Clinical Effectiveness of Percutaneous Epidural Neuroplasty According to the Type of Single-Level Lumbar Disc Herniation : A 12-Month Follow-Up Study

OBJECTIVE: To determine whether the outcomes of percutaneous epidural neuroplasty (PEN) are influenced by the type of lumbar disc herniation (LDH) and evaluate the effectiveness of PEN in patients with single-level LDH.METHODS: This study included 430 consecutive patients with single-level LDH who underwent PEN. Before treatment, the LDH type was categorized as bulging, protrusion, extrusion, and sequestration, while Pfirrmann grades were assigned according to imaging findings. Visual analog scale (VAS) scores for back and leg pain and success rates (Odom’s criteria) were assessed at 1, 3, 6, and 12 months after treatment.RESULTS: The mean preoperative VAS scores for back and leg pain were 6.90 and 4.23, respectively; these decreased after PEN as follows : 2.25 and 1.45, respectively, at 1 month; 2.61 and 1.68, respectively, at 3 months; 2.28 and 1.48, respectively, at 6 months; and 2.88 and 1.48, respectively, at 12 months (p<0.001). The decrease in VAS scores for leg pain was significantly greater in the extrusion and sequestration groups than in the other two groups (p<0.05); there were no other significant differences among groups. More than 70% patients exhibited good or excellent 12-month outcomes according to Odom’s criteria. Subsequent surgery was required for 59 patients (13.7%), with a significantly higher rate in the extrusion (25.0%) and sequestration (30.0%) groups than in the bulging (7.3%) and protrusion (13.8%) groups (p<0.05). Nevertheless, subsequent surgery was not required for >70% patients with extrusion or sequestration. Patients with Pfirrmann grades 1–3 (14.0–21.5%) showed a significantly higher rate of subsequent surgery than those with Pfirrmann grade 0 (4.9%; p<0.05).CONCLUSION: Our findings suggest that PEN is an effective treatment for back and leg pain caused by single-level LDH, with the outcomes remaining unaffected by the LDH type.

Clinical Effectiveness of Percutaneous Epidural Neuroplasty According to the Type of Single-Level Lumbar Disc Herniation : A 12-Month Follow-Up Study

OBJECTIVE: To determine whether the outcomes of percutaneous epidural neuroplasty (PEN) are influenced by the type of lumbar disc herniation (LDH) and evaluate the effectiveness of PEN in patients with single-level LDH. METHODS: This study included 430 consecutive patients with single-level LDH who underwent PEN. Before treatment, the LDH type was categorized as bulging, protrusion, extrusion, and sequestration, while Pfirrmann grades were assigned according to imaging findings. Visual analog scale (VAS) scores for back and leg pain and success rates (Odom’s criteria) were assessed at 1, 3, 6, and 12 months after treatment. RESULTS: The mean preoperative VAS scores for back and leg pain were 6.90 and 4.23, respectively; these decreased after PEN as follows : 2.25 and 1.45, respectively, at 1 month; 2.61 and 1.68, respectively, at 3 months; 2.28 and 1.48, respectively, at 6 months; and 2.88 and 1.48, respectively, at 12 months (p70% patients with extrusion or sequestration. Patients with Pfirrmann grades 1–3 (14.0–21.5%) showed a significantly higher rate of subsequent surgery than those with Pfirrmann grade 0 (4.9%; p<0.05). CONCLUSION: Our findings suggest that PEN is an effective treatment for back and leg pain caused by single-level LDH, with the outcomes remaining unaffected by the LDH type.

Percutaneous Epidural Neuroplasty

The percutaneous epidural neuroplasty is recently accepted as a useful interventional tool for management of chronic low back pain and radicular pain, which is refractory to other conservative treatments. The epidural adhesion is thought to be a cause of the refractory spinal pain because it could be a barrier preventing drug from reaching target lesion. It has been known that the adhesion is a result of post-operative scar change, fibrosis and chronic inflammatory response around the intervertebral disc and nerve root. The epidural neuroplasty is a catheterization technique for injecting therapeutic drug accurately into lesions of epidural space. Although the exact mechanisms of action of the procedure are unknown, the adhesiolysis could be induced by two postulated mechanisms, mechanical lysis by hydraulic pressure and catheterization, and chemical lysis by injected drugs. Normal saline, local anesthetics, and steroid are injected via the catheter. The large volume of injectant could wash out the pain substances and the pharmacologic effects of the injectant could relieve the pain. some possible adverse reactions of the procedure are known, but they could be prevented by exact technique and careful monitoring.

Epidural neuroplasty/epidural adhesiolysis

Epidural neuroplasty is a treatment modality for back pain and/or radiating pain caused by mechanical compression or neural inflammation of intra-spinal neural structures. Since epidural neuroplasty was first introduced as a treatment for pain caused by epidural adhesion such as failed back surgery syndrome (FBSS), it has been performed as a treatment for many kinds of pain of spinal origin including acute/chronic herniation of intervertebral disc, radiculopathy, spinal stenosis, FBSS, epidural adhesion, vertebral compression fracture, vertebral metastasis, resistant multilevel degenerative arthritis, epidural scar pain by infection or meningitis, and whiplash injury. Epidural neuroplasty is a catheterization technique used to treat back pain and/or radiating pain by injecting therapeutic drugs into lesions of epidural space shown as a filling defect in epidurogram. Usually, normal saline, local anesthetics, and steroid are used as therapeutic drugs. The exact mechanisms of action of the procedure are unknown but include 2 postulated mechanisms of action for pain relief. i.e., mechanical adhesiolysis by volume effect and chemical adhesiolysis by injected drugs. Relative large volumes of normal saline injection resolve adhesions and wash out accumulated pain substances; local anesthetics are used for stabilization and analgesia of flaring neural structures and for pain management for procedure related pain; and steroid is used for the treatment of inflammation of neural and peri-neural structures. The resolution of filling defect can be verified by post-procedure epidurogram. The key point of epidural neuroplasty for good results, is the exact localization of the epidural catheter into the epidural lesion.

Percutaneous Epidural Neuroplasty / 대한정형외과학회잡지

Interventional pain management by percutaneous epidural neuroplasty (PEN) has potential as a useful treatment method in chronic low back and/or radicular pain that is refractory to other conservative treatments. The effect of PEN is known to result from targeting of drug delivery to areas of pathology in the spinal epidural space. The procedure involves removing barriers, such as epidural fibrosis, that prevent drug from reaching target sites. Therefore, the goal during lysis of epidural adhesions is to penetrate mechanical barriers impeding injected material from spreading effectively into the areas of pathology in the epidural space by the catheter. An additional lavage effect, reducing the local concentration of proinflammatory substances seems possible. Although a true mechanical lysis of postsurgical adhesions or scar tissues by means of PEN appears to be impossible because it has been proven by experimental biomechanical study, mild to moderate adhesions may be broken up by a PEN catheter allowing the medications to reach the target site through the new channel made by the catheter. This review will focus on the adhesiolysis technique using the sacral hiatus approach in treatment of chronic low back pain with/without lumbosacral radiculopathy.

Acute Motor Weakness of Opposite Lower Extremity after Percutaneous Epidural Neuroplasty

Recently, percutaneous epidural neuroplasty has become widely used to treat radicular pain caused by spinal stenosis or a herniated intervertebral disc. A 19-year-old female patient suffering from left radicular pain caused by an L4-L5 intervertebral disc herniation underwent percutaneous epidural neuroplasty of the left L5 nerve root using a Racz catheter. After the procedure, the patient complained of acute motor weakness in the right lower leg, on the opposite site to where the neuroplasty was conducted. Emergency surgery was performed, and swelling of the right L5 nerve root was discovered. The patient recovered her motor and sensory functions immediately after the surgery. Theoretically, the injection of a large volume of fluid in a patient with severe spinal stenosis during epidural neuroplasty can increase the pressure on the opposite side of the epidural space, which may cause injury of the opposite nerve by barotrauma from a closed compartment. Practitioners should be aware of this potential complication.

Efficacy of Percutaneous Epidural Neuroplasty Does Not Correlate with Dural Sac Cross-Sectional Area in Single Level Disc Disease

PURPOSE: Percutaneous epidural neuroplasty (PEN) is a minimally invasive treatment. The efficacy of PEN has been relatively well investigated; however, the relationship between the clinical effectiveness of PEN and the severity of spinal canal stenosis by disc material has not yet been established. The purpose of this study was to compare clinical outcomes of PEN according to the dural sac cross-sectional area in single level disc disease. MATERIALS AND METHODS: This study included 363 patients with back pain from single level disc disease with and without radiculopathy. Patients were categorized into groups according to spinal canal compromise by disc material: Category 1, less or more than 50%; and Category 2, three subgroups with lesser than a third, between a third and two thirds, and more than two thirds. Clinical outcomes were assessed according to the Visual Analog Scale (VAS) score for back pain and leg pain and Odom's criteria at 1, 3, 6, 12, and 24 months after treatment. RESULTS: The demographic data showed no difference between groups according to spinal canal compromise by disc material except age (older age correlated with more spinal canal compromise). The dural sac cross-sectional area did not correlate with the VAS scores for back and leg pain after PEN in single level disc disease in Groups 1 and 2. Odom's criteria after PEN were also not different according to dural sac cross-sectional area by disc material. CONCLUSION: PEN is an effective procedure in treating single level lumbar disc herniation without affecting dural sac cross-sectional area.

Cerebellar Infarction Following Epidural Abscess after Epidural Neuroplasty

Epidural neuroplasty is found to be effective in removing fibrous tissue occurring in the epidural space for various reasons. We report a case of cerebellar infarction caused by epidural abscess after epidural neuroplasty. To the best of our knowledge, this is the first report of cerebellar infarction developed as a result of epidural abscess accompanying bacterial meningitis after epidural neuroplasty. We also discuss the etiology, pathogenesis, and prognosis of this rare pathologic entity.

Unintended Complication of Intracranial Subdural Hematoma after Percutaneous Epidural Neuroplasty

Percutaneous epidural neuroplasty (PEN) is a known interventional technique for the management of spinal pain. As with any procedures, PEN is associated with complications ranging from mild to more serious ones. We present a case of intracranial subdural hematoma after PEN requiring surgical evacuation. We review the relevant literature and discuss possible complications of PEN and patholophysiology of intracranial subdural hematoma after PEN.

Epidural Lysis of Adhesions

As our population ages and the rate of spine surgery continues to rise, the use epidural lysis of adhesions (LOA) has emerged as a popular treatment to treat spinal stenosis and failed back surgery syndrome. There is moderate evidence that percutaneous LOA is more effective than conventional ESI for both failed back surgery syndrome, spinal stenosis, and lumbar radiculopathy. For cervical HNP, cervical stenosis and mechanical pain not associated with nerve root involvement, the evidence is anecdotal. The benefits of LOA stem from a combination of factors to include the high volumes administered and the use of hypertonic saline. Hyaluronidase has been shown in most, but not all studies to improve treatment outcomes. Although infrequent, complications are more likely to occur after epidural LOA than after conventional epidural steroid injections.

Clinical Outcomes of Epidural Neuroplasty for Cervical Disc Herniation

Cervical disc herniation is a common disorder characterized by neck pain radiating to the arm and fingers as determined by the affected dermatome. This condition has a favorable prognosis, but pain can have a serious detrimental impact on daily activities. Epidural neuroplasty has been applied as a treatment option for cervical disc herniation; however, no study has addressed the clinical outcomes. This retrospective study evaluated the clinical outcomes of epidural neuroplasty on 128 patients for the treatment of cervical disc herniation. To measure pain-related disabilities over time, the changes of pain scores in neck and arm were evaluated using a numerical rating scale (NRS) and the neck disability index (NDI). Compared with preprocedural values, the pain NRS of neck and arm demonstrated significant improvement at day 1, and 1, 3, 6, and 12 months after the procedure (P < 0.001). Likewise, the NDI was significantly reduced at 3, 6, and 12 months after the procedure (P < 0.001). There were no serious complications. Cervical epidural neuroplasty shows good clinical outcomes in the treatment of cervical disc herniation and can be considered a treatment modality for cervical disc herniation refractory to conservative treatment.

Efficacy of Epidural Neuroplasty Versus Transforaminal Epidural Steroid Injection for the Radiating Pain Caused by a Herniated Lumbar Disc

OBJECTIVE: To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc. METHODS: Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment. RESULTS: In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00+/-1.52, 4.29+/-1.20, 2.64+/-0.93, 1.43+/-0.51 and those of FRI were 23.57+/-3.84, 16.50+/-3.48, 11.43+/-2.44, 7.00+/-2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22+/-2.05, 4.28+/-1.67, 2.56+/-1.04, 1.33+/-0.49 and those of FRI were 22.00+/-6.64, 16.22+/-5.07, 11.56+/-4.18, 8.06+/-1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically. CONCLUSION: Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.

Clinical Experiences of Transforaminal Balloon Decompression for Patients with Spinal Stenosis

Lumbar spinal stenosis is a commonly treated with epidural injections of local anesthetics and corticosteroids, however, these therapies may relieve leg pain for weeks to months but do not influence functional status. Furthermore, the majority of patients report no substantial symptom change over the repeated treatment. Utilizing balloon catheters, we successfully treated with three patients who complained persistent symptoms despite repeated conventional steroid injections. Our results suggest that transforaminal decompression using a balloon catheter may have potential in the nonsurgical treatment of spinal stenosis by modifying the underlying pathophysiology.

Ultrasound-guided removal of epidural catheter breakage after percutaneous epidural neuroplasty: A case report

The breakage of epidural catheter seldom makes severe complication, but it may be a stressful event to nervous chronic pain patients. We discovered a retained epidural catheter in plain x-ray image and CT scan following a percutaneous epidural neuroplasty for a 62-year-old woman. Even though surgical removal of the catheter was not tried for 1 year, we decided to remove the catheter fragment as the patient's request, if exploration would be easy. Sonographic evaluation showed that the tip of the epidural catheter beneath subcunateous tissue between sacral hiatus. Ultrasound will be an invaluable tool when trying to remove the broken catheter under local anesthesia if its tip is out of the sacral hiatus.

A Study of the Effects of Neuroplasty by Spinal Endoscopy in Herniated Nucleus Pulposus Patients for Therapeutic Purpose / 대한마취과학회지

BACKGROUND: Neuroplasty by spinal endoscopy is a new technique in the field of treatment of herniated nucleus pulposus patients. This new technique allows the operator to visualize directly the epidural space and contiguous structures, thus allowing for detailed examination leading to a better understanding of the role of epidural adhesion in the development of sciatica. The aim of this prospective study is to determine effects of neuroplasty by spinal endoscopy in herniated nucleus pulposus patients. METHODS: Twelve patients with herniated disc were taken neuroplasty by spinal endoscopy. The patients were followed with verbal rating scale(VRS) for 2 weeks, 3 months and 6 months after neuroplasty. RESULTS: Four patients were posterocentral type and eight pateints were posterlateral type. The effects of neuroplasty by spinal endoscopy in posterolateral type were significantly higher than that of posterocentral type. But, age, duration of back pain and amount of irrigation saline were not related to effects of neuroplasty by spinal endoscopy. CONCLUSIONS: We conclude that it is important to determine posterocentral type or posterolateral type on MRI before neuroplasty by spinal endoscopy and the effects of treatment is well in posterolateral type.