Lysis of Epidural Adhesions
DESCRIPTIONLysis of epidural adhesions, also called the Racz procedure, involves passage of a catheter (Racz catheter) endoscopically or percutaneously under fluoroscopic guidance into the epidural space under general anesthetic or conscious sedation. Various protocols for breaking up adhesions, and reducing pain and inflammation have been described. The catheter may be then manipulated to mechanically break up adhesions and various agents, that may include anesthetics, steroids, hyaluronidase, and hypertonic saline, are injected. In some early protocols, the catheter was left in place and injections repeated over several days.
Epidural fibrosis with or without adhesive arachnoiditis most commonly occurs as a complication of spinal surgery and may be included under the diagnosis of "failed back syndrome." Both result from manipulation of the supporting structures of the spine. Epidural fibrosis can occur in isolation, but adhesive arachnoiditis is rarely present without associated epidural fibrosis. Arachnoiditis is most frequently seen in patients who have undergone multiple surgical procedures.
Both conditions are related to inflammatory reactions that result in the entrapment of nerves within dense scar tissue, increasing the susceptibility of the nerve root to compression or tension. the condition most frequently involves the nerves within the lumbar spine and cauda equina. Signs and symptoms indicate the involvement of multiple nerve roots and include low back pain, tenderness, sphincter disturbances, limited trunk mobility, muscular spasm or contracture, and motor sensory and reflex changes. Typically, the pain is characterized as constant and burning. In some cases, the pain and disability are severe, leading to analgesic dependence and chronic invalidism.
Lysis of epidural adhesions, using fluoroscopic guidance, with epidural injections of hypertonic saline in conjunction with steroids and analgesics, has been investigated as a treatment option. Theoretically, the use of hypertonic saline results in a mechanical disruption of the adhesions. It may also function to reduce edema within previously scarred and/or inflamed nerves. Finally, manipulating the catheter at the time of the injection may disrupt adhesions. Spinal endoscopy has been used to guide the lysis procedure. Prior to the use of endoscopy, adhesions can be identified as non-filling lesions on fluoroscopy. Using endoscopy guidance, a flexible fiberoptic catheter is inserted into the sacral hiatus, providing 3-D visualization to steer the catheter toward the adhesions, to more precisely place the injectate in the epidural space and onto the nerve root. Various protocols for lysis have been described; in some situations the catheter may remain in place for several days for serial treatment sessions.
POLICYCatheter-based techniques for lysis of epidural adhesions, with or without endoscopic guidance, are considered investigational. Techniques used either alone or in combination include mechanical disruption with a catheter and/or injection of hypertonic solutions with steroids, analgesics, or hyaluronidase.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY10/3/2006: Policy added
1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions
8/3/2007: Policy reviewed, no changes
04/26/2010: Policy description updated regarding treatment protocols. Policy statement unchanged. Updated the codes table to indicate that CPT code 0027T was deleted on 12/31/2008. Also, moved CPT code 64999 to a separate row in the codes table. Removed deleted CPT code 76003 as this code was deleted on 12/31/2006.
04/20/2011: Policy description and statement unchanged. Removed deleted CPT code 0027T from the Code Reference section.
01/19/2012: Policy reviewed; no changes.
04/02/2013: Policy reviewed; policy statement unchanged. Added ICD-9 procedure code 03.6 to the Code Reference section.
03/12/2014: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association Policy # 8.01.18
CODE REFERENCEThis may not be a comprehensive list procedure codes applicable to this policy.