EPIDUROSCOPY: An Interventional Pain
Management forPost Laminectomy Pain - A First Case Report from India
DK BAHETI*, A DESHPANDE**, V PATIL***
*Chief Pain Management Clinic;
**Consultant Anaesthesiologist; ***Resident, Department of Anaesthesiology,
Bombay Hospital Institute of Medical Sciences, 12, New Marine Lines, Mumbai
report describes the first epiduroscopy done at Bombay Hospital and Medical
Research Centre, Mumbai, to perform adhesiolysis for relief of backache and
radiculopathy in a patient of post laminectomy pain due to epidural adhesions.
There was adequate pain relief and definite improvement in functional capacity
after epiduroscopic adhesiolysis.
Post laminectomy pain or failed back syndrome with its resultant chronic low
back pain is estimated to occur in 20% to 50% of the patients. Epidural adhesions
following surgery on the spine remains one of the important causes of chronic
low back pain. Soft tissue pathology is not easily examined so it is often overlooked
as a potential cause of some types of back pain syndrome.
MP 49 year male presented with
continuous low backache and radiating pain in left lower extremity. He was operated
twice (1998 and 2000) for prolapsed intervertebral L5 and S1 disc. There was
no history of any medical disorder and routine investigations and coagulation
profile were normal. The latest MRI showed epidural fibrosis at L5 S1 downwards.
This patient had temporary relief from pain by two fluoroscopic guided epidural
blocks i.e. volumetric adhesiolysis.
The patient was posted for elective epiduroscopic adhesiolysis in operation
theatre with stand by anaesthesiologist. The sedation Inj. Midazolam 1 mg and
Inj. Fentanyl 100 mg were given during the procedure. The monitoring of ECG,
SaO2, NIBP was done during the procedure.
The patient was kept in prone position with a pillow under the pelvis. A 17
gauge Toughy needle was advanced in sacral canal. The position of the needle
was confirmed under the fluoroscopy. Inj. Omnipaque 6-8 ml injected slowly,
patient experienced pain during injection suggestive of dense adhesions. The
caudal epidurogram showed the restricted/no spread of contrast on left side,
which is suggestive of adhesions and could be the cause of pain in left lower
extremity (Fig. 1).
A guide wire was passed through Tuoghy needle into caudal space and sacral canal
passage was dilated with dilator and introducer sheath. The dilator was removed
and introducer sheath was kept in situ. The caudal space was irrigated with
10-15 ml of normal saline to facilitate the visibility.
The steerable catheter (Vue-Cath system) has two ports. One port is used for
fiberscope and other is for irrigation of the audal space. The steerable catheter
along with 0.9 mm fiberscope was introduced in the caudal space via introducer
A total of 60 ml normal saline was used for irrigation intermittently. The movement
of steerable catheter could be seen through fluoroscopy. Once the patient confirmed
the reduction in the intensity of pain, which was suggestive of adequate adhesiolysis,
the procedure was stopped.
Now repeat caudal epidurogram was repeated which showed the adequate spread
of contrast on left side as well as compared to earlier epidurogram. The repeat
epidurogram is shown in (Fig. 2).
At the end of the procedure Inj. Depomedrol 80 mg (2 ml)+Inj. Hyaluronidase
500 IU (10 ml)+Inj. Lignocaine 1% 10 ml was injected in caudal space.
The vital signs were maintained during the procedure and recovery was uneventful.
The patient was discharged next day with adequate pain relief.
The inflammation and adhesions on and around the dura and spinal nerves are
presumed to be the major causes of low back pain and radiculopathy. The volumetric
adhesiolysis under fluoroscopy has been the standard mode of treatment. However
fluid takes the path of least resistance and may not reach the affected area.
Thatís why more sittings of epidural block may be required to achieve maximum
Epiduroscopy allows direct viewing of the contents of spinal canal in real colour
and actual activity. The epiduroscopy also provides the better access under
vision and the drug can be injected near affected area. Thus in one procedure
the two things i.e. one adhesiolysis and two injection of drug near affected
area can be achieved.
Preliminary reports on the use of fibreoptic epiduroscope to perform adhesiolysis
for the treatment of post laminectomy pain are encouraging.
Epiduroscopy provides one more option in the armamentarium of pain management
physician in the treatment of postoperative pain due to adhesions, which is
We are thankful to the management of Bombay Hospital trust and Bombay Hospital
and Medical Research Centre for procuring of the epiduroscope and providing
other facilities for this case report.