Epiduroscopy requires the placement of a 2mm flexible steerable endoscope through the sacral hiatus in to the epidural space around the dura. This technique avoids open surgery and allows direct access of the disc fragment can be removed. The camera can look sideways and laser fibres may be passed down these endoscopes and thus scarring in the epidural space surgery may be mobilised. We are developing a system that can extract the disc fragment completely. This technique is limited in its ability to address intradiscal and foraminal pain sources. However Mr Akmal is exploring methods of addressing these pain sources from this approach.
The goal of Epiduroscopic spinal surgery is to avoid open surgery and allow disc fragments, scar tissue, fibrosis and other inflammatory tissue to be removed internally from the epidural space. There is no muscle retraction and recovery is very fast. Most patients can return to work within 24 hours after surgery.
Percutaneous epidural adhesiolysis and spinal endoscopic adhesiolysis are interventional pain management techniques used to treat patients with refractory low back pain due to epidural scarring. Standard epidural steroid injections are often ineffective, especially in patients with prior back surgery. Adhesions in the epidural space can prevent the flow of medicine to the target area; lysis of these adhesions can improve the delivery of medication to the affected areas, potentially improving the therapeutic efficacy of the injected medications.
As with all minimally invasive spinal surgery techniques, the surgeon requires a considerable amount of experience in this procedure.
There may be awkward occasions where a large amount of disc material has extruded from its enclosure, wrapping itself around the nerves, causing severe inflammation, pain and even nerve damage. Such disc extrusions may be highly resistant to cortisone injections, or because of the nerve damage and severe pain, require immediate relief of pressure on the nerves. Where previously, the only option is an open discectomy/spinal decompression, we can now thread a small camera through a natural opening in the base of the spine directly to disc extrusion within the spinal canal.
Because we are exploiting the body’s natural openings and channels, we do not need to strip off any muscle or bone to access the spinal canal, save a small cut in the skin.
The camera allows us to directly visualise the nerves and disc fragments, and using endoscopic instruments, carefully separate the nerves from the discs. The disc fragments can then be vaporised either by laser or physically extracted.
Again, because it is a percutaneous technique, it can be performed under supervised sedation as a day case. Leading to faster recovery and rehabilitation.
Specialist in Minimally Invasive Spinal Surgery and Medical Director of The Spine Unit
Specialist in Spinal Surgery and previously worked as a consultant in Norway
I suffered a prolapse on a lower disc. We tried an epidural cortisone injection but the progress was not good enough. I had surgery about 4-5 weeks ago.
During Endoscopic Laser Foraminoplasty the anterior epidural space may be explored by means of flexible steerable endoscopes. Sidefiring and forward firing laser fibres may be passed down these endoscopes and thus anterior epidural space surgery may be treated, scarring resected and protrusions and extrusions and sequestra removed.
Epiduroscopy offers a novel view of this compartment. Minimal adhesions which are not visible in imaging and can promote pain. They can be partially diagnosed and treated by epiduroscopy. There are still marked limitations to epiduroscopy due to technical problems but we are developing this technique at The London Spine Unit with good success rates.
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