Evaluation of the therapeutic results of epiduroscopic adhesiolysis for failed back surgery syndrome

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.

Interdisciplinary Surgical Treatments and Long-Term Outcomes of Lumbar Spinal Tumors With Retroperitoneal Involvements: A Retrospective Case Series Study

Purpose

Surgical treatments are technically challenging for lumbar spinal tumor (LST) with extensive retroperitoneal involvements. Our study aimed to report the experience and outcomes concerning interdisciplinary surgical collaborations in managing such LSTs.

Patients and Methods

Nine patients underwent interdisciplinary surgical treatments which were performed by specialists, namely, spinal, vascular, and urinary surgeries. Data on clinical characteristics were collected, and the Visual Analogue Scale (VAS) and the Japanese Orthopaedic Association Score (JOAS) were used in the evaluation before and after surgery. The postoperative complications and the long-term outcomes were reported as well.

Results

The interdisciplinary work included double J catheter indwelling (n = 9), nephrostomy (n = 5), replacement of the common iliac vein (n = 2), abdominal aorta repair (n = 3), and vital vessel repair (n = 8). The early-stage complications included complaints of moderate low back pain and slight implant shift (n = 1, 11.1%) and tardive ureterodialysis (n = 1, 11.1%). The 3- and 5-year disease-free survival rates were 76.2 ± 14.8 and 50.8 ± 23.0%, respectively, during the mean follow-up of 34.6 ± 17.9 months (range, 9.5–68.7). Besides this, more blood loss was associated with recurrent and metastatic tumor status (p = 0.043) and surgery time >5 h (p = 0.023). Remarkable pain relief and favorable quality of life were achieved based on the postoperative VAS (3.3 ± 0.9, p < 0.001) and JOAS (16.6 ± 0.5, p < 0.001).

Conclusions

The treatments of LSTs with wide-range retroperitoneal involvements require interdisciplinary surgical collaborations to lower the risks and improve the long-term outcomes. High-quality prospective cohort studies with large samples are warranted to establish general surgical protocols in managing LSTs with extensive retroperitoneal involvements.

Effectiveness of Epiduroscopy for Patients with Failed Back Surgery Syndrome: A Systematic Review and Meta-analysis

INTRODUCTION

Low-back or leg pain in patients suffering from failed back surgery syndrome (FBSS) is often severe, having a major impact on functionality and quality of life. Despite conservative and surgical treatments, pain can be persistent. An alternative treatment option is epiduroscopy, a minimally invasive procedure based on mechanical adhesiolysis of epidural fibrosis. As epidural fibrosis is speculated to be a major contributor in the pathophysiologic process of FBSS, this review evaluates the effectiveness of epiduroscopy in FBSS patients.

METHODS AND MATERIALS

A systematic literature search was performed in PubMed, Embase, and Cochrane databases. Critical appraisal was performed using validated tools. Meta-analysis was performed using generic inverse variance analysis.

RESULTS

From the 286 identified articles, nine studies were included. The visual analogue scale (VAS) average was 7.6 at baseline, 4.5 at 6, and 4.3 at 12 months. The Oswestry Disability Index (ODI) average was 61.7% at baseline, 42.8% at 6, and 46.9% at 12 months. An average of 49% of patients experienced significant pain relief at 6 and 37% at 12 months. Meta-analysis showed a pooled VAS mean difference of 3.4 (2.6 to 4.1; 95% confidence interval [CI]) and 2.8 (1.6 to 4.0; 95% CI) and pooled ODI mean difference of 19.4% (12.5 to 26.4%; 95% CI) and 19.8% (13.8 to 25.9%; 95% CI) at 6 and 12 months, respectively.

CONCLUSION

Current literature demonstrates a clinically relevant reduction in pain and disability scores at 6 to 12 months after mechanical adhesiolysis in FBSS patients. The quality of evidence is moderate, and the level of recommendation is weak. Practitioners should consider the benefits of epiduroscopy after weighing the risks for individual patients with FBSS.

Customized "Whole-Cervical-Vertebral-Body" Reconstruction After Modified Subtotal Spondylectomy of C2-C7 Spinal Tumor Via Piezoelectric Surgery

BACKGROUND

Radical resection is the first-line option in managing cervical primary chondrosarcoma. Favorable anterior reconstruction is challenging after multilevel total spondylectomy in the cervical spine.

OBJECTIVE

To illustrate the application of piezoelectric surgery and three-dimensional (3D) printing techniques in spine surgery.

METHODS

A 27-yr-old patient was referred to our center with complaints of nocturnal neck pain and right upper extremity weakness. A 2-stage radical tumor resection was conducted using piezoelectric surgery with pathologically tumor-free margins. A 3D-printed titanium microporous prosthesis (3D-PTMP) was designed to reconstruct the anterior column of the cervical spine between C1 and T1 for stability.

RESULTS

The whole intraoperative blood loss was 2300 mL over the 2 procedures. The patient had an uneventful recovery, regaining ambulatory status 3 wk after the 2 operations without ventilator support or other severe complications. By the final 14-mo follow-up, the patient had achieved marked pain relief and favorable neurological improvement; a postoperative computed tomography scan indicated a good position of the 3D-printed construct between the endplates with no sign of tumor recurrence or implant subsidence.

CONCLUSION

The applications of piezosurgery in total spondylectomy and in 3D-PTMP in reconstruction can be a favorable alternative for managing multilevel cervical spinal tumors. Further studies are warranted to validate this surgical strategy.

Contrast Dispersion on Epidurography May Be Associated with Clinical Outcomes After Percutaneous Epidural Neuroplasty Using an Inflatable Balloon Catheter

BACKGROUND

Contrast dispersion pattern on epidurography may be associated with clinical improvement after epidural neuroplasty. However, insufficient evidence supports this theory. The current study aims to evaluate the relevance of contrast dispersion and clinical improvement after percutaneous epidural neuroplasty using an inflatable balloon catheter.

METHODS

One hundred patients with lumbar spinal stenosis who underwent combined balloon decompression and epidural adhesiolysis between March 2015 to December 2015 participated in the present study. Participants were divided into two groups by contrast dispersion pattern on postprocedural epidurography: the complete contrast dispersion (CCD) and incomplete contrast dispersion (ICCD) groups. The numeric rating scale (NRS), Oswestry Disability Index (ODI), and global perceived effects (GPE) were each assessed before and one, three, six, nine, and 12 months after the intervention.

RESULTS

After combined balloon decompression and adhesiolysis, significant pain reduction and functional improvement were maintained up to 12 months in patients with lumbar spinal stenosis. NRS and GPE in the CCD group were significantly lower than in the ICCD group from six to 12 months after the intervention. The ODI in the CCD group was also significantly lower compared with that in the ICCD group from one to 12 months after the intervention.

CONCLUSIONS

Combined balloon decompression and adhesiolysis with the inflatable balloon catheter can provide noteworthy pain reduction and improvement of physical function for a long-term period in patients with lumbar spinal stenosis. Because CCD showed better clinical improvement compared with ICCD, a contrast dispersion pattern may be associated with an improved clinical outcome.

Efficacy, Effectiveness, Safety, and Cost-effectiveness of Epidural Adhesiolysis for Treating Failed Back Surgery Syndrome. A Systematic Review

BACKGROUND

Failed back surgery syndrome (FBSS) has a profound impact on patients' quality of life and represents a major clinical challenge and a significant economic burden for society. Adhesiolysis is used as a treatment to eliminate perineural/epidural adhesions in patients with chronic pain attributed to FBSS.

OBJECTIVE

To evaluate the efficacy, effectiveness, safety, and cost-effectiveness of epidural adhesiolysis compared with other procedures for treating FBSS.

METHOD

A systematic review was conducted. The electronic databases Medline/PreMedline, EMBASE, Cochrane Library Plus, Centre for Reviews and Dissemination databases, SCOPUS, Science Citation Index, and PEDRO were consulted through April 2017. Predefined criteria were used to determine inclusion of the studies and to assess their methodological quality.

RESULTS

Ten reports were included. No randomized controlled trials (RCTs) on efficacy or cost-effectiveness were found. Three reports (corresponding to two RCTs, N = 212) suggested that adhesiolysis was effective, especially for pain and disability. However, both studies presented serious methodological flaws. In addition to RCTs, seven observational studies with high risk of bias reported data on effectiveness and safety. Fifty-eight adverse events were reported among 130 patients undergoing endoscopic adhesiolysis, and 19 among the 110 undergoing percutaneous adhesiolysis.

CONCLUSIONS

The evidence on the efficacy and cost-effectiveness of adhesiolysis for treating FBSS is nonexistent, whereas evidence on its effectiveness and safety is insufficient. Incorporating data from observational studies did not improve the quality of the evidence on effectiveness.

Lumbar foraminal neuropathy: an update on non-surgical management

Lumbar foraminal pathology causing entrapment of neurovascular contents and radicular symptoms are commonly associated with foraminal stenosis. Foraminal neuropathy can also be derived from inflammation of the neighboring lateral recess or extraforaminal spaces. Conservative and interventional therapies have been used for the treatment of foraminal inflammation, fibrotic adhesion, and pain. This update reviews the anatomy, pathophysiology, clinical presentation, diagnosis, and current treatment options of foraminal neuropathy.

Evaluation of the efficacy of epiduroscopic adhesiolysis in failed back surgery syndrome

Background/aim

We aimed to compare the results of the treatment of the patients with failed back surgery syndrome (FBSS) by mechanical lysis and steroid hylase injection via epiduroscopy due to their stabilization status and to detect the effect of pathological diagnostic markers on prognosis and ongoing treatment protocol.

Materials and methods

Eighty-two patients with FBSS symptoms were included. Two groups were composed as group I (stabilized) and group II (nonstabilized). All patients were evaluated using the oswestry disability index (ODI) and visual analogue scale (VAS) scores before and after treatment at 1, 3, 6, and 12 months and using the patient satisfaction scale at 12 months following treatment. Epidural scar tissue visual and mechanical signs were also recorded.

Results

Mean VAS scores were 7.8 and 3.28 points in group I (P < 0.001) and 7.51 and 2.74 points in group II (P < 0.001) at the beginning and at 12 months, respectively. Mean ODI scores were 34.05 and 22.16 points in group I (P < 0.001) and 30.74 and 19.46 points in group II (P < 0.001) at the beginning and at 12 months. VAS and ODI scores decreased significantly in both groups, but were more significant in the nonstabilized group (P < 0.001). Moderate or severe fibrous tissue was observed in 86.58% of the patients and patient satisfaction scores were very good or good in 78.06% of the patients. During the procedure, a dura rupture developed in four patients in the stabilization group and in two patients in the nonstabilization group; however, none of these patients developed a spinal headache and no significant permanent complication arose.

Conclusion

We suggest that epidural adhesiolysis, hyaluronidase, and steroid injection in patients with FBSS chronic low back pain and/or radicular symptoms may give reliable information about the quality of life, accuracy of diagnosis, and the possible course of the present findings and may be more effective in nonstabilized patients

Clinical Efficacy and Safety of Trans-Sacral Epiduroscopic Laser Decompression Compared to Percutaneous Epidural Neuroplasty

Percutaneous epidural neuroplasty (PEN) is an effective and safe procedure for herniated lumbar disc (HLD). Although PEN has an advantage of adhesiolysis, this procedure cannot decompress the protruded disc. Recently, trans-sacral epiduroscopic laser decompression (SELD) for HLD has been introduced as a promising alternative methodology. This study evaluated the clinical efficacy and safety of SELD compared to PEN, as well as the change in protruded disc volume after SELD through pre- and postoperative magnetic resonance imaging (MRI), in patients with HLD. Thirty consecutive patients underwent SELD (SELD group), and 45 patients underwent PEN (PEN group). The Visual Analog Scale (VAS) for leg pain; Oswestry Disability Index (ODI); 12-Item Short-Form Health Survey (SF-12); preoperative and postoperative 4-, 12-, and 24-week Macnab criteria; and preoperative and 24-week postoperative lumbar spinal MRIs after SELD were obtained. There was no significant difference in age, sex, duration of symptoms, and the distributions of disc level between the two groups (all P > 0.05). Between the SELD and PEN groups, preoperative VAS, ODI, and SF-12 scores had no significant differences. However, the VAS, ODI, and SF-12 scores improved significantly after the procedures by postoperative week 24 in each group (all P < 0.05). Furthermore, improvements of VAS, ODI, SF-12, and success rate of Macnab criteria in the SELD group were better than those in the PEN group (all P < 0.05). The protruded disc volume after SELD decreased significantly (P=0.034). All clinical and functional outcomes of patients undergoing SELD and PEN for HLD improved following the procedures. Notably, SELD was superior to PEN regarding the degree of improvement in clinical and functional outcomes. Therefore, we suggest that SELD can be used as an effective alternative to PEN to provide improved clinical and functional outcomes in patients with HLD.

Clinical Significance of Epidurography Contrast Patterns after Adhesiolysis during Lumbar Percutaneous Epidural Neuroplasty

Background

The correlation between epidurography contrast patterns and the clinical outcomes of percutaneous epidural neuroplasty (PEN) remains unclear.

Objective

To analyze the correlation between postadhesiolysis epidurography contrast patterns and the clinical outcomes of patients who undergo lumbar PEN.

Design

This study is a retrospective analysis of 78 consecutive patients who underwent lumbar PEN between April 2012 and March 2013.

Setting

The analysis was done in the university hospital center.

Method

The clinical outcomes of all patients were assessed before and 1, 3, 6, and 12 months after undergoing lumbar PEN. Specifically, the intensity of back and leg pain, quality of life, and procedural outcomes were evaluated using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and the 12-Item Short-Form Health Survey (SF-12).

Results

The VAS scores for back and leg pain, ODI score, and SF-12 score exhibited a significant improvement during the follow-up period (P < 0.01 versus preprocedural scores). At most follow-up time points, patients exhibiting extraforaminal contrast distribution (n=22) on postadhesiolysis epidurograms exhibited a similar improvement in VAS scores and a significantly better improvement in ODI and SF-12 scores compared with patients exhibiting intracanal contrast distribution (n=56).

Conclusion

Extraforaminal contrast distribution during lumbar PEN may be associated with better functional outcomes.

Neuropathic Pain after Spinal Surgery

Neuropathic pain after spinal surgery, the so-called failed back surgery syndrome (FBSS), is a frequently observed troublesome disease entity. Although medications may be effective to some degree, many patients continue experiencing intolerable pain and functional disability. Only gabapentin has been proven effective in patients with FBSS. No relevant studies regarding manipulation or physiotherapy for FBSS have been published. Spinal cord stimulation (SCS) has been widely investigated as a treatment option for chronic neuropathic pain, including FBSS. SCS was generally accepted to improve chronic back and leg pain, physical function, and sleep quality. Although the cost effectiveness of SCS has been proved in many studies, its routine application is limited considering that it is invasive and is associated with safety issues. Percutaneous epidural adhesiolysis has also shown good clinical outcomes; however, its effects persisted for only a short period. Because none of the current methods provide absolute superiority in terms of clinical outcomes, a multidisciplinary approach is required to manage this complex disease. Further studies concerning the etiology, diagnosis, treatment, and cost effectiveness of FBSS are warranted to deepen our understanding of this condition.

Therapeutic effect of epidural hyaluronic acid in a rat model of foraminal stenosis

PURPOSE

Since receiving a warning from the US Food and Drug Administration (FDA) about injection of corticosteroids into the epidural space having serious adverse events, we have sought alternative medications for injection at this site. Hyaluronic acid (HA) has anti-adhesive, anti-inflammatory, and lubricating properties, so could potentially be useful for spinal pain. The exact mechanism by which spinal stenosis develops is not fully understood, but is likely to involve inflammation. Therefore, we hypothesized that HA could have a therapeutic effect in spinal stenosis. This study evaluated the effects of epidural administration of HA on alleviation of pain in a rat model of foraminal stenosis.

MATERIALS AND METHODS

After creating the animal model, HA (HA group) or saline solution (S group) was administered via an epidural catheter. The paw-withdrawal threshold to mechanical stimulation and motor dysfunction were monitored for up to 21 days. Tissue was collected to evaluate the degree of adhesion, inflammation in the perineural area, and chromatolysis in the dorsal root ganglion (DRG).

RESULTS

The mechanical withdrawal threshold was restored in the HA group but not in the S group (P < 0.001). The HA group also showed less fibrosis (P = 0.026) and less chromatolysis (P = 0.002) than the S group.

CONCLUSION

HA administered epidurally had a therapeutic effect on the allodynia and hyperalgesia induced by chronic compression of the DRG.

Effects of cepae extract, allantoin, and heparin mixture on developing andalready formed epidural fibrosis in a rat laminectomy model

BACKGROUND/AIM

The study was designed to investigate whether local administration of a mixture composed of cepae extract, allantoin, and heparin (CAH) decreased already formed epidural fibrosis (EF) at the laminectomy site.

MATERIALS AND METHODS

Twenty-four adult male Sprague Dawley rats were equally divided into four groups. Laminectomy was performed at the L5 level in all rats. The group 2 and group 4 rats were treated with local drug administration. While the group 1 and 2 rats were sacrificed after 6 weeks, the remaining rats were reoperated and CAH mixture was applied in group 4. The vertebral columns of all rats were removed en bloc. Fibroblast numbers, EF, and arachnoidal involvement (AI) were evaluated.

RESULTS

The results of the treatment groups were separately compared with the control groups. The numbers of fibroblasts in the treatment groups were significantly lower than those in the control groups (P < 0.001). The grade of EF in group 2 was significantly less than that in group 1 (P < 0.05). There was no statistically significant difference regarding EF and AI grade between group 3 and group 4, and local application of the drug on EF and AI yielded better results than in the control groups.

CONCLUSION

The mixture composed of CAH might be a successful candidate for preventing EF in clinical practice.

Sudden occurrence of Roth spots and retinal hemorrhages following endoscopic adhesiolysis: an SD-OCT evaluation

PURPOSE

To document the occurrence of Roth spots and retinal hemorrhages by spectral-domain optical coherence tomography (SD-OCT) following endoscopic adhesiolysis for failed back surgery syndrome.

METHODS

Case report.

RESULTS

A 47-year-old patient noted progressive and bilateral visual loss immediately after epidural endoscopy and endoscopic adhesiolysis. Funduscopic examination showed multiple Roth spots and retinal hemorrhages at the posterior pole and the retinal midperiphery in both eyes. Spectral-domain optical coherence tomography demonstrated that Roth spots involved the inner retina, while dot hemorrhages involved the outer retina. Most retinal hemorrhages and Roth spots resolved over 6 weeks, with complete functional recovery in both eyes. However, SD-OCT revealed multiple areas of disruption of the outer retinal layers in the left eye.

CONCLUSIONS

Roth spots and retinal hemorrhages can occur after endoscopic spinal surgery. Although hemorrhages resolve quickly over few weeks, SD-OCT can demonstrate that retinal damage might persist, especially in the outer retina. This finding may explain cases of incomplete recovery of visual function after complicated endoscopic adhesiolysis.

Advantages of digital subtraction angiography during nerve block

Introduction:

Most pain physicians know that fluoroscopy might improve the safety, accuracy, and efficacy of nerve block; however, it is difficult to distinguish the previously administered contrast medium from the injecting contrast medium, and to identify accurate contrast medium diffusion flow in a case of existing radiodensities such as cement and screw. Digital subtraction angiography (DSA) can improve accuracy of nerve blocks.

Case Presentation:

We described our experiences with two successful transforaminal epidural injections and nerve block of two patients with 73 and 68 years of age who were diagnosed as failed back surgery syndrome.

Conclusions:

The advantages of DSA in fluoroscopy-guided transforaminal epidural block and nerve block are identification of the degree of appropriate contrast flow (epidural and nerve root sleeve) and the intravascular administration without overlapping radiodense structures.

Evaluations of computed tomography images and lumbar specimens in mimic operations of transverse rotation laminoplasty for lumbar spinal stenosis

Background:

Laminectomy is a major method to treat lumbar spinal stenosis (LSS), but it has lots of flaws such as scar tissue can form around the dura again or spinal instability. This study aimed to investigate the feasibility of transverse rotation laminoplasty (TRL) in the treatment of LSS.

Methods:

The mimic operations of TRL were performed both in the computerized image processing and on the lumbar specimen. Computed tomography (CT) images were either collected from 80 clinical patients with complaints of lumbago or obtained from 40 sets of lumbar specimens after rebuild of spinal canals. In the CT image processing the heights of the spinous process and laminae at L3–L5 were measured. The total length of the spinous process plus one side laminae after the operation was evaluated and compared with the length of inner margin of pedical before the operation. The areas of the vertebral canal were examined before and after the operation.

Results:

In the CT images, the height of spinous process of L3, L4 and L5 was 24.74 ± 3.45, 22.68 ± 5.96 and 21.54 ± 4.12 mm respectively, and that of laminae was 23.66 ± 2.32, 22.68 ± 5.36 and 20.99 ± 3.67 mm respectively (P > 0.05). Distance of inner border of pedical of L3, L4 and L5 was 23.01 ± 6.59, 24.65 ± 5.54 and 26.03 ± 7.34 mm respectively, and length of spinous process with laminae of those was 29.76 ± 4.91, 29.31 ± 6.43 and 32.53 ± 5.76 mm respectively (P < 0.05). Preoperative area of spinal canals of L3, L4 and L5 was 299.81 ± 10.09, 297.66 ± 9.54 and 308.22 ± 10.04 mm² respectively, and postoperative area was 480.01 ± 9.33, 487.32 ± 8.65 and 501.03 ± 9.12 mm² respectively (P < 0.05). In the human lumbar vertebrae specimen, the data similar to the former.

Conclusions:

The excised canal posterior was covered, and the lumbar canals enlarged by TRL. The TRL provided a new alternative in the treatment of LSS.

The failed back surgery syndrome: pitfalls surrounding evaluation and treatment

This article describes the costs and risk factors for failed back surgery syndrome and reviews the diagnosis and treatment strategies commonly used to address this syndrome. The purpose of this review is to describe some of the treatment pitfalls associated with these approaches from a physiatric perspective.

One-year results of an algorithmic approach to managing failed back surgery syndrome

BACKGROUND

Failed back surgery syndrome (FBSS) is a major clinical problem. Different etiologies with different incidence rates have been proposed. There are currently no standards regarding the management of these patients. Epiduroscopy is an endoscopic technique that may play a role in the management of FBSS.

OBJECTIVE

To evaluate an algorithm for management of severe FBSS including epiduroscopy as a diagnostic and therapeutic tool.

METHODS

A total of 133 patients with severe symptoms of FBSS (visual analogue scale score ≥7) and no response to pharmacological treatment and physical therapy were included. A six-step management algorithm was applied. Data, including patient demographics, pain and surgical procedure, were analyzed. In all cases, one or more objective causes of pain were established. Treatment success was defined as ≥50% long-term pain relief maintained during the first year of follow-up. Final allocation of patients was registered: good outcome with conservative treatment, surgical re-intervention and palliative treatment with implantable devices.

RESULTS

Of 122 patients enrolled, 59.84% underwent instrumented surgery and 40.16% a noninstrumented procedure. Most (64.75%) experienced significant pain relief with conventional pain clinic treatments; 15.57% required surgical treatment. Palliative spinal cord stimulation and spinal analgesia were applied in 9.84% and 2.46% of the cases, respectively. The most common diagnosis was epidural fibrosis, followed by disc herniation, global or lateral stenosis, and foraminal stenosis.

CONCLUSIONS

A new six-step ladder approach to severe FBSS management that includes epiduroscopy was analyzed. Etiologies are accurately described and a useful role of epiduroscopy was confirmed.

Does improvement in epidurography following percutaneous epidural neuroplasty correspond to patient outcome?

OBJECTIVE

The positive effects of percutaneous epidural neuroplasty (PEN) likely result from elimination of fibrous tissue. However, a direct link between epidural adhesions and pain symptoms is debatable. We tested the hypothesis that epidurographic improvements correspond to improved patient outcome.

METHODS

In this prospective study, patients with a filling defect on initial epidurography underwent PEN. Two weeks later, contrast agent distribution around the target area was assessed with repeat epidurography. A successful treatment was defined as over a 50% reduction in visual analog scale (VAS) score 2 weeks postprocedure. The demographic data, history of lumbar spine operation, target nerve, diagnosis, VAS scores, degree of epidurographic improvement, and patient satisfaction were compared between the successful treatment group (Group I) and unsuccessful treatment group (Group II).

RESULTS

Seventy-nine patients were included. Epidurographic findings improved in 67.1% of patients 2 weeks after the procedure. Following PEN, the mean VAS scores of all patients were significantly decreased at 2 weeks (4.12 ± 2.34), 1 month (3.56 ± 2.30), 3 months (3.84 ± 2.45), and 6 months (4.13 ± 2.71) compared with the initial scores (7.82 ± 1.78). In the comparison between Groups I and II, the rate of epidurographic improvement in Group I was higher than in Group II (P = 0.022). Satisfaction in patients that had epidurographic improvement (median satisfaction: 4) was higher than in patients that did not have epidurographic improvement (median satisfaction: 3; P = 0.003).

CONCLUSION

The epidurographic changes following PEN correlate with patient-assessed pain relief and satisfaction.

The Comparison of the Result of Epiduroscopic Laser Neural Decompression between FBSS or Not

Background

Epiduroscopic laser neural decompression (ELND) has been performed as a treatment tool for chronic refractory low back pain and/or radicular pain. There are some studies about the usefulness of epiduroscopy for post lumbar surgery syndrome, however, few studies about the effectiveness of epiduroscopy for patients without back surgery. We compared the satisfaction of patients who underwent ELND for chronic low back pain and/or radicular pain after back surgery and for the same symptoms without surgery.

Methods

We compared the degree of satisfaction of patients after ELND between who had underwent the lumbar spine surgery and who had not retrospectively by chart reviewing. We divided 39 patients who had received ELND into two groups, one is the group of patients who got the lumbar surgery (group 1), and the other is the group of patients who did not (group 2). Their medical records including age, sex, previous treatment, duration of illness, degree of symptom relief were investigated. We compared each items between two groups.

Results

The number of patients in group 1 was 17, and group 2 was 22. In group 1, 16 patients (94.1%) showed more than 'Acceptable', and 19 patients (86.4%) showed more than 'Acceptable' in group 2. There is no significant differences statistically in percentage of patients who showed more than 'Acceptable' in the satisfaction after ELND between two groups.

Conclusions

ELND provided satisfaction (more than 85%) for patients with chronic low back pain and/or leg pain regardless of previous back surgery history.

Occurrence of trochlear nerve palsy after epiduroscopic laser discectomy and neural decompression

Epiduroscopic laser discectomy and neural decompression (ELND) is known as an effective treatment for intractable lumbar pain and radiating pain which develop after lumbar surgery, as well as for herniation of the intervertebral disk and spinal stenosis. However, various complications occur due to the invasiveness of this procedure and epidural adhesion, and rarely, cranial nerve damage can occur due to increased intracranial pressure. Here, the authors report case in which double vision occurred after epiduroscopic laser discectomy and neural decompression in a patient with failed back surgery syndrome (FBSS).

The Correlation between Caudal Epidurogram and Low Back Pain

BACKGROUND

The common causes of lower back pain with or without leg pain includes disk disease and spinal stenosis. A definitive diagnosis is usually made by means of magnetic resonance imaging (MRI), but treatment is often difficult because the MRI findings are not consistent with the symptoms of the patient in many cases. The objective of this study was to observe the correlation between the patterns of epidurography performed in patients having lower back pain with or without leg pain and the position or severity of the pain as subjectively described by the patients.

METHODS

The subjects of this study were 69 outpatients with lower back pain with or without leg pain who visited our clinic and complained of predominant pain on one side. We performed caudal epidural block using an image intensifier. A mixture of the therapeutic drug and the contrast agent (10 ml) was injected to observe the contrast flow pattern. The patients who complained of predominant pain on one side were divided into the left side group and the right side group. A judgment of inconsistency was made if the contrast agent flowed to the side of the pain, while a judgment of consistency was made if the contrast agent flowed to the opposite side of the pain. The degree of the drug distribution was evaluated by counting the number of cells to which the contrast agent's flowed for evaluating the correlation between the contrasted cell and the severity of pain (one group ≤ VAS 7, the other group ≥ VAS 8) the degree of the contrast agent's contrast was evaluated by dividing and counting an image into 15 cells (the left, right, and middle sections at each level of L4, L5, S1, S2, and S3).

RESULTS

Thirty out of the 69 patients who had laterality in pain, that is, those who complained of predominant pain on one side, showed that the laterality of the pain and the contrast agent flow was consistent, while 39 patients showed that the laterality was inconsistent (P: 0.137). The evaluation of the correlation between the pain and the contrast agent flow showed that the mean number of contrasted cells was 9.0 ± 2.2 for the 46 patients in the group with a VAS of 7 or lower and 6.5 ± 2.0 for the 23 patients in the group with a VAS of 8 or higher, indicating that the former group showed a significantly greater number of contrasted cells (P < 0.001).

CONCLUSIONS

This study, conducted with patients having lower back pain with or without leg pain, showed that the contrast flow pattern of caudal epidurography had a significant correlation with the severity of the pain but not with the laterality of the pain.