Caudal Approach Adhesiolysis: The

Effectiveness for Back Pain

Pantja Wibowo, dr. SpAn.KMNRS Premier Bintaro

Objectives

To understand the caudal-epidural approach adhesiolysis procedures for relieving back pain

To understand the effectiveness the caudal-epidural approach adhesiolysis in relieving back pain

History1901: Cathelin1 introduced the concept of caudal anesthesia

1921: Siscard & Forestier performed the initial epidurography serendipituously.

1942: Caudal catheter anesthesia was introduced for obstetrics by Manalan.

1950: Payne and Rupp combined hyaluronidase with local anesthetic.

History1957: Lievre and coworkers reported the first use of corticosteroid.

1967: Hypertonic saline was first administered by Hitchcock.

1980: Hatten reported epidurography and selective nerve block via the sacral hiatus using the Seldinger technique.

1989: Racz and Holubec reported the first use of epidural hypertonic saline to facilitate lysis of adhesions.

IndicationsFailed back surgery syndrome

Disk disruption

Metastatic carcinoma of the spine leading to compression fracture

Multilevel degenerative arthritis

IndicationsFacet pain

Spinal stenosis

Pain unresponsive to spinal cord stimulation and spinal opioids

Efficacy1999, Heavner: evaluated 4 variations of percutaneous epidural adhesiolysis & concluded that all of the variations had similar outcomes, both at discharge & at 12 months follow-up

2004, Manchikanti: percutaneous adhesiolysis, with or without hypertonic saline neurolysis, is an effective treatment for chronic LBP

(Reg Anesth Pain Med 1999)

(Pain Phisician 2004)

Efficacy2005, Manchikanti: endoscopic adhesiolysis was associated with statistically significant improvements in all outcome measures at 12 months of follow-up

2006, Veihelmann: epidural neuroplasty results in significant alleviation of pain & functional disability in patients with chronic LBP & sciatica based on disc protrusion/prolapse or failed back surgery on a short-term basis as well as at 12 months of follow-up

(BMC Anesthesiol. 2005)

(.J Orthop Sci. 2006)

Efficacy2007, Trescot: there is strong evidence for short-term & moderate evidence for long-term effectiveness of percutaneous adhesiolysis & spinal endoscopy

2008, Sakai: epidural adhesiolysis followed by the injection of steroid & local anesthetic during epiduroscopy alleviated pain, & functional disability, & reduced dysfunction of Aβ and Aγ fibers in patients with chronic sciatica

(Pain Physician . 2007)

(J Anesth. 2008)

Efficacy2008, Racz: the cumulative evidence showed that percutaneous adhesiolysis with targeted drug delivery is an effective treatment for LBP and/or radiculopathy

2009, Manchikanti: percutaneous epidural adhesiolysis is effective in patients with post lumbar surgery syndrome and lumbar spinal stenosis

(Pain Pract. 2008)

(Pain Phisician. 2009)

Efficacy2009, Epter: percutaneous adhesiolysis is an effective treatment, it is superior to epidural steroid injections, & it is a safe procedure for failed back surgery syndrome when performed appropriately

2011, Donato: Significant improvements in pain scores were reported throughout the 48 month follow-up of 234 individuals with chronic LBP & applied mechanically removal of adherences, targeted ozone, hyaluronidase & ciprofloxacin

(Pain Physician. 2009)

(Acta Neurochir Suppl. 2011)

Efficacy2013, Gerdermeyer: analyze the clinical efficacy of percutaneous epidural lysis of adhesions in chronic radicular pain of 381 patients with chronic radicular pain lasting longer than 4 months, which failed to respond to conservative treatments. The pain scores were significantly better 3, 6, and 12 months in the lysis group vs the control group

Efficacy

2014, Jamison & Cohen: weak positive evidence that lysis of adhesion (LOA) is more effective than conventional caudal epidural steroid injections for failed back surgery syndrome and spinal stenosis, and that LOA is more effective than sham adhesiolysis and conservative management for lumbosacral radiculopathy

J Neurosurg Sci. 2014

Conclusions

Epidural adhesiolysis has been accepted as a treatment for post laminectomy syndrome, failed back syndrome, & radicular syndromes.

The efficacy of caudal approach epidural adhesiolysis depends on the proper diagnosis, patient’s condition, and better techinuqe.

Conclusions

The combined use of long term patient education for neural flossing exercises & the inclusion of the facet-delayed treatment in the algorithm further improves patient outcome.

Additional studies are underway to further refine the technique & indications.

Thank You