Direct visualization of the lumbosacral epidural space through the sacral hiatus

Minimally Invasive Trans-sacral Canal Plasty for Lumbar Canal Stenosis

Objective The elderly population is increasing in Japan. Along with the increase in the elderly population, the number of patients with lumbar degenerative diseases is also on the rise. In general, elderly patients tend to have more complications and are at higher risk for surgery. Many elderly people suffer from lumbar degenerative disease. We reviewed our initial experience with trans-sacral canal plasty (TSCP) for patients with lumbar spinal canal stenosis and examined the pertinent literature for this report. Methods An analytical observational study was performed on 120 patients with lumbar spinal canal stenosis who underwent TSCP at our single institution from March 2019 to October 2021. These patients had leg pain and/or lower back pain due to degenerative lumbar disease. Patients who had coagulation abnormality, pregnancy, contrast allergy, pyogenic spondylitis, or spinal metastasis were excluded. Results Immediately after TSCP, the average Visual Analog Scale (VAS) score for back pain improved from 58.2 to 29.3, and for leg pain from 72.0 to 31.3. Two years after TSCP, the average VAS score for back pain increased slightly and the average score for leg pain remained almost the same. Additional surgery was performed in 37 of 120 (31%) patients who underwent TSCP. The additional surgery group had significantly worse back pain at one and three months postoperatively than the conservative treatment group. The additional surgery group had significantly worse leg pain immediately after TSCP and at one and three months postoperatively than the conservative treatment group. Logistic regression analysis demonstrated that a decreased spinal canal area (OR 0.986, p = 0.039) was associated with additional surgery. Conclusions We reviewed the outcomes of TSCP at our hospital. The average VAS score for back pain and leg pain improved. However, 31% of patients who underwent TSCP required additional surgery. It was found that the spinal canal area was a major factor in the need for additional surgery.

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.

How to Restart the Interventional Activity in the COVID-19 Era: The Experience of a Private Pain Unit in Spain

INTRODUCTION

The situation generated in the health system by the COVID-19 pandemic has provoked a crisis involving the necessity to cancel non-urgent and oncologic activity in the operating room and in day-to-day practice. As the situation continues, the need to reinstate attention for patients with chronic pain grows. The restoration of this activity has to begin with on-site appointments and possible surgical procedures. On-site clinical activity has to guarantee the safety of patients and health workers.

OBJECTIVES

The objective of this review was to evaluate how to manage activity in pain units, considering the scenario generated by the pandemic and the implications of chronic pain on the immune system and proposed pharmacological and interventional therapies.

METHODS

Besides the established general recommendations (physical distance, surgical masks, gloves, etc.), we established specific recommendations that will allow patient treatment and relieve the disruption of the immune response. It is important to highlight the use of opioids with the least influence in the immune system. Further, individualized corticoid use, risk assessment, reduced immune suppression, and dose adjustment should take patient needs into account. In this scenario, we highlight the use of radiofrequency and neuromodulation therapies, techniques that do not interfere with the immune response.

CONCLUSIONS

We describe procedures to implement these recommendations for individual clinical situations, the therapeutic possibilities and safety guidelines for each center, and government recommendations during the COVID-19 pandemic.

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.

Feasibility of the Epiduroscopy Simulator as a Training Tool: A Pilot Study

Epiduroscopy is a type of spinal intervention that visualizes the epidural space through the sacral hiatus using a fiberoptic scope. However, it is technically difficult to perform compared to conventional interventions and susceptible to complications. Surgery simulator has been shown to be a promising modality for medical education. To develop the epiduroscopy simulator and prove its usefulness for epiduroscopy training, we performed a case-control study including a total of 20 physicians. The participants were classified as the expert group with more than 30 epiduroscopy experiences and the beginner group with less experience. A virtual simulator (EpiduroSIM™, BioComputing Lab, KOREATECH, Cheonan, Republic of Korea) for epiduroscopy was developed by the authors. The performance of the participants was measured by three items: time to reach a virtual target, training score, and number of times the dura and nerve are violated. The training score was better in the expert group (75.00 vs. 67.50; P < 0.01). The number of violations was lower in the expert group (3.50 vs. 4.0; P < 0.01). The realism of the epidural simulator was evaluated to be acceptable in 40%. Participants improved their simulator skills through repeated attempts. The epiduroscopy simulator helped participants understand the anatomical structure and actual epiduroscopy.

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.

Dexmedetomidine use during epiduroscopy reduces fentanyl use and postoperative nausea and vomiting: A single-center retrospective study

Objectives

Minimally invasive epiduroscopy has recently been reported as an effective treatment procedure for chronic and intractable low back pain. However, no study has determined safe anesthetics for monitored anesthesia care during epiduroscopy. We aimed to compare and evaluate conventional monitored anesthesia care drugs with dexmedetomidine.

Methods

A retrospective study including all patients who underwent epiduroscopy at the JR Tokyo General Hospital from April 2011 to March 2016 was designed. The epiduroscopy procedures were performed under anesthesia with dexmedetomidine plus fentanyl (dexmedetomidine group) or droperidol plus fentanyl (neuroleptanalgesia group). Patients who received analgesics other than fentanyl, another analgesic combined with fentanyl, any sedative other than dexmedetomidine or droperidol, or who had incomplete data were excluded. We compared (1) the type and dose of medication during the epiduroscopy and (2) the incidence of postoperative nausea and vomiting.

Results

We identified 45 patients (31 and 14 in the dexmedetomidine and neuroleptanalgesia groups, respectively) with a mean age of 69.0 years. The two groups had comparable characteristics, such as age, sex, body mass index, the American Society of Anesthesiologists Physical Status, analgesics used in the clinic, comorbidities, history of smoking, and the duration of anesthesia. The dexmedetomidine group received a significantly lower fentanyl dose during surgery (126 ± 14 vs 193 ± 21 µg, mean ± standard deviation, p = 0.014) and exhibited a significantly lower incidence of postoperative nausea and vomiting (1 vs 3, p = 0.047) than the neuroleptanalgesia group.

Conclusion

This study involved elderly patients, and the use of dexmedetomidine in monitored anesthesia care during epiduroscopy procedures in these patients may reduce the required fentanyl dose during surgery and the incidence of postoperative nausea and vomiting. This strategy may help prevent respiratory depression and aspiration.

Morphometric study of sacral hiatus in adult human Egyptian sacra: Their significance in caudal epidural anesthesia

Background:

The reliability and success of caudal epidural anesthesia depends on anatomic variations of sacral hiatus (SH) as observed by various authors. SH is an important landmark during caudal epidural block (CEB).The purpose of the present study was to clarify the morphometric characteristics of the SH in human Egyptian dry sacra and pelvic radiographs and identification of nearest ony landmarks to permit correct and uncomplicated caudal epidural accesses.

Methods:

The present study was done on 46 human adult Egyptian dry sacra. The maximum height, midventral curved length, and maximum breadth of each sacrum were measured and sacral and curvature indices were calculated. According to sacral indices, sacra were divided into 2 groups (22 male and 24 female sacra). SH was evaluated in each sacrum according to its shape, level of its apex, and base according to sacral and coccygeal vertebrae, length, anteroposterior (AP) diameter at its apex, and transverse width at its base. Linear distances were measured between the apex of SH and second sacral foramina, right and left superolateral sacral crests. The distance between the 2 superolateral sacral crests also was measured.

Results:

The most common types of SH were the inverted U and inverted V (in male) and inverted V and dumbbell shaped (in female). Absent SH was observed in male group only. The most common location of SH apex was at the level of S4 in all groups of dry sacra and S3 in all groups of lumbosacral spine radiographs, whereas S5 was the common level of its base. The mean SH length, transverse width of its base, and AP diameter of its apex were 2.1±0.80, 1.7±0.26, and 0.48±0.19 cm. Female sacra showed narrower SH apex than male. The distance between the S2 foramen and the apex of the SH was 4.1±1.14, 3.67±1.21, and 4.48±1.01 cm in total, female and male sacra, respectively.

Conclusion:

Sacrum and SH showed morphometric variations in adult Egyptians. The equilateral triangle is an important guide to detect SH easily and increases the success rate of CEB. Insertion of a needle into the SH for caudal block is suggested to be done at its base to avoid the anatomic variations of its apex.

Use of endoscopy for examination of the sacral epidural space in standing cattle

OBJECTIVE

To develop an epiduroscopic technique for use in standing cattle and describe the endoscopically visible anatomic structures of the epidural space in the sacrococcygeal area.

ANIMALS

6 healthy nonlactating, nonpregnant cows (mean +/- SD age, 60 +/- 18.5 months; mean weight, 599.7 +/- 63.87 kg) and 3 bovine cadavers.

PROCEDURES

Cadavers were used to allow familiarization with the equipment and refinement of the technique. Following these experiences, procedures were performed in live animals. Each cow was restrained in a stock. After sedation with xylazine (0.03 mg/kg, IV), 2% lidocaine hydrochloride (0.25 mg/kg) was injected epidurally in the first intercoccygeal or the sacrococcygeal intervertebral space. By use of an introducer set (guidewire and dilation trocar and shaft), a flexible endoscope (length, 75 cm; diameter, 2.3 mm) was inserted through the dilation shaft into the epidural space. To obtain an optimal view, small amounts of air were insufflated into the epidural space through the working channel of the endoscope via a syringe with special filter.

RESULTS

Anatomic structures of the epidural space that were viewed by means of the endoscopic procedure included blood vessels, connective tissue, fat, nerves, and the spinal dura mater. No adverse events were detected during epiduroscopy, and it was tolerated well by all 6 cows.

CONCLUSIONS AND CLINICAL RELEVANCE

In ruminants, epidural structures can be viewed via endoscopy. Such epiduroscopic procedures may be useful in anatomic studies as well as for the diagnosis of disease or therapeutic interventions in ruminants.

Epidural lysis of adhesions and myeloscopy

Chronic low back pain is one of the most common ailments in modern medicine, with as many as 79% of patients with acute pain continuing to suffer with chronic or recurrent low back pain 1 year after its onset. Lumbar epidural fibrosis and post-lumbar laminectomy syndrome are increasingly recognized as being responsible for persistent low back pain. Estimations show that approximately 5% to 40% of lumbar surgeries result in failed back surgery syndrome. Epidural adhesiolysis with myeloscopy is an interventional technique based on the premise that the three-dimensional visualization of the contents of the epidural space provides the physician with the ability to directly visualize the structures, perform appropriate adhesiolysis, and administer drugs specifically to the target. This review describes pathophysiologic aspects, purposes and goals, rationale and indications, complications, and effectiveness of epidural lysis of adhesions with myeloscopy.