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Evaluation of Transforaminal Versus Endoscopic

Epiduroplasty in Postlumbar Laminectomy Syndrome:


A Prospective, Controlled, and Randomized, 1-Year Follow-up Study.

Ahmed Fawzi El Molla, MBCHB,MS,MD (Egypt), PGcert (UK), FIPP (USA)


Assistant Professor of Pain Medicine & Anesthesia -Medical Research Institute, Alexandria
University, Egypt. Postgraduate certificate in pain management (UK).
Fellow of interventional pain practice (USA).

ABSTRACT Techniques Trans group 3 months EDS group

Background: Study protocol of epiduroplasty


3% 11% 17%
29%
Adhesions surrounding nerve roots as a result of post-laminectomy When used Solution volume 17% 1 1
40%
Day of intervention Iohexol (Omnipaque 240) 3 ml
syndrome (PLS) may interfere with their nutrition and blood supply and are Hyaluronidase in PF-NS(150 U/ml) 10 ml
2 2

29% 3 54% 3
potent contributors to radicular pain. Impairment of intraneural blood flow Bupivacaine (0.25%) & MPA( 8mg/ml) 10 ml 4 4
is probably the final common pathway leading to pain generation. It is NaCl (10%) (over 10 min) 10 ml
5 5
possible that adhesiolysis reduces pain generation through improvement Iohexol: non-ionic water-soluble contrast medium
in nerve root nutrition by removal of obstruction to blood supply and CSF PF-NS: preservative free normal saline
MPA: Methylprednisolone acetate
flow. Adhesiolysis may also interfere with the mobility of the dural sleeves
of the spinal roots with subsequent pain. The mobility of nerve roots may 12 months
be restored by adhesiolysis. RESULTS Trans group EDS group

Methods: Transforaminal epiduroplasty (TFEPI) (figure 1): 23% 23%


34%
Seventy two patients were allocated randomly into two groups. The Trans 1
9%
1

2 2
group (n=35) in whom patients underwent transforaminal epiduroplasty 43% 68%
3 3
and EDS group (n=37) in whom patients underwent endoscopic 4 4
epiduroplasty. Pain severity were measured by visual analogue score (VAS) 5 5
for both leg and back pain and functional activities were assessed using
Waddell and Main score with a follow-up to 12 months. Satisfaction was
observed at 3 and 12 months. Figure (6): Dissatisfaction/satisfaction after transforaminal epiduroplasty (Trans-group) and
endoscopic epiduroplasty (EDS group) at 3 and 12 months.
Results:
In both groups the follow-up VAS-leg pain score showed statistical
significant reduction (P<0.0001) at 1, 3, 6, 9, and 12 months. The follow-up None of the patients developed postoperative neurological complications.
VAS-leg pain score in EDS group showed statistical significant reduction Side-effects encountered were some persistent low back discomfort in all
(P<0.0001) at 1 and 12 months. The follow-up VAS-back pain score in both patients which was subsided after 2-3 weeks by the administration of the
groups showed statistical significant reduction (P<0.0001) up to 6 months. patient’s usual analgesic medications. One patient in the Trans group
The follow-up VAS-back pain score in EDS group showed statistical developed non-persistent paraesthesia of one lower limb which subsided
significant reduction (P<0.0001) at 1, 3, 6, and 9 months. The function spontaneously after 4 weeks. In EDS group four patients developed
scores showed statistical significant improvement (P<0.001) at 3 and 12 transient headache which subsided in one day, two patients had two-day
months in both groups. No complications occurred and side-effects were fluid leak of saline from the sacral hiatus and one patient had presacral
minimal. granuloma which partially subsided within two weeks fig (7).
Conclusion:
Figure (1): Contrast agent exiting along the path of a nerve root during transforaminal
Both transforaminal and endoscopic epiduroplasty resulted in meaningful epiduroplasty (Trans group)
improvement in both pain and disability in PLS. However, endoscopic
epiduroplasty appears to have better benefits. Epiduroscopy (EDS) (figure 2):

INTRODUCTION
“Post-lumbar laminectomy syndromes” (PLS) following surgical spinal
Figure (7): Granuloma at the sacral
procedures have been attributed to post-operative fibrosis, adhesions, and
hiatus after epiduroscopy.
inflammation. It has been reported that repeating the surgical procedure
Figure (2): Adhesions (red arrow) in the dorsal
does not always solve the problem. Instead, it may produce further epidural space (curved arrow) during
complications. In such patients, the painful symptoms reflect a
combination of pathological processes, such as interruption of blood flow,
venous congestion, ischemia, axonal damage and intraneural fibrosis.
epiduroscopy.
DISCUSSION
Epidural steroid injection has been one of the “gold standards” in the The main finding of the current study was that the targeted epidural
management of chronic low back pain and PLS for over 40 years. injection via the endoscopic epiduroplasty appears to achieve better
Controversy, however, continues its efficacy. benefits than the TFEPI. Adhesiolysis could be responsible for the long-term
pain relief in the EDS group. Three mechanisms were postulated to achieve
Pain score for leg pain

Using fluoroscopy in patients with previous back surgery, epidural injected adhesiolysis in EDS group. First, mechanical adhesiolysis was performed
steroid solution will spread to reach the level of pathology in only 26% of by manipulation of the tip of EDS. Second, hydrostatic adhesiolysis was
cases. Transforaminal epiduroplasty (TFEPI) may be indicated on those achieved by the distension of the epidural space and the pressure of the
occasions when the nerve roots are difficult to “open”, but their clinical irrigating saline which may be responsible for the mobilization of
effectiveness needs further support. Epiduroscopy (EDS) allows more adhesions. Furthermore, it may result in diluting local tissue concentration
accurate placement of drugs within the epidural space, which may improve of inflammatory mediators. In this regard, previous studies have reported
the efficacy of epidural steroids in “PLS”. The hypothesis is that targeted the importance of inflammatory mediators in causing low back and leg
epidural medication delivery nearby the desired nerve root may result in pain. Both mechanical and hydrostatic adhesiolysis would not be achieved
better pain relief. in the Trans group. Finally, “chemical” (medication- induced) adhesiolysis
Time in months was achieved by hyaluronidase and NaCl 10% injections. In this regard,
Therefore, TFEPI (exterior to the extraforaminal foramen) was evaluated Figure (3): hyaluronidase and NaCl 10% have been used to enhance the effect of lysis
with the endoscopic epidural targeted approach (interior to the Leg pain score after transforaminal epiduroplasty (trans-group, n=35) and endoscopic
of adhesions. Hyaluronidase was added because of its ability to hydrolyze
intraforaminal foramen). The proposed benefits of these two targeted epiduroplasty (EDS group, n=35). Individual points represent means ±SD. *P<0.001 compared
to baseline value, #P<0.001 compared between groups. the glycosaminic bonds of hyaluronic acid (e.g. nucleus pulposus) and other
medication delivery were believed to overcome the compliance gradient mucopolysaccharides of connective tissue.
which may be caused by the adhesions which may “shield” the
compromised nerve root. The primary goal of the current study was to The improvement after TFEPI for up to 12 months, as regard VAS-leg when
evaluate the efficacy of the non-endoscopic and endoscopic techniques of compared to the preoperative pain scores, might be attributed to the
targeted epidural injection to improve chronic leg pain severity in PLS dilution or “wash out” of inflammatory mediators with saline and other
Pain score for back pain

patients. The secondary goals were to evaluate the low back pain severity, injectates near by the targeted nerve root. In addition, the “chemical”
functional abilities, satisfaction/dissatisfaction, and complications (if any). adhesiolysis induced with the injection of hyaluronidase and NaCl 10%
might be of help. The rationale for transforaminal injection of a total of 30
ml of injectate was assumed to ensure the opening of the possible

METHODS adhesions around the painful nerve root from exterior. Moreover, in other
studies a protocol for TFEPI a total of 16 cc of a mixture of local anaesthetics
(LAs), hyaluronidase, and preservative-free saline was injected and followed
This prospective, controlled, and randomized study was approved by the by infusion of NaCl 10% via a catheter over 20 minutes without serious
local ethics committee and the written informed consent was obtained. complications. In the current study, 20 cc of a mixture was transforaminaly
Seventy-two patients were classified as having PLS who suffered mainly injected and followed by 10 cc NaCl 10% in three divided doses over 10
from mono-segmental chronic radicular pain. Patients were randomly Time in months minutes, therefore the injection of such volume with other safety measures
allocated into two groups. The Trans group (n=35) (control group) in whom Figure (4):
Back pain score after transforaminal epiduroplasty (trans-group, n=35) and endoscopic taken in the current study could not potentially unsafe. The improvement in
they underwent TFEPI whereas, EDS group (n=37) in whom they epiduroplasty (EDS group, n=35). Individual points represent means ±SD. *P<0.001 compared VAS-back and functional ability in Trans group for the first 6 months when
underwent endoscopic epiduroplasty. to baseline value, #P<0.001 compared between groups. compared to the preoperative values might be also explained on the
previous basis.
Inclusion criteria:
It is noteworthy, to emphasize that although the epiduroscopic views may
Patient’s age between 30 and 55 years, a duration of pain of at least 2 years, themselves confirm the presence of adhesions around the compromised
and predominance of leg pain rather than low back pain as measured by
Total Functional score

nerve root. The current study could not confirm that the major contributor
VAS on a 100 mm scale, for both leg (VAS-leg) and low back (VAS-back) pain. for the post-EDS improvement in pain relief would be attributed to
adhesiolysis. This limitation should be overcome in the future by doing both
pre- and post-procedure epidurography, Another limitation that may result
Exclusion criteria: in a study bias that the localization of the compromised nerve root was
clinically performed and reconfirmed by pain provocation test in EDS group
Patients who developed signs of progressive motor disorders or
whereas in the Trans group the localization was performed only by the
incontinence, those had local or systemic infections, coagulation disorders,
clinical assessment. The use of a nerve stimulator in the future may be of
glaucoma, malignancy, pregnancy, language barriers, and mental
help to overcome this limitation.
handicaps, and those with multi-segmental pain manifestations such as
burning sensations, dysesthesia or paraesthesia in the planter region or in a In conclusion: Both tansforaminal and endoscopic epiduroplasty resulted
wider leg or perineal area were also excluded. Time in months
Figure (5): in meaningful improvement in both pain and disability in PLS. However,
Two patients are excluded from EDS group due to improper (one case) & Functional score after transforaminal epiduroplasty (trans-group, n=35) and endoscopic endoscopic epiduroplasty appears to have better benefits
epiduroplasty (EDS group, n=35). Individual points represent means ±SD. *P<0.001 compared
impossibility (another case) of location of sacral canal. to baseline value, #P<0.001 compared between group

aelmulla@yahoo.co.uk
www.newinvent.com/elmulla3.htm

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