Neuroplasty – Adhesiolysis with Racz Catheter

Dimitris Papadopoulos MD Fellow Of Interventional Pain Practice (FIPP)

Updated 09 January, 2011


Adhesiolysis in the epidural region is known as the RACZ application, named after the man who discovered it. Adhesiolysis is the disruption (lysis) of adhesions and is a minimally invasive technique that was developed in the late 80s by Anaesthesiologist and Interventional Pain Physician Professor Gabor Racz. The application was proven to be effective in the treatment of chronic low back pain, sciatica and cervico-humeral pain due to scar tissue formation in the epidural region. The scar tissue may be  formed around nerve roots, irritate them and cause continuous neuropathic pain.

Adhesions are formed postoperatively following spine surgery but may also come as a result of chronic inflammation and nerve root irritation, e.g. in herniated intervertebral disc. The scar tissue, formed almost always following surgical operations, is not painful. The nerve root gets tangled with adhesions, becomes irritated and oedematous and has not enough space to move freely.
Nerves normally are accompanied in intervertebral foramina by epidural veins, which are obstructed by adhesions. The obstruction increases the intravenous pressure, inhibits the smooth circulation in the region and causes oedema within the epidural space.


The absolute indication for neuroplasty is radiculopathy due to adhesions formed within the epidural space and  the resulting nerve root entrapment.
In cases of chemically irritated nerves and “the unsuccessful spine surgery syndrome” with concomitant epidural inflammation, a catheter placed in the anterior epidural region has been proven to be highly effective.
In some patients with spinal canal stenosis, neuroplasty is quite relieving as it reduces  oedema and venous congestion in the epidural area, relieving compression exerted on the spinal cord and nerve roots.

In the lumbar spine, the sacrococcygeal approach via sacral hiatus is highly advantageous for the treatment of radiculopathy of the 5th lumbar and 1st sacral root. In case the problem is localized in the 4th lumbar spine or even at a higher spine level, the Racz catheter is placed in the anterior epidural region through the intervertebral foramen at the level of lesion. Transforaminal approach can be combined with the sacrococcygeal approach. Neuroplasty is rarely conducted in the thoracic spine, but it may be useful in acute herpes zoster or compression vertebral fractures. In the cervical spine it is used with high success in the same cases as indicated in the lumbar spine.



The technique is applied with the patient in the prone position, under local anaesthesia at the acupuncture site and under fluoroscopic guidance. A special needle is inserted into the epidural space through the sacral hiatus, infusing contrast medium to outline nerve roots. The image acquired with fluoroscopy is called epidurogram. Entrapped roots are not enhanced with contrast medium for the fluid follows the easiest route with the less resistance. Through the special acupuncture needle, the Racz catheter is directed to the regions where the nerve root is not enhanced and thus mechanical adhesiolysis is conducted. Then, contrast medium is infused again to confirm that the space has opened up (the nerve root is enhanced) and therapeutic substances are injected, such as corticosteroids, local anaesthetic and hyaluronidase causing chemical adhesiolysis.
Immediately after the above intervention, the patient may feel his/her legs a little heavy and some sensory changes, but this is transient and due to local anaesthesia. The local anaesthetic action subsides some hours later and there may remain a mild pain at the acupuncture site lasting 2-3 days. The anti-inflammatory action of the corticosteroid starts after about 48 hours.

The patient stays in the medical short-stay unit (MSSU) for a few hours and then can go home. In some cases, the catheter remains in its position and the patient stays in hospital for one night for the injection to be repeated once again the following day. This depends on the individual case of each patient. After having completed  the first application and evaluated the severity of adhesions, it is decided whether there is need for reinjection into the involved area in question.


As happens with all drugs and interventions, there are potential risks and complications that may occur. The most frequent complaint of the patient is some pain at the acupuncture site but the duration is short and it can be easily confronted with simple analgesics and anti-inflammatory drugs, if necessary.

Other more severe and less frequent complications are epidural haematoma, infection, haemorrhage and spinal cord compression.

Risks are reduced with the use of fluoroscopic guidance, good sterilization and thorough knowledge of the technique by the therapist physician.


The American Society of Interventional Pain Physicians (ASIPP)  have published a guideline regarding chronic spinal pain management with the use of nterventional techniques, based on evidence-based medical practice.
According to this guideline, there is strong evidence demonstrating the efficacy of neuroplasty with administration of corticosteroids in short- and long-term pain management in refractory cases of radiculopathy and neuropathic spinal pain.







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