History

• Dr. Gabor Racz in 1989, described a technique for lysis of epidural adhesions to treat lumbosacral radicular and/or low back pain. Since then, it has been used worldwide.

• The technique is minimally invasive and relatively easy to perform.

Indications

• Failed back surgery syndrome

• Epidural adhesions, epidural fibrosis

• Spinal stenosis

• Vertebral body compression fracture

• Radiculopathy

• Resistant multilevel degenerative arthritis

• Pain unresponsive to spinal cord stimulation and spinal opioids

Contraindications

• Sepsis

• Coagulopathy

• Local infection at the side of the procedure

• Patient refusal

• Syrinx formation

• Chronic infection

• Cauda equina syndrome

• Hydrocephaly

• Unstable angina

• Obstruction of the sacral canal

• Spinal dysraphism affecting area

• Inability to maintain position

• Allergy

• Severe stenosis

• Arachnoiditis

The technique involves

• Performing an epidurogram to identify filling defects indicative of epidural scarring

• Advancing a catheter in the anterolateral epidural space into the adhesions

• Injecting hyaluronidase to facilitate adhesiolysis and normal saline to hydraulically separate adhesions and wash out epidural proinflammatory cytokines

• Injecting anti–inflammatory and analgesic drugs and hypertonic saline to treat pain, inflammation and edema

Techniques

• Caudal approach

• Transformaminal approach

• Trans–S1 approach

Conclusion 1 Percutaneous epidural neuroplasty with the racz catheter is effective for pain reduction and functional improvement in patients with chronic low back and lower extremity pain refractory to conservative treatment and decreases the need for surgical treatment.

Definition

• is the visualization of the spinal canal using a flexible fiber optic light source and endoscope.

• myeloscopy

• epiduraloscopy or epiduroscopy

• Definition: ‘Epiduroscopy is a percutaneous minimally invasive endoscopic examination of the epidural space that can also be used for therapeutic inventions’.

• Spinal pain syndromes do not disappear by simply ignoring them.

• Epiduroscopy offers a technique for diagnosing and treating spinal pain syndromes.

Indications

• Diagnostic Indications

• This may involve distinguishing pathological and anatomical structures and circumstances, such as epidural fibrosis following invasive procedures and radiculopathies

• performing biopsies and smears,

• removing irrigation fluid,

• as well as performing an epidural pain provocation test (EPPT).

• Therapeutic Indications

• Direct application of pharmacologic therapy

• Lysis of scar tissue

• Catheter placement (epidural, intrathecal)

• Implantation of stimulation electrodes (radio frequency therapy, spinal cord stimulation) under direct vision

• Support during minimally invasive surgical procedures is another therapeutic indication for epiduroscopy.

Major Contraindications

• Bleeding tendency

• Therapy with anticoagulants

• Infections in the area of the puncture site

• Special neurological disorders – High risk of cardiovascular disease – Patient’s refusal to undergo the procedure

Conclusion 2 Epiduroscopy is one of the best diagnostic and therapeutic tools for difficult spinal pain syndromes with wider uses in the coming days.