17 Spinal Epiduroscopic Mechanical Adhesiolysis Endoscopic adhesiolysis is built on the principle that by safely utilizing flexible fiberoptic catheters to access the epidural space via the sacral hiatus, a three-dimensional visualization of the space will allow for targeted mechanical rupture of paincausing adhesions. The procedure allows for specific optical investigation of nerve roots and its pathology, and thus allows for adhesiolysis if pain is attributed to the visualized scarring noted. Adhesiolysis may be achieved by utilizing the fiberoptic catheter to mechanically disrupt connective tissue with injectate. Conditions for which endoscopic adhesiolysis is indicated include failed back surgery syndrome/postlaminectomy pain syndrome, epidural adhesions, and disk herniation. Endoscopic adhesiolysis is thus indicated in patients with an appropriate diagnostic evaluation with chronic lower back pain and radiculopathy who have failed to respond to more conservative treatment modalities. • Epidural fibrosis is an inflammatory reaction of the arachnoid, a nonvascular elastic tissue that encases the central nervous system. • Etiologies include hematoma, infection, annular tear, and surgical trauma, which lead to an inflammatory cascade including edema, venous congestions, and fibrosis.1 • In turn, the fibrosis and scarring cause a mechanical pressure on the nerve roots with a decrease in cerebrospinal fluid–mediated nutrient delivery, causing them to be hyperesthetic and hypersensitive to compression. • Nucleus pulposus application via herniation may also lead to rapid thrombus formation within the intraneural capillaries, causing an impairment of blood flow and thus abnormalities in nerve conduction and pain generation.5 • The epidural space lies between the dural sac and the ligamentous boundaries of the vertebral canal ( • This space is filled with areolar connective tissue, which surrounds the dural sac while lining the laminae and pedicles. This epidural membrane lines the vertebral bodies and then passes deep into the posterior longitudinal ligament. The membrane is also drawn laterally to form a sheath around the dural sleeve of the nerve roots.6 • The most commonly used method of epidurosopic adhesiolysis include the approach via the sacral hiatus; however, the transforaminal approach may be utilized for a more targeted approach on specific nerve roots, which may be inaccessible utilizing a posterior epidural approach. • Prior to undergoing endoscopic adhesiolysis, more conservative treatment modalities including medical management and epidural steroid injections should be exhausted. • Utilizing sterile precautions, the patient is placed in a prone position on the operating room table and the fluoroscope is adjusted over the lumbosacral regions to provide for both anteroposterior and lateral views. • After infiltration of local anesthetic, an epidural needle is introduced within the epidural space and a lumbar epidurogram is performed using approximately 2 to 5 mL of contrast. Fig. 17.1 Superior view at the level of the L4–L5 intervertebral disk. Normal relationship between the intervertebral disk and L4 exiting nerve root and L5 traversing nerve root in the epidural space is observed. The epidural space is indicated by the arrow.
17.1 Indications
17.2 Pathophysiology
A retrospective review of 182 surgical revisions in patients with failed back surgery found that more than 60% were due to epidural fibrosis, which did not respond well to surgery.2
As approximately 75% of the nutrition to the nerve roots depends upon cerebral spinal fluid flow,3 in disease states such as fibrosis, this may lead to a critical cause of neural damage.
A study testing sensory nerve function before and after epiduroscopic adhesiolysis found a significant improvement in A-beta and A-delta nerve conduction values.4
17.3 Anatomy
Fig. 17.1).
17.4 Technique
The advantages of the straight entry via the caudal approach include ease of access with passage of the endoscopic device into the epidural space, with less risk of complications including dural puncture and damage to the device itself (
Fig. 17.2).
Appropriate laboratory studies should be performed to rule out bleeding disorders, and anticoagulants should be stopped to avoid bleeding postoperatively.
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