EPIDUROSCOPYEPIDUROSCOPY“How I do it!”“How I do it!”

Dr. Gautam Das Dr. Gautam Das MD, FIPPMD, FIPP

Chairman: World Institute of Pain,Chairman: World Institute of Pain,

(Section: India, Iran & Pakistan)(Section: India, Iran & Pakistan)

What is Epiduroscopy?What is Epiduroscopy?

It is the process of visualization of epidural It is the process of visualization of epidural space by fine space by fine fibre optic camera which is fibre optic camera which is inserted percutaneously through the sacral inserted percutaneously through the sacral hiatus into the lower epidural space, and is hiatus into the lower epidural space, and is then guided upwards. then guided upwards.

Burman in 1931 first did the pioneering Burman in 1931 first did the pioneering work for direct visualization of spinal canal.work for direct visualization of spinal canal.

The procedure then evolved over next 60 The procedure then evolved over next 60 years to its present status in 1990s. years to its present status in 1990s.

Indications of EpiduroscopyIndications of Epiduroscopy

Diagnostic:Diagnostic:1.1. Visualization of normal anatomical structures, Visualization of normal anatomical structures,

e.g., dura mater, blood vessels, connective e.g., dura mater, blood vessels, connective tissue, nerves and fatty tissue.tissue, nerves and fatty tissue.

2.2. Visualization of abnormal anatomical Visualization of abnormal anatomical structure, e.g., adhesions, sequesters, structure, e.g., adhesions, sequesters, inflammatory processes, fibrosis and stenotic inflammatory processes, fibrosis and stenotic changes.changes.

3.3. Investigation and analysis of Investigation and analysis of environment, e.g., environment, e.g., biopsy, aspiration etc.biopsy, aspiration etc.

Indications of EpiduroscopyIndications of Epiduroscopy

Therapeutic:Therapeutic:

1.1. Injection of mixtures of drugs in epidural Injection of mixtures of drugs in epidural space at target. space at target.

2.2. Releasing epidural adhesions for the relief Releasing epidural adhesions for the relief of chronic LBP & Sciatica. of chronic LBP & Sciatica.

3.3. Placing catheter systems (epidural, spinal) Placing catheter systems (epidural, spinal)

4.4. Implanting stimulation electrodes (spinal Implanting stimulation electrodes (spinal cord stimulation)cord stimulation)

Contraindications of EpiduroscopyContraindications of Epiduroscopy Psychiatric disease that may potentially interfere with

informed consent and/or perception of pain. Retinal disease. Increased intracranial pressure. Pregnancy. Manifest bowel and bladder dysfunction and sensory

disturbances in S2-S4 area. Potential mitigating legal issues. Congenital anomalies that don't permit safe endoscopy. Cerebrovascular disease. Renal insufficiency. Abnormal coagulation profiles.

Complications of Epiduroscopy:Complications of Epiduroscopy:

Subcutaneous tissue infectionSubcutaneous tissue infection Subdural infection or abscessSubdural infection or abscess Secondary arachnoiditisSecondary arachnoiditis MeningitisMeningitis Persistent headache.Persistent headache. Direct Nerve Root Injury Direct Nerve Root Injury Dural Tears Dural Tears Macular HaemorrhagesMacular Haemorrhages

Complications: Direct Nerve Complications: Direct Nerve Root injuryRoot injury

Direct Nerve Root Injury is possible during Direct Nerve Root Injury is possible during epiduroscopy, but is minimized by having epiduroscopy, but is minimized by having the patient awake and able to verbally the patient awake and able to verbally communicate with the operator. communicate with the operator.

Complications: Complications: Dural Tears Dural Tears

Dural Tears can sometimes occur caused by the Dural Tears can sometimes occur caused by the epiduroscope making a small hole in the dural epiduroscope making a small hole in the dural membrane. This causes a Post Dural Puncture membrane. This causes a Post Dural Puncture (Spinal) Headache, which usually settles in a few (Spinal) Headache, which usually settles in a few days, but may continue to be problematic for days, but may continue to be problematic for several weeks in a minority of cases. several weeks in a minority of cases.

Complications: Complications: Macular Macular Hemorrhages Hemorrhages

Macular Hemorrhages or bleeding in the internal Macular Hemorrhages or bleeding in the internal layers of the eye, can occur when excessive layers of the eye, can occur when excessive volumes of saline flush are used during the volumes of saline flush are used during the procedure. Excessive saline causes an acute rapid procedure. Excessive saline causes an acute rapid rise in intra-cerebral pressure, leading to rise in intra-cerebral pressure, leading to hemorrhage in the eyes. These can be avoided by hemorrhage in the eyes. These can be avoided by limiting the volume of flush used during the limiting the volume of flush used during the procedure.procedure.

Instruments:Instruments:

Introduction of sheath Introduction of sheath

Epiduroscopy Epiduroscopy