Epiduroplasty for Failed Back Surgery in St. Louis

Surgery in or near the spinal canal sets off healing, and healing makes scar. In the epidural space around the spinal nerves, that scar (called peridural or epidural fibrosis) can wrap a nerve root and tie it down. The nerve can no longer slide freely in the canal. The scar also walls it off from medicine. That is exactly why a standard epidural steroid injection that once worked can stop working.

A thin tube goes into the epidural space through the sacral hiatus, a small opening near the tailbone. We steer it under fluoroscopic guidance (live X-ray) to the level of the scar. Dye (contrast) maps the scar bands and shows where medicine is not spreading. We then use the tube to break the bands apart. Medicine goes right onto the freed nerve root. Dye is used again at the end to confirm that spread is back.

The main use is failed back surgery syndrome. That is leg or back pain that stays or comes back after an operation that went well on paper. It is also used in some cases of severe spinal stenosis. It helps patients whose scans show scar bands blocking earlier shots from spreading. Diagnostic selective nerve root blocks often come first to confirm which level is to blame.

The procedure is usually done over one to three sessions on back-to-back days, based on how much scar there is. It is done under local anesthetic (numbing medicine) and no sedation, and takes about an hour. Most patients go home the same day. They go back to light activity within a few days.

Epidural fibrosis after spine surgery does not hurt by itself. Scar tissue has few nerves. It causes pain in two roundabout ways. First, it ties down the nerve root. The root can no longer glide in the canal when you bend forward and back. So normal movement tugs on the root again and again. Second, it slows blood draining away from the root. The blood backs up, pressure inside the nerve rises, and the nerve turns touchy.

There is a third, purely practical effect. Scar acts like a wall. An epidural steroid injection depends on medicine spreading through the epidural space to reach the inflamed root. Where scar blocks that spread, the drug never arrives in a useful amount. That explains a common story: a shot that worked well at first, then stopped working, with nothing else changed.

The procedure, described by Racz [Lysis of Epidural Adhesions] and refined since, threads a thin tube through the sacral hiatus. It is steered under fluoroscopy (live X-ray) to the problem level. Dye goes in first, and its pattern is a test in itself. A blank spot where dye will not spread marks the scar band. The tube is then used to push that space open.

Hyaluronidase is often added. It is an enzyme that breaks down hyaluronic acid in the tissue around cells. That thins the scar so the medicine spreads further. Some protocols use hypertonic saline (strong salt water) to draw fluid out of a swollen root. A second dye shot at the end confirms that spread is back. That is the hard proof the job is done, not a gut feeling.