Recommendations for Epiduroscopy

Abstract

The following recommendations are based on our years of clinical experience with epiduroscopy:

• To guarantee an efficient epiduroscopic procedure and ensure patient safety, the pain therapist performing the invasive intervention must be experienced in using the examination technique and have a well-founded theoretical background and a certain amount of manual dexterity.

• The procedure requires an epiduroscope or epiduroscopic equipment that meets the requirements for epiduroscopy.

• In addition to precise pain diagnostics and professional technical management, the success of an epiduroscopically assisted invasive pain management intervention depends on the selection of suitable patients.

• Basic prerequisites for performing the invasive epiduroscopic procedure are a thorough clinical and functional examination and imaging diagnostics.

• For quality assurance purposes, the basic information included in the informed consent discussion with the patient regarding epidural diagnostics and pain management must be documented.

• Regardless of the hospital structure, epiduroscopy should be performed only on cooperative patients with adequate continuous monitoring of vital signs (anesthesiological stand-by) in a suitable operating room.

• The anatomical architecture of the vertebral canal and the vulnerability of the spinal structures, especially in the cervical and thoracic segments, require epiduroscopy to be performed in a precise, standardized manner.

• We recommend that prior to each epiduroscopy, epidurography be performed with contrast media either via the needle introduced with a sacral approach or via the introducer.

• The use of a flexible, steerable epiduroscope requires a sacral approach to the epidural space.

• The sacral approach technique calls for the patient to be placed in a prone position on the operating table.

• Epiduroscopy should be performed under local anesthesia or analgosedation.

• Once the sacral hiatus has been punctured, an aspiration test should be performed. If it is negative, a guidewire should be introduced into the sacral hiatus via the puncture needle over a short distance using the Seldinger technique.

• Using a C-arm can be helpful for identifying the guidewire and locating the position and level of the epiduroscope in the vertebral canal.

• The dilatator and sheath are advanced a short distance in the sacral canal via the introduced guidewire.

• Continuous epidural irrigation with physiological saline solution at body temperature adapted as needed is absolutely mandatory for epiduroscopy. The aspects pressure-infusion volume limits, and if necessary, epidural pressure monitoring and drainage of the epidural irrigation fluid, must be taken into account.

• The epiduroscope may only be navigated if good vision (saline irrigation) is ensured. Interventions should be carried out only if endoscopic vision is good.

• For safety reasons, a laser should be on hand if coagulation is needed to stop bleeding.

• Prior to the procedure, instruments to be introduced into the working channel of the endoscope must be checked to ensure they are in good operating condition.

• The epiduroscopy must be recorded in a protocol. Endoscopic imaging should be documented on a video film, a memory stick, a CD-ROM or DVD.

• With suitable epiduroscopic equipment, ensuring optimal vision and by gaining experience with the epiduroscopic technique, complications can be kept to a minimum.

• Epiduroscopy is superior to imaging procedures, failed conservative treatment and open surgical techniques, especially with regard to the high rate of patient satisfaction and the remarkably low number of complications.