Epidural lysis of adhesions

Comparative-effectiveness study evaluating outcomes for transforaminal epidural steroid injections performed with 3% hypertonic saline or normal saline in lumbosacral radicular pain

BACKGROUND

Transforaminal epidural steroid injections (TFESI) are commonly employed to treat lumbosacral radiculopathy. Despite anti-inflammatory properties, the addition of 3% hypertonic saline has not been studied.

OBJECTIVE

Compare the effectiveness of adding 0.9% NaCl (N-group) vs. 3% NaCl (H-group) in TFESI performed for lumbosacral radiculopathy.

METHODS

This retrospective study compared TFESI performed with lidocaine, triamcinolone and 0.9% NaCl vs. lidocaine, triamcinolone and 3% NaCl. The primary outcome was the proportion of patients who experienced a ≥ 30% reduction in pain on a verbal rating scale (VRS; 0-100) at 3 months. Secondary outcome measures included the proportion of patients who improved by at least 30% for pain at 1 and 6 months, and who experienced ≥15% from baseline on the Oswestry disability index (ODI) at follow-up.

RESULTS

The H-group experienced more successful pain outcomes than the N-group at 3 months (59.09% vs. 41.51%; P = .002) but not at 1 month (67.53% vs. 64.78%; P = .61) or 6 months (27.13% vs 21.55%: P = .31). For functional outcome, there was a higher proportion of responders in the H-group than the N-group at 3 months (70.31% vs. 53.46%; P = .002). Female, age ≤ 60 years, and duration of pain ≤ 6 months were associated with superior outcomes at the 3-month endpoint. Although those with a herniated disc experienced better outcomes in general with TFESI, the only difference favoring the H-group was for spondylolisthesis patients.

CONCLUSIONS

3% hypertonic saline is a viable alternative to normal saline as an adjunct for TFESI, with randomized studies needed to compare its effectiveness to steroids as a possible alternative.

REGISTRATION

Thai Clinical Trials Registry ID TCTR 20231110006.

Analysis of the efficacy of retrodiscal approach percutaneous epidural adhesiolysis with WHIP catheter® in patients with lumbar radiculopathy: A retrospective study

Percutaneous epidural adhesiolysis (PEA) is an effective treatment for patients with lumbar radiculopathy unresponsive to single steroid injections. Various approaches and instruments have been developed to access these lesions. This study aimed to evaluate the utility of a retrodiscal approach for epidural adhesiolysis using a WHIP catheter®. This retrospective study was conducted at Bundang Seoul National University Hospital, reviewing cases from January to December 2022. Forty-seven patients diagnosed with lumbar radiculopathy, aged 20 to 80 years, who underwent PEA with the WHIP catheter® were included. Outcomes assessed Numeric Rating Scale (NRS) for pain, Patients' Global Impression of Change (PGIC) scores, and the incidence of procedure-related complications. Follow-up evaluations occurred at 1, 3, and 6 months post-procedure. Among 47 patients, 41 completed the study, showing significant pain reduction at all follow-up points: 1 month (N = 41, 1.32 ± 1.68, P < .001), 3 months (N = 31, 1.90 ± 2.14, P < .001), and 6 months (N = 30, 2.50 ± 2.30, P < .001). PGIC scores indicated that 40% of the patients reported substantial improvement at one-month post-procedure. The complications were minimal, with only one case of intradiscal injection and 2 cases of vascular uptake. The retrodiscal approach PEA using the WHIP catheter® demonstrated significant efficacy in pain reduction with minimal safety concerns for patients with lumbar radiculopathy. These findings suggest that this procedure is a viable option for patients who are unresponsive to conservative treatment. However, the retrospective nature of this study and its small sample size necessitate further prospective controlled studies to confirm our results and establish long-term outcomes.

Factors leading to open revision surgery after trans-sacral canal plasty for lumbar spine disease

Trans-sacral canal plasty (TSCP) is a minimally invasive lumbar spine surgery under local anaesthesia. TSCP is expected to be effective regardless of whether the patient has had previous surgery. However, there are cases in which open revision surgery is required after TSCP. This study aimed to identify risk factors for open revision surgery after TSCP in order to determine surgical indications and limitations. A retrospective case-control study was conducted in patients who underwent TSCP for lumbar spine disease. Data of 112 patients were analysed. During an observation period of 7-23 months, 34 patients (30.4%) required open revision surgery and 78 (69.6%) did not. The following patient background characteristics were investigated: age, sex, body mass index (BMI), diagnosis, history of spine surgery and the institution where the surgery was performed. Comorbidities were scored using the Elixhauser Comorbidity Index. Preoperative imaging parameters were investigated, including the lesion level (L4/5, L5/S1, other), presence of intervertebral instability, dural sac area, presence of bony stenosis and presence of epidural lipoma. Multivariate analysis revealed that intervertebral instability (odds ratio 2.56, confidence interval 1.00-6.51, p = 0.046) and a narrow dural sac area (odds ratio 0.98, confidence interval 0.97-0.99, p = 0.002) were significant risk factors for open revision surgery after TSCP.

Postoperative Epidural Fibrosis: Challenges and Opportunities - A Review

Postoperative epidural fibrosis (EF) is still a major limitation to the success of spine surgery. Fibrotic adhesions in the epidural space, initiated via local trauma and inflammation, can induce difficult-to-treat pain and constitute the main cause of failed back surgery syndrome, which not uncommonly requires operative revision. Manifold agents and methods have been tested for EF relief in order to mitigate this longstanding health burden and its socioeconomic consequences. Although several promising strategies could be identified, few have thus far overcome the high translational hurdle, and there has been little change in standard clinical practice. Nonetheless, notable research progress in the field has put new exciting avenues on the horizon. In this review, we outline the etiology and pathogenesis of EF, portray its clinical and surgical presentation, and critically appraise current efforts and novel approaches toward enhanced prevention and treatment.

1. Lumbosacral radicular pain

INTRODUCTION

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%.

METHODS

The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized.

RESULTS

Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers.

CONCLUSIONS

The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

Predictive Factors Associated with Successful Response to Percutaneous Adhesiolysis in Chronic Lumbar Radicular Pain

Percutaneous adhesiolysis (PEA) is of interest in the treatment of lumbar radicular pain. This study aimed to assess the effectiveness of PEA in patients with chronic lumbar radicular pain refractory to epidural steroid injections and to determine predictive factors, including demographic, clinical, and procedural data, to provide superior treatment efficacy. One hundred and ninety-three patients were reviewed. Successful treatment outcome was described as a 50% reduction in the visual analog scale score. Among the 193 patients, 109 (56.2%) exhibited a positive treatment response at 12 months. In multivariate logistic regression analysis, no depression (OR, 3.105; 95% CI, 1.127-8.547; p = 0.028), no spondylolisthesis (OR, 2.976; 95% CI, 1.246-7.092; p = 0.014), no previous lumbar surgery (OR, 2.242; 95% CI, 1.067-4.716; p = 0.033), mild foraminal stenosis (OR, 3.460; 95% CI, 1.436-8.333; p = 0.006), no opioid use (OR, 1.782; 95% CI, 0.854-3.717; p = 0.123), and baseline pain scores (OR, 0.787; 95% CI, 0.583-1.064; p = 0.120) were the predictive factors significantly associated with unsuccessful treatment outcome. PEA is a useful treatment option for patients with chronic lumbar radicular pain refractory to epidural steroid injections. A history of lumbar surgery, spondylolisthesis, depression, and severe foraminal stenosis could be associated with a poor prognosis.

Involvement of the spinal γ-aminobutyric acid receptor in the analgesic effects of intrathecally injected hypertonic saline in spinal nerve-ligated rats

Background

: Hypertonic saline is used for treating chronic pain; however, clinical studies that aid in optimizing therapeutic protocols are lacking. We aimed to determine the concentration of intrathecally injected hypertonic saline at which the effect reaches its peak as well as the underlying γ-aminobutyric acid (GABA) receptor-related antinociceptive mechanism.

Methods

: Spinal nerve ligation (SNL; left L5 and L6) was performed to induce neuropathic pain in rats weighing 250-300 g. Experiment 1: one week after implanting the intrathecal catheter, 60 rats were assigned randomly to intrathecal injection with 0.45%, 0.9%, 2.5%, 5%, 10%, and 20% NaCl, followed by behavioral testing at baseline and after 30 minutes, 2 hours, 1 day, and 1 week to determine the minimal concentration which produced maximal analgesia. Experiment 2: after determining the optimal intrathecal hypertonic saline concentration, 60 rats were randomly divided into four groups: Sham, hypertonic saline without pretreatment, and hypertonic saline after pretreatment with one of two GABA receptor antagonists (GABAA [bicuculline], or GABAB [phaclofen]). Behavioral tests were performed at weeks 1 and 3 following each treatment.

Results

: Hypertonic saline at concentrations greater than 5% alleviated SNL-induced mechanical allodynia and had a significant therapeutic effect, while showing a partial time- and dose-dependent antinociceptive effect on thermal and cold hyperalgesia. However, pretreatment with GABA receptor antagonists inhibited the antinociceptive effect of 5% NaCl.

Conclusions

: This study indicates that the optimal concentration of hypertonic saline for controlling mechanical allodynia in neuropathic pain is 5%, and that its analgesic effect is related to GABAA and GABAB receptors.

Relationship between Time Elapsed Since Pain Onset and Efficacy of Pain Relief in Patients Undergoing Lumbar Percutaneous Epidural Adhesiolysis

PURPOSE

The aim of this study was to investigate the relationship between pain duration and pain relief after epidural adhesiolysis.

MATERIALS AND METHODS

Patients with low back pain who underwent lumbar epidural adhesiolysis were enrolled. A clinically significant reduction in pain score was defined as a ≥30% reduction at 6-month follow-up evaluation. Variables were compared based on pain duration categories. Changes in pain scores and pain outcome were also compared. Logistic regression analysis was conducted to identify factors associated with pain relief after adhesiolysis.

RESULTS

A total of 169 patients, including 77 (45.6%) patients with a favorable pain outcome, were included for analysis. Patients with a pain duration ≥3 years reported lower baseline pain scores and showed more frequent severe central stenosis. Pain scores significantly decreased over time after the procedure except in patients with a pain duration ≥3 years. Most patients who experienced pain for ≥3 years showed poor pain relief (80.8%), unlike other pain duration categories (pain duration <3 months=48.1%, 3 months-1 year=51.8%, 1-3 years=48.6%). A pain duration ≥3 years and lower baseline pain score were independent factors associated with an unfavorable pain outcome.

CONCLUSION

Pain lasting ≥3 years prior to lumbar epidural adhesiolysis was associated with worse outcomes in terms of pain relief. Therefore, this intervention should be considered early before pain chronification in patients with low back pain.

Evaluation of Paraspinal Muscle Degeneration on Pain Relief after Percutaneous Epidural Adhesiolysis in Patients with Degenerative Lumbar Spinal Disease

Background and Objectives: The analgesic effectiveness of epidural adhesiolysis may be influenced by morphological changes in the paraspinal muscles, particularly in elderly patients. The objective of this study was to assess whether the cross-sectional area or fatty infiltration of the paraspinal muscles impacts the treatment outcomes of epidural adhesiolysis. Materials and Methods: The analysis included a total of 183 patients with degenerative lumbar disease who underwent epidural adhesiolysis. Good analgesia was defined as a reduction in pain score of ≥30% at the 6-month follow up. We measured the cross-sectional area and fatty infiltration rate of the paraspinal muscles and divided the study population into age groups (≥65 years and <65 years). Variables were compared between the good and poor analgesia groups. Results: The results revealed that elderly patients experienced poorer analgesic outcomes as the rate of fatty infiltration in the paraspinal muscles increased (p = 0.029), predominantly in female patients. However, there was no correlation between the cross-sectional area and the analgesic outcome in patients younger than or older than 65 years (p = 0.397 and p = 0.349, respectively). Multivariable logistic regression analysis indicated that baseline pain scores < 7 (Odds Ratio (OR) = 4.039, 95% Confidence Interval (CI) = 1.594-10.233, p = 0.003), spondylolisthesis (OR = 4.074, 95% CI = 1.144-14.511, p = 0.030), and ≥ 50% fatty infiltration of the paraspinal muscles (OR = 6.576, 95% CI = 1.300-33.268, p = 0.023) were significantly associated with poor outcomes after adhesiolysis in elderly patients. Conclusions: Fatty degeneration of paraspinal muscles is correlated with inferior analgesic outcomes following epidural adhesiolysis in elderly patients, but not in young and middle-aged patients. The cross-sectional area of the paraspinal muscles is not associated with pain relief after the procedure.

Interventional Pain Procedures: A Narrative Review Focusing On Safety and Complications. PART 2 Interventional Procedures For Back Pain

In patients where conservative approaches have failed to relieve from chronic pain, interventional procedures may be an option in well selected patients. In recent years there has been an increase in the use and development of invasive procedures. Concomitantly, there has also been an increase in the complications associated with these procedures. Taken this into consideration, it is important for healthcare providers to take a cautious and vigilant approach, with a focus on patient safety, in order to minimize the risk of adverse events and ensure the best possible outcome for the patient. This may include careful selection of patients for procedures, use of proper techniques and equipment, and close monitoring and follow-up after the procedure. The aim of this narrative review is to summarize the primary complications associated with commonly performed image-guided (fluoroscopy or ultrasound-guided) interventional procedures and provide strategies to reduce the risk of these complications. We conclude that although complications from interventional pain procedures can be mitigated to a certain degree, they cannot be eliminated altogether. In order to avoid adverse events, patient safety should be given considerable attention and physicians should be constantly aware of the possibility of developing complications.

Comparison of Adjuvant Hypertonic Saline and Normal Saline for Epidural Block in Patients with Postherpetic Neuralgia: A Double-Blind, Randomized Trial

Background

In patients with postherpetic neuralgia (PHN), the effectiveness of epidural block and the benefits of adjuvant hypertonic saline (HS) have not been fully determined. Therefore, we investigated these issues in this study.

Methods

At a tertiary medical center's single pain clinic in Seoul, Republic of Korea, patients complaining of PHN even after 4 months of herpes zoster onset were enrolled and randomly assigned to either the HS or normal saline (NS) group. After epidural block with adjuvant HS or NS administration according to each protocol, outcomes were assessed at baseline and one and three months after the intervention. The primary outcome was pain intensity on the numerical rating scale (NRS). The secondary outcomes were the insomnia severity index (ISI), the medication quantification scale (MQS), and the global perceived effect of satisfaction (GPES).

Results

Thirty-six patients (NS: 17, HS: 19) were included in the intention-to-treat analysis. The estimated pain intensity decreased in both groups at one and three months after the procedure (P < 0.001), without a significant group difference. The estimated ISI and MQS were not significantly different at 1 month compared with baseline but significantly decreased at 3 months in each group (P < 0.001 and P < 0.001, respectively), without group differences. In addition, there was no difference between the groups on the GPES scale at one and three months after the procedure.

Conclusions

Epidural steroid injection may have the advantages of short-term pain relief, improved sleep quality, and decreased medication usage in patients with PHN. In addition, adjuvant HS administration with epidural steroid injection did not show beneficial effects in patients with PHN. Further studies are needed to clarify the potential effectiveness of HS in treating neuropathic pain such as PHN. This trial is registered with KCT0002845.

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.

Assessing the impact of adding bupivacaine on immediate and delayed post-procedure pain scores in interlaminar epidural steroid injections

OBJECTIVE

A local anesthetic is frequently administered as part of a lumbar epidural steroid injection (LESI); however, there is a rare potential for this to result in transient paralysis if administered incorrectly. The purpose of this retrospective study is to determine if the addition of bupivacaine significantly improves patient-reported pain scores.

MATERIALS AND METHODS

This retrospective review includes patients undergoing LESI over an approximately 1 year time span. Pre-procedure, immediate post-procedure, and 1-week integer scaled pain scores were recorded. Ordinal regression was used to compare the distributions of the aggregated ordinal pain score categories between bupivacaine- and non-bupivacaine-injected patients.

RESULTS

Two hundred fifty-eight patients met the inclusion criteria (126F:132 M, mean age 64.7 years) with 164 receiving bupivacaine and steroids and 94 receiving steroids alone. The relative frequency distributions for pre-injection pain did not differ between the bupivacaine patients and the non-bupivacaine patients (p = 0.114). Similarly, the relative frequency distributions for immediate and 1-week post-procedure pain did not differ between the bupivacaine patients and the non-bupivacaine patients (p = 0.293 at immediate time point and p = 0.306 at 1-week time point). Odds ratios comparing pain severity change between the bupivacaine and non-bupivacaine patients also were not significantly different at either the immediate post-procedure (p = 0.769) or 1-week (p = 0.203) time points.

CONCLUSION

The lack of a significant downward shift in the bupivacaine patients' post-procedure pain scores compared to the non-bupivacaine patients' post-procedure pain scores raises doubts about bupivacaine's utility as a standard component of a lumbar epidural injection.

Effect of Previous Caudal Block to Predict Successful Outcome after Adhesiolysis using a Steerable Catheter in Lumbar Failed Back Surgery Syndrome: A Retrospective Study

Adhesiolysis is minimally invasive and commonly used for pain associated with adhesion after lumbar spine surgery. Caudal epidural block may be used for radiating pain due to failed back surgery syndrome. We evaluated the predictive value of response to caudal block performed prior to adhesiolysis in failed back surgery syndrome. Between January 1, 2013 and June 30, 2020, 150 patients with failed back surgery syndrome were treated with adhesiolysis using a steerable catheter at the pain clinic of a tertiary hospital after failed conservative treatment (including caudal block). Patient demographics, pain duration, and lumbar magnetic resonance imaging findings were examined. Response to previous caudal block was determined as a binary result (yes or no). Patients were followed up 3 months after adhesiolysis. Successful outcome was defined as a ≥2-point reduction in the numeric rating scale scores for radicular pain 3 months after adhesiolysis, evident in 81/150 (46%) patients. Multivariable logistic regression analysis revealed that caudal block response was an independent predictor of successful adhesiolysis (odds ratio = 4.403; p = 0.015). Response to prior caudal block is a positive predictor of successful adhesiolysis.

The Comparison of Fluoroscopy-Guided Epidural Anesthesia with Conscious Sedation and General Anesthesia for Endoscopic Lumbar Decompression Surgery: A Retrospective Analysis

BACKGROUND

With advances and refinements in endoscopic lumbar spine surgery showing effective and satisfactory results, the need for simple yet effective anesthetic techniques for minimally invasive endoscopic spine surgery has increased. The aim of this study was to compare feasibility and postoperative outcomes of fluoroscopy-guided epidural anesthesia with general anesthesia in patients undergoing endoscopic lumbar decompression surgery (≤3 levels).

METHODS

Patients who underwent 1-3 levels of endoscopic lumbar decompression surgery under either fluoroscopy-guided epidural or general anesthesia between January 2019 and October 2020 were retrospectively reviewed. Postoperative pain intensity and use of rescue analgesics for up to 48 hours were compared between the epidural and general anesthesia groups. Intraoperative anesthetic data and postoperative recovery profiles were also analyzed.

RESULTS

Postoperative pain scores were significantly lower in the epidural anesthesia group compared with the general anesthesia group at 10 minutes after recovery room admission (2.1 ± 1.8 vs. 5.7 ± 1.9, P < 0.001), 24 hours postoperatively (3.3 ± 1.0 vs. 5.4 ± 1.8, P < 0.001), and 48 hours postoperatively (3.2 ± 0.6 vs. 4.4 ± 1.4, P < 0.001). The proportion of patients requiring rescue analgesics in the recovery room was significantly lower in the epidural anesthesia group (1.9% vs. 20.5%, P = 0.027). The median 15-item Quality of Recovery score on postoperative day 1 was significantly higher in the epidural anesthesia group (118.0 [113.5-123.0] vs. 82.0 [73.5-111.5], P < 0.001). Occurrence of nausea, vomiting, and voiding difficulty up to 48 hours postoperatively did not differ between groups.

CONCLUSIONS

Compared with general anesthesia, epidural anesthesia provided better analgesia and recovery characteristics during the early postoperative period in endoscopic lumbar decompression surgery.

IFN-α-2b Inhibits the Proliferation and Migration of Fibroblasts via the TGFβ/Smad Signaling Pathway to Reduce Postoperative Epidural Fibrosis

Epidural fibrosis after lumbar laminectomy refers to a serious complication, and excessive proliferation of fibroblasts is considered the major factor. Interferon-alpha-2b (IFN-α-2b) can exert antiviral and antiproliferative effects, which has been suggested to effectively prevent several fibrotic diseases. However, the effect of IFN-α-2b on the prevention of epidural fibrosis (EF) and its possible mechanism remain unclear. In this study, in vitro and in vivo experiments were performed to examine the possible mechanism of IFN-α-2b for preventing EF. Cell counting kit-8 (CCK-8), cell cycle test, Edu incorporation, wound healing assay, transwell test, and Western blotting assay were performed to investigate the inhibitory effect of IFN-α-2b on the proliferation and migration of fibroblasts in vitro. As indicated from the results, IFN-α-2b was capable of inhibiting proliferation and migration of fibroblasts and inhibiting the activity of the transforming growth factor β (TGFβ)/Smad signaling pathway. In vivo, the effect of IFN-α-2b on the reduction of EF was determined by performing histological macroscopic evaluation and histological and immunohistochemical staining. As suggested from the results, IFN-α-2b significantly inhibited EF after laminectomy. As revealed from the mentioned results, IFN-α-2b may have a promising application for preventing EF in the future.

Comparison Between a Single Subpedicular Transforaminal Epidural Steroid Injection and Lateral Recess Steroid Injection in Reducing Paracentral Disc Herniation-Related Chronic Neuropathic Leg Pain: A Retrospective Study

BACKGROUND

This retrospective study compares the results of 2 different techniques of transforaminal epidural steroid injection (TFESI)-subpedicular (SP-TFESI) and lateral recess epidural steroid injection (LRSI) in relieving chronic lumbar radicular pain.

METHODS

Records of 97 patients who had undergone injection for unilateral lumbar radicular pain and had a paracentral disc were analyzed. Numerical rating scale (NRS) and Oswestry Disability Index (ODI) scores were measured at baseline and at 2, 4, 12, and 24 weeks thereafter.

RESULTS

At 24 weeks, the NRS was significantly lower than the baseline in both groups; NRS in the LRSI group was significantly lower than NRS in the SP-TFESI group at 12 and 24 weeks (P = 0.02 each). ODI score was also significantly lower in the LRSI group through the 12-week time point (P = 0.003 at 2 weeks; P = 0.009 at 4 weeks; P = 0.02 at 12 weeks). At the end of 24 weeks, a significantly greater number of patients in the LRSI group achieved minimal clinically important difference for NRS and ODI (P = 0.008 and 0.016, respectively).

CONCLUSIONS

At the end of 24 weeks, LRSI appears to be a superior technique in relieving unilateral lumbar radicular pain due to a paracentral disc.

An Evidence Based Review of Epidurolysis for the Management of Epidural Adhesions

PURPOSE OF REVIEW

This review presents epidurolysis as a procedure to alleviate pain and disability from epidural adhesions. It reviews novel and groundbreaking evidence, describing the background, indications, benefits and adverse events from this procedure in an effort to provide healthcare experts with the data required to decide on an intervention for their patients.

RECENT FINDINGS

Epidural adhesions (EA) or epidural fibrosis (EF) is defined as non-physiologic scar formation secondary to a local inflammatory reaction provoked by tissue trauma in the epidural space. Often, it is a sequelae of surgical spine intervention or instrumentation. The cost associated with chronic post-operative back pain has been reported to be up to nearly $12,500 dollars per year; this, coupled with the increasing prevalence of chronic lower back pain and the subsequent increase in surgical management of back pain, renders EF a significant cost and morbidity in the U.S. Though risk factors leading to the development of EA are not well established, epidural fibrosis has been reported to be the culprit in up to 46% of cases of Failed Back Surgery Syndrome (FBSS), a chronic pain condition found in up to 20-54% of patients who receive back surgery. Moreover, EF has also been associated with lumbar radiculopathy after lumbar disc surgery. Epidurolysis is defined as the mechanical dissolution of epidural fibrotic scar tissue for persistent axial spine or radicular pain due to epidural fibrosis that is refractory to conservative therapy Endoscopic lysis of adhesions is a procedural technique which has been shown to improve chronic back pain in one-third to one-half of patients with clinically symptomatic fibrous adhesions. Here we review some of the novel evidence that supports this procedure in EA and FBSS.

SUMMARY

The literature concerning epidurolysis in the management of epidural adhesions is insufficient. Prospective studies, including randomized controlled trials and observational studies, have suggested epidurolysis to be effective in terms of pain reduction, functional improvement, and patient satisfaction scores. Observational studies report epidurolysis as a well-tolerated, safe procedure. Current evidence suggests that epidurolysis may be used as an effective treatment modality for epidural adhesions. Nonetheless, further high quality randomized controlled studies assessing the safety and efficacy of epidurolysis in the management of epidural adhesions is needed.

Analysis of Subdural Injection During Lumbar Interlaminar Epidural Injection in Failed Back Surgery Syndrome

Persistent or recurrent back and leg pain following spinal surgery, known as failed back surgery syndrome (FBSS), significantly limits daily life activities. A lumbar epidural injection can reduce adhesions, inflammation, and nerve compression, although the epidural space can be distorted due to dura mater and epidural tissues changes after spinal surgery. This study analyzed subdural injection during lumbar epidural injection in FBSS patients. We retrospectively analyzed data from 155 patients who received a lumbar interlaminar epidural injection to manage FBSS. We grouped the patients based on the injected contrast medium appearance in the subdural (group S) or epidural spaces (group E) in fluoroscopic contrast images. Demographic, clinical, surgical and fluoroscopic data were recorded and evaluated, as were the pain scores before and after injection. There were 59 patients (38.1%) in the subdural group. Injection distance from the surgery level differed between the groups. Risk of subdural injection at level 1 distance from the surgery level had an odds ratio of 0.374, and at level ≥2, it was 0.172, when compared to level 0. Subdural incidence differed with the distance from surgical site. Physicians should strive to reduce subdural incidence when the injection is planned at surgery site in FBSS.

Effect of supraneural transforaminal epidural steroid injection combined with caudal epidural steroid injection with catheter in chronic radicular pain management: Double blinded randomized controlled trial

Background: Epidural steroid injection (ESI) has been used in managing chronic radicular pain. Regarding various techniques of ESI, the synergistic effect of caudal ESI (CESI) on transforaminal ESI (TFESI) in chronic lumbosacral radicular pain in prospective randomized controlled trial has not been determined.  Methods:  A total of 54 eligible patients with lumbosacral radicular pain were randomly allocated to undergo TFESI plus CESI (TC group) or TFESI alone (T group).  The effective response to treatment was predefined by at least a 30% reduced verbal numerical rating scale (VNRS) from baseline between group comparison and the functional outcomes as measured by improved Oswestry Disability Index by least 15 points from baseline. All participants were evaluated using a single blinded outcome assessor before the  procedure and at 1, 3 and 6 months after the procedure. P <0.05 was considered as statistically significant.  Results:  Average VNRS reduced significantly from baseline after receiving procedure at 1, 3 and 6 months in both groups (P-value <0.05). The TC group exhibited more effective and showed significant pain relief compared with the T group at 3 months (P=0.01). However, no statistical difference was observed between sub group analysis in pain relief and insignificant difference between group comparisons of functional outcomes.

Conclusions: A treatment combining TFESI and CESI showed significant pain relief over TFESI alone at 3 months. No effect was found concerning functional evaluation.

Registration: Thai Clinical Trials Registry ID TCTR20171101002 01/11/2017F

Is Percutaneous Adhesiolysis Effective in Managing Chronic Low Back and Lower Extremity Pain in Post-surgery Syndrome: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

The growing prevalence of spinal pain in the USA continues to produce substantial economic impact and strain on health-related quality of life. Percutaneous adhesiolysis is utilized for recalcitrant, resistant conditions involving spinal pain when epidural injections have failed to provide adequate improvement, especially low back and lower extremity pain, specifically in post-lumbar surgery syndrome. Despite multiple publications and systematic reviews, the debate continues in reference to effectiveness, safety, appropriate utilization, and medical necessity of percutaneous adhesiolysis in chronic pain. This systematic review, therefore, was undertaken to evaluate and to update effectiveness of percutaneous adhesiolysis to treat chronic refractory low back and lower extremity pain, post-surgical patients of the lumbar spine.

RECENT FINDINGS

From 2009 to 2016, there was a decline of 53.2% utilization of percutaneous adhesiolysis with an annual decline of 10.3% per 100,000 fee-for-service (FFS) Medicare population. Multiple insurers, including Medicare, with Medicare area contractors of Noridian and Palmetto have issued noncoverage policies for percutaneous adhesiolysis resulting in these steep declines and continued noncoverage by Medicare Advantage plans, Managed Care plans of Medicaid, and other insurers. Since 2005, 4 systematic reviews of percutaneous adhesiolysis were published with 3 of them showing proper methodology and appropriate results with effectiveness of adhesiolysis, whereas one poorly performed systematic review showed negative results. In addition, there were only 4 randomized controlled trials (RCTs) to be included in the previous systematic reviews of post-surgery syndrome, whereas now, the RCTs and other studies have increased. This systematic review shows level I or strong evidence for the effectiveness of percutaneous adhesiolysis in managing chronic low back and lower extremity pain related to post-lumbar surgery syndrome.

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.

A Randomized, Multicenter, Double-Blind, Parallel Pilot Study Assessing the Effect of Mechanical Adhesiolysis vs Adhesiolysis with Corticosteroid and Hyaluronidase Administration into the Epidural Space During Epiduroscopy

OBJECTIVE

Epiduroscopy is a proven method of diagnosis and treatment for chronic radicular pain after spinal surgery, which is known as failed back surgery syndrome (FBSS). The aim of the study was to compare the efficacy of drugs (the enzyme hyaluronidase and corticosteroid DEPO-Medrol) administrated into the epidural space during epiduroscopy, performed within the ventral and ventro-lateral epidural space with a focus on releasing foraminal adhesions.

METHODS

Forty-eight patients with diagnosed FBBS were randomized into two groups before epiduroscopy. Group A received the standard treatment-mechanical lysis of fibrotic tissue in the epidural space. Group B received hyaluronidase and corticosteroid methylprednisolone acetate during the procedure. Subjects were followed for six and 12 months via scheduled double-blinded examinations by pain physicians. Leg and back pain intensity was assessed by an 11-point numerical rating scale, and patients' functional disability was assessed by the Oswestry Disability Index (ODI).

RESULTS

Study subjects showed a significant decrease in ODI score in both groups (P < 0.05). Significantly lower pain scores for leg pain (P < 0.05) and back pain (P < 0.05) were also recorded after the six-month follow-up. However, the one-year follow-up showed a return to the baseline ODI values of most monitored pain scores in both groups (P > 0.05). Improvement was only noted on the NRS for back pain at one-year follow-up (P < 0.05).

CONCLUSIONS

A significant improvement of leg and back pain was found in both groups after six months. ODI was significantly improved only in group B in both the six- and 12-month intervals. Back pain at one-year follow-up was only improved in group B.

Advantages of the Combination of Conscious Sedation Epidural Anesthesia Under Fluoroscopy Guidance in Lumbar Spine Surgery

Background

With the increase in life expectancy seen throughout the world, the prevalence of degenerative spinal pathology and surgery to treat it has increased. Spinal surgery under general anesthesia leads to various problems and complications, especially in patients with numerous medical comorbidities or elderly patients. For this reason, there is a need for safer anesthetic methods applicable to unhealthy, elderly patients undergoing spinal surgery.

Purpose

To report our experience with utilizing fluoroscopy-guided epidural anesthesia in conjunction with conscious sedation in spinal surgery.

Patients and Methods

We performed a retrospective review of 111 patients at our institution that received fluoroscopy-guided epidural anesthesia for lumbar surgery from February to September 2018. Patients’ records were evaluated to evaluate patient demographics, American Society of Anesthesiology Physical Classification System (ASA) class, and pain numerical rating scores (NRS) preoperatively and throughout their recovery postoperatively. Intraoperative data including volume of epidural anesthetic used, extent of epidural spread, and inadvertent subdural injection was collected. Postoperative recovery time was also collected.

Results

The mean age of our patients was 60 years old with a range between 31 and 83 years old. All patients experienced decreases in postoperative pain with no significant differences based on age or ASA class. There was no association between ASA class and time to recovery postoperatively. Older patients (age 70 years or greater) had a significantly longer recovery time when compared to younger patients. Recovery also was longer for patients who received higher volumes of epidural anesthesia. For every 1 mL increase of epidural anesthetic given, there was an increase in the extent of spread of 1.8 spinal levels.

Conclusion

We demonstrate the safety and feasibility of utilizing conscious sedation in conjunction with fluoroscopy-guided epidural anesthesia in the lumbar spinal surgery.

The effect of additional transforaminal epidural blocks on percutaneous epidural neuroplasty with a wire-type catheter: A retrospective observational study

Percutaneous epidural neuroplasty (PEN) is an effective interventional treatment for radicular pain. However, in some cases, contrast runoff to the spinal nerve root does not occur. We investigated whether contrast runoff to the spinal nerve root affects the success rate of PEN and whether additional transforaminal epidural blocks for intentional contrast runoff affect the success rate of PEN in cases in which contrast runoff is absent.This study was registered at ClinicalTrials.gov (Identifier: NCT03867630) in March 2019. We reviewed the medical records of 112 patients who underwent PEN with a wire-type catheter from May 2016 to August 2018. Patients were divided in 3 groups (Runoff group, Non-runoff group, Transforaminal group).Patients with low back pain and leg radicular pain who did not respond to lumbar epidural steroid injectionsPEN was performed in 112 patients with a wire-type catheter in target segment. We compared the success rate of PEN betweenThe success rate was significantly different between the Runoff group and the Non-runoff group (P < .0007) and between the Non-runoff group and the Transforaminal group (P = .0047), but not between the Runoff group and the Transforaminal group (P = .57).Contrast runoff influenced the success rate of PEN. In cases without contrast runoff, additional transforaminal epidural blocks for intentional contrast runoff increased the success rate of PEN with a wire-type catheter.

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.

Effectiveness of continuous hypertonic saline infusion with an automated infusion pump for decompressive neuroplasty: a randomized clinical trial

Background

Hypertonic saline (HS) injections for decompressive neuroplasty (DN) can cause pain. We assessed whether a continuous infusion of HS through an infusion pump would reduce injection-related pain compared with repeated bolus administrations.

Methods

Fifty patients scheduled for DN were randomized to either the bolus injection or the continuous infusion group. After appropriately placing the epidural catheter, 4 mL of 5% NaCl was injected as four boluses of 1 mL each at 15-minute intervals or infused over 1 hour using an infusion pump. The severity of pain induced by HS injection, as measured by the 11-point numerical rating scale (NRS), was the primary outcome. The severity of low back or lower extremity pain, as measured by the 11-point NRS and Oswestry Disability Index (ODI), 3 months following the procedure, was the secondary outcome.

Results

Data from 21 patients in the bolus group and 23 in the continuous infusion group were analyzed. No statistically significant difference in injection-related pain was identified between the two groups during the initial HS administration (P = 0.846). However, there was a statistically significant reduction in injection-related pain in the continuous infusion group compared to the bolus injection group from the second assessment onwards (P = 0.001, < 0.001, and < 0.001, respectively). No significant between-group differences in the NRS and ODI scores 3 months post-procedure were noted (P = 0.614 and 0.949, respectively).

Conclusions

Our study suggests that administering HS through a continuous infusion is a useful modality for reducing HS injection-related pain during DN.

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.

Artesunate inhibits fibroblasts proliferation and reduces surgery-induced epidural fibrosis via the autophagy-mediated p53/p21waf1/cip1 pathway

Fibroblast proliferation is considered to be a major cause in the process of epidural fibrosis formation. Autophagy is a tightly-regulated catabolic process in charge of degrading intracellular components. Although autophagy has been associated with fibrosis of different tissues, the effect of autophagy on epidural fibrosis is still unknown. The aim of this study was to investigate the function and mechanism of autophagy induced by Artesunate (ART), a classical antimalarial agent extracted from the Chinese medicinal herb. In vitro, the effect of ART on inducing fibroblast autophagy was evaluated via LC3 immunofluorescent staining, Transmission Electron Microscopy (TEM) and western blotting analysis. Moreover, the effect of ART on inhibiting fibroblast proliferation was investigated by CCK-8 assay, EdU incorporation assay, flow cytometry and western blotting analysis. Results indicated that ART could induce autophagy and inhibit proliferation in fibroblasts. The inhibitory effect of ART on fibroblast proliferation was associated with the upregulation of p53 and p21^waf1/cip1 proteins. Intriguingly, 3-MA, a classical autophagy inhibitor, attenuated ART-induced p53/p21^waf1/cip1 pathway activation and fibroblast proliferation inhibition. In vivo, the effect of ART on reducing epidural fibrosis was detected by histological macroscopic assessment, hydroxyproline content analysis, histological and immunohistochemical staining. The results revealed that ART had significant suppressive effects on epidural fibrosis following laminectomy in rats. In conclusion, this research demonstrated that ART could inhibit fibroblast proliferation and reduce epidural fibrosis formation after laminectomy, and the potential mechanism might through autophagy cascade-mediated p53/p21^waf1/cip1 pathway. It might provide a novel reagent for reducing epidural fibrosis after spinal laminectomy surgery.

The outcome of epiduroscopy treatment in patients with chronic low back pain and radicular pain, operated or non-operated for lumbar disc herniation: a retrospective study in 88 patients

Background

Patients with lumbar disc herniation are treated with physiotherapy/medication and some with surgery. However, even after technically successful surgery some develop a failed back syndrome with persistent pain. Our aim was to evaluate the efficacy of epiduroscopy in patients who suffer chronic low back pain and/or radicular pain with or without surgery and the gender difference in outcome.

Methods

A total of 88 patients were included with a mean age of 52 years (27-82), 54 women and 34 men. 66 of them were operated previously and 22 were non-operated. They all had persistent chronic back pain and radicular pain despite of medication and physical rehabilitation. Visual Analog Scale (VAS) for pain and Oswestry Disability Index (ODI) were evaluated preoperatively, after one month, six months and one-year after the epiduroscopy.

Results

All patients, and also the subgroups (gender and operated/non-operated) improved significantly in pain (VAS) and disability (ODI) at one month. A significant improvement was also seen at one year. No differences were found between men and woman at the different follow-up times. A slight worsening in VAS and ODI was noticed over time except for the non-operated group.

Conclusions

Epiduroscopy helps to improve the back and leg pain due to lumbar disc herniation in the early stage. At one year an improvement still exists, and the non-operated group seems to benefit most of the procedure.

Effectiveness of Percutaneous Lumbar Extraforaminotomy in Patients with Lumbar Foraminal Spinal Stenosis: A Prospective, Single-Armed, Observational Pilot Study

Objective

In lumbar foraminal spinal stenosis (LFSS), numerous ligaments may play an important role in causing radiculopathy by narrowing the exit of the nerve root. In order to achieve effective decompression of lumbar foraminal ligaments, a specially designed instrument for percutaneous lumbar extraforaminotomy (PLEF) was invented. The purpose of this study was to evaluate the effectiveness of PLEF in patients with intractable radiculopathy from LFSS.

Design

A prospective, single-armed, observational pilot study.

Setting

A pain center in a tertiary university-based hospital.

Methods

The PLEF was performed in patients who suffered from radiculopathy with concordant imaging evidence of a mild to severe degree of LFSS. For each patient, an 11-point numerical rating scale (NRS) pain score, the Oswestry Disability Index (ODI), the Roland Morris Disability Questionnaire (RMDQ) score, and any adverse events were evaluated at three-month follow-ups. Successful responder percentage defined as 40% or greater reduction from baseline NRS score with no increase in ODI, and the RMDQ score was assessed at three months.

Results

Among 26 patients who underwent PLEF, 20 patients completed the study protocol. PLEF was successful in 12 patients (60%). The overall mean pain reduction at three months was 36.3%. Patients who responded well also showed improvement in the ODI (-20%) and RMDQ score (-8.4) at their three-month follow-up. No serious complications were reported in the study.

Conclusions

The PLEF can be an effective and safe treatment option, as well as a minimally invasive procedure, for the management of patients suffering from refractory radiculopathy caused by LFSS.

The Results of Treating Failed Back Surgery Syndrome by Adhesiolysis: Comparing the One- and Three-Day Protocols

Background

The optimal treatment of failed back surgery syndrome (FBSS) is controversial. Limited studies have demonstrated the satisfactory outcomes of percutaneous adhesiolysis in FBSS, which can be performed as a 1 day or 3 days procedure. In the current randomized clinical trial, we compared the clinical and functional outcomes of these 2 techniques.

Methods

In this study, 60 patients with FBSS were randomly assigned into 2 equal groups: 1 day group and 3 days group. Before and at 4 and 12 weeks after the procedure, pain intensity was measured using visual analogue scale (VAS). The Oswestry disability index (ODI) was also completed. Pain reduction of 50% or more was defined as treatment success.

Results

Significant pain relief and ODI improvement were obtained in the 2 groups with adhesiolysis (P < 0.001). However, pain intensity remained the same before and at 4 and 12 weeks after adhesiolysis. ODI score was significantly lower in 1 day group in the 1 month visit (P < 0.001). Treatment was successful in 76.7% and 83.3% of the patients in 1 day and 3 days groups, respectively (P = 0.519).

Conclusions

Adhesiolysis is an effective treatment for pain relief and functional improvement in FBSS. The results of 1 day and 3 days procedures are comparable. Based on these findings, the authors recommend using 1 day technique, which can potentially decrease the patients' discomfort, hospital stay, and cost of treatment.

Factors for Predicting Favorable Outcome of Percutaneous Epidural Adhesiolysis for Lumbar Disc Herniation

Background. Lower back pain is a common reason for disability and the most common cause is lumbar disc herniation. Percutaneous epidural adhesiolysis has been applied to relieve pain and increase the functional capacity of patients who present this condition. Objectives. In this study, we retrospectively evaluated the factors which predict the outcome of percutaneous epidural adhesiolysis in patients who were diagnosed with lumbar disc herniation. Methods. Electronic medical records of patients diagnosed with lumbar disc herniation who have received percutaneous epidural adhesiolysis treatment were reviewed. The primary outcome was the factors that were associated with substantial response of ≥4 points or ≥50% of pain relief in the numerical rating scale pain score 12 months after the treatment. Results. Multivariate logistic regression analysis demonstrated that the presence of high-intensity zone (HIZ) at magnetic resonance imaging was a predictor of substantial response to percutaneous epidural adhesiolysis for 12 months (P = 0.007). The presence of a condition involving the vertebral foramen was a predictor for unsuccessful response after 12 months (P = 0.02). Discussion and Conclusion. The presence of HIZ was a predictor of favorable long-term outcome after percutaneous epidural adhesiolysis for the treatment of lower back pain with radicular pain caused by lumbar disc herniation.

Comparative effectiveness of percutaneous epidural adhesiolysis for different sacrum types in patients with chronic pain due to lumbar disc herniation: A propensity score matching analysis

For percutaneous epidural adhesiolysis (PEA) in patients with chronic low back and/or leg pain, comparative efficacy of lumbar PEA between the sacral types has not yet been investigated. This study aimed to determine the comparative efficacy of lumbar PEA between the sacral types in chronic pain with lumbosacral herniated intervertebral disc (L-HIVD).A total of 1158 chronic low back and/or leg pain patients who diagnosed with L-HIVD and underwent PEA between February 2011 and March 2015 were retrospectively examined. All enrolled patients were divided into 2 types: dome-sacral type and flat type. To avoid confounding bias, propensity score analysis was used. Numeric rating scales (NRS) and Patients' Global Impression of Change (PGIC) were compared between the 2 types at baseline and at 3 months post-PEA.After conducting a propensity score matching analysis, 114 patients were included in each type. The mean sacral angle significantly differed between the flat-sacral and dome-sacral types (P < 0.001). A linear mixed effect model analysis showed that the adjusted NRS score at baseline was 7.58 [95% confidence interval (CI): 7.40-7.76] for the flat-sacral type and 7.47 (95% CI: 7.29-7.64) for the dome-sacral type. The adjusted NRS score after 3 months post-PEA was 4.27 (95% CI: 3.77-4.77) for the flat-sacral type and 3.71 (95% CI: 3.21-4.21) for the dome-sacral type. We detected no significant differences in NRS at baseline (P = 0.371) and after 3 months (P = 0.121) between the 2 groups. No significant differences were observed in terms of the NRS score between the 2 groups during the 3 months follow-up (omnibus P = 0.223). There were no significant differences in PGIC between flat-sacral and dome-sacral types at 3 months after the follow-up period (4.40 ± 2.17 and 4.67 ± 1.88, respectively, P = 0.431).PEA provides sufficient pain relief for chronic pain due to L-HIVD at 3 months postprocedure. The sacral type might not affect the outcome of lumbar PEA in chronic pain associated lumbar HIVD.

Needle Tip Position and Bevel Direction Have No Effect in the Fluoroscopic Epidural Spreading Pattern in Caudal Epidural Injections: A Randomized Trial

Background. Caudal epidural steroid injections (CESIs) are an effective treatment for pain. If the injection spreads in a specific pattern depending on the needle position or bevel direction, it would be possible to inject the agent into a specific and desired area. Objectives. We conducted a prospective randomized trial to determine if the needle position and bevel direction have any effect on the epidural spreading pattern in CESI. Methods. Demographic data of the patient were collected. During CESI, the needle position (middle or lateral) and direction (ventral or dorsal) were randomly allocated. Following fluoroscope-guided injection of 4 mL contrast media and 10 mL of injectates, the epidural spreading patterns (ventral or dorsal, bilateral or lateral) were imaged. Results. In the 210 CESIs performed, the needle tip position and bevel direction did not influence the epidural spreading patterns at L4-5 and L5-S1 disc levels. A history of Lumbar spine surgery was associated with a significantly limited spread to each disc level. A midline needle tip position was more effective than the lateral position in spreading to the distant disc levels. Conclusions. Neither the needle tip position nor the bevel direction affected the epidural drug spreading pattern during CESI.

Evaluation of epiduroscopy for detection of vertebral canal and spinal cord lesions in dogs

OBJECTIVE To evaluate the potential usefulness of epiduroscopy for clinical diagnosis and treatment of vertebral canal and spinal cord lesions in dogs. SAMPLE Cadavers of 6 mixed-breed dogs. PROCEDURES Dogs were positioned in sternal recumbency, and an endoscope was introduced into the lumbosacral epidural space. A fiberscope (diameter, 0.9 mm; length, 30 cm) was used for 3 dogs, and a videoscope (diameter, 2.8 mm; length, 70 cm) was used for the other 3 dogs. Visibility and identities of anatomic structures were recorded, and maneuverability of the endoscopes was assessed. Extent of macroscopic tissue damage was evaluated by manual dissection of the vertebral canal at the end of the procedure. RESULTS Intermittent saline (0.9% NaCl) solution infusion, CO2 insufflation, and endoscope navigation improved visualization by separating the epidural fat from the anatomic structures of interest. Images obtained with the fiberscope were small and of poor quality, making identification of specific structures difficult. Maneuverability of the fiberscope was difficult, and target structures could not be reliably reached or identified. Maneuverability and image quality of the videoscope were superior, and spinal nerve roots, spinal dura mater, epidural fat, and blood vessels could be identified. Subsequent manual dissection of the vertebral canal revealed no gross damage in the spinal cord, nerve roots, or blood vessels. CONCLUSIONS AND CLINICAL RELEVANCE A 2.8-mm videoscope was successfully used to perform epiduroscopy through the lumbosacral space in canine cadavers. Additional refinement and evaluation of the technique in live dogs is necessary before its use can be recommended for clinical situations.

Ultrasound versus fluoroscopy-guided caudal epidural steroid injection for the treatment of chronic low back pain with radiculopathy: A randomised, controlled clinical trial

Background and Aims:

Caudal epidural steroid administration is an effective treatment for chronic low back pain (LBP). Fluoroscopy guidance is the gold standard for pain procedures. Ultrasound guidance is recently being used in pain clinic procedures. We compared the fluoroscopy guidance and ultrasound guidance for caudal epidural steroid injection with respect to the time needed for correct placement of the needle and clinical effectiveness in patients with chronic LBP.

Methods:

Fifty patients with chronic LBP with radiculopathy, not responding to conventional medical management, were randomly allocated to receive injection depot methyl prednisolone (40 mg) through caudal route either using ultrasound guidance (Group U, n = 25) or fluoroscopy guidance (Group F, n = 25). Pre-procedural visual analogue scale (VAS) score and Oswestry Disability Index (ODI) were noted. During the procedure, the time needed for correct placement of needle was observed. Adverse events, if any, were also noted. All patients were followed up for next 2 months to evaluate Visual Analogue Scale (VAS) score and ODI at the 2^nd week and again at the end of 1^st and 2^nd month.

Results:

The needle-placement time was less using ultrasound guidance as compared to fluoroscopy guidance (119 ± 7.66 vs. 222.28 ± 29.65 s, respectively, P < 0.001). Significant reduction in VAS score and ODI (clinical improvement) was noted in the follow-up time points and comparable between the groups at all time points.

Conclusion:

Ultrasound guidance can be a safe alternative tool for achieving faster needle placement in caudal epidural space. Clinical effectiveness (reduction of VAS and ODI scores) remains comparable between both the techniques.

Efficacy of Percutaneous Adhesiolysis in the Treatment of Lumbar Post Surgery Syndrome

Context

Lumbar post-surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous adhesiolysis is often contemplated in managing lumbar post surgery syndrome. Recent guidelines and systematic reviews have reached different conclusions about the level of evidence for the efficacy of epidural injections and percutaneous adhesiolysis in managing lumbar post surgery syndrome. The objective of this systematic review was to determine the efficacy of all 3 percutaneous adhesiolysis anatomical approaches (caudal, interlaminar, and transforaminal) in treating lumbar post-surgery syndrome.

Evidence Acquisition

Data Sources: A literature search was performed from 1966 through October 2014 utilizing multiple databases. Study Selection: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and percutaneous adhesiolysis in managing lumbar post-surgery syndrome was performed including methodological quality assessment utilizing Cochrane review criteria, Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment (IPM–QRB), and grading of evidence using 5 levels of evidence ranging from Level I to Level V. Data Extraction: The search strategy emphasized post-surgery syndrome and related pathologies treated with percutaneous adhesiolysis procedures.

Results

The search criteria yielded 16 manuscripts on percutaneous adhesiolysis assessing post-surgery syndrome. Of these, only 4 randomized trials met inclusion criteria for methodological quality assessment, 3 of them were of high quality; and the fourth manuscript was of low quality. Based on these 3 randomized controlled trials, 2 of them with one-day procedure and one with a 3-day procedure, the level of evidence for the efficacy of percutaneous adhesiolysis is Level II based on best evidence synthesis.

Conclusions

Based on this systematic review, percutaneous adhesiolysis is effective in managing patients with lumbar post-surgery syndrome after the failure of conservative management including fluoroscopically directed epidural injections.

Percutaneous Epidural Adhesiolysis with Epidural Steroid Injection: A Non-inferiority Test of Non-particulate Steroids Versus Particulate Steroids

OBJECTIVES

To evaluate the efficacy of dexamethasone sodium phosphate (DSP), a non-particulate steroid, during percutaneous epidural adhesiolysis (PEA), as compared with triamcinolone acetate (TA).

DESIGN

Retrospective observational study.

SETTING

Interventional pain management clinic in a tertiary care center.

SUBJECTS

Patients scheduled to receive PEA between March 2011 and January 2014.

METHODS

47 patients underwent the procedure with TA (TA group), and 26 patients underwent the procedure with DSP (DSP group). At the end of the procedure, 20 ml of 0.18% ropivacaine containing 3000 units of hyaluronidase and 80 mg of TA or 10 mg of DSP was injected. Success rates and means of percent decreases in terms of verbal numerical rating scale (VNRS) of pain and Oswestry Disability Index (ODI) at follow-up visits 3 and 6 months after PEA were compared. Non-inferiority test was used for statistical analysis.

RESULTS

At 3 months, the success rate in VNRS of TA group and DSP group were 59.6% and 53.8%. The mean percent decreases of VNRS were 42.4% and 46.1% in TA group and DSP group, respectively. At this time point, non-inferiority was not demonstrated. In contrast at 6 months, the success rate in aspect of VNRS was 45.2% in TA group and 62.5% in DSP group. The mean of percent decreases in the VNRS was 34.9% in TA group and 52.8% in DSP group. The non-inferiority was met in two measurements.

CONCLUSIONS

DSP presents non-inferiority to TA in terms of success rate and percentage decrease of the VNRS 6 months after PEA.

Percutaneous Adhesiolysis Versus Transforaminal Epidural Steroid Injection for the Treatment of Chronic Radicular Pain Caused by Lumbar Foraminal Spinal Stenosis: A Retrospective Comparative Study

OBJECTIVE

To investigate the efficacy of percutaneous adhesiolysis (PA) compared to fluoroscopy (FL)-guided transforaminal epidural steroid injection (TFESI) in patients with radicular pain caused by lumbar foraminal spinal stenosis (LFSS) by assessing pain relief and functional improvement at 4 and 12 weeks post-procedure.

METHODS

This retrospective study included 45 patients who underwent PA or FL-guided TFSEI for radicular pain caused by LFSS of at least 3 months' duration. Outcomes were assessed with the Oswestry Disability Index (ODI) and Verbal Numeric Pain Scale (VNS) before the procedure and at 4 and 12 weeks post-procedure. A successful outcome was defined by >50% improvement in the VNS score and >40% improvement in the ODI score.

RESULTS

ODI and VNS scores improved 4 and 12 weeks post-procedure in both groups. Statistically significant differences between groups were observed in ODI and VNS at 12 weeks (p<0.05). The proportion of patients with successful outcomes was significantly different between the two groups only at the 12-week time point.

CONCLUSION

Our study suggests that PA is effective for pain reduction and functional improvement in patients with chronic radicular pain caused by LFSS. Therefore, PA can be considered for patients with previous ineffective responses to conservative treatment. Although PA seems to be more effective than TFEFI according to the results of our study, in order to fully elucidate the difference in effectiveness, a prospective study with a larger sample size is necessary.

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.

Cerebellar infarction following epidural abscess after epidural neuroplasty

Epidural neuroplasty is found to be effective in removing fibrous tissue occurring in the epidural space for various reasons. We report a case of cerebellar infarction caused by epidural abscess after epidural neuroplasty. To the best of our knowledge, this is the first report of cerebellar infarction developed as a result of epidural abscess accompanying bacterial meningitis after epidural neuroplasty. We also discuss the etiology, pathogenesis, and prognosis of this rare pathologic entity.

Acute motor weakness of opposite lower extremity after percutaneous epidural neuroplasty

Recently, percutaneous epidural neuroplasty has become widely used to treat radicular pain caused by spinal stenosis or a herniated intervertebral disc. A 19-year-old female patient suffering from left radicular pain caused by an L4-L5 intervertebral disc herniation underwent percutaneous epidural neuroplasty of the left L5 nerve root using a Racz catheter. After the procedure, the patient complained of acute motor weakness in the right lower leg, on the opposite site to where the neuroplasty was conducted. Emergency surgery was performed, and swelling of the right L5 nerve root was discovered. The patient recovered her motor and sensory functions immediately after the surgery. Theoretically, the injection of a large volume of fluid in a patient with severe spinal stenosis during epidural neuroplasty can increase the pressure on the opposite side of the epidural space, which may cause injury of the opposite nerve by barotrauma from a closed compartment. Practitioners should be aware of this potential complication.