Introduction to Lysis of Adhesions

The results of epidural lysis of adhesions from the first series of patients presented in the first edition of Techniques of Neurolysis in 1989 are now reinforced with data from numerous studies. The first published case in the first edition was related to an on-the-job injury which the procedure was denied by workers’ compensation. This was the first documented observation of scar formation in the epidural space without a history of surgery. The post-lysis discogram showed a leaky disk. The workers’ compensation panel ruled that the lysis procedure and surgery was a “flight into health” and declared experimental. This case was eventually presented in court, and the judge ruled that the lysis procedure and surgery were compensable. The procedure is becoming accepted worldwide and used with the goal of reducing both unnecessary surgeries and additional procedures in patients who have a variety of indications, such as multilevel disk protrusions. The more people in academic centers who look at these procedures and do studies, the more we learn. Multiple studies from a number of specialties have been recognized in the way of CPT codes in the USA by the AMA CPT code committee: 62263 and 62264. Significant studies have come from our multispecialty colleagues in interventional pain, neurosurgery, orthopedic surgery, and others. The late Dr. Sam Hassenbusch, representing neurosurgery on the committee, was most influential after seeing results in his patients that he not only referred to us but also observed the outcomes in patients he treated himself with the procedure. The work and studies of Lax Manchikanti led to the 62264 code for the one-day percutaneous neuroplasty procedure. There are animal, clinical, and laboratory studies that are not completely transferable to clinical practice, and there were some new experiences and information that very much improve our understanding of the basic principles that have evolved during the last 30 years. For example, a laboratory study concluding that the Racz® catheters are not stiff enough to carry out mechanical lysis of adhesions is misleading. The attempt was to interpret the catheter lysis as it is a mechanical procedure by the catheter alone [1]. The principle used from the beginning has been to place the catheter in the appropriate location and tissue plane for the injected fluid to find the path of least resistance. The injected fluid will open up the immediate surrounding compartment and find the path of least resistance to spread and open up the adjoining compartment. This compartmental filling principle has been nicely described by Angelo Rocco from Harvard. So long as lysis is carried out laterally and safe runoff is verified, fluid dissection can be safely performed. Flexion and rotation, especially in the cervical area, is an important addition to the technique to allow neuroforaminal runoff by increasing the size of the neuroforamina. An important principle of interventional pain management is that there is a learning curve for the procedures and gaining knowledge and improving the techniques is vital. Birkenmeyer et al. studied the effect of injection components during the lysis procedure and found that hyaluronidase has no impact on the human fibrocyte culture, but steroid and hypertonic saline inhibit fibrocyte regeneration and growth [2]. This study has provided significant information and an explanation for the long-lasting effect of the lysis procedure, where re-scarring does not occur for multiple years in the location where the hypertonic saline has been applied in the epidural space. These observations have been possible in patients where long-term follow-up contact has been possible. One of these patients has been written up in multiple textbooks [3–5].