Complication of epiduroscopy: a brief review and case report

A Comparative Study of Endoscopic versus Percutaneous Epidural Neuroplasty in Lower Back Pain: Outcomes at Six-Month Follow Up

Background and Objectives: Endoscopic epidural neuroplasty (EEN) facilitates adhesiolysis through direct epiduroscopic visualization, offering more precise neural decompression than that exhibited by percutaneous epidural neuroplasty (PEN). We aimed to compare the effects of EEN and PEN for 6 months after treatment with lower back and radicular pain in patients. Methods: This retrospective study compared the visual analog scale (VAS) and Oswestry disability index (ODI) scores in patients with low back and radicular pain who underwent EEN or PEN with a steering catheter. The medical records of 107 patients were analyzed, with 73 and 34 undergoing EEN and PEN, respectively. Results: The VAS and ODI scores decreased at all time points after EEN and PEN. VAS and ODI scores decreased more in the EEN group than those in the PEN group at 1 day and 1- and 6-months post-procedure, indicating superior pain relief for both lower back and radicular pain through EEN. Conclusions: EEN is a superior treatment of pain control than PEN in lower back and radicular pain patients.

Manejo de adherencias epidurales y dolor lumbar crónico posquirúrgico con epiduroscopia

Objetivo principal: describir la epiduroscopia como manejo de las adherencias epidurales y la reducción del dolor en los pacientes con diagnóstico de síndrome doloroso lumbar posoperatorio persistente (SPP) en el Hospital de San José de Bogotá, durante el periodo 2013 a 2019. Objetivos secundarios: referirla como un procedimiento seguro de bajo riesgo hemorrágico y de lesión neural, y considerarla como alternativa. Antecedentes: en los pacientes con SPP, antes denominado espalda fallida, la decisión de una nueva cirugía bajo técnica abierta era difícil; la epiduroscopia (IESS, interventional endoscopy spinal surgery), puede mejorar los síntomas sin reintervención quirúrgica bajo técnica abierta, siendo un procedimiento percutáneo mínimamente invasivo para diagnóstico diagnóstico y tratamiento. Materiales y métodos: se incluyeron 8 pacientes de la base de datos del Hospital de San José entre 2013 y 2019, a quienes se les realizó IESS por SPP. Se evaluó la escala visual análoga (EVA), describiendo características poblacionales y complicaciones. Resultados: 75% presentaron EVA menor de 7.5 en comparación a 10/10 inicial, el estudio mostró una mejoría clínica superior al 20%, con una mediana de 6 y un valor mínimo de 4; se presentaron complicaciones en 44% de los pacientes, 22% cefalea que respondió a manejo analgésico convencional, 11% radiculitis y 11% punción dural que se encuentra por debajo de la literatura publicada. Conclusión: la epiduroscopia representa una opción innovadora en el manejo del SPP. Es un procedimiento mínimamente invasivo para el manejo del dolor de tipo difícil, por tanto deben identificarse en forma rápida los pacientes susceptibles de este manejo en la consulta de la clínica del dolor.

The Dorsomedian Ligamentous Strand: An Evaluation In Vivo with Epiduroscopy

Several anatomical studies have described the morphology of the spinal space; however, researchers do not all agree on the presence of the dorsomedian ligamentous strand (DLS), which divides the epidural space. The possible existence of this structure still influences some clinical practice, such as locoregional anesthesia and pain therapy. Since the number of procedures occurring inside the epidural space have increased, this study’s primary objective was to describe the composition of this space through epiduroscopy. We conducted a retrospective analysis of video recorded during epiduroscopy. Two independent doctors performed blind analyses of morphological aspects of peridural space visualized during the procedure in each patient for the maximum possible extension depending on the underlying pathology in the tract from S1 to L1. We enrolled 106 patients who underwent epiduroscopy; 100% of patients presented no medial longitudinal segmentation dividing the epidural channel at any level of the spinal tract investigated, including in the epidural space with pathological fibrotic scars and in those with no adherence. The main finding of our study was the visual absence of any anatomical structure dividing the epidural channel. We report that in vivo, in our experience, with direct epiduroscopy, the DLS is not visible.

Efficacy of Minimally Invasive Trans-Sacral Canal Plasty between Patients with and without Failed Back Surgery Syndrome

Background and Objectives: Clinicians are required to manage a growing number of elderly patients with several medical comorbidities, and invasive surgical treatments are sometimes not advisable for these patients. The aim of this study was to evaluate the efficacy of minimally invasive intraspinal canal treatment, trans-sacral canal plasty (TSCP), for patients with and without failed back surgery syndrome (FBSS). Materials and Methods: A multicenter analysis was conducted. TSCP was performed in patients with chronic low back pain and leg pain due to lumbar spinal disorders. An adhesiolysis by TSCP was carried out, then a mixture of steroid and local anesthesia was injected. Visual Analog Scales (VAS) for low back pain and leg pain, and complications were evaluated. Results: A total of 271 patients with a minimum 6-month follow-up were enrolled. There were 80 patients who had a history of previous lumbar spinal surgery (F group), and 191 patients without previous lumbar spinal surgery (N group). There were no significant differences in sex and age between the two groups. VAS scores for low back pain (N group/F group) preoperatively, immediately postoperatively, and 1 month, 3 months and 6 months postoperatively, were 51/52 mm, 24/26 mm, 33/34 mm, 30/36 mm, and 30/36 mm, respectively. VAS scores for leg pain were 69/67 mm, 28/27 mm, 39/41 mm, 36/43 mm, and 32/40 mm, respectively. Both VAS scores for low back pain and leg pain were significantly decreased from baseline to final follow-up in both groups (p < 0.01). However, VAS scores for leg pain at 3 months and 6 months postoperatively were significantly higher in F group (p < 0.05). There were three catheter breakages (2/3 in F group), and one dural tear in F group. Conclusions: TSCP significantly reduced both VAS scores for low back and leg pain in patients with and without FBSS. However, co-existence of intractable epidural adhesion might be associated with less improvement in FBSS.

Pressure monitoring devices may undetect epidural space: a report on the use of Compuflo® system for epidural injection

Lumbar epidural infiltration (EI) is a feasible procedure performed in pain therapy. Even though epidural analgesia is widely applied, it remains a blind technique, based on the operator's hand sensations, and it is associated with significant failure rate and several potential complications. Compuflo® (Compuflo, Milestone Scientific, Livingston, NJ) is a computerized injection pump which precisely detects the real time pressure at the tip of a Tuohy needle when placed in human tissues, thanks to a continuous fluid path. In our institution, we usually perform EI for chronic back pain guided by the Compuflo device, especially for expected difficult procedures. However, we report 6 false negative cases on a total number of 60 procedures in which the Compuflo system didn't meet the criteria of epidural space entry, even though the epidural space was actually reached. A mild pressure decrease (less than 50%) which lasted for more than 5 s was reported on the monitor, and the acoustic signal changed in a little bit lower sound, without a clear indication on stopping or not the needle advancement. This unspecific drop in monitored pressure gives false negatives using the Compuflo® system and may lead to excessive advancing of the needle. In conclusion, we consider the epidural pressure monitoring device Compuflo as a tool which may be able to ease the correct positioning of an epidural needle. The percentage of 10% false negative identifications of the epidural space in our case series however suggests more investigations on adequate or specific settings for this epidural system. In the meantime, in chronic pain patients, this anesthetic technique should only be used by experienced hands.

24-Month Effectiveness of Periduoscopic Adhesiolysis in Reducing the Use of Spinal Cord Stimulation in Patient With Chronic Lumbar Pain: A Possible Therapeutic Regimen?

Objectives

Epiduroscopy is a minimally invasive procedure that is used in pain therapy to treat lumbar and root pain that is resistant to medical and infiltrative therapies. The indications for periduroscopy are partly shared with those of spinal cord stimulation (SCS): failed back surgery syndrome (FBSS) and stenosis of the vertebral canal in particular. The costs and risks of periduroscopy are considerably lower than those of SCS. The purpose of this study is to evaluate the clinical and economic advantages of integrating periduroscopy as a step prior to SCS for patients with severe lumbar or radicular pain that is unresponsive to pharmacological and infiltrative treatments.

Materials and Methods

Patients were enrolled if they had FBSS and spinal stenosis with indications for SCS and accepted periduroscopy treatment before the possible SCS trial. Patients were followed up for 24 months with evaluations of clinical data on the day after the procedure and at one and 24 months. The pain trend, satisfaction with the periduroscopy procedure, and the incidence of SCS implants in the study period were analyzed.

Results

A total of 106 patients were enrolled. Immediately after the procedure and in the first month, the reduction of pain and the level of patient satisfaction were high, but they were drastically reduced at 24 months with a progressive reappearance of symptoms that substantially overlapped with the pre-surgery levels. At 24 months, 48% of the patients underwent a neurostimulation trial, and a significant percentage of them were able to avoid the implantation of an SCS.

Conclusions

Periduroscopy appears to be rational as a step prior to SCS in terms of the improvement of pain symptoms in the short term, the definitive results in a significant percentage of patients, and the significant economic savings for the health system.

One-year evaluation of epiduroscopy in chronic back pain with and without radiculopathy: a retrospective study

Background

Back pain is a frequent complaint among the individuals in the society. It significantly affects the daily activities and the social and psychological life aspects leading to an economic health burden. Epiduroscopy is a relatively new minimally invasive technique that is used as a diagnostic and therapeutic tool in cases of chronic back pain.

Aim of the study

To evaluate the extent of long-term benefit of epiduroscopy in patients with refractory chronic back pain with/without radiculopathy.

Materials and methods

Retrospective data of 148 patients with failed back surgery syndrome (FBSS) and/or symptomatic lumbosacral disc prolapse who underwent epiduroscopy were collected. A 50% reduction in the visual analog scale (VAS) score was set as the primary outcome. Pre- and post-procedure analgesic use, quality of sleep, and changes in the activities of daily livings (ADLs) after 1-year follow-up were reviewed. Incidence and types of complications were recorded.

Results

The mean age of the studied sample was 56.6 years with a higher percentage of females (61.5%). Patients having radicular pain represented 45.1%. Disc prolapse was prevalent (61.5%) compared to patients with FBSS (38.5%). A reduction of 50% or more in VAS score was reached in 52.7% (p < 0.01). This reduction was more evident in younger patients (p = 0.004). There was an improvement in ADLs (p < 0.01), quality of sleep (p < 0.05), and analgesic intake (p < 0.05).

Conclusion

Epiduroscopy is a relatively recent, safe, and minimally invasive tool that showed effectiveness in the difficult to treat patients with back pain with/without radiculopathy especially in FBSS.

Use of intraoperative neurophysiological monitoring during epiduroscopy as a safety measure

Objective

In this study, we present the first 12 cases of the use of intraoperative neurophysiological monitoring (IONM) during therapeutic epiduroscopy in patients with clinical canal stenosis.

Methods

IESS was performed using two working instruments: an epidural balloon to dilate the epidural space without damaging the nerve structures (Resaloon®) and an element to perform flavotomy of the ligamentum flavum (Resaflex®). The procedure was performed at levels of the greatest stenosis, as detected using preoperative magnetic resonance imaging.

Results

Of the 12 cases that used IONM, 2 patients presented neurotonic activity in roots during ligamentum flavum ablation, 1 patient presented neurotonic activity while using Resaloon® in a root contralateral to the level at which the procedure was conducted, and other presented neurotonic activity in a root below the level at which the ligamentum flavum was ablated. In all cases, potentially harmful discharges stopped when the procedure was interrupted momentarily.

Conclusions

Intraoperative neurophysiological monitoring detected alterations in surgical field and roots below and/or contralateral to the field, which disappeared with complete recovery after interrupting the procedure; this can avoid the possible prolonged or even permanent complications postoperatively.

Significance

Intraoperative neurophysiological monitoring during epiduroscopy is safe, thus optimizing surgical outcomes.

Assessment of Optic Nerve Sheath Diameter in Patients Undergoing Epiduroscopy

Background

Epiduroscopy is commonly used for the evaluation and treatment of low back pain. Saline with or without local anesthetic addition was used to visualize epidural space structure during this procedure. A rapid increase in epidural space pressure is transmitted into the spinal space to the optic nerve sheath. This study aimed to estimate the effects of epiduroscopy on optic nerve sheath diameter (ONSD) according to the volume of fluid using the ultrasonographic measurement of optic nerve diameter in adult patients.

Material/Methods

Sixty patients who had been treated for low back pain with epiduroscopy using low-volume (LV) or high-volume (HV) fluid application were enrolled into the study. Measurement of ONSD was performed before (T0) and immediately after epiduroscopy (T1), at 10 min (T2), and 20 min (T3) after the epiduroscopy.

Results

Both groups showed significant differences over time in ONSD (PGroup×Time=0.001). The HV group showed greater changes from T0 to T2 and T3 than the LV group in ONSD. However, in both groups, ONSDs at T2 and T3 were significantly larger than those with the highest values at T2 compared to T0.

Conclusions

Ultrasonography of ONSD presents a good level of diagnostic accuracy for identifying epidural hypertension. In the clinical decision-making phase, this may help physicians to be more cautious about volume when performing epidural injections to treat this disease.

Fluoroscopic evaluation of the influence of needle gauge on epidural spread in caudal block

Caudal block has limited injectate distribution to the desired lumbar level due to the relatively long distance from the injection site and reduction in the volume of injectate due to leakage into the sacral foramen. The objective of this study was to investigate the influence of needle gauge on fluoroscopic epidural spread and to assess the correlation between the spread level and analgesic efficacy in patients undergoing caudal block. We retrospectively analyzed data from 80 patients who received caudal block for lower back and radicular pain. We categorized patients based on the epidural needle gauge used into group A (23 gauge), group B (20 gauge), and group C (17 gauge). Fluoroscopic image of the final level of contrast injected through the caudal needle and pain scores before the block and 30 minutes after the block recorded using a numerical rating scale, were evaluated. Of the 80 patients assessed for eligibility, 7 were excluded. Thus, a total of 73 patients were finally analyzed. Age, sex, body mass index, diagnosis, lesion level, lesion severity, and duration of pain did not differ among the 3 groups. All patients showed cephalic spread of contrast. Contrast spread beyond L5 was seen in 26.9% of patients in group A, 41.7% in group B, 39.1% in group C, and 35.6% overall; there was no significant difference among the groups (P = .517). Analgesic efficacy was not significantly different among the groups (P = .336). The needle gauge did not influence the level of epidural spread or analgesic efficacy in caudal block.