Percutaneous Epidural Neuroplasty

Overview

Back pain affects millions of people and is one of the leading causes of patients seeking medical assistance. Back pain affects up to 80% of people at some point in their life, with the frequency of low back pain growing by 2-5 percent each year. Furthermore, more than 80% of afflicted individuals report recurring episodes.

Lumbar disc herniation (LDH) is a common cause of lumbar nerve root compression and accounts for 4% of all occurrences of low back pain. Compression of the lumbar spinal root is also known to occur as a result of spinal canal stenosis and post-laminectomy syndrome.

It is important to consider the involvement of epidural fibrosis as a source of these diseases, even after apparently successful lumbar surgery. Before considering a forthcoming operation, when conservative therapy and epidural steroid injections have failed, percutaneous epidural Neuroplasty has shown promising outcomes in the management of severe pain syndromes. Transforaminal percutaneous epidural Neuroplasty might be a suitable choice for the successful treatment of unilateral lumbar radiculopathy linked or not with axial pain, especially when dealing with recurrent lumbar radicular discomfort started on high lumbar levels.

Conservative therapy with various epidural injection procedures may be beneficial for people with low back pain who do not have neurological problems. 

What is Percutaneous epidural Neuroplasty (PEN)?

Percutaneous Epidural Neuroplasty (PEN), also known as percutaneous epidural neurolysis, percutaneous epidural adhesiolysis, or the Racz procedure, is a minimally invasive spine intervention that involves inserting a catheter directly into the herniated disc or scar tissue that is compromising the nerve root. PEN is used for epidural scar lysis, tailored medication distribution, ventral drug instillation, and neural decompression. A catheter is advanced to the location of adhesion, which is shown by an epidurogram, and adhesiolysis is done.

The adhesiolysis approach includes mechanical lysis with the catheter, chemical lysis using hyaluronidase, and hydrostatic lysis with saline and contrast media. PEN has been used to treat persistent pain caused by post-surgery syndrome, in which scar tissue has developed in the epidural space.

It has been used to treat people suffering from refractory persistent low back pain or failed back surgery syndrome. The technique may also be useful in treating spinal stenosis and radicular pain caused by a herniated lumbar disc, according to evidence.

The purpose of PEN is to reduce abnormal adhesions, which might physically obstruct direct drug administration around nerves, and to administer medication to the intended spot. Thus, in patients with persistent lower back or leg discomfort caused by LDH, this surgery may result in pain reduction and functional improvement.

If a nerve is being crushed by scar tissue, you may experience pain ranging from "moderate" to "searing," tingling, or numbness.

A fluoroscopically guided catheter is inserted into the spinal scar tissue during a Neuroplasty, which is normally performed on the same day. Following that, medicine is injected through the catheter to open up the scarring, relieving pressure on the nerve.

The injectable treatment consists of an enzyme combined with saline solution, a steroid, and a local anesthetic. The enzyme-saline combination aids in the distribution of the steroid and anesthetic into the afflicted tissue cells. The steroid reduces related inflammation, while the local anesthetic relieves acute pain.

What Does Neuroplasty Treat?

Neuroplasty was first used to relieve back discomfort after spinal surgery. Its new indications are as follows:

• Spinal stenosis
• Spinal compression fractures
• Inflamed or pinched nerves
• Degenerated, bulging, or herniated discs
• Facet joint syndrome is caused by degenerative changes in the spine
• Epidural inflammation or fibrosis
• Chronic pain following neck or back surgery
• Refractory back pain

Causes and diagnosis of adhesions

Except for direct compression of nerve structures owing to acute disc herniation or fractures of peripheral structures due to accidents, activation of chemical mediators is a key source of pain in most cases of spinal pain associated with degenerative changes. It is fairly rare for there to be a disparity between real imaging results and symptoms, and it is not uncommon for the pain to remain unresolved even after surgically eliminating the physical pressure considered to be the source of the discomfort.

It is unclear whether intravertebral inflammation is the result of degenerative changes or herniation of the intervertebral disc, or whether the preceding inflammation is the result of degenerative changes or herniation of the intervertebral disc. However, it is apparent that degenerative changes occur as a result of multiple variables, including age, continuous weight bearing, and individual genetic predisposition, and that degenerative changes affect various intravertebral structures (particularly intervertebral disc degeneration). An endogenous inflammatory reaction and an external inflammatory response via blood vessels produce inflammation of neurons and adjacent tissues.

Because the intervertebral disc is nearby and blood vessels and nerves have grown, the anterior epidural space (ventral epidural space) is the most susceptible location for inflammation. When there is inflammation, there is redness, hyperemia, and edema in the nerves and surrounding tissues, as well as sensitization of pain-related nerves, which causes discomfort. Pain can be generated by either direct nerve stimulation by different inflammatory mediators or by pulling or squeezing enlarged inflammatory nerve structures in response to bodily movements.

Adhesions caused by tissue fibrosis are the final outcome of inflammation. Severe iatrogenic adhesions are most prevalent in epidural intrathecal hemorrhage associated with spinal surgery or during the healing phase of tissue injury induced by surgery, in general. Adhesions form as a result of an inflammatory reaction and deposition of fibrotic cells by the nucleus pulposus spilled into the epidural space owing to disc herniation or leakage of the nucleus pulposus component in combination with degenerative alterations.

Adhesion has a varied propensity factor depending on where it occurs. Adhesions are frequent in the anterior epidural space owing to disc lesions such as disc herniation, and in the posterior epidural area due to disc lesions such as disc herniation. Adhesions produced by lateral disc herniation, facet overgrowth, and neuroforaminal stenosis are frequent in the lateral epidural space. As a result, it is critical to position the catheter in the right lesion on the front, back, and outside of the epidural area in order to effectively treat epidural adhesions with epidural Neuroplasty.

The specific lesion is established using laboratory tests, radiographic examination, electromyography or nerve conduction testing, and other laboratory findings after determining the troublesome vertebral segment from the patient's clinical symptoms, signs, and medical history. Computed tomography (CT) or magnetic resonance imaging (MRI) is particularly useful in identifying epidural fibrosis and adhesions.

Adhesions that do not clearly represent epidural fibrosis are difficult to detect with CT or MRI. Because epidural endoscopy penetrates the epidural space directly and visually examines the lesion's condition of inflammation, fibrosis, and adhesions, it may precisely find and diagnose the lesion without the constraints of CT or MRI. Furthermore, when employing an epidural endoscope, the degree of adhesion detachment may be immediately monitored in real-time, and the adhesion detachment can be physically accomplished.

Who’s a Candidate for Neuroplasty?

If you are unable to undergo surgery or just do not want to have extensive spine surgery, you may wish to investigate Neuroplasty.

Generally, Neuroplasty should be evaluated prior to major surgery, and anyone who has not responded to conservative therapy for back and/or extremities pain would be a candidate. Medication or physical therapy are examples of conservative therapies.

Neuroplasty can also be a very successful therapy for individuals who have nerve function alterations as a result of disc herniation-related inflammation and irritation. Furthermore, it may help individuals who are experiencing nerve discomfort as a result of epidural adhesions that form after spine surgery.

Pre-examination for epidural Neuroplasty

A blood coagulation test (PT, aPTT, BT, platelet count) must be conducted to precisely identify the patient's condition via questionnaire, physical examination, and radiological examination, as well as to limit the chance of epidural bleeding during the treatment. Check for and prepare for any underlying diseases that could be impacted by the surgery. Patients with liver illness, in particular, must have their bleeding propensity checked with a blood coagulation test, and if there is a bleeding tendency, it must be corrected before the treatment is performed.

Furthermore, because the process causes hemodynamic changes, if you have cardiovascular disease, the present cardiovascular system is precisely detected, and the patient's state is continuously monitored during or after the surgery for a set length of time. Furthermore, if you are taking anticoagulants, you must discontinue them ahead of time and execute the treatment while keeping the drug's half-life in mind. In patients with blood coagulation problems, infections, high intracranial pressure, central nervous system space occupancy disruption, or cerebrovascular disease, epidural adhesion removal is not recommended.

Surgical Procedure

Percutaneous epidural Neuroplasty (PEN) has the potential to be an effective therapeutic approach for chronic low back and/or radicular pain that has not responded to conventional conservative therapies. The action of PEN is believed to be due to medication administration targeting pathology in the spinal epidural space. The method entails eliminating obstacles that prevent drugs from reaching target areas, such as epidural fibrosis. As a result, the purpose of epidural adhesion lysis is to breach mechanical barriers that prevent injected material from spreading efficiently into regions of disease in the epidural space via the catheter.

It appears that an additional lavage action, lowering the local concentration of proinflammatory chemicals, is conceivable. Although true mechanical lysis of postsurgical adhesions or scar tissues by PEN appears to be impossible due to experimental biomechanical studies, mild to moderate adhesions may be broken up by a PEN catheter, allowing medications to reach the target site via the new channel created by the catheter.

It appears that an additional lavage action, lowering the local concentration of proinflammatory chemicals, is conceivable. Although true mechanical lysis of postsurgical adhesions or scar tissues by PEN appears to be impossible due to experimental biomechanical studies, mild to moderate adhesions may be broken up by a PEN catheter, allowing medications to reach the target site via the new channel created by the catheter.

After epidurography and confirmation of proper needle location, a Racz catheter is pushed via the RK needle to the region of the filling deficiency or disease as confirmed by MRI. Adhesiolysis was next done, and the catheter was finally positioned in the lateral and ventral epidural areas.

At least 3 mL of contrast agent was administered once the catheter was properly positioned. If no subarachnoid, intravascular, or other extra-epidural filling was noted, and if sufficient filling in the target areas was observed, 6 mL of 0.2 percent preservative-free ropivacaine containing 1500 units of hyaluronidase and 4 mL of betamethasone sodium phosphate was administered. An hour after the surgery, 6 mL of 8% sodium chloride solution was administered over 30 minutes in the recovery area while being monitored.

When all parameters were found to be satisfactory, the intravenous line and epidural catheter were withdrawn, and the patient was discharged. The initial follow-up appointment was set for two weeks after the treatment. During these two weeks, all patients got similar dosages of nonsteroidal anti-inflammatory medications and muscle relaxants to alleviate procedure-related pain. 

Intraoperative patient monitoring

The technique is usually conducted under local anesthetic. However, even with a moderate dose of anxiolytic medicines, some patients, particularly the elderly, may have excessive sedation or respiratory depression, and in some circumstances, acute agitation. If this occurs, discovery may be delayed, thus anti-anxiety medications should be avoided as much as possible.

Patient monitoring for percutaneous oxygen saturation, blood pressure, and pulse must be performed at a minimum, and ECG monitoring must be performed for patients with pre-existing cardiovascular disease or those who are expected to undergo rapid changes in their cardiovascular system as a result of the procedure. Medical staff, equipment, and pharmaceuticals capable of conducting emergency resuscitation should be available in case of cardiovascular collapse, and general anesthetic equipment should be available in case of total spinal anesthesia, which may occur if drugs are accidentally delivered intrathecally. 

How Long Does Neuroplasty Recovery Take?

Unlike major spine surgery, you will be able to return home the same day as the treatment and resume work and/or your usual routine the next day after Neuroplasty.

Typically, back pain alleviation will either go immediately or diminish over a few weeks following the treatment. As the anesthetic wears off, you may have some achiness. Relief may not come immediately in some people but may arrive later when the patient performs the neural flossing.

Neural flossing, often known as "nerve flossing," comprises activities meant to mobilize nerves and reduce discomfort caused by compressed or inflamed nerves. The exercises aid in an increasing range of motion, reducing discomfort and preventing nerve injury. The exercises can also help with flexibility and strength.

Mechanically stretching the nerve root using neural flossing activities Should be repeated two to three times per day for several months to maximize the hydrodynamic impact of the injection and avoid entrapment recurrence. Medication may be recommended after the treatment to reduce and prevent nerve irritation.

In general, Neuroplasty should be performed prior to more invasive treatments such as surgery or spinal cord or peripheral nerve stimulation. According to some studies, pain alleviation with Neuroplasty might endure for two years or longer. Overall, Neuroplasty is a tool in the toolbox of a spine expert, but it may be the ideal tool for the job for you.

Complications of epidural Neuroplasty

Percutaneous epidural Neuroplasty (lysis of epidural adhesions, injection of hypertonic saline epidurally) is an interventional method used to treat pain caused by spinal problems. Epidural Neuroplasty has been shown to be helpful in removing fibrous tissue from the epidural space for a variety of causes; nevertheless, the treatment is not without risk of catastrophic consequences.

Neuroplasty was only explored in individuals who had tried and failed conservative therapies for low back and cervical pain. Among the recognized complications are:

• Bending of the tip of the introducer needle,
• Shearing/tearing of the catheter, 
• Misplacement of the catheter,
• Inadvertent blockage of the catheter or catheter tip, 
• Migration of the catheter,
• Hypotension, 
• Respiratory depression,
• Urinary and/or fecal incontinence,
• Urinary hesitancy, 
• Sexual dysfunction,
• Paresthesia,
• Epidural abscess, and
• Meningitis.

One of the most serious consequences of bacterial meningitis is cerebral vasculopathy. Large arteries near the base of the brain, medium arteries, tiny pial and intraparenchymal arteries, and sinus and cortical veins may be impacted.

Changes in cerebral blood flow in major capillaries near the base of the brain have previously been demonstrated using ultrasonography in patients with bacterial meningitis. Streptococcus pneumonia, Neisseria meningitides, Haemophilus influenza, Staphylococcus aureus, and other infections have all been linked to brain infarction. However, the precise process of vascular occlusion is still unknown.

Most ischemic lesions are most likely explained by distant vasculitis and decreased cerebral blood supply. The occlusion of the major cerebral arteries has been linked to both vasospasm and thrombosis. Ischemic lesions usually damage the cerebral cortex, but the cerebellum is seldom affected. Bacterial meningitis with cerebrovascular consequences has a dismal prognosis. Brain ischemia may result in a bad outcome due to direct focal cerebral injury and elevated intracranial pressure caused by cytotoxic edema.

Conclusion 

Chronic low back pain, whether or not linked with radicular pain, is a severe health concern that affects the majority of the population at some point in their lives. The social, labor, and psychological consequences are significant, particularly among adults of productive age. PEN has been demonstrated to have high clinical effectiveness when used to treat persistent back pain that has been resistant to other conservative treatment techniques. Indeed, the surgery has outperformed not just physical therapy but also caudal epidural steroid injections in the treatment of persistent lower back and leg pain.

The amount of spinal stenosis has no influence on the efficacy of Neuroplasty. Neuroplasty can be done in the lumbar, thoracic, and cervical spines, as well as via caudal, transforaminal, and interlaminar routes. Postoperative home exercises are an essential component of the process. Patients with chronic back and/or extremities pain should be offered Neuroplasty before surgery.