Adhesions

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Adhesions

• The inflammation and adhesions on and around the
  dura and spinal nerves are presumed to be the
  major causes of chronic back pain and
  radiculopathy.
• Smyth J, Wright
• compression on normal nerve root causes
  paraesthesia and numbness
• compression on injured nerve root causes
  pain
• The lysis of epidural adhesions is considered as
  one of the effective therapeutic modalities of
  management of these patients.
• The adhesinolysis may be performed either
  non-endoscopically or endoscopically

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History

• first attempted using the myeloscope around 1931.
  
• Development of fiber optics and video technology.
• The U.S. F DA approved it for visualization of
  the epidural space in September 1996.

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Fluoroscopy Vs endoscopy
When fluoroscopic imaging is used alone to direct
the steroid injection, judging the distribution
of nonionic contrast can be difficult because the
fluoroscopic projection is two-dimensional
Spinal endoscopy delivers three dimensional
color views of investigated tissue in real time.
As spinal endoscopy cannot distinguish one
level from another . therefore fluoroscopy must
be used simultaneously to insure delivery to a
specific level.
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mechanism of analgesia
lavage of algesic substances (e.g., cytokinins,
substance P) by saline utilized to enhance
optical visualization of the epidural space
. stimulation of the neuroinhibitory system by
the pulsating effect on the dura and the salutory
effect of injection of steroids under direct
visualization in the epidural space. more
controlled studies needed
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Choosing a Modality

• MR
• Soft tissues T2 fluid is bright
• Multiplanar T1 fluid is dark
• -No radiation
• CT
• Bones Fluid is dark on CT
• Low cost Acute (clotted) blood is bright
• Ubiquitous

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Indications for epiduroscopy

• Research
• Epiduroscopy in human autopsy cases has revealed
  a dorsomedial connective tissue band in the
  epidural space
• Kitamura et al showed that repeated bupivacaine
  injections caused haemorrhage and congestion in
  the epidural space
• Igarashi et al showed that In those patients who
  had received several previous epidural blocks,
  aseptic inflammatory changes including adhesions
  were observed.

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therapeutic
Shimoji et al. were able to identify adhesions
and "arachnoid" filaments Spinal cord
stimulation electrodes can be placed at the
lumbar level under epiduroscopic guidance Schutze
G, Groll O It is very difficult to identify
the diseased structure in the epidural space when
the flexible fibrescope is introduced directly
between the spinous processes
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Indications
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Contraindications

• Coagulopathy
• Pregnancy
• Renal insufficiency
• Chronic liver dysfunction
• History of adverse reactions to local
  anesthestics or anti-inflammatory drugs
• History of gastrointestinal bleeding ulcers
• Patients unable to understand informed consent

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TECHNIQUE OF EPIDUROSCOPY/SPINAL ENDOSCOPY
17-gauge Tuoghy needle is inserted into the
sacral canal guide wire is placed through Tuoghy
needle Tuoghy needle is then removed canal
passage is widened with 11 scalpel dilator and
sheath are passed over the wire The sidearm of
the introducer sheath is flushed with 10 ml of
normal saline.
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The steerable catheter containing fibreoptic
cable is passed through the introducer The
epidural space is distended with 10 to 15 ml of
normal saline The fibreoptic cable along with
steerable catheter is introduced The
intermittent distension and irrigation of
epidural space with normal saline may be
required. The total volume of normal saline
should not exceed more than 70 ml.
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OUTCOMES
best outcome is found in cases of monoradicular
pain without neurological deficit. A
prospective outcome is comparison with use of a
single endoscopic procedure to repeat epidural
injections would be an important project.
Approximately 6000 or more cases have been
performed during past five years. No permanent
injury has been reported. Pre and post-procedural
survey, data indicate a trend toward less opioid
medication and improved functional capacity.
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Future

• It appears the Epiduroscopy will evolve, as
  arthroscopy and laparoscopy did, to become the
  diagnostic and therapeutic instrument of choice
  for many procedures in the spine. Endoscopic
  procedures have proven to be safer, more
  effective, and less costly than open surgical
  procedures the spine will not be an exception to
  the fact.