Epiduroscopy is an endoscopic diagnosis and treatment of pain in the spinal cord.
Epiduroscopy is understood as a percutaneous minimally invasive endoscopic examination of the epidural space, which makes it possible to obtain volumetric and color images of such anatomical structures in the spinal cord as Dura mater spinalis, Ligamentum flavum, Ligamentum longitudinale posterior, blood vessels, neural structures, and adipose tissue. Also, pathological structures and changes, such as adhesions, sequestration, inflammatory processes, fibrosis, and stenosing processes can be detected using the endoscopic method.
Epiduroscopy procedure - percutaneous minimally invasive endoscopic examination of the epidural space.
Indications for epiduroscopy
Diagnosis of pain in the spinal cord is the main indication for epiduroscopy. Differentiation of pathological relationships, for example, epidural fibrosis after invasive procedures and radiculopathy, as well as carrying out the so-called "Memory Pain" -procedures expand the range of diagnostic indications.
Therapeutic indications for epiduroscopy include procedures such as targeted topical pharmacotherapy, biopsy, scar removal, catheter placement, and direct observation of stimulating electrodes if there is obstructed passage into the epidural space, or if the placement is not possible with a radiological method, or there is a risk to the patient ... Epiduroscopy as an adjunct method in minimally invasive surgery is another example of a therapeutic indication.
Necessary conditions for epiduroscopy
The main condition for achieving the effectiveness of epiduroscopy and patient safety is the experience of conducting examinations, as well as solid theoretical knowledge and a certain skill and skill of a doctor-specialist in painful invasive therapy. In addition to accurate pain diagnosis and professional technical management, the success of invasive pain therapy with epiduroscopic support depends on competent patient selection. A prerequisite for an invasive epiduroscopic examination is a thorough clinical and functional examination and imaging diagnostics.
Regardless of the structure of the clinic, epiduroscopy should be performed, if possible, only in patients who are willing to cooperate, as well as under constant supervision and observation of vital functions in the appropriate operating room.
Technique of access to the epidural space during epiduroscopy
By the sacral access to the epidural space, the patient is placed on the operating table in a prone position. After thorough disinfection of a large area of skin and a sterile cover over the sacral foramen (Hiatus), local anesthesia is performed. After the initiation of local anesthesia, the puncture is performed using a puncture cannula from the sacral foramen set at an angle of 45 ° and a distance of 4 cm from the intergluteal sulcus (Rima ani).
After the guide cannula perforates the Ligamentum sacrococcygeum, the cannula is adjusted to the axial position of the spinal canal. After a negative aspiration test at two levels, it is possible to insert the guide rod to a shallow depth into the sacral opening (Hiatus sacralis). Control lateral fluoroscopy helps to identify the guide rod in the sacral foramen (Hiatus sacralis).
After a small incision, a 9.5 Fr. dilator can be inserted. with a tube with a lateral nozzle for a tube through the rod percutaneously into the spinal canal. A plastic sluice from the insertion set, placed in the sacral foramen, provides a reliable relatively atraumatic sacral insertion, as well as the advancement of the epidroscope and very important protection against shearing.
Epiduroscopy requires continuous and controlled epidural lavage with physiological saline through the working channel of the epidroscope. Epiduroscopy, depending on the anatomical structure of the spinal canal and professional examination technique, can be performed through the sacral foramen (Hiatus sacralis) in the direction from sacral to cervical. For interventions with epiduroscopic support, such as biopsy, adhesion dissection, scar tissue resection, stopping blood, and removal of foreign bodies through the working channel of the epidroscope, flexible surgical instruments, a laser light guide, and a catheter are available to the surgeon.
There is a possibility of endoscopic resection of scar tissue, depending on the result of pathological analysis within a certain framework. Due to the anatomical data of the spinal canal, the tip of the epidoscope can only be navigated within narrow boundaries provided by anatomical features.
By using gentle external rotations of the epidoscope or changing the direction of the epidoscope tip, which can be steered up 120 ° and down 170 °, the epidural position of the epidroscope tip can be improved. Adhesions and fibrous tissue can be mobilized or removed by using grasping forceps or using a laser to reach the target area despite adhesions.
The position of the height of the epidoscope in the spinal canal can be easily determined using an X-ray image converter. Today there are epiduroscopes with markings at a distance of 5 cm, allowing the doctor to easily determine the position of the height. To reach the target in the epidural space, the epidroscope should never be moved blindly or using force. A constant and optimal endoscopic view protects against inadvertent complications.
At the end of the epiduroscopic intervention, blood dryness is checked. Finally, the epidoscope is carefully removed from the epidural space under constant optical control.
To ensure reliability, epiduroscopy must be recorded in the protocol. It is recommended to save the results of endoscopic examination on video and/or video printers or a floppy disk, CD, or DVD. Epiduroscopy makes an important contribution to patient safety and quality control. Without a significant additional burden for the patient, Epiduroscopy expands the diagnostic and therapeutic possibilities and opens, especially in the treatment of chronic pain syndromes in the spinal cord, new avenues for their therapy, also long before their chronic form.
Instrumentation used for epiduroscopy
- Flexible Epiduroscope - Designed for sacral access to the epidural space (Spatium epidurale), the 2.8 mm outer diameter epidroscope impresses primarily with its large viewing angle and flexibility of the controlled distal end (120 ° up, 170 ° down), as well as its diameter working channel 1.2 mm.
- Biopsy forceps - to obtain tissue samples from the epidural space, it is possible to introduce the appropriate microsurgical instrumentation through the working channel of the epidroscope.
- Optional Equipment - For an optimal presentation of endoscopic images, an IMAGE 1 ™ digital endoscopic camera and color monitor are connected to the epidroscope. The IMAGE 1 ™ camcorder guarantees the resolution and sensitivity required to obtain the highest quality digital images.
- Endoscopy equipment can be connected to the KARL STORZ AIDA DVD ™ or AIDA DVD system for digital storage and archiving of fixed images, video sequences, audio data, and external data on CD-ROM, DVD, or in a database. These systems provide a compact, digital alternative to video printers and VCRs.
Indications for percutaneous epiduroscopy
- Image of pathological conditions
- Targeted use of medicines
- Placement of catheterization systems
- SCS electrode implantation (neuromodulation)
- Support for minimally invasive surgery
Advantages of catheter insertion and SCS electrode implantation with EDS support:
- Safe epidural access
- Epidural diagnosis
- Precise placement of catheters or electrodes
- Bypass pathological obstacles
- Speeding up the implantation process
- Reduced X-ray load
- Improving documentability
Contraindications to epiduroscopy
The contraindications for percutaneous epiduroscopy correspond to those for local anesthesia in the spinal cord region. The most important additional contraindications are:
- Hemorrhagic diathesis
- Anticoagulant treatment (exception: mild heparinization with blood clotting control, administration of acetylsalicylic acid, Epiduroscopy after 4 days)
- Puncture site infection
- Neurological diseases
- Patients at high cardiovascular risk
- Refusal of the patient from epiduroscopy