Efficacy of percutaneous epidural neuroplasty does not correlate with dural sac cross-sectional area in single level disc disease

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.

Spinal Injections: A Narrative Review from a Surgeon's Perspective

Spinal pain is one of most frequent complaints of the general population, which can cause decreased activities of daily living and absence from work. Among numerous therapeutic methods, spinal injection is one of the most effective treatments for spinal pain and is currently widely applied in the clinical field. In this review, spinal injection is discussed from a surgeon's perspective. Recently, although the number of spinal surgeries has been increasing, questions are arising as to whether they are necessary. The failure rate after spinal surgery is high, and its long-term outcome was reported to be similar to spinal injection. Thus, spinal surgeries should be performed conservatively. Spinal injection is largely divided into diagnostic and therapeutic blocks. Using diagnostic blocks, such as the diagnostic selective nerve root block, disc stimulation test, and diagnostic medial branch block (MBB), the precise location causing the pain can be confirmed. For therapeutic blocks, transforaminal nerve root injection, therapeutic MBB, and percutaneous epidural neuroplasty are used. When unbearable spinal pain persists despite therapeutic spinal injections, spinal surgeries can be considered. Spinal injection is usefully used to identify the precise location prior to a patient undergoing injection treatment or surgery and can reduce pain and improve quality of life, and help to avoid spinal surgery. Pain physicians should treat patients with spinal pain by properly utilizing spinal injection.

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.

Efficacy of Percutaneous Adhesiolysis in Managing Low Back and Lower Extremity Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

INTRODUCTION

Chronic refractory low back and lower extremity pain recalcitrant to conservative management and epidural injections secondary to postsurgery syndrome, spinal stenosis, and disc herniation are sometimes managed with percutaneous adhesiolysis. Consequently, this systematic review and meta-analysis was undertaken to assess the efficacy of percutaneous adhesiolysis in managing low back and lower extremity pain.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was performed. A comprehensive literature search of multiple databases from 1966 to July 2022, including manual searches of the bibliography of known review articles was performed. Quality assessment of the included trials, meta-analysis, and best evidence synthesis was performed. The primary outcome measure was a significant reduction in pain (short term up to 6 months and long term more than 6 months).

RESULTS

The search identified 26 publications, with 9 trials meeting the inclusion criteria. The results of dual-arm and single-arm analyses showed significant improvement in pain and function at 12 months. Opioid consumption was also significantly reduced at 6 months with dual-arm analysis, whereas single-arm analysis showed a significant decrease from baseline to treatment at the 3-, 6-, and 12-month analyses. At 1 year follow-up, seven of seven trials were positive for improvements in pain relief, function, and diminution of opioid use.

DISCUSSION

Based on the present systematic review of nine RCTs, the evidence level is I to II, with moderate to strong recommendation for percutaneous adhesiolysis in managing low back and lower extremity pain. The limitations of the evidence include paucity of literature, lack of placebo-controlled trials, and the majority of the trials studying post lumbar surgery syndrome.

CONCLUSION

The evidence is level I to II or strong to moderate based on five high-quality and two moderate-quality RCTs, with 1 year follow-up that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain.

The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis

BACKGROUND

Recalcitrant disc herniation may result in chronic lumbar radiculopathy or sciatica. Fluoroscopically directed epidural injections and other conservative modalities may provide inadequate improvement in some patients. In these cases, percutaneous neurolysis with targeted delivery of medications is often the next step in pain management.

METHODS

An evidence-based system of methodologic assessment, namely, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. Multiple databases were searched from 1966 to January 2021. Principles of the best evidence synthesis were incorporated into qualitative evidence synthesis. The primary outcome measure was the proportion of patients with significant pain relief and functional improvement (≥ 50%). Duration of relief was categorized as short-term (< 6 months) and long-term (≥ 6 months).

RESULTS

This assessment identified one high-quality randomized controlled trial (RCT) and 5 moderate-quality non-randomized studies with an application of percutaneous neurolysis in disc herniation. Overall, the results were positive, with level II evidence.

CONCLUSIONS

Based on the present systematic review, with one RCT and 5 nonrandomized studies, the evidence level is II for percutaneous neurolysis in managing lumbar disc herniation.

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.

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.

Clinical Effectiveness of Percutaneous Epidural Neuroplasty According to the Type of Single-Level Lumbar Disc Herniation : A 12-Month Follow-Up Study

Objective

To determine whether the outcomes of percutaneous epidural neuroplasty (PEN) are influenced by the type of lumbar disc herniation (LDH) and evaluate the effectiveness of PEN in patients with single-level LDH.

Methods

This study included 430 consecutive patients with single-level LDH who underwent PEN. Before treatment, the LDH type was categorized as bulging, protrusion, extrusion, and sequestration, while Pfirrmann grades were assigned according to imaging findings. Visual analog scale (VAS) scores for back and leg pain and success rates (Odom’s criteria) were assessed at 1, 3, 6, and 12 months after treatment.

Results

The mean preoperative VAS scores for back and leg pain were 6.90 and 4.23, respectively; these decreased after PEN as follows : 2.25 and 1.45, respectively, at 1 month; 2.61 and 1.68, respectively, at 3 months; 2.28 and 1.48, respectively, at 6 months; and 2.88 and 1.48, respectively, at 12 months (p<0.001). The decrease in VAS scores for leg pain was significantly greater in the extrusion and sequestration groups than in the other two groups (p<0.05); there were no other significant differences among groups. More than 70% patients exhibited good or excellent 12-month outcomes according to Odom’s criteria. Subsequent surgery was required for 59 patients (13.7%), with a significantly higher rate in the extrusion (25.0%) and sequestration (30.0%) groups than in the bulging (7.3%) and protrusion (13.8%) groups (p<0.05). Nevertheless, subsequent surgery was not required for >70% patients with extrusion or sequestration. Patients with Pfirrmann grades 1–3 (14.0–21.5%) showed a significantly higher rate of subsequent surgery than those with Pfirrmann grade 0 (4.9%; p<0.05).

Conclusion

Our findings suggest that PEN is an effective treatment for back and leg pain caused by single-level LDH, with the outcomes remaining unaffected by the LDH type.

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

Background

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

Objective

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

Design

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

Setting

The analysis was done in the university hospital center.

Method

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

Results

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

Conclusion

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

Surgical treatment of a broken neuroplasty catheter in the epidural space: a case report

Background

Percutaneous epidural neuroplasty with a Racz catheter is widely used to treat radicular pain caused by spinal stenosis or a herniated intervertebral disc. The breakage or shearing of an epidural catheter, particularly a percutaneous epidural neuroplasty catheter, is reported as a rare complication. There has been a controversy over whether surgical removal of a shorn epidural catheter is needed. Until now, only three cases related to sheared Racz neuroplasty catheters have been reported. We report a case of a neuroplasty catheter which completely broke when it was inserted into the epidural space, and compressed root symptoms were exacerbated by the broken catheter.

Case presentation

A 68-year-old Asian man with leg pain and lower back pain caused by lumbar vertebral body 4 to lumbar vertebral body 5 intervertebral disc herniation and stenosis underwent percutaneous epidural neuroplasty. During the procedure, the epidural neuroplasty catheter was trapped in the left foraminal portion and broke. Our patient complained of left-side leg pain and numbness. Surgery performed to remove the broken catheter led to complete resolution of his leg pain and numbness.

Conclusions

We report a rare case of catheter breakage occurring during epidural neuroplasty. We suggest surgical removal because the implanted catheter can aggravate a patient’s symptoms and lead to the development of neurologic deficits due to infection, fibrosis, or mechanical neural irritation.