1. 2019;22;555-560Hyaluronidase in Neuroplasty: A Review
   Review
   Gabor Racz, MD, and Standiford Helm II, MD.

BACKGROUND: Neuroplasty, also known as percutaneous adhesiolysis, is an effective treatment for persistent axial and radicular pain.

OBJECTIVES: One issue of concern is whether hyaluronidase should be used when performing neuroplasty. The objective of this narrative review is to evaluate the current literature relating to hyaluronidase and its role in neuroplasty.

METHODS: The literature relating to hyaluronidase was examined via a search of PubMed and Google Scholar until April 2019, review of the citations of relevant literature, and the authors’ knowledge of the literature and activity in the field. The literature was reviewed in light of hyaluronidase’s physiologic role, allergenicity, medical uses, and evaluation specifically for neuroplasty.

RESULTS: Hyaluronidase facilitates the spread of medications in the extracellular matrix by breaking down polysaccharides in the interstitial space. While allergic reactions to hyaluronidase have been reported, these reactions occurred with animal-derived preparations. The current human recombinant hyaluronidase does not have any reports of allergic reactions. Laboratory studies show that it does not evoke an immune response. Hyaluronidase has been extensively used in a variety of medical applications, including intrathecal treatment of arachnoiditis.

There have been multiple studies reporting benefit from the use of hyaluronidase in interventional procedures. One randomized trial specifically looking at the use of hyaluronidase in neuroplasty found that the addition of hyaluronidase improved pain ratings at 12 months compared to other techniques and decreased the number of procedures needed to gain effect.

LIMITATIONS: There have been limited studies examining the enhanced efficacy of neuroplasty when hyaluronidase is added.

CONCLUSIONS: Because of enhanced efficacy and safety, and because of the decrease in the number of procedures needed to be performed, hyaluronidase should be considered when deciding which medications to use when performing neuroplasty.

KEY WORDS: Neuroplasty, adhesiolysis, hyaluronidase, spinal stenosis, failed back surgery synderome, post lumbar surgery syndrome