21 Transforaminal Epiduroscopic Laser Annuloplasty for Diskogenic Pain

21.1 Introduction

Pain in the lower back can affect up to 85% of the population at some point in life.1 In most cases, low back pain is self-limiting; however, it can become chronic and disabling in 5% of patients.² The precise anatomic cause can often be difficult to identify. It has been estimated that approximately 40% of chronic low back pain originates from the intervertebral disk.³ Histologic analysis of intervertebral disk revealed significant sensory innervation in the posterolateral aspect of the annulus fibrosis.⁴ Direct stimulation of the outer annulus fibrosis in vivo demonstrated concordant pain.⁵

Treatment of chronic diskogenic low back pain has been challenging. Conservative measures often fail to reduce the pain or improve function. Lumbar arthrodesis for diskogenic pain reported only a 46% satisfactory clinical outcome.⁶ Successful fusion by elimination of a painful motion segment has not demonstrated a significant improvement in pain and functional status.⁷ In addition, the surgery is associated with its complication risks, morbidity, and prolonged recovery. This has led to the development of minimally invasive intradiskal therapeutic approaches to open surgical procedures, including intradiskal electrothermal therapy (IDET), radiofrequency ablation (RFA), cryotherapy, percutaneous endoscopic laser diskectomy (PELD), and percutaneous endoscopic laser annuloplasty (PELA).^8,9 The proposed mechanism of action of intradiskal therapy is a combination of destruction of the annulus nociceptors and shrinkage of the intervertebral disk.

Given that the pain-generating regions of diskogenic pain are located in the posterolateral aspect of the annulus, an extradikcal epidural approach can also be utilized for assessment and treatment. An extradiskal epidural approach has the added benefit of direct visualization of the epidural space and its structures with a flexible endoscope (epiduroscopy). In addition, the epidural structures can be assessed to determine whether it is concordant with the patient’s clinical symptoms. Lumbosacral epiduroscopy has been demonstrated to be more accurate in identifying vertebral level pathology than clinical assessment or magnetic resonance imaging (MRI).¹⁰ In addition, epiduroscopic findings were noted to be predictive of treatment outcomes.¹¹ The epiduroscopic approach has been previously reported to treat lumbar stenosis and back–leg pain syndrome.^{12,13,14,15,16,17,18} However, the traditional approach of epiduroscopy with its entry site through the sacral hiatus may be limited by bony stenosis of the hiatus, lumbar stenosis, or epidural scaring from previous surgery.

In combination with epiduroscopy, the use of a laser can enhance the treatment efficacy of diskogenic pain. Systematic review of the literature for use of laser in lumbar disk decompression demonstrated positive results, with 75% of patients treated reporting significant pain relief for 12 or more months.¹⁹ Laser disk decompression has also been demonstrated to be comparable to diskectomy.²⁰ Various types of lasers have been used in managing spinal disorders.^21,22,23 One type, the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, has been demonstrated to be effective in managing spine disorders in several clinical studies.^24,25,26,27

In this chapter, we describe an approach for the management of diskogenic pain utilizing a novel curved spinal endoscope and introduction technique in combination with an Nd:YAG laser. The curved endoscope provides transforaminal access where current rigid spinal endoscopes or anatomic barriers may limit passage ( Fig. 21.1). Transforaminal epiduroscopic laser annuloplasty (TELA) provides a minimally invasive and direct approach to the evaluation and treatment of diskogenic pain.

21.2 Indications for Transforaminal Epiduroscopic Laser Annuloplasty

21.3 Contraindications for Transforaminal Epiduroscopic Laser Annuloplasty

21.4 NeedleView CH Endoscope System

• The endoscopic system is a disposable semirigid fiberoptic based microendoscope with a single working channel (NeedleView CH, BioVision Technologies). The endoscope has a 160-mm working length with a 3.4-mm outer diameter. There is a 1.85-mm diameter working channel and a built-in 0.7-mm fiberoptic channel with 17,000-pixel resolution ( Fig. 21.2).

• The distal third of the endoscope can be bent to a desired angle to facilitate entry into the ventral epidural space from a transforaminal approach ( Fig. 21.3).

Fig. 21.1 The standard endoscope (left) has a fixed trajectory to the neural foramen from the skin entry site. A curved endoscope (right) has a similar skin entry site and can navigate into the neural foramen with a less steep trajectory, thus bypassing potential anatomic barriers.

Fig. 21.2 (a) NeedleView CH microendoscope compared with a Vertebris endoscope (Richard Wolf). (b) NeedleView CH’s outer diameter is 3.4 mm compared to Vertebris’ outer diameter of 5.9 × 5.0 mm.

Fig. 21.3 The endoscope is bent to the desired entry angle. (a) The endoscope is placed on the molding frame. (b) A curve in the distal end is made to the desired angle. (c) The final configuration of the bent endoscope.

21.5 NeedleCam HD Visualization System

21.6 Equipment

• The laser is delivered through a 550-μm side-firing opening ( Fig. 21.4).

• Equipment required for endoscope introduction includes the following ( Fig. 21.5):

• 18-gauge spinal needle.

• 21-gauge spinal needle.

• 14-gauge × 127-mm Tuohy needle.

• 18-gauge × 152-mm Tuohy needle.

• 12-Fr cannula and 12-Fr dilator.

• 70-cm guidewire.

• Endoscope bender.

• No. 15 blade.

21.7 Anesthesia

21.8 Positioning

Fig. 21.4 (a) Side-firing Nd:YAG laser tip. (b) Insertion of laser fiber through the endoscope.

Related posts:

Patient Assessment for Epiduroscopy Clinical Indications and Considerations for Epiduroscopy Pathophysiology of Spinal Pain and Pain Pathways Anatomic Origin of Spinal Pain and Clinical Presentations Spinal Epiduroscopic Laser Therapy Sacral Hiatus Epiduroscopic Approach

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