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Letters to the Editor: Letter to the Editor

Neuroplasty Is a Safe, Effective Procedure

Racz, Gabor MD; Candido, Kenneth MD; Helm, Standiford MD

Author Information
doi: 10.1213/ANE.0000000000002546
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To the Editor

We read with interest Bhatia et al’s1 editorial. We commend their focus on patients receiving safe, effective, cost-efficient procedures. We were confused by their description of Choi’s study as being a negative trial. Despite methodological flaws, Choi reported over 40% pain relief at 6 months. The value of his study is showing that 5% saline is as effective as 10% saline, not that neurolysis is not effective.

The editorial discusses the mechanism of action of neuroplasty, referencing a 1989 report. Its authors miss the 2016 report, which shows that the current understanding of the mechanism of neuroplasty is not disruption of scarring, but rather the hydraulic separation of tissue planes and inhibition of recurrent scar formation.2

The editorial references a study documenting the expected lack of efficacy of facet procedures in fibromyalgia patients to provide an explanation for the lack of efficacy of neurolysis, although there is no explanation as to why neuroplasty would be disproportionately affected by aberrant central processing.

The editorial states flatly that there is a 4% rate of dural puncture with neuroplasty, although neither Choi nor a subsequent high-quality, multicenter, placebo-controlled study by the same group that reported the 4% rate had any dural punctures.3

The authors call for world-wide studies regarding neuroplasty. These studies have already been published.3–5 They reflect the evolution of neuroplasty. In looking at the same cohort of patients, Moon et al4 found that patients without surgery did better than those with surgery. Han et al5 reported better outcomes with transforaminal contrast flow. The evolution of our understanding of adhesiolysis, including mechanism, patient selection, and technical considerations, highlights the need to be aware of incremental changes in technique and patient selection. In this way, we can continue to offer our patients safe, effective, cost-efficient procedures, such as neuroplasty, and avoid procedures with lesser efficacy, for example, interlaminar epidural injections, which do not generate transforaminal flow, for the treatment of spinal stenosis.

Gabor Racz, MD
Texas Tech University
Lubbock, Texas

Kenneth Candido, MD
University of Illinois at Chicago
Chicago, Illinois
Department of Anesthesiology
Advocate Illinois Masonic Medical Center
Chicago, Illinois

Standiford Helm, MD
The Helm Center for Pain Management
Laguna Woods, California
[email protected]


1. Bhatia A, Nelson A, Cohen SP. Breaking bad (tissue): epidural adhesiolysis and its outcomes. Anesth Analg. 2017;124:1755–1757.
2. Racz GB, Heavner JE, Noe CE, Racz GB, Noe CE, et al. Epidural lysis of adhesions and percutaneous neuroplasty. Techniques of Neurolysis. 2016:2nd ed. Cham, Switzerland: Springer International Publishing119–143.
3. Gerdesmeyer L, Wagenpfeil S, Birkenmaier C, et al. Percutaneous epidural lysis of adhesions in chronic lumbar radicular pain: a randomized, double-blind, placebo-controlled trial. Pain Physician. 2013;16:185–196.
4. Moon DE, Park HJ, Kim YH. Assessment of clinical outcomes of cervical epidural neuroplasty using a Racz-catheter and predictive factors of efficacy in patients with cervical spinal pain. Pain Physician. 2015;18:E163–E170.
5. Han YJ, Lee MN, Cho MJ, Park HJ, Moon DE, Kim YH. Contrast runoff correlates with the clinical outcome of cervical epidural neuroplasty using a Racz catheter. Pain Physician. 2016;19:E1035–E1040.
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