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Adhesions

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Title: FAILED BACK SYNDROME Author: Preferred Customer Last modified by: Ghaleb Created Date: 2/16/2002 6:59:13 AM Document presentation format – PowerPoint PPT presentation

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Title: Adhesions


1
Adhesions
  • The inflammation and adhesions on and around the
    dura and spinal nerves are presumed to be the
    major causes of chronic back pain and
    radiculopathy.
  • Smyth J, Wright
  • compression on normal nerve root causes
    paraesthesia and numbness
  • compression on injured nerve root causes
    pain
  • The lysis of epidural adhesions is considered as
    one of the effective therapeutic modalities of
    management of these patients.
  • The adhesinolysis may be performed either
    non-endoscopically or endoscopically

2
History
  • first attempted using the myeloscope around 1931.
  • Development of fiber optics and video technology.
  • The U.S. F DA approved it for visualization of
    the epidural space in September 1996.

3
Fluoroscopy Vs endoscopy
When fluoroscopic imaging is used alone to direct
the steroid injection, judging the distribution
of nonionic contrast can be difficult because the
fluoroscopic projection is two-dimensional
Spinal endoscopy delivers three dimensional
color views of investigated tissue in real time.
As spinal endoscopy cannot distinguish one
level from another . therefore fluoroscopy must
be used simultaneously to insure delivery to a
specific level.
4
mechanism of analgesia
lavage of algesic substances (e.g., cytokinins,
substance P) by saline utilized to enhance
optical visualization of the epidural space
. stimulation of the neuroinhibitory system by
the pulsating effect on the dura and the salutory
effect of injection of steroids under direct
visualization in the epidural space. more
controlled studies needed
5
Choosing a Modality
  • MR
  • Soft tissues T2 fluid is bright
  • Multiplanar T1 fluid is dark
  • -No radiation
  • CT
  • Bones Fluid is dark on CT
  • Low cost Acute (clotted) blood is bright
  • Ubiquitous

6
Indications for epiduroscopy
  • Research
  • Epiduroscopy in human autopsy cases has revealed
    a dorsomedial connective tissue band in the
    epidural space
  • Kitamura et al showed that repeated bupivacaine
    injections caused haemorrhage and congestion in
    the epidural space
  • Igarashi et al showed that In those patients who
    had received several previous epidural blocks,
    aseptic inflammatory changes including adhesions
    were observed.

7
therapeutic
Shimoji et al. were able to identify adhesions
and "arachnoid" filaments Spinal cord
stimulation electrodes can be placed at the
lumbar level under epiduroscopic guidance Schutze
G, Groll O It is very difficult to identify
the diseased structure in the epidural space when
the flexible fibrescope is introduced directly
between the spinous processes
8
Indications
9
Contraindications
  • Coagulopathy
  • Pregnancy
  • Renal insufficiency
  • Chronic liver dysfunction
  • History of adverse reactions to local
    anesthestics or anti-inflammatory drugs
  • History of gastrointestinal bleeding ulcers
  • Patients unable to understand informed consent

10
TECHNIQUE OF EPIDUROSCOPY/SPINAL ENDOSCOPY
17-gauge Tuoghy needle is inserted into the
sacral canal guide wire is placed through Tuoghy
needle Tuoghy needle is then removed canal
passage is widened with 11 scalpel dilator and
sheath are passed over the wire The sidearm of
the introducer sheath is flushed with 10 ml of
normal saline.
11
The steerable catheter containing fibreoptic
cable is passed through the introducer The
epidural space is distended with 10 to 15 ml of
normal saline The fibreoptic cable along with
steerable catheter is introduced The
intermittent distension and irrigation of
epidural space with normal saline may be
required. The total volume of normal saline
should not exceed more than 70 ml.
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18
OUTCOMES
best outcome is found in cases of monoradicular
pain without neurological deficit. A
prospective outcome is comparison with use of a
single endoscopic procedure to repeat epidural
injections would be an important project.
Approximately 6000 or more cases have been
performed during past five years. No permanent
injury has been reported. Pre and post-procedural
survey, data indicate a trend toward less opioid
medication and improved functional capacity.
19
Future
  • It appears the Epiduroscopy will evolve, as
    arthroscopy and laparoscopy did, to become the
    diagnostic and therapeutic instrument of choice
    for many procedures in the spine. Endoscopic
    procedures have proven to be safer, more
    effective, and less costly than open surgical
    procedures the spine will not be an exception to
    the fact.
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