Epidural lysis of adhesions breaks down scar tissue in the epidural space that is tying down a nerve root.
What it is
After surgery, or after long-standing inflammation, scar tissue can bind a nerve root. Then the nerve cannot move freely, and normal epidural medicine cannot reach it. A catheter (a thin, soft tube) places medicine exactly where it is needed and pulls apart the adhesions (bands of scar).
What we use it for
- Lasting pain after spine surgery
- Epidural scarring seen on imaging
- Radicular pain (pain that runs down a nerve into the arm or leg) that has not responded to standard epidural injection
What to expect
- Under fluoroscopy (live X-ray) with contrast dye, 30 to 45 minutes.
- Contrast shows where the medicine is spreading and where it is not. That pattern tells us something on its own.
- May be done over more than one session.
- No sedation is used, so most patients drive themselves home. If a leg feels weak or numb, have someone else drive until that wears off.
Risks
It takes longer than a standard epidural. It uses a catheter and more fluid, so pressure sensations during injection are stronger. Specific risks include dural puncture (a hole in the sac around the nerves) and catheter shearing (a piece of the tube breaking off). Because of the fluid volumes, there is also a rare risk of raised pressure in the epidural space. Hypertonic saline (strong salt water), when used, burns. That burning is managed with local anesthetic first.
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How we judge whether it worked
The spread of contrast is the part that tells us the most, and we see it in real time. When medicine will not travel past a level, that marks the scar tissue. It also confirms why past epidurals did nothing.
We usually judge it over several weeks, and now and then repeat it. It is a targeted answer to a specific problem. It is not a general escalation after failed injections.
Before and after your procedure
This takes longer than a standard epidural. No sedation is used, so most patients drive themselves home; if a leg feels weak or numb, have someone else drive until that wears off. Expect strong pressure during the injection. If a catheter is left in place over more than one session, you will get specific care instructions. Report a severe headache that is worse upright, new weakness, or fever.
How the procedure is actually done
Scar tissue in the epidural space ties down nerve roots. It also keeps injected medicine from reaching them. That is why normal epidurals often stop working after spine surgery. Lysis of adhesions uses a fine catheter, guided by live X-ray, to reach the scarred area directly. Contrast is injected to map where flow is blocked. The catheter then pushes those areas open before medicine goes into the freed space.
Who it suits, and who it does not
It suits patients with lasting radicular pain after spine surgery when imaging or contrast flow suggests scarring. It also suits patients for whom normal epidurals have stopped working. It does not suit patients whose pain comes from a new structural problem, such as a repeat herniation or an unstable spine. That is why we review current imaging before we offer it.
What happens if it does not work
A treatment that makes no measurable change is a reason to rethink the diagnosis, not to repeat the treatment. That rethink is a normal part of the process, not a setback. Often the negative result narrows the field in a useful way. Then the next step is chosen on better information than the first.
Common questions
Why did my ordinary epidural not work?
If scar tissue is blocking the space, the medication never reaches the nerve. Contrast imaging shows this directly.
Why did my epidurals stop working?
Scar tissue can keep the medicine from reaching the nerve. The contrast pattern usually shows this clearly, because flow stops at the scarred segment.
The standard caudal approach is described in Caudal Epidural Injection.
Is this the same as a normal epidural?
No. A catheter is steered to the exact area and opens the scarred layer first, which a standard injection cannot do.
A standard targeted epidural is described in Transforaminal Epidural Steroid Injection.
Does the scarring come back?
It can form again over time. When the procedure helps, the benefit often lasts months, and it can be repeated.
Sources
- Manchikanti L et al. Effectiveness of Percutaneous Adhesiolysis in Managing Chronic Central Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis. Pain physician, 2019. PubMed 31775400
- Manchikanti L et al. Is Percutaneous Adhesiolysis Effective in Managing Chronic Low Back and Lower Extremity Pain in Post-surgery Syndrome: a Systematic Review and Meta-analysis. Current pain and headache reports, 2020. PubMed 32468418
- Lee F et al. Epidural lysis of adhesions. The Korean journal of pain, 2014. PubMed 24478895
- Helm Ii S et al. Percutaneous adhesiolysis in the management of chronic low back pain in post lumbar surgery syndrome and spinal stenosis: a systematic review. Pain physician, 2012. PubMed 22828693
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