tissue causes the nerve roots to be fixed into one position, often causing deep and relentless pain, and preventing pain medications from even reaching the site. This makes adhesiolysis the best possible treatment for this specific kind of pain. It dissolves the tissue, and therefore, often eliminates the problem and even further need for oral pain medications (Trescot et al, 2007). Adhesiolysis has been proven to be the best treatment after epidural steroid injections and other traditional pain-blocking attempts have failed (Boswellet et al, 2007). In the short term, adhesiolysis, has shown great success and moderate success in long term pain magagement situations. In a recent study, it was revealed that 100% of patients experienced relief in the first three months after treatment (Bosewell et al, 2007). An additional study showed 93% pain relief in 14 patients who underwent adhesiolysis procedures, and 93%, experienced immediate relief. This number decreased to 71% within one month, and to 57% at the three month mark, 43% at six months and 21% at one year (Hammer et al, 2001). While the short term success rate is very high, more than one treatment is needed to sustain the positive pain management results long-term (Manchikanti et al, 2000).

Risks:

In general, adhesiolysis is considered a safe procedure, but all medical procedures have their risks and side effects. A patient scheduled for an adhesiolysis procedure should not be on blood thinning medications, pregnant, allergic to any of the anesthetics used or have an active infection (Hammer et al, 2001).

Some additional, but rare, risks are:

Spinal cord compression.
Mild pain at the injection site.
Catheter shearing.
Excessive intraspinal and intracranial pressures.
Epidural hematoma.
Bleeding at the injection site.
Infection.
Visual deficiencies and even blindness (Boswell et al, 2007).

Outcomes:

The most common form of spinal pain, low back pain, affects 15% to 39% of the population. Scar tissue is often the culprit. Adhesiolysis is the best option to treat scar tissue, as it is a safe and effective treatment and has a high success rate. Additionally, it is minimally invasive and requires only a short recovery period. And according to a recent study, patients that have undergone adhesiolysis treatment reported an improved emotional and physical state and were less dependent on pain medications (Manchikanti et al, 2000).