OrthoNeuroSpine & Pain Institute

Epiduroscopy

Epiduroscopy is a relatively new procedure developed in the 1990’s and is a must 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.

Epiduroscopy and Sciatica

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. The source of the pain is usually where the root of the nerve passes through the lumbar vertebrae. 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.

Epiduroscopy and Nerve Root Blocks

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.

What is epiduroscopy/adhesiolysis?

Epiduroscopy is a method of directly visualizing and potentially treating pain generators inside of the spinal column. A small flexible fiberoptic catheter is inserted through a tiny incision and the areas of concern can be visualized on a video monitor. Medication can then be injected through the same catheter.

EpiduroscopyWhat is epiduroscopy?

An epiduroscopy involves looking inside the epidural space. Inside your vertebral column there is a space containing the spinal cord. Cerebrospinal fluid surrounds this spinal cord which in turn is surrounded by a strong membrane called the dura.

Surrounding this strong membrane is another space called the epidural space. Looking inside this space is called an epiduroscopy. The epidural space contains nerves that connect the spinal cord to the rest of the body.

Using an epiduroscope, a special scope which has a camera attached to a catheter we can look inside the epidural space. This catheter is inserted into the epidural space through an opening in the sacrum (near the tail bone).

What do we see with epiduroscopy?

The epiduroscopy can be used to see what problems there might be with regard to the nerve roots and/or surrounding tissue such as fat.

We can see whether or not the nerve roots are inflamed and whether there is any scar tissue or inflamed fat tissue present.

When do I need an epiduroscopy?

If you have lower back pain, with or without radiation to one or both legs, that has not responded to other means of treatment then your pain physician may decide to perform an epiduroscopy on you

What is epiduroscopy supposed to treat?

Apart from allowing the doctor to see what the problem is, epiduroscopy can also be used as a means of treatment. As a result of scar formation there may be adhesions around the nerve root that can be released.

In an epiduroscopy drugs are injected into the area around an inflamed nerve root.

If substances have been released by the intervertebral disc then these can irritate the nerve root. These irritants can be removed by rinsing.

An epiduroscopy can also be used to partly remove small nerve fibres from the nerve roots.

What should I be aware of before undergoing an epiduroscopy?

Any of the following situations should be reported to your pain specialist if he proposes epiduroscopy:

• If you are pregnant: since X-ray equipment is used, pregnant women may not undergo epiduroscopy.
• If you are ill or have a fever on the day of treatment you cannot undergo epiduroscopy, in which case a new appointment will have to be made.
• If you are allergic to iodine, plasters, anaesthetics or contrast fluids, you should notify your pain specialist before the appointment for treatment is made.
• If you are taking blood thinners, you should notify that your pain specialist before the appointment for treatment is made. He will then consider whether the use of certain medications should be ceased temporarily.

Who needs Epiduroscopy?

The procedure is utilized in relieving pain that arises due to adhesions that form following spinal surgery. It is also used in managing long standing sciatica. Epiduroscopy is also used for diagnostic purposes, as it can help your doctor determine the cause, location, and severity of scar tissue or adhesions.

What are the steps in Epiduroscopy?Preparing for the Procedure

In order to perform the procedure, the patient is asked to lie on their stomach so that access can be obtained to the lower back. After cleaning the skin with antiseptic solution, a small amount of local anesthetic is injected into it to numb it.

Inserting the Needle

Under the guidance of x-rays, a needle is inserted into the sacral hiatus, which is a small opening in the bottom of the sacrum. The needle is passed all the way into the spine.

Inserting the Guide Wire

A small guide wire is then inserted through the needle, and the needle is pulled back out over the guide wire. A series of dilators are then passed over this guide wire in order to create a large enough opening to pass the epiduroscope through.

Inserting the Camera

A small catheter with a fiber-optic camera at the tip of it is passed through this opening into the epidural space. This helps visualize exactly where the catheter is being passed to. Sometimes additional imaging is also utilized to ensure the right location is reached with the catheter.

Administering the Injection

Once the catheter is in place, it is gently maneuvered to break down the adhesions. Then, an injection of local anesthetic and steroids is given. This can numb the nerves that are in this area and help reduce pain.

After Surgery

Following the procedure, the patient is observed for a short period of time and is discharged home after that. This procedure may effectively help reduce pain due to adhesions and sciatica. This is because the structures that are affected can be directly visualized, and treatment can be a lot more targeted.

Complications are fairly rare and can include mild bleeding at the site of the procedure. Patients may feel slightly uncomfortable and may experience mild pain following the procedure but this usually passes after a short period of time.

How should I prepare for epiduroscopy?

• The treatment will take place in a day-care centre.
• You will be asked not to eat or drink after midnight on the day before treatment.

How does epiduroscopy work?

• After you have reported to the surgical day-care centre, you will be escorted to the operating theatre.
• There, you will be placed on a bed and prepared for epiduroscopy.
• After a drip has been inserted and the necessary monitoring equipment (heart rate, blood pressure) put in place, you will be asked to lie on your stomach.
• The treatment is performed under local anaesthesia, possibly with the addition of a mild sedative to ensure that you are calm and relaxed.
• A scope will be inserted after a local anaesthetic has been applied at the level of the coccyx.
• During the procedure, you will sometimes be asked questions. You will also be asked to report immediately report if you feel anything in particular, such as a headache or neck pain.
• During epiduroscopy, a sterile fluid is injected into the epidural space (see epidural injections), which will remain in this space.
• The amount of fluid is constantly monitored, as is the pressure in the epidural space.
• Fluoroscopy is used to ensure that the scope is in the correct position.
• The treatment is recorded on video.
• As a protection against infection, some form of antibiotic will be administered by means of a drip.
• The treatment will takes approximately one hour.
• After treatment you will be taken to the recovery room.
• You will remain there for further controls for about four hours.
• When will I be discharged from hospital?
• Before you are discharged, the treating pain specialist will give you the results of the epiduroscopy.
• Since local anaesthetics have been used, there can be decreased strength and numbness in the legs, resulting in diminished coordination.
• You must therefore ensure that you have someone to take you home.
• On the day of treatment, you should take it easy and are advised not to drive for the first 24 hours after treatment.

What after care is necessary?

• Since the effects of treatment can be expected to last for several months, the first control appointment will be made at three months after the procedure.
• Thereafter, additional control appointments will be scheduled for 6, 12 and 24 months after the procedure.
• What are dangers and side effects of epiduroscopy?
• As in the case of all examinations/treatments, epiduroscopy can cause side effects. The most serious of these occur during or directly after treatment.
• During treatment, you may experience complaints such as headache, neck pain or pins and needles in the legs.
• If the complaints become serious, treatment will be halted.
• What are the main uses of epiduroscopy/adhesiolysis?

Adhesions, or scar tissue, that may be pulling on or irritating specific nerve roots can sometimes be effectively stretched or loosened using this device. By so doing, steroids injected through the catheter can be more effective.

Who benefits from epiduroscopy/adhesiolysis?

Anyone with low back pain or sciatic and a history of an inflamed disc or prior surgery can potentially benefit.