In Response

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We thank Drs Racz, Candido, and Helm for their interest in our editorial on epidural adhesiolysis.1 We appreciate the authors’ interest and belief in this procedure. The authors make several comments about statements in our article. We have therefore provided a point-by-point response to their remarks. Regarding the results of the study by Choi et al,2 we maintain that this study had several limitations that we identified in our editorial. The authors also contend that we did not refer to Dr Racz’s more recent work—a nonpeer-reviewed book chapter—on postulated mechanisms of analgesic benefit from neuroplasty that include “hydraulic separation of tissue planes.” However, any attribution of benefit to a particular mechanism is purely speculative in the absence of high-quality preclinical and clinical studies, and one might additionally question how truly different this is from the disruption of scar tissue, the mechanism mentioned in our article. Regarding their question about why outcomes of neuroplasty would be affected by central processing, the answer lies in the fact that persistent pathology (including scarring) in or around the dorsal root ganglion of exiting spinal nerve roots is associated with both peripheral and central sensitization.2 Moreover, conditions characterized by abnormal central pain processing have been shown to be associated with abnormal responses to interventional procedures.3 In response to their comment regarding proof for the incidence of dural puncture quoted by us (4%), Talu and Erdine4 reported an incidence of 4.4% for intrathecal catheter placement during epidural adhesiolysis. Finally, we stand by our statement that the pain community must continue to seek evidence for efficacy and safety of this procedure in large, multicenter trials rather than relying on small trials from centers with interventionalists who have expertise in this procedure.
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