A review of the role of epidural percutaneous adhesiolysis

SUMMARY Low back and leg pain can arise for a variety reasons, including epidural scarring caused by post lumbar surgery syndrome, infection or bleeding. Treatment options for low back and/or leg pain caused by epidural scarring include conservative approaches, such as physical therapy and medication management, and procedures, such as epidural steroid injections. Despite appropriate treatment, pain can persist in these patients. Surgery is often not an option for patients whose pain is caused by scarring. Percutaneous adhesiolysis is a minimally invasive technique, which is effective in treating refractory low back and leg pain arising from epidural scarring. It involves the use of a spring-wound, shear-resistant catheter, ideally placed in the ventrolateral aspect of the epidural space for the lysis of adhesions, allowing medications to reach the involved nerve and removing compression of the nerve. After mechanical lysis of adhesions, relatively large volumes of local anesthetic, saline, steroid and radiopaque contrast material are injected. Either hypertonic or normal saline may be used, along with hyaluronidase. After the procedure, the patient should perform exercises to stretch the nerve roots. While this has been studied as a caudal procedure, thoracic and cervical procedures have also been described, using both transforaminal and interlaminar approaches. With trained practitioners, complications are minimal. The effectiveness of the procedure has been documented by high-quality randomized controlled trials and observational studies for both postlumbar surgery syndrome and spinal stenosis.