ABSTRACT
Epidural brosis are common reason of back pain, usually related with failed back spine surgery with or without neurological de cits. Traditional open surgeries for surgical release and decompression have some poor results and complications. Our aim is to nd to pain generators and prospect of eliminating the pain with epiduroscopic treatment. is study presents 360 patients caused by Failed back Spine Surgery symptoms leading backpain. e patients underwent epiduroscopic adesiolysis restore epidural neural stucrtural release. Following the procedure, our patient’s satisfaction is very high and experienced signi cant improvements in pain, numbness, and muscle strength. Magnetic resonance assessments con rmed successful decompression of the spinal canal. Previous studies have used a measure of successful outcome≥ 50% of original pain relief as a successful outcome. Measure our study also included this point. e study emphasizes the bene ts of epdiuroscopic adesionolysis in enhancing patient recovery for failed back spine surgery. us, this report acknowledges certain limitations of visual and optic devices need for further development utilizing this approach. In conclusion, epiduroscopy promise as a valuable treatment of Failed Back spines surgery instead of traditional open surgeries, o ering potential advantages in terms of complications and recovery pain management. Epiduroscopic management enhances a multimodal philosophy and opens up new treatment strategies for patients. If used early on, it can control pain well before chronicity sets in.
Introduction
Epidural brosis are mostly part of failed back spine surgery, usually related with failed back surgery. Traditional open surgeries for surgical release and decompression have some poor results and complications but epiduroscopic adesiolysis has very successful results reported that current literature results. It has reported that a
clinically relevant reduction in pain and disability a er mechanical adhesiolysis in FBSS patients [1].
Epiduroscopy is the endoscopic visualization of epidural structures. e epidural space is part of spinal canal; It is the space above the dural membrane, anteriorly, directly bounded by the Flavum,
containing the Posterior Longitudinal ligament, periosteum, and posteriorly, adipose tissue, venous plexus. Marchesini M et al. reported that presence of the dorsomedian ligamentous strand (DLS), which divides the epidural space. e possible existence of this structure still in uences some clinical practice, such as locoregional anesthesia and pain therapy [2]. ere is normally no uid circulation in this negative pressure space. e epidural space is surrounded by the periosteum in the cranium and contains the venous sinuses in a dense structure. e epidural venous plexus is a valveless system that communicates with the basivertebral vein, the intracranial sigmoid, occipital, and basilar venous sinuses, and the azygous system. In this respect, the optic nerve, which has venous ow associated with the cavernous sinuses, is sensitive to changes caused by pressure increases in the epidural space [3]. ere may be retinal hemorrhages and visual loss due to increased venous pressure. Ocular ndings in epidural cranial hemorrhages are pathognomonic in this respect. Epiduroscopy is a treatment option and as kind of spinal endoscopy allows targeted epidural brosis to release and addionally to deliver analgesic pharmacologic therapy for a ected nerve roots or other painful regions in the epidural space. Treatment options provided by epiduroscopy include laser-assisted adhesiolysis or resection of pain-generating brosis, catheter placement, as well as support with other invasive procedures for pain relief and Failled back Spine Surgery (FBSS) [4]. Professional Endoscopy of Spine management enhances a multimodal philosophy and opens up new treatment strategies for patients. If used early on, it can control pain well before chronicity sets in. By the way patient’s history, physical examination, diagnostic modalities (Xray, MRI, Medulagraphy), nerve conduction studies should be completed blood count, coagulation tests, urinalysis very important desicion making and patient selection and might be Ophthalmoscopy should be noted before intervention. Diagnostic algoritm is the key of treatment. Physical examination, to distinguish sclerotmal and radicular pain, motor de sits. Simple xray has never been underestimated than it is the most important way to understand mechanic skeletal problems. MRI is very usefull to evaluate neural comprimise and axial neural channel problems Computerized Tomography and for some cases myelography is also very helpful. Percutaneous discography and foraminal injections could be performed neurologic compromised.
Material and Methods 360 patients were included prospective study. All patients are selected Failled Back Spine Surgeries (FBSS). Evaluate responsible reason of FBSS mechanic and neurologic compromise Etiology of FBSS would be poor selection for surgery of the patient have had a psychological pro le or pathophysiology. It could be related improper selection and misdiagnosis with inadequate preoperative evaluation and diagnostic work-up. is siuttion w-may leaded improper or inadequate surgery, which is resulted FBSS. Our series main age is 58 years old, 97 men, 263 women, follow up 8 months (range 3-36 months). 346 patients are treated single epiduroscopic way, 8 patients combined with open surgery remove hardware and limited decompression without fusion and in additional two surgical procedure have been performed, 2 patient have fusion surgery because of recurrent spondilolysthesis a er one level discectomy,4 patient had extremely spinal stenosis, and hardware occupation, excesive decompression and posterior short fusion. All patients be performed epiduroscopic treatment beside 4000- 10000 IU Hylase injection immediate a er surgery. During epiduroscopy procedure, such as epidural release with mechanic baloon and/or laser adesionolysis performed.
Surgical Technique Patient position must be properly pop up maximum pelvic posterior inclination with lumbar exion 30 degrees, hip Flexion 45 degrees, knee and abdominal cushion support should be provided. Under local skin anesthesia and C Arm Xray image intensi er locating of hiatus sacral than insertion of 18 gauge needle. e guide wire must be screened on C-Arm radiography each step. A er make sure guide wire intra channel position, to removal needle and deliver obturator on wire. Removal of the sheath obturator than take out of guide wire from channel. A er removal obturator of working sheet to Insert of endoscope and make connection camera and other devices.
Results Previous studies have used a measure of successful outcome≥ 50% of original pain relief as a successful outcome. Measure our study also included this point. e rst VAS and Questionnaire score had been taken respectively high before surgery. ese two scores (preoperative and postoperative) were then used to provide absolute di erencemorethan50percent.Wehavenocomplicationsexcepts mild headache, neckpain some cases. No hematoma, no infection, no retinal hemohage and no temporal blindness inspected. Our results suggest that although all ages have the potential to bene t from epiduroscopy and with or without interventional techniques. I highly encourage future research into the healing nature of our CSF to include an examination of it’s groundable electrical, conductive properties as well as an examination of any impact the earth’s pulsatile electrical eld may have on the pulsatile movement of CSF within our own brains.
Discussion Combined to endoscopic diagnostic and treatment methods immediately or very soon. Spinal cord stimulation and Neuromodulations (permanently painfull) Treatment options for patients with chronic low back pain with a neuropathic and/or mixed neuropathic/nocioceptive pain component are o en limited and unsatisfactory. Possible explanations proposed in the literature include neuroplasticity. Treatment strategies are varies in order distinguished main and satelite problems. It is di ucult to identi ed or recti ed main problems (visible changes) like Instability. We strongly recommend visible skeletal problems that hardware failure, pseudoarthrosis must be resolved beside stenosis and impingement. Back pain is not satellite problem of radiculopathy. Muscle Atrophy and weakness would be associated epidural brosis and medullopathy. Faset arthropathy should be considered in the di erential diagnosis and eliminated. Tricks rst stage avoid to new iatrogenic injury that beginner surgeons should be trained by simulators. Lee JJ et al. designed a simulator for enhance to learning curve of epiduroscopy training skills [5-7]. Skilled surgeons intervention will be reduced to problem palliative treatment results instead of terminal treatment. Epiduroscopy protected massive surgical treatments, which is not enough to relieve failed back’s pain. Main philosophy that avoid open surgical treatment and never lead to create a new generator for this cohort has o en been discounted or has failed, leaving patients with few treatment options) Osteoporotic fractures must be treated with vertebraplasty. Vymazal et al. combined vertebra- lastly with epiduroscopy [8]. Combined to endoscopic diagnostic and treatment methods very useful essepicially persistent cases. We performed some cases transforaminal endoscopic procedures for neglected foramina stenosis. Avellanal et al. reported transforaminal epiduroscopic treatments and good results [4]. Spinal cord stimulation and Neuromodulations (permanently painfull) would be performed failed epiduroscopic results. Postoperative nausea or retinal problems have been reported. Suzuki et al. reported that use of dexmedetomidine during epiduroscopy procedures may reduce the required fentanyl dose during surgery and the incidence of postoperative nausea and vomiting [9].
Conclusion Epiduroscopy is an option, which is signi cantly reduced pain in almost all patients with FBSS. Pain relief was signi cantly and highly correlated with reduced analgesic intake and patient satisfaction. Epiduroscopy should be considered as a potential treatment option for FBSS. It is not palliative treatment in which terminal stage of all other options.
Epiduroscopy has proven to be a safe, efficient and future-oriented interventional endoscopic procedure for everyday clinical use in diagnosing and managing pain syndromes. Epiduroscopy can be used in the sacral, lumbar, thoracic and even cervical regions of the spine to identify pathological structures, carry out tissue biopsies and perform epidural pain provocation tests to assess the pain relevance of visualized anomalies, making it an excellent diagnostic tool. Spinal endoscopy allows targeted epidural analgesic pharmacologic therapy for a ected nerve roots or other painful regions in the epidural space. Treatment options provided by epiduroscopy include laser-assisted adhesiolysis or resection of pain-generating brosis, catheter placement, as well as support with other invasive procedures for pain relief. Epiduroscopic management enhances a multimodal philosophy and opens up new treatment strategies for patients. If used early on, it can control pain well before chronicity sets in.
American Journal of Neurology Research
Ali Ihsan Isik and Tolgay Satana
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