A review of the role of epidural percutaneous neuroplasty

Percutaneous Epidural Neuroplasty for Symptomatic Lumbar Juxtafacet Cysts

Background and Objectives: The term "Juxtafacet cyst" refers to both synovial cysts and ganglion pseudocysts associated with the lumbar facet joint. As conservative treatment for the juxtafacet cyst has a minimal effect, complete excision through surgery is considered the first choice of treatment. In this study, we retrospectively reviewed the clinical outcomes of percutaneous epidural neuroplasty for symptomatic lumbar juxtafacet cysts. Materials and Methods: We conducted a retrospective review of 34 patients with symptomatic juxtafacet cysts who visited a single institute from January 2010 to September 2023. Patients who received conservative treatment for at least 6 weeks but experienced no or insufficient effects were eligible for this study. After neuroplasty, a medical history check and neurological examination were performed during follow-up at 2 weeks, 1 month, 2 months, 3 months, 6 months, and once a year thereafter. Results: The pain improved for all patients to a VAS score of 3 or less immediately after neuroplasty; however, four of those patients (11%) had pain that worsened eventually to the same level as before the procedure and required surgery. The results showed that, regardless of cyst size, in cases with severe stenosis of the spinal canal, the outcome of neuroplasty was poor and often eventually required surgery. The cyst size was not associated with the procedure results. In addition, if the cyst was present at the L4-L5 level, or if diabetes mellitus was present, the likelihood of future surgery was significant (p-value = 0.003). Conclusions: Percutaneous neuroplasty showed a better success rate than other non-surgical treatments. In addition, severe spinal stenosis (Schizas grade C or higher), L4-L5 level, or diabetes mellitus produced a high possibility of surgery due to recurrence.

Percutaneous epidural balloon neuroplasty: a narrative review of current evidence

Percutaneous epidural balloon neuroplasty (PEBN) can be used to perform balloon decompression combined with percutaneous epidural neuroplasty (PEN), leading to significant pain relief and functional improvement in patients with lumbar spinal stenosis. Several studies have demonstrated the effectiveness of PEBN and supported its relatively long-term outcomes (at least 6 months, sustained for up to 12 months). Balloon neuroplasty appears to be superior to conventional PEN. Moreover, it has been shown to be effective in patients unresponsive to conventional PEN or in those with post lumbar surgery syndrome. In addition, balloon neuroplasty achieved successful outcomes regardless of the approach used, such as retrodiscal, transforaminal, contralateral interlaminar, or caudal. Chronic lumbar radicular pain without back pain, neurogenic claudication, and minimal neuropathic component were favorable predictors of successful PEBN from a symptomatic perspective. A short duration of pain after lumbar surgery, lumbar foraminal stenosis caused primarily by degenerative disc, mild foraminal stenosis, and perineural adhesion by degenerative discs were associated with successful outcomes of PEBN from pathological aspects. Ballooning ≥ 50% of the target sites and complete contrast dispersion after ballooning seemed to be crucial for successful outcomes from a technical perspective. In addition, PEBN was effective regardless of the accompanying redundant nerve roots or a mild degree of spondylolisthesis. Studies on balloon neuroplasty have reported occasional minor and self-limiting complications; however, no PEBN-related significant complications have been reported. Given the present evidence, balloon neuroplasty appears to be a safe and effective procedure with minimal complications for the treatment of lumbar spinal stenosis.

Correlation Between Intravascular Injection Rate, Pain Intensity, and Degree of Cervical Neural Foraminal Stenosis During a Cervical Transforaminal Epidural Block

Purpose

Cervical transforaminal epidural blocks (CTEBs) are useful for the treatment of cervical radicular pain. However, during CTEBs, inadvertent intravascular injection can introduce particulate steroids into the bloodstream, thus leading to serious complications. Moreover, the risk factors associated with intravascular injection during CTEBs have not been identified. Cervical neural foraminal stenosis (CNFS) is a form of neural foraminal narrowing and a common cause of cervical radicular pain. In this study, we aimed to identify whether there is a correlation between the incidence of intravascular injection during CTEB, pain intensity, and the degree of CNFS.

Patients and Methods

A total of 126 patients were recruited. The patients were classified into two subgroups (group M and group S) based on the routine cervical T2-weighted axial magnetic resonance imaging (MRI) findings. Group M (n = 63) consisted of moderate CNFS patients, while group S (n = 63) consisted of severe CNFS patients. The occurrence of intravascular injection during CTEB was established using real-time fluoroscopy. The intravascular injection was determined by the spreading of the contrast medium through the vascular channel during the injection. Additionally, pain intensity was scored using a Numeric Rating Scale (NRS) before the procedure and 1 month after the procedure.

Results

There was no significant difference in the incidence of intravascular injection during CTEB between group M and group S (41.3% vs 39.7%, respectively; p = 0.99) and in the NRS scores before and 1 month after CTEB. However, both groups showed a significant decrease in the NRS scores at 1 month after the procedure compared with that before the procedure.

Conclusion

The degree of CNFS does not affect the incidence of intravascular injection during CTEB. Regardless of whether patients have moderate or severe CNFS, caution should be exercised during CTEB procedures.

Factors Associated with Successful Response to Balloon Decompressive Adhesiolysis Neuroplasty in Patients with Chronic Lumbar Foraminal Stenosis

Epidural neuroplasty, often called percutaneous epidural adhesiolysis, is often performed in refractory patients with chronic lumbar radiculopathy or neurogenic claudication. Recent studies have showed that decompressive adhesiolysis with an inflatable balloon catheter (balloon neuroplasty) is efficient in patients who experience refractory pain from epidural steroid injection or even epidural neuroplasty with a balloon-less catheter. However, exact indications or predictive factors for epidural balloon neuroplasty have not been fully evaluated. Therefore, to assess associated factors that could affect a favorable outcome, we analyzed a prospectively collected multicenter cohort of patients with chronic refractory lumbar foraminal stenosis after balloon neuroplasty. At the 6-month point in follow-up, 92 (44.4%) patients among 207 subjects were classified as successful responders according to a robust combination of outcome measures. Multivariate logistic regression analysis also showed that mild grade lumbar foraminal stenosis may be an independent factor associated with a successful response 6 months after balloon neuroplasty (odds ratio = 2.829; 95% confidence interval = 1.351–5.923; p = 0.006). However, we found that there were 29.4% and 24.6% successful responders with moderate and severe foraminal stenosis, respectively. Attempting balloon neuroplasty in refractory lumbar foraminal stenosis, especially mild grade, may be worthwhile.