Epiduroscopic Adhesiolysis

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Chapter 14 Epiduroscopic Adhesiolysis

Pyung-Bok Lee, MD, PhD, Seong Oh Kim, MD, Yong-Chul Kim, MD, PhD

With epiduroscopy, it is now possible to directly observe pathologic conditions such as epidural fibrosis, perineural scars, postoperative tissue changes, herniated nucleus pulposus, and hypertrophied ligamentum flavum. Several new procedures have also been made possible by epiduroscopy. Through manipulation of the equipment, the adhesion or fibrosis of the perineural area can be lysed. With insertion of an epidural catheter, chemical adhesiolysis can be performed. Also, drugs can be more effectively administered to a target nerve [1].

There are, however, a few limitations of epiduroscopic adhesiolysis. During epiduroscopy, the epidural space can be visualized only if it is kept distended by repeated injections of saline. More importantly, epiduroscopic procedures can elevate the intracranial pressure and intraorbital pressure. The procedural time requires 45 to 60 minutes for lumbar epidural space examination [2–5].

Treatment objectives

Epiduroscopic adhesiolysis is performed for the following reasons [6]:

image Observation of pathology and anatomy of the epidural space
image Direct drug application
image Direct lysis of epidural scars (mechanical or chemical)
image Placement of catheter and electrode systems (epidural or subarachnoid)
image As an adjunct to minimally invasive surgery

Preoperative preparation

History and Physical Examination

The history and physical examination of a patient to undergo epiduroscopic adhesiolysis should include the following assessments:

image Presence of infection or distorted anatomy at the skin entry site
image Straight-leg raising test for documentation of radiculopathy

Imaging Diagnosis

Magnetic resonance imaging or computed tomography of the lumbar and sacral spine should be considered to assess the contents of spinal canal and seek spinal stenosis [7].

Other Studies and Issues

The following studies should also be performed in a patient being considered for epiduroscopic adhesiolysis:

image Nerve conduction study and electromyography
image Baseline ophthalmologic examination using funduscopy (Fig. 14-1)
image Complete blood count, coagulation battery, and urinalysis
image

Figure 14–1 A normal funduscopic finding.

Nonsteroidal anti-inflammatory drugs, aspirin, and anticoagulants should be discontinued for 3 to 7 days before and after the procedure.

Indications

Indications for epiduroscopic adhesiolysis are as follows:

image Confirmation of a physiologic basis for radicular pain when other diagnostic studies are negative
image Diagnosis of a radiculopathy in patients who can not undergo an MRI due to a pacemaker
image Epidural steroid injection in failed back surgery syndrome patients for more accurate placement of drugs within the epidural space [8,9]
image Treatment for pain in patients not responding to conservative therapy

Contraindications

Epiduroscopic adhesiolysis should not be performed in the presence of any of the following conditions:

image Coagulation abnormality
image Pregnancy
image Cerebrovascular disease
image Space-occupying lesion in the intracranial space or vertebral foramen
image Renal insufficiency
image Chronic liver dysfunction
image Local infection at the skin entry site

Complications

The following complications may occur after epiduroscopic adhesiolysis:

image Neck and shoulder pain
image Infection of the incision site
image Hematoma
image Headache (caused by dural puncture or induced by hydrostatic pressure) [10]
image Chronic adhesive arachnoiditis
image Retinal hemorrhage and temporal blindness (Fig. 14-2) can occur when the sudden increase in epidural pressure is transmitted to the subarachnoid space [11]. The optic nerve and its vasculatures may be compressed by the resulting higher cerebrospinal fluid pressure. The vasculature compression may rupture retinal blood vessels.
image Other vision changes
image Confusion
image

Figure 14–2 Funduscopic demonstration of a flame-shaped retinal hemorrhage.

Instrumentation

Instruments

The instruments and supplies needed for epiduroscopic adhesiolysis are as follows:

image Equipment for epiduroscopy: monitoring set, recording set, and light source
image 0.8- to 1.0-mm (outer diameter) fiberoptic scope (Fig. 14-3)
image Steerable video-guided catheter (Fig. 14-4)
image Epiduroscopy access kit (Fig. 14-5), which consists of the following items:

18-gauge Tuohy needle
9F and 10F central access catheters with dilators
Guidewire
No. 11 blade scalpel
IV T-piece extension
Three-way stopcock
25-gauge, ¼-inch skin infiltration needle
Transparent surgical dressing
image Suture needle
image Epidural catheter
image Epidural catheter connector
image

Figure 14–3 A fiberoptic scope and a light source.

image

Figure 14–4 Steerable video-guided catheter (Myelotec, Roswell, GA).

image

Figure 14–5 Epiduroscopy access kit, which includes 18-gauge Tuohy needle, 9 French (F) introducer sheath, 9F obturator, 12F dilator, straight guidewire, No. 11 blade scalpel, 15-drop non-vented IV set, three-way stopcock, fenestrated drape, gauze sponges, and 18-gauge, 22-gauge and 25-gauge needles.

Solutions

The following solutions are needed for epiduroscopic adhesiolysis:

image Lidocaine for skin infiltration
image 0.125% bupivacaine or 0.2% ropivacaine
image Preservative-free normal saline, 100-mL pack
image Contrast agent
image 1500 IU hyaluronidase (Fig. 14-6) [12]
image Corticosteroids
image

Figure 14–6 Hyaluronidase, 1500 IU (H-lase, L&H Pharm, Seoul, Korea).

Procedure

1. The patient’s written informed consent is obtained.
2. A preprocedural prophylactic antibiotic injection should be considered (e.g., cefazolin 1 g IV).
3. The patient is placed in the prone position with a pillow under the lower abdomen (Fig. 14-7).
4. Sterile skin preparation and draping are performed (Fig. 14-8).
5. Skin infiltration with 2 to 5 mL lidocaine is injected into the floor of the sacral canal. At this time, the sacral hiatus can be identified with a C-arm (fluoroscope) lateral image (Fig. 14-9).
6. A 17- or 18-gauge Tuohy needle is inserted into the sacral hiatus and advanced in the cephalad direction. The loss-of-resistance technique can be used to determine correct placement of the needle into the caudal canal. C-arm images and contrast-enhanced images may also be used.
7. The epidurogram is confirmed with contrast agent on lateral and anteroposterior (AP) fluoroscopic images. This epidurogram may show scar adhesions, the outline of nerve roots, and other spinal canal structures.
8. The flexible end of the guidewire is inserted via Tuohy needle, and the needle is removed. If the tip of the guidewire is inserted too deeply or handled roughly, bleeding can occur, obscuring the epiduroscopic images.
9. A skin incision is made with the scalpel for the introducer after additional local anesthetics with epinephrine are administered.
10. The dilator and sheath are carefully introduced over the wire, and the soft tissue is dilated.
11. The introducer (video-guided catheter) is inserted.
12. The side arm of the introducer is connected and flushed with normal saline (Fig. 14-10).
13. The epiduroscope is inserted via the introducer. The fiberscope is focused on a sterile rule or other recognizable structure.
14. Direct observation of the epidural space and adhesiolysis is gained through the manipulation of the epiduroscope. Preservative-free normal saline is flushed for a better view of the epidural structures. The amount of normal saline used for flushing should be closely monitored; the recommended amount is less than 60 mL.
15. If needed, drugs are administered directly to the pathologic sites (i.e., local anesthetics with or without 1500 to 3000 IU of hyaluronidase and/or steroids). If needed, a catheter is inserted via the introducer to the targeted nerve (Fig. 14-11).
16. Tunneling is performed (Fig. 12-8).
17. The skin is sutured, and sterile dressing is applied.
image

Figure 14–7 Preparing for the procedure. The patient is placed on the table in the prone position. A pillow may be placed under the lower abdomen. The patient’s legs are abducted with the toes turned inward to relax the gluteal muscles for easy identification of the sacral hiatus.

image

Figure 14–8 The patient is draped with a full drape.

image

Figure 14–9 The procedure of epiduroscopy: (1) Skin infiltration of local anesthetics. (2) Insertion of a 18-gauge Tuohy needle. (3) Threading the 0.9-mm guidewire. (4) Removal of the epidural needle and skin nick with a blade for easy insertion of the dilator. (5) Threading with the 12 French dilator over the guidewire. (6) Threading with the 9 French introducer sheath and 9 French obturator over the guidewire. (7) Removal of the guidewire. (8) Removal of the obturator. (9) Connecting the epiduroscope and light source. (10) Inserting the epiduroscope into the steerable video-guided catheter and preparing the normal saline for epidural irrigation. (11) Adjustment of insertion depth of myeloscope. (12) Insertion of the steerable catheter through the introducer sheath.

image

Figure 14–10 The manipulation (A) and irrigation (B) of the epidural space using an epiduroscope.

image

Figure 14–11 Insertion of an epidural catheter for epidural adhesiolysis after epiduroscopy.

Postprocedural management

image A postoperative neurologic examination should be performed. If any new neurologic deficits are detected, magnetic resonance imaging and neurologic consultation should be considered.
image The patient is instructed not to bathe for 5 days.
image The appropriate analgesics are prescribed.
image Prophylactic antibiotics are given for 3 days.
image The regimen for epiduroscopic adhesiolysis is summarized in Box 14.1.

BOX 14.1 Regimen for Chemical Epiduroscopic Adhesiolysis

The use of hypertonic saline has been controversial. We, therefore, do not use the hypertonic saline for epidural adhesiolysis procedure.

First Day

1500 to 3000 IU of hyaluronidase* in 4 mL and then followed by 9 mL of 0.125% ropivacaine

30-min neurologic observation

Second Day

1500 IU of hyaluronidase in 2 mL and then followed by 40 mg of triamcinolone** in 9 mL of 0.125% ropivacaine

Remove the catheter

30-minute neurologic observation

* Only 9 mL of 0.125% ropivacaine is injected on the first day if the hyaluronidase is injected during the epiduroscopy.

** Triamcinolone should not be included in the mixed solution of the second day if the triamcinolone is injected during the epiduroscopy.

Epiduroscopic findings

Table 14.1 and Figure 14-12 illustrate common epiduroscopic findings during the adhesiolysis procedure.

Table 14.1 Characteristics of Structures Seen on Epiduroscopic Images

Structure Characteristics
Epidural fat Yellowish, loose globular, and glistening
Dura mater Convex, tubular, gray-white, with blood vessels on the surface, giving the appearance of a road map
Nerve root
From the dura and extending laterally toward the neural foramen
Gray-white tube shape with a vessel running longitudinally down the center

Ligamentum flavum White and concave tube without vessels Blood vessels
The arteries appear as a thin red thread with pale opaque insulation, and pulsatile flow can be seen
Veins are not detected
Adhesions Fibrous bands of tissue that are clear to white Scar
Dense fibrous tissue
Usually white and appears avascular
Inflammation
Inflamed erythematous tissue
Blood vessels appear distended

Data from http://www.myelotec.com/en/phys/anatpath.html

image

Figure 14–12 Possible epiduroscopic findings.

Case study 14.1

A 58-year-old woman with a history of previous discectomy was diagnosed with failed back surgery syndrome. Her pain was noted predominantly in the left L5 and S1 distributions.

On the epidurogram taken during epiduroscopy, a complete filling defect of contrast agent was noted above the left L5-S1 disc level, whereas contrast agent flowed freely into the right epidural space (Fig. 14-13B). Many fibrous bands of tissue, white avascular scars, and inflamed erythematous tissue were noted around the left L5 foramen. After left L5 mechanical adhesiolysis, flushing with normal saline, and injection of hyaluronidase 1500 IU, the steerable catheter could freely pass the L5 neural foramen (Fig. 14-13C).

image

Figure 14–13 Anteroposterior images of left S1 and L5 epiduroscopic mechanical adhesiolysis. A, Left S1 foraminotomy. B, Contrast agent spreads along the left S1 nerve. Note the complete filling defect of contrast agent above the lower L5 vertebral level in comparison with the free flow of contrast agent into the right epidural space. C, Left L5 foraminotomy. After mechanical adhesiolysis of the L5 nerve, the steerable catheter can freely pass the L5 neural foramen.

Chemical epidural adhesiolysis was performed daily for 3 days after the epiduroscopy according to our pain center regimen. One week after the procedure, the patient’s pain was significantly reduced.

References

1 Schmerztherapeutisches Kolloquiurn, Iserlohn, G. Schütze, Hagenerstr. 121, 58642 Iserlohn. http://schmerz-ambulanz.com/index.php?option=com_content&view=article&id=71:epiduroskopie-konsensus &catid=18:publikationen&Itemid=51

2 Blomberg R., Olsson S. The lumbar epidural space in patients examined with epiduroscopy. Anesth Analg. 1989;68:157-160.

3 Saberski L.R., Kitahata L.M. Direct visualization of the lumbar epidural space through the sacral hiatus. Anesth Analg. 1995;80:839-840.

4 Manchikanti L., Rivera J.J., Pampati V., et al. One-day lumbar epidural adhesiolysis and hypertonic saline neurolysis in treatment of chronic low back pain: A randomized, double-blind trial. Pain Physician. 2004;7:177-186.

5 Manchikanti L., Boswell M.V., Rivera J.J., et al. [ISRCTN 16558617] A randomized, controlled trial of spinal endoscopic adhesiolysis in chronic refractory low back and lower extremity pain. BMC Anesth. 2005;5:10.

6 Saberski L.R. Current application of spinal canal endoscopy: Is it a diagnostic tool or a therapeutic modality? In: Syllabus: Current Concepts in Acute, Chronic and Cancer Pain Management ‘99. New York: The World Foundation for Pain Relief and Research; 1999:171-181.

7 Krasuski P., Poniecka A.W., Gal E., et al. Epiduroscopy: Review of techniques and results. Pain Clinic. 2001;13:71-76.

8 Igarashi T., Hirabayashi Y., Seo N., et al. Lysis of adhesions and epidural injection of steroid/local anesthetic during epiduroscopy potentially alleviate low back leg pain in elderly patients with lumbar spinal stenosis. Br J Anesth. 2004;93:181-187.

9 Racz G.B., Holubec J.T. Lysis of adhesions in the epidural space. In: Racz G.B., editor. Techniques of Neurolysis. Boston: Kluwer Academic; 1989:73-86.

10 Manchikanti L., Singh V. Epidural lysis of adhesions and myeloscopy. Curr Pain Headache Rep. 2002;6:427-435.

11 Amirikia A., Scott I.U., Murray T.G., Halperin L.S. Acute bilateral visual loss associated with retinal hemorrhage following epiduroscopy. Arch Ophthalmol. 2000;118:287-289.

12 Heavner J.E., Racz G.B., Raj P. Percutaneous epidural neuroplasty: Prospective evaluation of 0.9% NaCl versus 10% NaCl with or without hyaluronidase. Reg Anesth Pain Med. 1999;24:202-207.

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