ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
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Epiduroscopy or Spinal Endoscopy
Epidural lysis of adhesion and direct deposition of corticosteroids
in the spinal canal are also achieved with a threedimensional
view provided by epiduroscopy or spinal endoscopy.
Buurman (654) in 1931 pioneered direct visualization of
the spinal canal and its contents. In 1985 Blomberg (655)
of Sweden described a method of epiduroscopy. In 1991,
Saberski and Kitahata (656) started using fiberoptic
endoscopes for epiduroscopy. Heavner and colleagues
(657) also reported in 1991 on endoscopic evaluation of
the epidural and subarachnoid spaces in animals and human
cadavers. By 1996, epidural spinal canal endoscopy
was used frequently for delivery of epidural steroid medication
(658-663).
There have been a few retrospective analyses performed
to evaluate the efficiency of spinal endoscopy; however,
there are no randomized, controlled trials (650, 661, 663).
Manchikanti et al (650), in a study evaluating the effectiveness
endoscopic adhesiolysis in post lumbar laminectomy
syndrome in 60 patients, showed that 100% of the
patients reported significant pain relief at one month,
whereas 75% reported significant relief at three months;
40% reported at six months, and 22% reported at 12
months. It was concluded that endoscopic adhesiolysis
with administration of corticosteroids is a safe and possibly
cost-effective technique for relief of chronic intractable
pain failing to respond to other modalities of treatments.
Manchikanti et al (661) studied the value and safety of
epidural endoscopic adhesiolysis. In this retrospective
evaluation on 85 consecutive patients undergoing 112 epidural
endoscopic procedures. They reported significant
pain relief in 100% of the patients, initially decreasing to
94% at one to two months, to 77% at two to three months,
to 52% at three to six months, to 21% at six to twelve
months, and to 7% after 12 months. They concluded that
epidural endoscopy with adhesiolysis is a relatively safe
and possibly cost-effective technique in the management
of chronic refractory low back pain.
Saberski (663), in a retrospective analysis of spinal endoscopy
and laminectomy, reported outcome data in a pilot
study. This pilot study included two groups of patients,
Group I, with 22 patients treated via spinal endoscopy;
and Group II with 13 patients treated via laminectomy.
After spinal canal endoscopy, only 32% of Group I patients
were continued on opioid medication; whereas 92%
of Group II patients were continued on opioid medication
after laminectomy. In addition, 72% from the spinal canal
endoscopy group and only 28% from the laminectomy
group returned to work. He concluded that this study suggested
remarkable differences in outcomes when comparing
patients who underwent spinal canal endoscopy to a
similar population who underwent lumbar laminectomy.
Based on the above, the type and strength of efficacy evidence
analysis places spinal endoscopy into type IV-limited,
which is defined as evidence from well designed non
experimental studies from more than one center or research
group: but this evidence is also complemented by clinical
experience.
Intradiscal Electrothermal Annuloplasty
Primary discogenic pain is a common entity with or without
internal disc disruption and is responsible for chronic
low back pain in approximately 39% of patients (174).
This is in contrast to disc herniation, which is seen in a
small number of patients ranging from 4% to 6% (173,
222, 223, 255-260). Intradiscal electrothermal
annuloplasty (IDET) is a minimally invasive treatment for
chronic discogenic low back pain that is an alternative to
interbody fusion surgery (664). Application of thermal
energy to the disc alters collagen structure and may perform
a functional deafferentation on the disc. The technique
of intradiscal electrothermal annuloplasty utilizes this
principle to treat patients with intractable low back pain.
Multiple investigators have studied the effectiveness of
intradiscal thermal annuloplasty (664-674). However, only
one published study included a control group (669),
whereas another study incorporated results of a multicenter
cohort study (670) and the remaining five studies were
descriptive in nature (664, 666-668, 674). Apart from
these, there were presentations at multiple meetings, some
of which are listed here; however, it appears many of them
included the same patients but were presented repeatedly.
Karasek and Bogduk (669) studied 53 patients with back
pain determined by CT discography to be due to internal
disc disruption. The outcomes of 35 patients treated with
IDET were compared with those of a convenience sample
of 17 patients treated with a physical rehabilitation program,
by using VAS scores, use of analgesics, and return
to work as measures. They reported that, at 3 months,
only one control patient obtained any significant degree of
relief of pain, compared with 23 in the index group. Re-
Pain Physician Vol. 4, No. 1, 2001