Minimal invasive lumbar spine procedures

EPIDUROSCOPY

Introduction

Lumbosacral epiduroscopy is a relatively new technique used in the diagnosis and treatment of low back pain and/or radiculopathy involving the lower extremities.
Epiduroscopy is a less invasive procedure than traditional surgeries performed on the lower back. Not only has this procedure been successful in helping to relieve some instances of chronic sciatica, it has also proven to be effective in cases where traditional epidurals and nerve root blocks have failed.

Sciatica and Epiduroscopy

Sciatica is the term for pain down the leg that is caused by the irritation of the sciatic nerve, which is the largest nerve that carries messages back and forth to the brain. Sciatica is very often caused by the degeneration of the intervertebral disc, or the cushion between the vertebrae that aid with movement and works as a shock absorber, causing the vertebrae to come closer together and putting pressure on the sciatic nerve. Adhesions can form around the nerve roots after decompressive surgery has been performed and even in cases when the area has been very inflamed after a bad bout of sciatica. This is when epiduroscopy can be helpful.
Just as the sciatic nerve can become irritated or inflamed and cause pain down the leg, other nerves that pass through the vertebrae to destinations throughout the body must pass through the delicate network of bones and joints of the spine and are vulnerable to irritation and pressure. Not only can a nerve root block help reduce the pain, but anti-inflammatory medication, such as steroids, injected at the nerve root can fight the inflammation and may even stop the pain from returning. However, when adhesions are present at the location of the nerve root, they can stop the solution from reaching the nerve root and the pain will not be relieved. In this case, an epiduroscopy can be effective.

Procedure Epiduroscopy

Preparation

Epiduroscopy must be performed under full sterile operating theatre conditions. Before the procedure (30 minutes), the patient receives antibiotic prophylaxis (local protocol). In addition, video monitors, an anaesthetic monitor, C-arm, arterial pressure system, and infuse system, video-guided catheter for epiduroscopy, flexible scope, and an insertion set, must be available. The flexible scope should be sterilised according to the hospital's local protocol.
During the procedure, the patient receives standard anaesthetic monitoring (blood pressure, heart frequency and saturation). The patient receives light sedation. During the entire procedure, communication must be possible with the patient.
The patient lies in the prone position on the operating table with a pillow under the pelvis, in such a way that the sacral bone is rotated in a ventral direction. The area around the sacral hiatus is disinfected.

Procedure

The skin, underlying tissues and sacral hiatus are anaesthetised with local anaesthetics. A needle is advanced 2-3 cm into the sacral canal. Care must be taken not to exceed the level of S3, in order to prevent intradural placement of the needle and subsequent equipment. A guide wire is directed cranially through the needle, as close as possible to the target area. After removal of the needle, a small incision is made at the introduction site, and a dilator is passed over the guide wire followed by the introducer sheath. A flexible 0.9 mm fiber-optic endoscope is introduced through one of the two main access ports of a disposable 2.2 mm steering catheter. The steering catheter also contains two side channels for fluid instillation. After distention of the sacral epidural space with normal saline, the steering catheter with the fiber-optic endoscope is slowly advanced to the target area. The epidural space is kept distended with normal saline, but the pressure should be limited to minimize the risks of compromised perfusion. Total saline volume ranges between 50 and 250 ml. When fibrosis or adhesions become visible during epiduroscopy, these can be mobilized with the tip of the endoscope. It is recommended to limit the duration of the procedure to a maximum of 60 minutes.

Benefits of the Procedure

The images produced during an epiduroscopy can reveal a number of problems in the interior of the spinal canal, including various types of scar tissue, abnormal pressure on the spinal cord or spinal nerves, inflammation in the spinal cord or spinal nerves and inflammation of a form of fat found inside the epidural space. In addition, the doctor can use a diagnostic epiduroscopy to examine the spinal canal in the aftermath of an unsuccessful back surgery, or to perform any necessary follow-up procedures if he uncovers significant problems. Epiduroscopy also gives us detailed information on the spinal health that he can’t get from an MRI scan or other types of scans.

Risks of the Procedure

Epiduroscopy is a safe procedure with theoretically potential risks associated with diagnostic epiduroscopy and include infections, bleeding, leg spasms, full-body spasms, pain in your neck, use of too much saline to widen the epidural space, headaches resulting from excessive widening of the space, unusual nerve sensations resulting from excessive widening of the epidural space, damage to the dura surrounding the spinal cord, and headaches triggered by cerebrospinal fluid leaking from a damaged dura. Most people undergo epiduroscopy without developing significant forms of these problems.

General Information

After the procedure, patients will rest in the recovery room and be monitored by medical staff. Most patients will be able to go home the same day, but should have someone available that can escort them home and stay with them for the remainder of the day. Some patients may feel immediate relief, while other may have to wait a few weeks, but the long lasting effects of the procedure can last for many months.