Neuroplasty and epiduroplasty are advanced interventional pain techniques in which a special catheter introduced into the epidural space is used to dissolve adhesions around nerve roots, decompress structures and deliver medications directly to the source of pain. This is the method of choice for patients with Failed Back Surgery Syndrome (FBSS) and spinal canal stenosis who have not responded to standard conservative treatment.

What are Epidural Adhesions and Why Do They Cause Chronic Pain?

Following disc herniation or spinal stenosis surgery, 5–40% of patients develop Failed Back Surgery Syndrome (FBSS). The rate of complications rises with each subsequent operation: the success rate of the first surgery is >50%, of the second 30%, of the third 15%, and of the fourth only 5%. The main cause of FBSS is adhesions (scar tissue) that form in the epidural space around the operated nerve root.

Adhesions act as a mechanical and biochemical trap – they compress the nerve root, restrict its natural mobility during spinal flexion and rotation, block venous vessels (causing local oedema and nerve root ischaemia), and prevent medications administered via conventional epidural blocks from reaching the painful site. This explains why standard steroid blocks often fail in post-surgical patients.

The Racz Procedure – Gold Standard of Neuroplasty

The Racz procedure (Racz catheter epidural adhesiolysis) was developed by Prof. Gabor Racz in 1989 at Texas Tech University. Since then it has been refined and validated in numerous Level I and II studies. It involves the introduction of a special soft catheter with a spring-guided tip (Spring Guide Catheter, Epimed) through the sacral hiatus or intervertebral foramen into the epidural space, and directing it under fluoroscopic X-ray guidance to the specific painful nerve root.

Three-stage mechanism of action:

  • MECHANICAL disruption of adhesions – the catheter physically breaks through the perineural scar tissue, opening the space around the nerve root (so-called fluid foraminotomy)
  • ENZYMATIC dissolution of adhesions – HYALURONIDASE (1,500 units in 10 ml saline) breaks down hyaluronic acid in the scar tissue, facilitating its loosening. Hyaluronidase has documented efficacy in improving outcomes in the majority of clinical studies
  • OSMOTIC dehydration of oedema – HYPERTONIC SALINE 10% NaCl acts osmotically, dehydrates the oedematous nerve root and limits local inflammation
  • Additionally: STEROID (e.g. triamcinolone, betamethasone, depo-medrol, dexamethasone) – long-acting anti-inflammatory effect; LIDOCAINE/BUPIVACAINE – immediate analgesic effect; X-RAY CONTRAST – visualisation of drug spread in the epidural space (epidurography).

Enhanced Version: Racz Catheter + Pulsed PRF of the Nerve Root

At our Centre we offer an advanced version of the procedure in which, after performing neuroplasty, we additionally apply pulsed radiofrequency (PRF) to the painful nerve root. The combination of both techniques produces a synergistic effect: Racz opens the space around the nerve root and delivers medications, while PRF modulates pain conduction through the same root.

Epiduroplasty with the Episol H Catheter

Episol H is a modern epiduroplasty catheter with a specially designed tip that enables precise access to hard-to-reach areas of the spinal canal, including the ventral (anterior) surface of the intervertebral foramen, where disc herniations or post-inflammatory adhesions most commonly occur. The catheter design allows greater manoeuvrability than the classic Racz catheter, increasing efficacy in patients with advanced adhesions. Additionally, the catheter has a balloon at its tip which enables mechanical disruption of adhesions through injection of contrast medium into the balloon.

REZASCOPE Epiduroplasty – with Direct Visualisation

REZASCOPE is the most advanced epiduroplasty technology – epidural endoscopy (epiduroscopy). The system contains an ultrathin fibre optic and a working channel that allows the physician to DIRECTLY SEE the epidural space, adhesions, nerve roots and disc herniations on an HD monitor. Under direct visual control it is possible to precisely:

  • Identify pathological structures (adhesions, fibrosis, inflammatory tissue, fibromata)
  • Mechanically disrupt adhesions under visual control – using two types of balloons introduced through the endoscope
  • Apply medications directly to the pathologically affected site with absolute precision
  • Perform pulsed thermolesion (PRF) of the nerve root and dura mater
  • Use a specialised blade to cut through hard adhesions in the epidural space under visual control
  • Directly assess the procedural result – visible nerve root release
  • Exclude other pathologies (bleeding, infection)

REZASCOPE epiduroscopy is currently the most effective method for treating FBSS and multilevel stenosis, although due to the advanced technology and operator experience required, it is available only at select centres.

Neuromodulation with Boston Scientific Electrode (DRG, Dura Mater)

Stimulation of the dura mater and dorsal root ganglion (DRG) with a Boston Scientific electrode is a neuromodulation procedure involving the introduction of a fine electrode into the epidural space and connecting it to an external stimulator. The electrode generates pulsed radiofrequency (PRF) electrical impulses that modulate pain conduction in the nerve root and spinal cord. DRG (Dorsal Root Ganglion) stimulation is particularly effective for very difficult-to-treat neuropathic pain: CRPS (Complex Regional Pain Syndrome), post-amputation neuropathy, and post-traumatic neuropathies. A test procedure with an external stimulator allows assessment of whether the patient is a candidate for permanent system implantation.

Transforaminal Neuroplasty of Nerve Roots (Foraminoplasty)

A less invasive and more cost-effective alternative to the full Racz procedure, performed under fluoroscopic X-ray guidance. It involves the precise administration of a mixture of HYALURONIDASE + 0.9% NaCl + STEROID + LOCAL ANAESTHETIC through a needle directly into the intervertebral foramen where nerve root compression is present. The procedure achieves nerve root hydrodecompression (foramen widening by fluid volume), enzymatic adhesion loosening and anti-inflammatory action. Particularly effective in single-level foraminal stenosis and post-surgical radicular pain.

Indications for Neuroplasty/Epiduroplasty

  • Failed Back Surgery Syndrome (FBSS) – the most common and best-documented indication
  • Spinal canal stenosis – lumbar and cervical segments – following careful imaging evaluation
  • Chronic sciatica or cervicobrachial neuralgia after failure of steroid blocks
  • Radicular pain following disc herniation, resistant to conservative treatment
  • Epidural fibrosis – visible on MRI
  • Patients who wish to avoid further spinal surgery or have contraindications to it

Procedure Sequence (Racz – Standard 1-Day Protocol)

  • Qualifying consultation with MRI/CT assessment of the spine, determining the level(s) to be treated.
  • Patient on the procedure table in the prone position. Peri-procedural analgesia with a short-acting opioid.
  • Under fluoroscopic X-ray guidance, introduction of the guide needle (Tuohy 16G) through the sacral hiatus, interlaminar approach or transforaminal approach.
  • Initial epidurography – injection of iodine contrast (Omnipaque) reveals the outlines of adhesions (so-called ‘filling defects’).
  • Through the needle, the Racz catheter (Epimed) is introduced – directed under X-ray guidance to the specific symptomatic nerve root.
  • Sequential medication delivery through the catheter:
    • 1,500 units hyaluronidase in 10 ml 0.9% NaCl – dissolution of adhesions
    • 5–10 ml 0.5% lidocaine or bupivacaine – anaesthesia
    • Repeat contrast epidurography – assessment of efficacy (spread of contrast into previously blocked areas – so-called ‘Christmas tree appearance’)
    • 6–10 ml saline (0.9% NaCl) – flushing of pro-inflammatory factors
    • Steroid (triamcinolone 40 mg or depo-medrol 80 mg)
  • Post-procedure observation for 1–2 hours; same-day discharge with transport.
  • Entire procedure duration: 45–90 minutes.

Preparation

  • Current spinal MRI (no older than 6 months)
  • Antibiotic prophylaxis – single intravenous antibiotic dose 30 minutes before the procedure
  • Discontinuation of anticoagulants per ASRA protocol (NOACs – 48–72h, warfarin – INR <1.5)
  • Fasting for 6 hours before the procedure
  • Return transport mandatory
  • No driving for 24 hours
  • Post-procedure physiotherapy is recommended – significantly increases durability of the effect; plus daily performance of specific exercises for life

Effects

  • First relief: 1–7 days after the procedure
  • Full effect: 4–6 weeks
  • Duration of effect: 6–24 months (in Manchikanti et al. observations – up to 75–80% of patients with significant improvement at 12-month follow-up)
  • Improvement in spinal function (Oswestry Disability Index – ODI) and quality of life
  • In many patients, significant reduction in analgesic consumption, including opioids
  • Procedure can be repeated after 12 months or upon recurrence of symptoms
  • Best results achieved when combined with physiotherapy, manual therapy and a deep core muscle strengthening programme

Possible Side Effects

  • Common and mild: pain at the puncture site (1–7 days), minor haematoma, transient headache
  • Less common: transient paraesthesia or muscle weakness (hours to days)
  • Rare: catheter shearing and retention of a fragment (minimal risk with modern Spring Guide systems), inadvertent dural puncture
  • Very rare: infection (prevented by antibiotic prophylaxis), epidural abscess, neurological deficits, haemodynamic instability
  • Complications related to hypertonic saline: burning pain in the lumbar area (self-limiting) – at our centre we do not administer hypertonic NaCl epidurally

Contraindications

  • Active infection (local or systemic)
  • Uncontrolled coagulopathy
  • Raised intracranial pressure
  • Pregnancy
  • Allergy to hyaluronidase, iodine contrast or local anaesthetics
  • Untreated heart or renal failure

FAQ

Will the Racz procedure replace my spinal reoperation?

In well-selected patients with FBSS – yes, in 75–80% of cases it allows reoperation to be avoided or deferred by years. Spinal reoperations have low success rates (second 30%, third 15%, fourth 5%), so the Racz procedure is often MORE effective than the next surgical intervention.

How does the Racz procedure differ from a standard epidural block?

A standard epidural block delivers medication into the general epidural space – if adhesions are present, the medication cannot reach the painful nerve root. The Racz procedure is a PRECISE, targeted mechanical and enzymatic opening of adhesions around a specific nerve root, followed by medication delivery directly around the released root. The efficacy of the Racz procedure in FBSS is better documented than conventional ESI (epidural steroid injection).

When should REZASCOPE be chosen instead of the Racz catheter?

REZASCOPE (epiduroscopy) is chosen for difficult, advanced FBSS cases with extensive adhesions visible on MRI, in patients after multiple operations, or when the classic Racz procedure did not achieve full effect. It allows direct visualisation and precise treatment of the pathology. The cost is higher, but efficacy in very difficult cases is also higher.