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SPINE and NEUROSURGICAL CARE
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What is a spinal endoscopy?
Spinal endoscopy is a procedure in which a small endoscope is passed up through the tailbone into the epidural space. This allows for direct video imaging of the inside of the spinal canal. Spinal endoscopy is also known as epiduroscopy because the endoscope is looking into the epidural space. During a spinal endoscopy, an attempt to remove some of the scar tissue or adhesions from around trapped nerves. The spinal endoscopy may allow medications to better reach the affected areas, especially the spinal nerve roots.
Am I a candidate for spinal endoscopy?
Spinal endoscopy is most often used in patients who have had prior lumbar spine surgery. Most of these patients have MRI or other X-ray evidence of scarring. On some occasions, patients who have not had back surgery but have not responded well to other treatments might also under spinal endoscopy. Spinal endoscopy is typically used only when other, more conservative treatments have not been effective.
What causes scarring?
Scars or adhesions are thought to be commonly caused from bleeding into the epidural space after back surgery. It is probably a natural occurrence following surgical intervention. In the subsequent healing process, some patients react more than others and form scars or adhesions. Sometimes scarring can occur when a disk ruptures and its contents leak out and cause a dramatic inflammatory reaction.
What is the purpose of spinal endoscopy?
The purpose of spinal endoscopy is to confirm the diagnosis of scarring around the nerve roots, to remove or displace some of the scarring and to allow medications to reach affected nerves so that pain and other symptoms may be treated.
How long does a spinal endoscopy take?
A spinal endoscopy can take anywhere from twenty minutes to an hour.
What is actually injected?
The first injection consists of an x-ray contrast dye to visualize the scarred space under x-ray. The next injections consist of saline injected under pressure to hydraulically dissect some of the scar tissue. The final injection, a mixture of local anesthetic, pain medication, steroid medication and sometimes hyaluronidase, is used to treat the exposed nerve roots and further soften the scarring.
Will the spinal endoscopy hurt?
The procedure involves inserting a needle through skin and deeper tissues of the tailbone. Some pain is involved. The skin and deeper tissues are numbed partially with a local anesthetic before inserting the endoscope. During the dissection, many patients feel pressure and some tingling or shooting pain when work is done around the nerve roots. Most patients also receive some intravenous sedation, which can make the procedure easier to tolerate.
Will I be "put out" for a spinal endoscopy?
No. This procedure is done under local anesthesia and light sedation. The amount of sedation given generally depends upon the patient. The patient will usually talk with the physician during the procedure to help assess the proper location of the epiduroscopy and the sensitivity of the nerve roots. The patient is conscious, though some may have enough amnesia that he or she does not remember all parts of the procedure.
How is a spinal endoscopy actually performed?
The patient lies on his stomach and is monitored with EKG, blood pressure cuff and an oxygen-monitoring device. The skin of the lower back and buttocks is cleaned with antiseptic solution. The procedure is performed under sterile conditions. The skin is numbed and a locator needle is passed under x-ray guidance. Once the locator needle is in the caudal canal, a guide wire is passed through the needle and the needle removed. A plastic endoscope introducer sheath is then placed in the caudal canal over the guide wire. This usually feels like a strong heavy pressure. One the introducer sheath is in place, the wire is removed and the endoscope can be passed through the introducer into the canal. At this point, the actual procedure begins. The endoscope is gradually passed up to the level of the scarring and efforts are made to remove some of the scarring using both gentle blunt dissection and hydraulic distension and dissection with saline. At the conclusion of the procedure, medication is injected directly onto the exposed nerve roots. The endoscope is removed and either a small stitch is placed or a pressure dressing is applied.
What should I expect after the spinal endoscopy?
After the spinal endoscopy, the patient may have a tight or achy feeling in the back. The pain in the lower back or legs may be better, although improvement may come over the next several days to weeks. The local anesthetic might cause numbness for a few hours at the injection site. Some bruising may occur.
When can I return to work?
Unless there are complications, the patient can usually return to work the following day or the day after that. The most common feeling the following day is a sore lower back.
How long do the effects of the medications last?
The immediate effect is usually from the local anesthetic and pain medication that is injected. This wears off within the first day or so. The other medications start working in about 3 to 7 days and their effect can last for several days to a several months.
How many times do I need to have this procedure performed?
If the first procedure does not relieve your symptoms in about two weeks, you may be recommended to repeat the procedure once more. If you respond to either the first or second procedure, but still have residual pain, you may be recommended to repeat the procedure up to three times. If there is no obvious improvement after two spinal endoscopies, it is unlikely that a third procedure will provide any relief.
Can I have more than three epiduroscopies?
Most patients do not undergo more than three epiduroscopies. This is because if three procedures have not gotten rid of the pain, it is very unlikely that you will get any further pain relief from repeating the procedure further. Also, more procedures increase the likelihood of side effects from the injected medications.
Will the spinal endoscopy help me?
It is sometimes difficult to predict if the procedure will actually help or not. Generally speaking, the patients who have scarring that has developed within the previous year respond better than those with very old scarring. Some patients have very loose scar that is easy to dissect; others have very dense scar that is almost impossible to do anything with except to take some pictures. Some patients in whom a lot of scar is dissected get a lot of relief; others get very little. Conversely, some patients in whom very little scar is removed get more relief than one might expect. Patients respond very differently in this regard.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects and possibility of complications. The most common side effects are temporary pain, bruising and soreness. Other less common risks include headaches, infection, bleeding, nerve damage, worsening of symptoms, etc. Unusual allergic reactions to the injected medications are also possible, though uncommon.
Who should not have this procedure?
If the patient is allergic to any of the medications to be injected, on a blood thinning medication, has an active infection going on, or has poorly controlled diabetes or heart disease, they should not have the injection or at least consider postponing it if postponing would improve your overall medical condition.
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