Trans-Sacral Epiduroscopic Laser Decompression (SELD) for Low back pain secondary to herniated lumbar disc in the Philippines: A case report and review of literature

@#LBP has a lifetime prevalence ranging from 54% to 80%, an annual prevalence of 15-45%, and a point prevalence of 30%. Lumbar radicular pain often results from a Lumbar disc herniation. With recent advances in technique and access in instrumentation, minimally invasive spine surgery has ushered in a renaissance of spine care. SELD has promising positive effects in controlling LBP following HLD. This is a case of a 26 year old with radicular LBP of 2 years duration secondary to HLD, underwent conservative management of LBP but offered no relief and improvement, hence he became the case for the pioneering procedure of SELD in the Philippines. Immediate and significant improvement in the patient was noted. SELD was proven to be an effective therapeutic modality for patients with LBP secondary to HLD.

Effects of ozone on the pain and disability in patients with failed back surgery syndrome / Efeitos do ozônio na dor e na incapacidade em pacientes com síndrome dolorosa pós-laminectomia

Summary Introduction: Low back pain is one of the painful disorders of higher prevalence. It has several etiologies and surgery may be indicated in the presence of neurological deficits or compression syndromes. However, in up to 40% of cases, patients develop worsening of pain and failed back surgery syndrome (FBSS), which is an important cause of chronic pain with high morbidity and disability. In the last two decades, ozone has been shown to be a new therapeutic option for FBSS due to its analgesic and anti-inflammatory properties. Objective: To evaluate the effect of ozone therapy on pain and disability in patients with failed back surgery syndrome. Method: We selected 19 patients undergoing epiduroscopy and injection of ozone. Patients were evaluated preoperatively and 21 days after the procedure, using the following instruments: Visual Analogue Scale (VAS), Brief Pain Inventory, Roland-Morris Questionnaire Disability, Oswestry Disability Index (ODI), Neuropathic Pain Symptom Inventory and Douleur Neuropathique 4. Results: The patients showed significant pain relief, but no improvement was observed in the functional scales. Conclusion: Our results suggest that epidural ozone therapy can be a treatment option in FBSS to reduce the intensity of the pain.

Resumo Introdução: A dor lombar é um dos distúrbios dolorosos de maior prevalência. Tem diversas etiologias e, na presença de déficits neurológicos ou síndromes compressivas, pode ser indicada cirurgia. Entretanto, em até 40% dos casos os pacientes podem evoluir com piora da dor e síndrome dolorosa pós-laminectomia (SDPL), que se constitui em uma importante causa de dor crônica com grande morbidade e incapacidade. Nas últimas duas décadas, o ozônio tem se mostrado uma nova opção terapêutica para a SDPL em virtude das suas propriedades analgésicas e anti-inflamatórias. Objetivo: Avaliar o efeito da ozonioterapia na dor e na incapacidade de pacientes com SDPL. Método: Foram selecionados 19 pacientes, submetidos a epiduroscopia e aplicação de ozônio. Os pacientes foram avaliados no pré-operatório e 21 dias após o procedimento, por meio de Escala Visual Analógica, Inventário Breve de Dor, Questionário Roland-Morris de Incapacidade, Oswestry Disability Scale, Inventário de Sintomas de Dor Neuropática e Questionário de Dor Neuropática. Resultados: Os pacientes apresentaram redução significante nos escores das escalas de avaliação de dor; porém, essa redução não foi observada na avaliação da incapacidade funcional. Conclusão: Os dados obtidos sugerem que a ozonioterapia epidural pode ser uma opção de manejo da SDPL na diminuição da intensidade da dor.

Epiduroscopic Removal of a Lumbar Facet Joint Cyst

Facet joint synovial cysts are usually associated with osteoarthritis of the adjacent facet joint and/or spondylolisthesis. In between the conservative and operative ends of the treatment spectrum lie minimally invasive techniques such as cyst rupture using epiduroscopy. In this report, we describe an 82-year-old male patient presenting with low back pain radiating to his lower left extremity and associated paresthesia. Magnetic resonance imaging of the lumbar spine revealed a synovial cyst at left L4/5 facet joint. Using epiduroscopy, the cyst was mechanically ruptured by popping it with the tip of the scope. The patient remained symptom-free at his successive visits until 12 months after the procedure, and was opened for desired follow up.

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.

Iatrogenic Intradural Lumbosacral Cyst Following Epiduroscopy

We report a rare complication of iatrogenic spinal intradural following minimally invasive extradural endoscopic procedues in the lumbo-sacral spines. To our knowledge, intradural cyst following epiduroscopy has not been reported in the literature. A 65-year-old woman with back pain related with previous lumbar disc surgery underwent endoscopic epidural neuroplasty and nerve block, but her back pain much aggravated after this procedure. Postoperative magnetic resonance imaging revealed a large intradural cyst from S1-2 to L2-3 displacing the nerve roots anteriorly. On T1 and T2-weighted image, the signal within the cyst had the same intensity as cerebrospinal fluid. The patient underwent partial laminectomy of L5 and intradural exploration, and fenestration of the cystic wall was accomplished. During operation, the communication between the cyst and subarachnoid space was not identified, and the content of the cyst was the same as that of cerebrospinal fluid. Postoperatively, the pain attenuated immediately. Incidental durotomy which occurred during advancing the endoscope through epidural space may be the cause of formation of the intradural cyst. Intrdural cyst should be considered, if a patient complains of new symptoms such as aggravation of back pain after epiduroscopy. Surgical treatment, simple fenestration of the cyst may lead to improved outcome. All the procedures using epiduroscopy should be performed with caution.

Assessment and Treatment of Chronic Pain / 全日本鍼灸学会雑誌

The definition of Pain, “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (International Association for the Study of Pain : IASP, 1994), which is often used to explain its subjectivity. It is necessary to evaluate the pain objectively for diagnosis and effectiveness of therapy.<BR>As an evaluation method of chronic pain, Visual Analog Scale (VAS) and Numerical Rating Scale (NRS) are used. Recent years, face visual analog scale and Current Perception Threshold (CPT) testing are also used commonly. Drug challenge test draws attention as it combines an evaluation method and an effective therapy. Meanwhile as a therapy of chronic pain, the reports of epiduroscopy and phototherapy are increasing. The epiduroscopy is an endoscopic operation for patients with the chronic low back pain. In Japan the therapy is performed increasingly for patients with the low back pain of spinal canal stenosis, failed back syndrome and lumbar disc herniation. Regarding the phototherapy, the reports which show the effectiveness of linear polarized infrared raytherapy and xenon phototherapy are mainly observed. Though the nerve block is still the dominant therapy in pain clinics, acupuncture therapy and phototherapy are prospected to increase their demands in future.

The Efficacy of Spinal Epiduroscopy in Patients with Low Back Pain

OBJECTIVE: Spinal epiduroscopy has been introduced. Thus, we herein present low back pain patients with variable duration of herniated intervertebral disc (HIVD), spinal stenosis and failed back surgery syndrome to determine and analyze the result of spinal epiduroscopy. METHOD: Fifty low back pain patients who enrolled in Bundang CHA rehabilitation center from April 2000 to November 2001 with variable duration of HIVD, spinal stenosis and failed back surgery syndrome were treated with spinal epiduroscopy. The patients were grouped according to the duration and the disease. The efficacy of treatment was assessed with visual analog scale (VAS), Oswestry low back pain (LBP) questionnaire and Pain Disability Index (PDI)before the treatment, at 1 day, 1 week, 3 months and 6 months after the treatment. RESULTS: VAS of all patients after spinal endoscopic epiduroplasty were significantly decreased (p<0.05). PDI of all patients after spinal endoscopic epiduroplasty were significantly decreased (p<0.05). Oswestry LBP questionnaire of all patients after spinal endoscopic epiduroplasty were significantly decreased (p<0.05). CONCLUSION: Spinal endoscopic epiduroplasty is one of the best treatment that can be applied to low back pain patients with variable duration of HIVD, spinal stenosis and failed back surgery syndrome.

The Change of Cervical Epidural Pressure according to Infused Normal Saline in Epiduroscopy / 대한마취과학회지

BACKGROUND: Normal saline is used to dilate the epidural space to provide a focal length for the lens and to wash the epidural adhesive neural tissue in an epiduroscopy. Saline infusion into the epidural space during an epiduroscopy might affect pressure-volume compliance of the CSF which has a high compliance; therefore, it might cause neurological sequelaes. The purpose of this study was to investigate the change of cervical epidural pressure according to the volume of infused saline during epiduroscopy. METHODS: Twenty-one patients who complained of low back pain with radiculopathy that did not respond to conservative pain management and underwent an epiduroscopy were included in this study. The epidural catheter was placed between the 5th and 6th cervical epidural space under fluoroscopic guidance and cervical epidural pressure was monitored. Next, an epiduroscopy via caudal route was performed and cervical epidural pressure was measured after each 10 ml of infused saline. We also checked neurological sequelaes that might be resulted from increased epidural pressure. RESULTS: All patients except two showed no difference in basal cervical epidural pressure. One patient who had failed back surgery syndrome complained of a headache and dizziness when the cervical epidural pressure was rapidly increased from 90 mmHg to 5 mmHg following an infusion of 27 ml of saline. One patient who had a herniated disc showed posterior nuchal pain and stiffness following an infusion of 48 ml of saline despite a stable cervical epidural pressure (range: 0 - 3 mmHg) during the procedure. There were no residual neurological sequelaes in this study. CONCLUSIONS: There are variable patterns in cervical epidural pressure according to the volume of infused saline. Close monitoring of intracranial pressure is therefore neccessary during an epiduroscopy.