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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 400 020.

This 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.

INTRODUCTION

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.

CASE REPORT

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).


Fig.1
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 sheath.

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).

Fig.2
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.

DISCUSSION

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 pain relief.

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 worth exploring.

ACKNOWLEDGEMENT

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.



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