26 Epiduroscopy: Complications and Complication Avoidance Epiduroscopy is a minimally invasive technique useful in the diagnosis and treatment of a variety of chronic low back pain conditions. The procedure is generally well tolerated; however, as with any procedure, there are risks, and although rare, a number of epiduroscopic complications have been reported in the literature ( • Visual impairment is an uncommon but significant complication following epiduroscopy. • It is believed to be caused by increased cerebrospinal fluid (CSF) pressure and subsequent retinal hemorrhage. • The injection of fluid (usually saline) helps to open the epidural space during epiduroscopy, increasing epidural pressure and transiently increasing CSF pressure; the increase in pressure is directly proportional to the rate and volume of injection. • The epidural injection of just 30 mL of saline over 1 minute can cause CSF pressure to rise to 60 mm Hg.3 • A sudden increase in CSF pressure is transmitted through the subarachnoid extension around the optic nerve, compressing the nerve and its vasculature, which results in the rupture of retinal blood vessels. • Additional contribution to retinal hemorrhage may result from the increase in CSF pressure, decreasing cerebral blood flow with a reflex increase in ophthalmic artery pressure, resulting in venous collapse and the rupture of capillaries. • In 2005, Gill and Heavner reported 12 cases of visual impairment after epiduroscopy. The volume of solution injected ranged from 20 to 120 mL. Approximately 58% of patient had bilateral retinal hemorrhages and 21% had residual vision loss or hemorrhage.3 • In order to minimize this complication, epidural injection should be administered at a low speed, 1 mL per 1 to 2 seconds, and the volume should not be exceed 100 mL per 60 minutes.3 • In 2015, Beyaz reported a case of generalized tonic–clonic seizure and transient complete motor paralysis and sensory loss after epiduroscopy.2 • Increased intracranial pressure (ICP) was hypothesized to be the etiology of the observed deficits. • Physiologic ICP is 5 to 10 mm Hg at rest, and the epidural injection of just 10 mL has been shown to increase ICP to 11 to 63 mm Hg. Those with above-average ICP at rest can have a severe, devastating response to injection 10 mL of epidural solution, with ICP reaching around 300 mm Hg. The increase in ICP occurs within seconds of epidural injection and returns to baseline level in approximately 2 to 6 minutes.2 Table 26.1 Complications associated with epiduroscopy and prevention strategies
26.1 Introduction
Table 26.1).
26.2 Visual Impairment
26.3 Transient Neurologic Deficits and Seizure
Complication | Presumed etiology | Prevention strategy |
Visual impairment | Increased CSF pressure secondary to high rate and large volume epidural injection resulting in retinal hemorrhage3 | Low injection volume with slow injection speed = 1 mL per 1–2 seconds |
Transient neurologic deficits and seizure | Increased ICP secondary to large volume, bolus injection of saline in epidural space2,3 | Slow injection speed and low injection volume = 100 mL per 60 minutes |
Avoid unnecessary epidural fluid administration. | ||
Dural tear resulting in intradural cyst and orthostatic headache | Direct visualization of dura with epiduroscopy | |
Aspiration of CSF when tear is suspected | ||
Contrast injection during fluoroscopy |
