13 Diagnostic and Functional Epiduroscopic Procedures Determining the cause of back pain is complicated as it is often multifactorial and also because anatomic abnormalities, which may not be relevant with clinical symptoms, are common in the spine. Epiduroscopy allows spatial and color pictures of epidural anatomic structures, including spinal dura mater, ligamentum flavum, posterior longitudinal ligament, blood vessels, connective tissue, nerve, and fatty tissue. Using epiduroscopy, it is possible to determine a source of pain by identifying the pathology of the epidural space or by making diagnostic blocks onto the target structure.1,2 Fluoroscopy allows for exact location of the tip of the flexible scope with respect to the bony spinal canal, while direct visualization gives the relative orientation with respect to the surrounding anatomic structures in the epidural space of the lumbosacral spine. In addition to identifying the lumbar epidural pathology, epiduroscopy can also be used functionally to investigate the outcome of treatment. In a study by Bosscher and Heavner,3 epiduroscopic treatment predicted its therapeutic outcome based on direct visual information (hyperemia, vascularity, and fibrosis) and mechanical information (pain to touch, contrast spread, and patency). In Bosscher and Heavner’s study, a prediction of outcome using diagnostic epiduroscopy was correct in 89 of 114 patients (accuracy of 78%) with sensitivity and specificity of 75 and 82%, respectively. These results suggest that information obtained through epiduroscopy may carry significant diagnostic and prognostic value. This chapter reviews the diagnostic and functional uses of epiduroscopy. In the epiduroscopic procedure, adhesion is observed as tissue organized in strings and sheets of white fibers or as a dense white tissue, which appears generally avascular, regardless of their severity ( Bosscher and Heavner rated fibrous adhesion identified during the epiduroscopic procedure using the grading system from grade 1 (loose strings and sheets of fibrosis) to grade 4 (dense continuous fibrous material, the epiduroscope cannot be advanced) in accordance with its severity ( In the epiduroscopic procedure, the normal epidural cavity is usually seen with fat tissue (clusters of white or pale-yellow globular tissue with shiny appearance), dura (grey-white, with blood vessels), veins, arteries and fibrous strings or sheets, and ligaments. In acute and chronic inflammation, hyperemia can be observed as a discrete area of the dura root sleeve, peridural membrane, or other epidural structure, with or without adhesions, as compared to normal appearance of the epidural space ( When the epiduroscope is administered into the anterior epidural space, the disk can be seen. If the disk bulging is large and without annular tear, the disk can push the dura upward (
13.1 Introduction
13.2 Diagnosis of Epidural Adhesions
Fig. 13.1). In some patients, adhesions are so solid that the fibrous scar tissue makes mechanical adhesiolysis using epidural impossible (
Fig. 13.2). In such cases, it is possible to perform epiduroscopic adhesiolysis with holmium: yttrium-aluminum-garnet laser ablation (
Fig. 13.3). If inflammation is visible, then flushing the epidural space with saline and medication can play an important role (
Fig. 13.4).
Fig. 13.5).4
13.3 Diagnosis of Inflammation in Epidural Space
Fig. 13.6).
13.4 Diagnosis of Herniated Disks
Fig. 13.7). The dura is observed as a white-yellowish band with traverse blood vessels; sometimes, it may look gray-white. If there is an annular tear, a whitish nucleus pulposus can be observed in a red or yellowish inflammatory soup (
Fig. 13.8). If disk is migrated downward, the migrated disk is shown as a mass-like lesion (
Fig. 13.9).
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