16 Step-by-Step Epiduroscopic Techniques Chronic, radicular lower back pain remains one of the most challenging symptoms to properly diagnose and treat. Although imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) have made significant advancements in the past several decades, they cannot offer direct visualization of epidural scarring and fibrotic tissue. Although myeloscopy has been described since the 1930s,1 only since the 1990s has flexible fiberoptic epiduroscopy been regularly described in the literature. It is a technique in which a small-diameter flexible endoscope is introduced into the epidural space. This allows direct visualization of the epidural space along with structures such as the dura, nerve roots, and neuroforamina. It also allows the practitioner to diagnose pathology such as epidural scarring or fibrosis via direct visualization of such structures. The injection port of the epiduroscope can be, and oftentimes is, used in a therapeutic manner to inject local anesthetics, corticosteroids, hyaluronidase, etc. As this is a relatively new technique in the field of percutaneous interventional epidural procedures, it is important to review the anatomy and the step-by-step techniques involved in epiduroscopy. • Epiduroscopy is most commonly performed for patients with postlaminectomy syndrome. • Patients should have chronic pain of more than 3 months’ duration. • The primary pain complaint in patients should be radicular pain. • As epiduroscopy is used primarily for diagnosis and treatment of epidural scarring and fibrosis, it follows that patients who have had at least one surgical spine procedure are candidates for this procedure.2 • Patients with largely nonradiating back pain should be approached with caution as determination of pain generators in these patients using a technique such as epiduroscopy has not been fully established.3 • Conservative and traditional interventional treatments should first be attempted as per the standard of care in the treating location including, but not limited to, physiotherapy, pharmacotherapy, epidural corticosteroid injections, and epidural lysis of adhesions. • Patients should be able to tolerate the prone position with minimal sedation so as not to confound the diagnostic value of the procedure. • As with all interventional procedures, epiduroscopy is contraindicated in patients with surgical site/systemic infections or bleeding diathesis. • Patients should have imaging with CT or MRI to rule out any other treatable pathology prior to epiduroscopy. • Radicular symptoms may be discordant to findings on imaging, owing to the poor visualization of epidural scarring and fibrosis on these imaging modalities. • Severe central canal stenosis or cauda equine crowding may be a relative contraindication as introducing an endoscope into an epidural space that is close to being compromised may cause neural compression owing to the epiduroscopic technique as well as the size, albeit relatively small, of the epiduroscope. • As with all procedures, all risks of the procedure should be discussed with the patient and informed consent obtained. • Although an interlaminar technique for epiduroscopy has been described,4 most approaches in the literature support access to the epidural space via the sacral hiatus. The transforaminal approach has also been increasingly used and its steps have been covered in this book. • With either approach, the patient is placed in the prone position with appropriate padding of bony prominences. Tolerance of this position with minimal sedation is required. • Preoperative antibiotics within 30 minutes of skin violation have been described due to the invasiveness of the procedure and can be accomplished with 1,000 to 2,000 mg of intravenous cefazolin or 600 to 900 mg of intravenous clindamycin for those who are penicillin-allergic (current institutional standards should be utilized). • Sterile preparation of the operative site should be achieved with either chlorhexidine or povidone-iodine as per current institutional standards. • Full surgical gown and gloves after thorough, standard hand scrub should be donned by those involved in the procedure. • Sterile draping of the lumbosacral spine as well as the operative fluoroscope should be performed using strict aseptic technique. • Small, flexible, fiberoptic endoscopes vary in size, and those used for epiduroscopy are typically 2.5 to 3 mm in diameter. • The tip of the endoscope is typically bidirectional and rotates in either direction up to 170 degrees. • The working port of the endoscope is smaller, approximately 1 mm in diameter, and allows the introduction of injectate as well as tools such as forceps and laser fiber. • The skin entry site and trajectory to the sacral hiatus are identified with anteroposterior (AP) and lateral fluoroscopy. Local anesthetic is injected into the overlying skin. • The caudal space is accessed using a Tuohy needle ( • Entry into the space is confirmed on AP and lateral fluoroscopy with injection of radiopaque contrast dye.
16.1 Introduction
16.2 Patient Selection
16.3 Preoperative Imaging
16.4 Patient Preparation
16.5 Epiduroscope Insertion
Fig. 16.1 demonstrates the equipment required to perform epiduroscopy.
Fig. 16.2, 
Fig. 16.3, and 
Fig. 16.4).
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