Transforaminal Epiduroscopy in Patients with Failed Back Surgery Syndrome

BACKGROUND

Epiduroscopy is a useful diagnostic and therapeutic tool for managing failed back surgery syndrome (FBSS). The conventional approach is via either the sacral hiatus or the interlaminar. Major causes of FBSS include epidural fibrosis, disc herniation, and stenosis. When these problems are located at the intervertebral foramen level, it can be difficult to reach the lateral recess and the foramen with the epiduroscope. Transforaminal epiduroscopy could be a useful alternative approach in patients with FBSS located at the foraminal level.

OBJECTIVE

We present a new procedure for lumbar epiduroscopy via a transforaminal approach and its application in patients with FBSS. The technique is described and long-term results are reported.

STUDY DESIGN

This study used a single-arm prospective observational design.

SETTING

The research took place at the University Hospital in Spain.

METHODS

Patients with FBSS suffering severe chronic radicular pain (Numeric Rating Scale [NRS-11] > 7) who had not responded to other treatments were included. Selective root stimulation during a pulsed radiofrequency procedure confirmed the origin of pain by means of an exact reproduction of typical pain. Transforaminal epiduroscopy was performed at the affected level. The severity of fibrosis observed was recorded. The NRS-11 score was reevaluated at 1, 6, and 12 months after the procedure. Any complications related to the treatment were recorded.

RESULTS

Twenty-four patients were included. The mean number of back surgeries was 1.66 (range, 1-5). The basal NRS-11 score was 7.83 (0.14); at 1 month, 3.66 (0.38) (P < 0.001); at 6 months, 4.46 (0.48) (P < 0.01); and at 1 year after treatment, 4.17 (0.51) (P < 0.01). Most patients (54%; 95% CI, 34%-74%) obtained > 50% pain reduction on the NRS-11, maintained during a 1-year follow-up period. No major complications were registered.

LIMITATIONS

The research was limited by the lack of a control group.

CONCLUSIONS

We have described a new procedure for epiduroscopy via the transforaminal approach. It is a useful and safe approach to managing FBSS at the foraminal level and shows better long-term results than other endoscopic procedures.

KEY WORDS

Epidural, epiduroscopy, chronic pain, spinal cord, back surgery.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interlaminar approach for epiduroscopy in patients with failed back surgery syndrome

BACKGROUND

Epiduroscopy is a relatively new diagnostic and therapeutic technique used in patients with chronic low back pain with or without radiculopathy. We present our experience with a new interlaminar approach in patients with failed back surgery syndrome (FBSS).

METHODS

Patients with severe symptoms of FBSS who did not respond to other treatments were included. Lumbar epiduroscopy was performed via interlaminar approach through a 14 G epidural needle under fluoroscopy. A flexible, 0.77 mm, endoscope was introduced through a 4F catheter into the epidural space and advanced in a cephalad direction. Flushes of normal saline through the catheter (via a Y-adapter/haemostasis valve) enabled distension of the space. Adhesions were mechanically mobilized under direct vision. A mixture of triamcinolone 60 mg, hyaluronidase 600 IU, and bupivacaine 0.0625% was instilled.

RESULTS

Nineteen patients were included. The mean number of operations at lumbar level was 2.26. Major findings included adhesions, inflammation, stenosis, and nerve root hypotrophia. The visual analogue scale (VAS) score was 7.89 at baseline, 5.95 (P<0.001) 3 months later, and 6.05 (P<0.001) 6 months later. Six patients (31.6%) did not show any improvement, and six other patients showed a very significant improvement (at least three points reduction in the VAS) 3 months later. We had four cases of dural puncture, but only one patient required hospital admission.

CONCLUSIONS

We have described a new procedure for epiduroscopy with approximately 50% reduced outer diameter of the catheter, which allows interlaminar approach. Its diagnostic efficacy is clear and there were a significant number of patients who had improved outcome.