Lysis of epidural adhesions involves passage of a catheter endoscopically or percutaneously into the epidural space, where it may be manipulated mechanically or injected with various agents (anesthetics, corticosteroids, hyaluronidase or saline) to break up adhesions. The procedure may be performed with fluoroscopic guidance under general anesthesia or conscious sedation. The procedure may be referred to as epidural adhesiolysis and has been investigated as a procedure to reduce or eliminate adhesions, fibrosis, or scars which most commonly occur as a complication of spinal surgery and may be included under the diagnosis of “failed back surgery syndrome”. Symptoms of epidural adhesions can include low back pain, radicular pain, muscular spasms and contractures, sphincter disturbances, and motor/sensory disturbances.
Endoscopic epidurolysis is also being investigated for the treatment of degenerative chronic low back pain, including spondylolisthesis, stenosis and hernia associated with radiculopathy. Along with mechanical adhesiolysis, hyaluronidase, ciprofloxacin and ozone have been applied.
In some situations the catheter may remain in place for several days to permit repeat/serial treatments.
Lysis of epidural adhesions, with or without endoscopic guidance, is considered investigational.
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
Published scientific evidence in the form of well-designed studies in peer-reviewed journals regarding the utilization of catheter based lysis of epidural adhesions continues to be lacking. There remains insufficient evidence to permit conclusions regarding this technology at this time.
American Society of Interventional Pain Physicians. (April, 2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations. Retrieved March 15, 2016 from the National Guideline Clearinghouse (NGC: 009842).
BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2017). Lysis of epidural adhesions. (8.01.18). Retrieved November 20, 2017 from BlueWeb. (21 articles and/or guidelines reviewed)
Gerdesmeyer, L., Wagenpfeil, S., Birkenmaier, C., Veihelmann, A., Hauschild, M., Wagner, K., et al. (2013). Percutaneous epidural lysis of adhesions in chronic lumbar radicular pain: a randomized, double-blind, placebo-controlled trial. Pain Physician, 16, 185-196. (Level 1 evidence)
Helm, S., Hayek, S., M., Colson, J., Chopra, P., Deer, T. R., Justiz, R., et al. (2013). Spinal endoscopic adhesiolysis in post lumbar surgery syndrome: an update of the assessment of the evidence. Pain Physician, 2013 (16) SE125-SE150. (Level 1 evidence)
Hsu, E., Atanelov, L., Plunkett, A., Chai, N., Chen, Y., and Cohen, S. (2014, January) Epidural lysis of adhesions for failed back surgery and spinal stenosis: factors associated with treatment outcome. Anesthesia Analgesia Journal, 118(1), 215-24. Abstract retrieved November 20, 2017 from PubMed database.
National Institute for Health and Clinical Excellence. (2010, February). Procedural guidance: therapeutic endoscopic division of epidural adhesions. Retrieved January 9, 2012 from http://www.nice.org.uk.
Pereiro, P., Severo, M., Monteiro, P., Silva, P., Rebelo, V., Castro-Lopes, J., & Vaz, R. (2014). Results of lumbar endoscopic adhesiolysis using a radiofrequency catheter in patients with postoperative fibrosis and persistent or recurrent symptoms after discectomy. Pain Practice, the Official Journal of World Institute of Pain, 16 (1), 67-79. Abstract retrieved March 15, 2016 from PubMed database.
ORIGINAL EFFECTIVE DATE: 6/1998
MOST RECENT REVIEW DATE: 12/14/2017
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
This document has been classified as public information.