Epidural Scarring
Definition
Epidural scarring refers to the formation of fibrous tissue in the epidural space, typically following spinal surgery (laminectomy, discectomy, etc.). It is a common finding postoperatively and can contribute to nerve root tethering, chronic pain, and postlaminectomy syndrome.
Pathophysiology
Reactive fibrous tissue forms as part of normal wound healing
Can envelop nerve roots, causing mechanical tethering and neuroinflammation
May impair nerve root mobility during motion or Valsalva maneuvers
Can coexist with recurrent disc herniation, making diagnosis complex
Risk Factors
Repeated surgery at the same spinal level
Excessive tissue dissection or bleeding
Lack of epidural fat preservation
Smoking, diabetes, poor wound healing
Clinical Relevance
Can cause persistent radicular pain despite anatomically successful decompression
Common cause of postlaminectomy syndrome
Pain may be neuropathic, burning, dysesthetic, or positional
Does not usually cause motor deficits, unless severe or accompanied by other pathology
Diagnosis
MRI with gadolinium contrast:
Scar tissue enhances (vascularized)
Recurrent disc does not enhance or enhances peripherally
May show nerve root encasement or adherence
CT myelography (if MRI contraindicated)
Clinical history is essential – progressive pain after initial relief post-surgery
Management
Conservative
Neuropathic pain medications (gabapentinoids, TCAs, SNRIs)
Epidural steroid injections – often less effective in dense fibrosis
Physical therapy – to maintain mobility and reduce secondary deconditioning
Interventional
Adhesiolysis via catheter (e.g., Racz catheter technique)
Spinal cord stimulation (SCS) – effective in selected cases with refractory radicular pain
Surgical revision is rarely indicated unless associated with new compressive pathology
Prevention
Minimize epidural dissection
Use of hemostasis and preservation of epidural fat
Investigational use of barrier gels (e.g., ADCON-L) – controversial efficacy