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.

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.

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.

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.

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.

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.