8 Clinical Indications and Considerations for Epiduroscopy Epiduroscopy allows direct visualization of anatomic structure of epidural space ( Fig. 8.1 (a) Lumbar superior view of anatomic structures in relation to the epidural space. (b) Lumbar left lateral view with partially sectioned in midsagittal plane of anatomic structures in relation to the epidural space. (c) Sacral midsagittal section of anatomic structures in relation to the epidural space. The indications for epiduroscopy are diagnosis and treatment of spinal pathology. Biopsy can be performed for histopathologic or histochemical analysis. Helpful treatments such as irrigation, lysis of adhesions, and direct application of therapeutic agent can be easily performed. In addition, the epiduroscope is also useful tool in performing minimally invasive spinal surgery such as disketomy and spinal cord stimulator implant.7 The primary indications for epiduroscopy are as follows: • Chronic refractory back pain refractory to conservative therapies. • Axial back pain with radiculopathy. • Lumbar spinal stenosis. • Cervical disk disorder with radiculopathy. • Postlaminectomy syndrome. • Epidural adhesion. • Failed back surgery syndrome. • Diagnosis of epidural fibrosis after invasive procedure. The contraindications for epiduroscopy are similar to epidural anesthesia, as listed in the following:7,8 • Bleeding tendency or coagulopathy disorders. • Systemic or local infection at the puncture site. • Neurologic disorder with increased intracranial pressure. • Severe cardiovascular disease with low cardiac output. • Cerebrovascular disease, renal, or liver insufficiency. • Severe lumbar disk herniation with cauda equina syndrome. • Patient’s refusal to undergo the procedure. • Pregnancy. • Retinal disease. • Severe respiratory insufficiency (chronic obstructive pulmonary disease). • Psychiatric diseases that interfere with informed consent. • Patient’s inability to lie in a prone position for more than 60 minutes. A detailed, written informed consent should be obtained prior to the procedure. The potential benefits and risks of the procedure should be explained, including reduction of pain, increase in intracranial pressure, bowel and bladder dysfunction, sensory disturbances in the S2–S4 area, and all other complications related with the procedure.7,8 Following the procedure, patient should be examined for both sensory and motor functions to ensure safe discharge. A few days of bed rest is suggested. Antibiotics, analgesics, and anti-inflammatory agents may be prescribed postoperatively. Although epiduroscopy is generally a safe procedure, it is not without potential complications. Some of the possible complications are as follows: • Dural tear and puncture headache. • Epidural hematoma. • Epidural injuries. • Radicular neuralgia. • Bladder and rectal dysfunction. • Infection: meningitis and epidural abscess. • Neurologic dysfunction (e.g., confusion, weakness). • Adverse reaction to contrast and therapeutic agents.
8.1 Introduction
Fig. 8.1). By combining fluoroscopy and the magnifying properties of the epiduroscope (
Fig. 8.2), lesions of the epidural cavity can be visualized in great detail without the surgical exploration. In addition to its diagnostic function, the mechanical action of the epiduroscope can be utilized to remove adhesions, and the working channel for surgical instrument of the scope permits for targeted injection of therapeutic medications (
Fig. 8.3).1,2,3,4,5,6
8.2 Indications
8.3 Contraindications
8.4 Considerations and Complications
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