Epidural Neuroplasty with Single Bolus Injection versus Continuous Infusion of Steroid in Patients with Spinal Stenosis

OBJECTIVE: To compare the efficacy of epidural adhesiolysis with a single bolus steroid injection (EAS) and continuous steroid infusion (EAC).METHOD: Thirty-one patients were allocated to the EAS group (10 patients) and EAC group (21 patients). EAS received single bolus of 10 mg of dexamethasone. EAC received a total of 96 mL dexamethasone solution (20.0 mg of dexamethasone) for 48 hrs. Oswestry Disability Index (ODI) was evaluated before, one month after the procedure. Three months after the procedure, the Patient’s Global Impression of Change (PGIC) was evaluated.RESULTS: Pre-treatment ODI was 38.3 ± 3.1 in EAS and 46.40 ± 4.0 in EAC. One month later, ODI was decreased to 35.60 ± 3.33, 43.08 ± 6.96 in each group (p=0.174). Three months later, 2 patients in the EAS (20.0%) and 8 patients in EAC (38.1%) showed ‘much improvement’ in PGIC, 5 patients in EAS (50.0%) and 6 patients in EAC (38.1%) showed ‘slight improvement’, 3 patients in EAS (30.0%) and 7 patients in EAC (33.3%) showed ‘no improvement’ (χ2=1.588, p=0.510).CONCLUSION: Epidural adhesiolysis with continuous infusion did not show any superiority than single bolus injection.

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.

A Novel Balloon-Inflatable Catheter for Percutaneous Epidural Adhesiolysis and Decompression

Epidural adhesions cause pain by interfering with the free movement of the spinal nerves and increasing neural sensitivity as a consequence of neural compression. To remove adhesions and deliver injected drugs to target sites, percutaneous epidural adhesiolysis (PEA) is performed in patients who are unresponsive to conservative treatments. We describe four patients who were treated with a newly developed inflatable balloon catheter for more effective PEA and relief of stenosis. In the present patients, treatments with repetitive epidural steroid injection and/or PEA with the Racz catheter or the NaviCath did not yield long-lasting effects or functional improvements. However, PEA and decompression with the inflatable balloon catheter led to maintenance of pain relief for more than seven months and improvements in the functional status with increases in the walking distance. The present case series suggests that the inflatable balloon catheter may be an effective alternative to performing PEA when conventional methods fail to remove adhesions or sufficiently relieve stenosis.

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.

Spinal cord stimulation in complex regional pain syndrome with severe epidural adhesions: A case report

Complex regional pain syndrome (CRPS) is often a devastating neuropathic condition that has been recognized with increasing frequency in the lower extremities. Patients with CRPS may worsen to such a degree that the individual may never return to a satisfactory and productive life. Spinal cord stimulation (SCS) is one of the most minimally invasive and effective treatments for intractable pain such as CRPS. The most important factor for successful stimulation of the spinal cord is proper lead position that stimulation and pain regions match completely. A 39-year-old male patient, suffering from CRPS type II in his lower extremity, visited our pain clinic. It was a difficult case that the electrode for spinal cord stimulation was positioned at the proper site due to the adhesion of the epidural space by frequent epidural blocks and procedures. We report the efficacy of a steerable epidural catheter for adhesiolysis on the setting the electrode to the proper site in the epidural space.

Clinical Experience of Epidural Adhesiolysis in Patients with Failed Back Surgery Syndrome / 대한마취과학회지

BACKGROUND: Epidural adhesiolysis is advocated in radiculopathy due to epidural adhesion following previous back surgery. Traditionally, a Racz catheter through a R-K needle is used as a standard tool in this procedure. We report our experiences of clinical results and the usage of various catheters for epidural adhesiolysis in patients with failed back surgery syndrome. METHODS: We investigated the medical records of 15 patients with failed back surgery syndrome who received epidural adhesiolysis. An R-K epidural needle was inserted through the sacral hiatus and a Racz catheter was advanced through the needle and repeatedly passed through the adhesion site under fluoroscopic visualization. The authors used Racz catheter in addition to the several kinds of catheter, e.g., the Fogarty balloon, and pulmonary artery or ureteral catheters to improve the epidural adhesion lysis. Bupivacaine, triamcinolone, hypertonic saline and/or hyaluronic acid were injected through the catheter daily for 3 days. Patients were evaluated for pain intensity and side effects 3 days and 2 months after the procedure. RESULTS: Pain scores (numerical rating scale) were significantly lower at 3 days and 2 months (3.1 +/- 1.8, 5.7 +/- 2.0, respectively P <0.01) than pre-procedure values (8.6 +/- 0.9). Complications were 2 mild posterior neck pain during procedure and 1 myoclonus in the recovery room. CONCLUSIONS: We conclude that epidural adhesiolysis is a relatively effective therapeutic means in patients with failed back surgery syndrome. Furthermore, a new balloon catheter with the advantages of Racz and Fogarty catheters, should be made available to improve the quality of lysis.