The role for radicular veins in nerve root pain is underestimated: Limitations of imaging studies

Excessive swelling of nerve roots : Important factor for recurring sciatica after lumbar surgery

OBJECTIVE

The aim of the study was to investigate the occurrence of unexpectedly swollen nerve roots and to investigate the relationship between nerve root edema and recurrent radicular pain.

METHODS

During the period from August 2010 to August 2015, a total of 462 patients with degenerative lumbar disease underwent surgery in this study group. Magnetic resonance imaging (MRI) was used to evaluate the details of the nerve root. Of the patients with recurring radiating pain 13 met the inclusion criteria of the study group and 24 patients without any complications volunteered as the control group. The visual analog scale (VAS), Oswestry Disability Index (ODI), and medical outcomes study item short form health survey (SF-36) were used to evaluate the clinical outcomes.

RESULTS

The preoperative diameter of the nerve root showed no significant difference between the two groups (P = 0.28). The postoperative nerve diameter of the study group was larger than that of the control group (P < 0.01). The initial operation improved the symptoms and the VAS was significantly decreased (P < 0.01). After recurrence of the neuralgia, the VAS score significantly increased (P < 0.01). The pain of the study group improved to the same level as that of the control group 4 weeks after subsequent surgery (P = 0.47), while the quality of life was still lower than that of the control group (P < 0.05). The scores collected 3 months after surgery showed that the clinical outcomes were not different between the two groups (P > 0.05).

CONCLUSION

In surgery for degenerative lumbar disease accompanied by nerve root edema, excessive nerve root swelling is an important factor for recurrent radiating pain. With a properly carried out intervention in the re-exploration, the recurrent symptoms can be gradually relieved.

Combined epidural adhesiolysis and balloon decompression can be effective in intractable lumbar spinal stenosis patients unresponsive to previous epidural adhesiolysis

Moderate evidence exists regarding percutaneous epidural adhesiolysis (PEA) being an effective treatment for lumbar spinal stenosis (LSS). Although PEA is successfully performed using balloon-less epidural catheters, many patients with severe adhesions cannot obtain satisfactory results. Combined treatment with balloon-inflatable catheters for PEA and balloon decompression recently demonstrated sufficient pain relief and functional improvement in patients with intractable LSS. We compared the effects of PEA and balloon decompression in patients with intractable LSS who did not undergo PEA and those who were unresponsive to previous PEA with a balloon-less catheter.We examined 315 patients who underwent PEA and balloon decompression with balloon-inflatable catheters. Patients with intractable LSS were divided into those without previous PEA (No-PEA) and those unresponsive to previous PEA using balloon-less catheters (Prev-PEA). The numeric rating scale, Oswestry disability index, and global perceived effect of satisfaction scale were measured at 0, 1, 3, and 6 months after the intervention. Responder analysis was performed based on changes in measured scales and indices.A successful treatment response was observed at 1, 3, and 6 months after the intervention in 56.4%, 42.7%, and 32.9%, respectively, of the No-PEA group and in 48.9%, 37.8%, and 25.6%, respectively, of the Prev-PEA group. No significant between-group differences were detected. Pain intensities and functional status improved and were maintained throughout follow-up after PEA with balloon decompression using balloon-inflatable catheters.This modality may represent a useful alternative to overcome the limitations of preexisting adhesiolysis procedures.

A review of the role of epidural percutaneous neuroplasty

Degeneration, whether from age or postsurgical, in the ventral and lateral epidural space can lead to irritation of both the nerve roots and of the nerves present in the epidural space, the peridural membrane and the posterior longitudinal ligament. This irritation is often accompanied by mild scarring. Neuroplasty is a specific procedure designed to relieve this irritation. The effectiveness of neuroplasty is not affected by the extent of spinal stenosis. Neuroplasty can be performed in the lumbar, thoracic and cervical spine, and using caudal, transforaminal and interlaminar approaches. Postprocedural home exercises are an integral part of the procedure. There are multiple high-grade studies positive for the effectiveness and safety of neuroplasty. Neuroplasty should be offered prior to surgery in patients with persistent back and/or extremity pain.

The influence of epidural catheter on the incidence of intravascular injection during caudal block

OBJECTIVE

The aim of this study was to analyze the influence of epidural catheters on the incidence of intravascular injection and to identify possible predictors of intravascular injection in patients undergoing a caudal block using fluoroscopy.

METHODS

A total of 154 patients scheduled to receive a caudal block were randomized into group N (those without epidural catheter) or group C (those with epidural catheter). Demographic and clinical data were recorded and analyzed.

RESULTS

The incidence of intravascular injection was 15.6% in group N, 6.5% in group C, and 11.0% overall, without statistical differences between the two groups (P = 0.105). Univariate analysis revealed that blood at hub (P = 0.047) and positive aspiration test (P = 0.045) were more frequently observed in group N than in group C. Quality of analgesia was significantly higher in group C than in group N (P = 0.029). Multivariate analysis identified older age (P = 0.024), blood at hub (P = 0.003), and positive aspiration test (P = 0.001) as predictors of intravascular injection.

CONCLUSIONS

In this study, while the incidence of intravascular injection during caudal blocks was less frequent with epidural catheter use, it was not statistically significant. However, a caudal block using an epidural catheter provided a lower incidence of blood at hub, fewer positive aspiration tests, and superiority in pain improvement.

Effectiveness and Factors Associated with Epidural Decompression and Adhesiolysis Using a Balloon-Inflatable Catheter in Chronic Lumbar Spinal Stenosis: 1-Year Follow-Up

OBJECTIVES

This study aimed to investigate the efficacy of the combined balloon decompression with a balloon-inflatable catheter (ZiNeu) in addition to conventional epidural adhesiolysis, and to identify factors that predict patient responses.

STUDY DESIGN

An institutional single-armed prospective observational study.

SUBJECTS

Chronic refractory lumbar spinal stenosis.

METHODS

This study was performed in 61 patients with spinal stenosis who suffered from chronic (at least 3 months) lumbar radicular pain with or without lower back pain. Patients had failed to maintain improvement for more than 1 month with conventional epidural injection. The numeric rating scale (NRS) and Oswestry disability index (ODI) were each measured at 1, 3, 6, and 12 months after percutaneous epidural adhesiolysis and balloon decompression with a ZiNeu catheter.

RESULTS

The percentage of successful responders was 72.1%, 60.7%, 57.4%, and 36.1% of patients at 1, 3, 6, and 12 months, respectively. A single combined treatment of percutaneous epidural adhesiolysis and balloon decompression with a ZiNeu catheter provided sufficient pain relief and functional improvement in patients with chronic refractory lumbar spinal stenosis, and the improvement was maintained for 12 months (P < 0.001). Multivariate logistic regression analysis showed that absence of diabetes independently predicted successful response at 12 months after percutaneous epidural decompression and adhesiolysis with the balloon catheter (Odds ratio = 0.080; 95% confidence interval = 0.009-0.676; P = 0.020).

CONCLUSIONS

The combined epidural adhesiolysis and balloon decompression with a ZiNeu catheter led to significant pain relief and functional improvement in a subset of patients with refractory spinal stenosis.

Similar outcome despite slight clinical differences between lumbar radiculopathy induced by lateral versus medial disc herniations in patients without previous foraminal stenosis: a prospective cohort study with 1-year follow-up

BACKGROUND CONTEXT

It has been claimed that lumbar radiculopathy induced by foraminal disc herniations had poorer outcome and different clinical features, including: 1-more progressive onset, but shorter duration between the first sign and request of medical care; 2-more severe radiculopathy; 3-less frequent/severe back pain; 4-less limitation of straight leg raising (SLR); 5-more frequent neurologic deficiencies; 6-poorer outcome.

PURPOSE

To check whether this still holds true when including only patients without other reasons for foraminal stenosis, that is, whether patients with medial disc herniations had different features and outcome than those with more lateral disc herniations.

STUDY DESIGN

All patients hospitalized to treat a lumbar radiculopathy within a 6-month period in two French rheumatology units in 2012 were included in this prospective study each time computed tomography scan or magnetic resonance imaging had already been performed and showed clear disc bulging/herniation but no features of medial or lateral spinal stenosis.

PATIENT SAMPLE

Fifty-nine patients (31 males, 49 with sciatica only) were included: 31 (53%) had medial disc herniations and 28 (47%) had more lateral herniations (posterolateral in 3, foraminal in 20, and far lateral in 5).

OUTCOME MEASURES

Outcome was assessed by a phone call 1 year after the baseline assessment using a standardized questionnaire. Patients were asked whether they experienced a relapse of their radiculopathy after discharge from the hospital; whether they had been operated or not; whether they felt it had improved or not; whether they felt cured or not; to assess their level of pain radiating in the leg when standing on a 0 to 10 verbal scale; and how long they could walk.

METHODS

Features of patients with medial disc herniations were compared with patients with more lateral herniations.

RESULTS

No significant differences according to the location of herniations were noticed for the speed of radiculopathy onset, time elapsed since onset, back pain (both lying or standing), and leg pain (both lying or standing), but slight significant differences (t test<0.05) were observed for other items: the 28 patients with lateral herniations were 8 years older (53.4 ±15.8 vs. 45.2±12.6), their herniations involved discs from upper levels of the lumbar spine (above L4-L5: 7/28 vs. 3/31), motor weakness was more frequent (25% vs. 3%), SLR was less restricted (65.0°±24.5° vs. 51.1°±25.7°), DN4 score of neuropathic pain was higher (4.4±2.1 vs. 3.2±1.8), anxiety level was higher (10.3±4.1 vs. 7.9±3.2), length of hospital stay was longer (5.7±2.4 days vs. 4.5±1.4 days), and physician's prognosis of a good outcome was poorer (6.6±2.2 vs. 8.0±1.6). However, at the end of follow-up (12.2±3.3 months), outcome was similar: 37% (vs. 41% for medial herniations) had transiently relapsed, 66% felt finally improved (vs. 63%), and walking capacity was nearly identical despite the fact that only 18% had to be operated (vs. 32% of those with medial herniations).

CONCLUSIONS

Despite differences in clinical presentation, the outcome of radiculopathy induced by the more lateral lumbar disc herniations was not worse than the outcome of patients with only medial disc herniations. Previous claims of poorer outcome in foraminal herniations might be explained by the inclusion of patients with associated foraminal stenosis.

A novel balloon-inflatable catheter for percutaneous epidural adhesiolysis and decompression

Epidural adhesions cause pain by interfering with the free movement of the spinal nerves and increasing neural sensitivity as a consequence of neural compression. To remove adhesions and deliver injected drugs to target sites, percutaneous epidural adhesiolysis (PEA) is performed in patients who are unresponsive to conservative treatments. We describe four patients who were treated with a newly developed inflatable balloon catheter for more effective PEA and relief of stenosis. In the present patients, treatments with repetitive epidural steroid injection and/or PEA with the Racz catheter or the NaviCath did not yield long-lasting effects or functional improvements. However, PEA and decompression with the inflatable balloon catheter led to maintenance of pain relief for more than seven months and improvements in the functional status with increases in the walking distance. The present case series suggests that the inflatable balloon catheter may be an effective alternative to performing PEA when conventional methods fail to remove adhesions or sufficiently relieve stenosis.

A review of the role of epidural percutaneous adhesiolysis

SUMMARY Low back and leg pain can arise for a variety reasons, including epidural scarring caused by post lumbar surgery syndrome, infection or bleeding. Treatment options for low back and/or leg pain caused by epidural scarring include conservative approaches, such as physical therapy and medication management, and procedures, such as epidural steroid injections. Despite appropriate treatment, pain can persist in these patients. Surgery is often not an option for patients whose pain is caused by scarring. Percutaneous adhesiolysis is a minimally invasive technique, which is effective in treating refractory low back and leg pain arising from epidural scarring. It involves the use of a spring-wound, shear-resistant catheter, ideally placed in the ventrolateral aspect of the epidural space for the lysis of adhesions, allowing medications to reach the involved nerve and removing compression of the nerve. After mechanical lysis of adhesions, relatively large volumes of local anesthetic, saline, steroid and radiopaque contrast material are injected. Either hypertonic or normal saline may be used, along with hyaluronidase. After the procedure, the patient should perform exercises to stretch the nerve roots. While this has been studied as a caudal procedure, thoracic and cervical procedures have also been described, using both transforaminal and interlaminar approaches. With trained practitioners, complications are minimal. The effectiveness of the procedure has been documented by high-quality randomized controlled trials and observational studies for both postlumbar surgery syndrome and spinal stenosis.