OrthoNeuroSpine & Pain Institute

Epiduroscopy

A relatively new procedure, epiduroscopy provides more extensive diagnostic information and enables targeted therapy for various lumbar spine disorders, chronic sciatica in particular. It involves inserting a very small camera through the sacrococcygeal membrane in the lumbar region to directly see inflamed nerve roots in the spinal canal. Epiduroscopy also enables the precise injection of local anesthetic and steroids to reduce inflammation and pain.

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.

An epiduroscopy or periduroscopy is a percutaneous (through the skin), minimally invasive examination of the epidural cavity (space between the exterior dura mater of the spinal cord, and the vertebrae). By using what are the equivalent of the eyes of a tiny snake, which can make its way around many structures in the spinal canal, we can take a look in almost every corner of the epidural cavity.

The epiduroscopy makes it possible to gain insights that are not possible with any other procedure, which means that the diagnosis can differentiate between and document local inflammation, adhesions, scar tissue, constrictions, the consequences of slipped discs, and nerve injuries.

Notwithstanding purposes of the observation of pathology and anatomy, it can also be used to loosen scarring, to position catheters and to administer painkillers directly. Tissue samples can also be taken. The epiduroscopy has both diagnostic and therapeutic uses. The indication range for this innovative method is very broad, ranging from pain syndromes of patients that have already been operated on but are still suffering from their symptoms, to patients that cannot be operated on due to their generally bad state of health, and patients for which conservative (non-surgical) therapy has been unsuccessful until now.

It makes it possible to diagnose and document pains of unclear origin near the spine, especially when it is thought that the cause is in the epidural cavity. It is also used to take samples in the case of inflammatory processes, such as when there is a suspected tumour. Thanks to the epiduroscopy, electrical and mechanical tests can be carried out very close to the spinal cord, catheters can be positioned precisely, and foreign objects can be removed. Above all, scar tissue and adhesions that occur following an operation can be effectively loosened and sometimes even removed. Medicine can be administered very precisely to particular nerves.

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.

The Procedure

An epiduroscopy is typically performed as a day procedure and the patient is usually awake and can communicate with the doctor. After light sedation and a local anaesthetic are administered, a very small incision is made and a fibre optic camera is inserted in the lower back and guided up towards the affected nerve roots. Thanks to the small camera and miniscule tools, the adhesions can be cut away and injections of local anaesthetic and steroid solutions can be made.

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 for NaCl flushing, video-guided catheter for epiduroscopy (diameter 2.4-3,0 mm), flexible scope (6000-15000 pixels), 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 has been asked to fast before the procedure. The patient receives light sedation with one of, or a combination of, the following: midazolam, remifentanyl, propofol. During the entire procedure, communication must be possible with the patient.

Position and anatomical landmarks

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. Both cornu of the sacral hiatus are marked and palpated. When this proves to be difficult, internal rotation of the feet will widen the gluteal cleft, thus facilitating identification of the sacral hiatus. The area around the sacral hiatus is disinfected.

Procedure

The skin, underlying tissues and sacral hiatus are anaesthetised with local anaesthetics. An 18-G Tuohy 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 Tuohy needle, as close as possible to the target area. After removal of the Tuohy needle, a small incision is made at the introduction site, and a dilator is passed over the guide wire followed by the introducer sheath. The side arm of the introducer sheath is left open to allow drainage of excess saline. A flexible 0.9 mm (outer diameter) fiber-optic endocscope (magnification X45) is introduced through one of the two main access ports of a disposable 2.2 mm (outer diameter) steering catheter. The steering catheter also contains two side channels for fluid instillation. One of these side channels is used for the intermittent flush of normal saline. The other side channel is connected to an automatic monitoring system by means of a standard arterial pressure monitoring system, in order to allow for the continuous monitoring of epidural/saline delivery pressure. 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 minimise 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 mobilised with the tip of the endoscope. It is recommended to limit the duration of the procedure to a maximum of 60 minutes.

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.

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.

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.

During the first 5-6 hours after the procedure, the following problems can occur:

Headaches: if you suffer from headaches, make sure you drink plenty of fluids and take some painkillers, which will usually be effective.

Weak-feeling legs and dizziness: This is a consequence of your blood pressure adjusting, and should you suffer from this, stay in bed.

Pain in the area around the incision: In this case, painkillers should help.

Complications

• Dural puncture with post-puncture headache.
• Catheter shearing and infection.
• Increased pressure in the epidural space, due to the continuous pressurised liquid injection necessary to obtain a clear image. Careful monitoring of pressure fluctuations is warranted in order to reduce the risk of prolonged increased liquor pressure, and the duration of the procedure should be limited to a maximum of 60 minutes. Retinal haematoma can occur.
• If a patient complains of neck pain and/or headache, the procedure should be stopped (temporarily).
• Epidural bleeding and meningitis.
• Local pain and infection.

What is Epiduroscopy?

An epiduroscopy, also called spinal endoscopy, is a procedure performed to treat spinal nerve pain such as sciatica and adhesions. In this procedure, a tiny fiber-optic camera is inserted into the epidural space through the sacral bone.

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.