Neurosurgery Coding Alert

Epidural scarring and adhesions: Adhesions in the epidural space are caused by scarring. This means that the epidural fat is replaced by fibrotic tissue. This usually happens as a consequence of surgery or a disc rupture. The scar tissue entraps the nerves causes irritation and inflammation. This causes pain. Adhesiolysis may help to relieve pain.

“Some physicians believe that tethering of the nerves by scar tissue can contribute to persistent or recurrent radiculopathy,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.

What to Look For in Operative Note

When you read the operative note and spot terms like ‘Racz Procedure’ or NaviCath System,’ you should catch the cue that your surgeon did an epidural neurolysis. Alternatively, your surgeon could use an endoscope to view and lyse the adhesions. When you read terms like epidural spinal canal endoscopy, spinal endoscopy, spinal or lumbar epiduroscopy, myeloscopy, epidural myeloscopy or endoscopic adhesiolysis in the operative note, you confirm your surgeon adopted an endoscopic approach to break the epidural adhesions. 

What is a Racz procedure? The Racz procedure is an invasive method to lyse the spinal epidural adhesions. “This method uses the effects of mechanical disruption by fluid instillation as well as enzymatic disruption followed by concentrated saline to help disrupt adhesions,” Przybylski says.  The procedure generally takes around 30 to 60 minutes. Your surgeon may provide a single or a series of up to three injections in a twelve-month period. In this procedure, the surgeon places a guide wire and catheter through the tailbone and advances it into the caudal canal and the lumbar epidural space. The surgeon then infuses an enzyme called hyaluronidase to break down the scar tissue. The surgeon also infuses hypertonic saline through the catheter to provide relief from pain and facilitate dissolution of the adhesions. Following this, steroids may be used. This may be a stepwise 3-day procedure with different materials injected on each day. The surgeon may leave the catheter in place to complete the procedure over three days. The Racz procedure is a fluoroscopically guided lysis of epidural adhesions.

What is the NaviCath system? The NaviCath system is a semi-rigid, flexible, and steerable plastic catheter. The NaviCath being stiffer than the Racz catheter is used to break up denser epidural scars. The NaviCath procedure is done under guidance of fluoroscopy.  “This method primarily uses mechanical disruption of adhesions in contrast to the Racz procedure,” Przybylski says.