Epiduroscopy - this is endoscopic diagnosis and therapy of pain in the spinal cord.
Epiduroscopy refers to a percutaneous, minimally invasive endoscopic examination of the epidural space, which allows to obtain three-dimensional and color images of such anatomical structures in the spinal cord as Dura mater spinalis, Ligamentum flavum, Ligamentum longitudinale posterior, blood vessels, nerve structures and adipose tissue. Also, pathological structures and changes, such as adhesions, sequestration, inflammatory processes, fibrosis and stenosing processes can be identified 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 pathoanatomical relationships, such as 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 such procedures as targeted local pharmacotherapy, biopsy, scar removal, placement of catheters and implantation of stimulating electrodes under direct observation in case of difficult passage into the epidural space or if the radiological method does not accommodate the patient or . Epiduroskopiya as an auxiliary method for minimally invasive surgical interventions is another example of therapeutic indications.
Necessary conditions for epiduroscopy
The main condition for achieving efficacy and patient safety is the experience of examinations, as well as thorough theoretical knowledge and a certain skill and skill of a physician-specialist in invasive pain therapy. In addition to accurate pain diagnostics and professional technical management, the success of invasive pain therapy with epiduroscopic support depends on the competent choice of the patient. A prerequisite for an invasive epiduroscopic examination is a thorough clinical and functional examination, as well as imaging diagnostics.
Regardless of the structure of the clinic, epiduroscopy should be carried out, if possible, only in patients who are ready to cooperate, and also under constant control and monitoring of vital functions in the relevant operating room.
Technique of access to the epidural space during epiduroscopy
In accordance with the sacral access to the epidural space, the patient is placed on the operating table in a prone position on the abdomen. After thorough disinfection of a wide area of skin and a sterile cover over the sacral opening (Hiatus), local anesthesia is performed. After the onset of local anesthesia, the puncture cannula from the sacral orifice set is punctured at an angle of 45 ° and at a distance of 4 cm from the interyagic 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 (Hiatus sacralis) to a small depth. Control lateral fluoroscopy is used to identify the guide rod in the sacral opening (Hiatus sacralis).
After a small puncture incision, you can enter a dilator of 9.5 Fr. with a tube with a lateral nozzle for a tube through a rod transcutaneously into the spinal canal. The plastic gateway from the input kit, placed in the sacral opening, provides reliable, relatively atraumatic sacral input, as well as the promotion of the epiduroscope and the very important protection against shear.
Epiduroscopy requires continuous and controlled epidural flushing with physiological saline through the epiduroscope working channel. Epiduroscopy, depending on the anatomical structure of the spinal canal and the professional examination procedure, can be performed through the sacral opening (Hiatus sacralis) in the direction from sacral to cervical. For such surgeries with epiduroscopic support, such as biopsy, dissection of adhesions, scar tissue resection, blood stoppage and removal of foreign bodies through the epiduroscope working channel, the surgeon has flexible surgical instruments, a laser light guide and a catheter.
There is the possibility of endoscopic resection of scar tissue, depending on the outcome of the autopsy analysis within certain limits. Due to the anatomical data of the spinal canal, the tip of the epiduroscope is navigable only in narrow, provided anatomical features, boundaries.
With careful external rotation of the epiduroscope or changes in the direction of the tip of the epiduroscope, which can be controlled in upward directions by 120 ° and downwards by 170 °, the epidural tip of the epiduroscope can be improved. In order to reach the surveyed area, despite the adhesion zones, with the help of exciting forceps, or using a laser, adhesions and fibrous sections of tissue can be mobilized or removed.
The position of the height of the epiduroscope in the spinal canal can be easily determined using an x-ray image transducer. Today, there are epiduroscopes with markings at a distance of 5 cm, allowing the doctor to easily determine the position of height. In order to achieve the goal in the epidural space, the epiduroscope should in no case advance blindly or with the use of force. Constant and optimal endoscopic vision provides protection against accidental complications.
At the end of an epiduroscopic intervention, a check is made for dry blood. Finally, the epiduroscope under constant optical control is carefully removed from the epidural space.
To ensure reliability, epiduroscopy should be recorded in a protocol. It is recommended to save the results of endoscopic examination on video and / or video printers or on a floppy disk, CD or DVD. Epiduroscopy makes an important contribution to patient reliability and quality control. Without significantly additional burden for the patient, epiduroscopy expands the diagnostic and therapeutic possibilities and opens up, especially in the treatment of chronic pain syndromes in the spinal cord, new ways to treat them, also long before their chronic form.
Used instruments for epiduroscopy
- Flexible epiduroscope - an epiduroscope designed for sacral access to the epidural space (Spatium epidurale) with an outer diameter of 2.8 mm impresses, first of all, with its large viewing angle and flexibility of the controlled distal end (120 ° up, 170 ° down), as well as 1.2 mm working channel.
- Biopsy forceps - for obtaining tissue samples from the epidural space, it is possible to introduce appropriate microsurgical instruments through the working channel of the epiduroscope.
- Additional equipment - an IMAGE 1 ™ digital endoscopic video camera and a color monitor are connected to the epiduroscope for optimal presentation of endoscopic images. The IMAGE 1 ™ camcorder guarantees the resolution and sensitivity needed to obtain the highest digital image quality.
- For digital storage and archiving of fixed images, footage, audio data and external data on a CD-ROM, DVD or database, endoscopic equipment can be connected to the KARL STORZ AIDA DVD ™ system or AIDA DVD system. These systems are a compact, digital alternative to video printers and video recorders.
Indications for percutaneous epiduroscopy
- Image pathological conditions
- Targeted use of drugs
- Placement of catheterization systems
- Implantation of SCS-electrodes (neuromodulation)
- Support for minimally invasive operations
Advantages of inserting catheters and implanting SCS electrodes with EDS support:
- Safe epidural access
- Epidural diagnosis
- Accurate placement of catheters or electrodes
- Pathological pathological obstruction
- Acceleration of the implantation process
- X-ray load reduction
- Improved documentation capabilities
Contraindications to epiduroscipia
Contraindications for percutaneous epiduroscopy correspond to the contraindications for local anesthesia in the spinal cord. The most important additional contraindications are:
- Hemorrhagic diathesis
- Treatment with anticoagulants (exception: poor heparinization in the control of blood coagulation, the appointment of acetylsalicylic acid, epiduroskopiya after 4 days)
- Infection at the puncture site
- Neurological diseases
- Patients with high cardiovascular risk
- Patient failure of epiduroscopy
What is the epidural space
The epidural space (EP) is a part of the spinal canal that extends from the foramen occipitale magnum (large occipital foramen) up to the hiatus sacralis (sacral gap), bounded by the dura mater, the periosteum of the vertebrae, the ligaments lining the walls of the spinal canal, and the veins and nerves .
Specifically, EP is limited to:
- front - posterior longitudinal ligament (ligamentum longitudinale posterior),
- behind - a yellow bunch (ligamentum flavum),
- on the side, nerves and veins opening into the foral fossa,
- in the sacrococcygeal division, the epidural space is limited to the sacrococcygeal ligament (lig. Sacrococcygeum).
- adipose tissue
- blood and lymph vessels and nerves,
- connective tissue.
In each case, without good reason, this procedure is rather complicated both for the doctor and for the patient. It belongs to the category of operations, so epiduroscopy must be preceded by:
- the results of spondylography, CT or MRI,
- identification, including with the help of laboratory tests, possible contraindications to epiduroscopy,
- examination of medications used for epidural administration.
Epiduroscopy is indicated:
- With chronic radiculopathy or phantom pains (pain that remains after the removal of any organ or limb):
- for this purpose, selective delivery of medication in EP is used at the level of the corresponding spinal segment — steroid anti-inflammatory drugs are often used.
- Severe pain syndrome, for example, after laminectomy - intervertebral hernia surgery, or in case of a complex fracture:
- In the first days after surgery, narcotic analgesics may be introduced into EP.
- Tumors and metastases in the spine in the last stages:
- for anesthesia, a catheter is inserted into the EP to supply narcotic opium drugs to the pathological segment.
- Adhesiolis - adhesion removal surgery for postoperative cicatricial-adherent epiduritis. Such intervention has to be resorted to very often.
- Spinal arachnoiditis.
- Neurological pathologies and myopathies, accompanied by motor disorders and disorders of the functions of organs:
- Parkinson's disease,
- paresis or paralysis caused by neurological and spinal disorders,
- dysfunction of the bladder and rectum,
- chronic cramps and pain.
Neurological problems and myopathy are treated by electromyostimulation of the spinal cord by implantation into the epidural space of an electrode SCS - stimulator.
Who should not conduct epiduroscopy
This procedure has contraindications:
- Blood clotting disorders, both natural and caused by the use of anticoagulants.
- Damage to the skin (for example, during hemorrhagic diathesis).
- Infectious local processes occurring near the site of the endoscope insertion.
- Concomitant infectious diseases (influenza, ARVI, parotitis, rubella, chickenpox, sore throat, etc.)
Preparation for epiduroscopy
This operation requires preparation - combined anesthesia:
- local anesthesia + intravenous administration of an anesthetic preparation of ultrashort action time.
These measures are necessary for continuous monitoring of the patient’s neurological condition throughout the entire procedure.
If necessary, premedication administration of antibiotics is made.
The operation takes place in the hospital.
After epiduroscopy, you must remain calm and lie for two to three hours.
Discharge from the hospital is usually done in three days.
Types of epiduroscopy
Epiduroscopy is performed mainly in the posterior method in two ways:
- in the first (median) endoscope is inserted in the lumbar region,
- in the second (sacral) - the sacral-coccygeal.
In both cases, the head and foot ends of the operating table are lowered, and the patient is placed on the table in the supine position.
(For preoperative epidural anesthesia, the patient is laid on its side).
The operating skin surface is treated with antiseptics, and anesthetic is injected into the working area of the puncture.
An epiduroscope has several channels:
- primary (for insertion of the catheter),
- optical (for the introduction of microcamera),
- worker (to supply saline NaCl).
The operation is carried out according to the method of Seldinger:
- With the help of X-rays is determined by the position of the sacrococcygeal ligament and sacral gap.
- A 17G or 14G needle is inserted at the set point.
- Then you can resort to a guide-needle of 0.9 mm, under the control of X-ray by entering it into the epidural space.
- A catheter is inserted through the needle guide, and the needle itself is removed.
Why do I need saline?
To ensure good visual control and advancement of the endoscopic tube into the working channel of the endoscope, NaCl solution is constantly injected, which allows a good look at the contents of the epidural space, as well as all pathologies:
- fibrosis, tumors, adhesions, deformations of the epidural space,
- inflammatory processes
- pathology of ligaments, etc.
Essence of adhesiolis: with the help of saline supplied under pressure into the epidural space, the meninges are separated and the epidural adhesions are destroyed.
How best to conduct epiduroscopy
Epiduroscopy is most successful in the lumbar region, however, the endoscope can move up to the cervical region:
- In the lumbar region, the endoscope progresses better in the anterior section of the EP.
- In the posterior part, due to its anatomical features (the spread of epidural tissue under the yellow ligament to the vertebral plates), the movement of the endoscope can be difficult.
- In the thoracic region, despite its narrowness, the EA is continuous, and the endoscope usually progresses smoothly.
If you need a quick hit of the drug in the brain and heart, organs of the chest and abdominal cavity, a selective supply of medication into the epidural space is best done at the level of the vertebrae T10 - L2, since there is a kind of main vascular junction - the venous plexus, the veins of which are reported:
- with the sinuses of the brain,
- chest and abdominal veins,
- ileal veins.
Do not forget that epidural endoscopy refers specifically to minimally invasive neurosurgical operations, which means that only a qualified neurosurgeon can perform it.
At the same time, any anesthesiologist should be able to do epidural anesthesia even in the prenatal centers.
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Indications for diagnosis - pain in the spine of unknown origin, postoperative pain. It is possible to take a biopsy.
With epiduroscopy, it is possible to remove postoperative scars and adhesions, placement of catheterization systems, targeted administration of drugs, implantation of SCS (Spinal Cord Stimulation) - electrodes (neuromodulation). Electrical stimulation of the spinal cord is indicated for severe pain syndrome with phantom pains, peripheral causalgias and neuropathies, spinal arachnoiditis ... as a kind of “replacement” of the antinociceptive system.
SCS is a device - a source of pulses, epidural electrodes and conductors. Purposeful administration of drugs (narcotic analgesics, steroid anti-inflammatory drugs) inhibits the conduction of pain impulses along the C-nerve fibers. Catheterization provides palliative long-term neurochemical therapy for tumor processes.
A study is conducted in the operating room under sterile conditions by a specially trained specialist.
Local anesthesia with simultaneous intravenous administration of a sleeping pill. The dose of anesthesia is small and the examination can be carried out in cases where general anesthesia is contraindicated (serious condition, old age ...).
In the position of the patient lying on his back, a small incision is made in the region of the sacral opening, an endoscope is inserted into the epidural space. The patient may feel weak pressure. Under full control of the X-ray apparatus, the endoscope is pushed towards the area under study. Water is constantly injected to improve visibility.
An epiduroscope has several channels — the main one, optics, and water. The flexible epiduroscope has an outer diameter of 2.8 mm, an angle of view of 120 º up and 170 º down, a working diameter of 1.2 mm. The monitor produces a clear contrast image of everything happening in the spinal canal, you can take photos, document all changes and the course of the operation. Use of a contrast agent is possible.
Adhesions are removed mechanically - with a cold laser or forceps.
Perhaps the introduction of anti-inflammatory substances, stop bleeding, tissue sampling for histological examination.
After the test, rest is prescribed, after 2-3 hours you can get up. The patient may experience pain at the site of the incision for a short time, headache, general weakness and in the legs. The degree of risk of intervention is stipulated on the eve of the operation, taking into account the individual condition of the patient. The patient receives the endoscopy result on a digital disk.
Hospital stay - 3 days. Antibiotics are prescribed on the day of surgery and the next three days to prevent infection. The stitches are removed for 7 days.
Within a few weeks it is necessary to limit physical activity. Other restrictions are associated with the detected disease and are negotiated individually.
1. Back pain
Those or other diseases of the spine, according to statistics, suffer more than 80% of the world's population. In other words, almost every adult person sooner or later faces such an unpleasant and difficult to treat problem as backache. The back of the brain and its frame is the most complex neurobiomechanical apparatus, which evolved in different conditions and adapted to completely different loads and modes than the way of life of modern civilization. Hence, such a high epidemiological prevalence of spinal diseases, a tendency to “rejuvenate” these diseases, a significant proportion of cases of disability or temporary disability. Hence, the regular attention that is given to this problem at once by several related medical sciences - vertebrology, neurophysiology, neurosurgery, orthopedics, etc.
The development of modern medicine is towards a permanent decrease in invasiveness, i.e. priority approaches that provide maximum effect with minimum consequences for healthy tissues and organs. One such approach is endoscopy. The endoscope is a long flexible hose inserted into the visceral (internal) space of the body through natural openings (FGDS, colonoscopy, transvaginal ultrasound) or a special puncture. The development of new generations of endoscopes combines two dominant trends: firstly, miniaturization - devices are becoming more and more thin and mobile, secondly multifunctionality - modern models are equipped with lighting, wide-focus video camera, 3D-navigation sensors, surgical and analytical manipulators, channels for the introduction of anesthetic and medicines.
Epiduroscopy - private, used in vertebrology and neurosurgery, a method of diagnosis, therapy and / or surgery. It consists in the fact that the endoscope is inserted into the epidural space - the lumen between the hard shell of the spinal cord and its hard "cover". Currently, it is the only minimally invasive way of visualizing innumerable problems “from the inside” for the spinal zone.
Epiduroscopy is performed under local anesthesia with the use of general sedative drugs. The pain is insignificant, the rehabilitation period is very short: after 2-4 hours after epiduroscopy, you can get up, and the total time of hospitalization does not exceed several days.