Transforaminal Epiduroscopy in Patients with Failed Back Surgery Syndrome.

BACKGROUND: Epiduroscopy is a useful diagnostic and therapeutic tool for managing failed back surgery syndrome (FBSS). The conventional approach is via either the sacral hiatus or the interlaminar. Major causes of FBSS include epidural fibrosis, disc herniation, and stenosis. When these problems are located at the intervertebral foramen level, it can be difficult to reach the lateral recess and the foramen with the epiduroscope. Transforaminal epiduroscopy could be a useful alternative approach in patients with FBSS located at the foraminal level. OBJECTIVE: We present a new procedure for lumbar epiduroscopy via a transforaminal approach and its application in patients with FBSS. The technique is described and long-term results are reported. STUDY DESIGN: This study used a single-arm prospective observational design. SETTING: The research took place at the University Hospital in Spain. METHODS: Patients with FBSS suffering severe chronic radicular pain (Numeric Rating Scale [NRS-11] > 7) who had not responded to other treatments were included. Selective root stimulation during a pulsed radiofrequency procedure confirmed the origin of pain by means of an exact reproduction of typical pain. Transforaminal epiduroscopy was performed at the affected level. The severity of fibrosis observed was recorded. The NRS-11 score was reevaluated at 1, 6, and 12 months after the procedure. Any complications related to the treatment were recorded. RESULTS: Twenty-four patients were included. The mean number of back surgeries was 1.66 (range, 1-5). The basal NRS-11 score was 7.83 (0.14); at 1 month, 3.66 (0.38) (P < 0.001); at 6 months, 4.46 (0.48) (P < 0.01); and at 1 year after treatment, 4.17 (0.51) (P < 0.01). Most patients (54%; 95% CI, 34%-74%) obtained > 50% pain reduction on the NRS-11, maintained during a 1-year follow-up period. No major complications were registered. LIMITATIONS: The research was limited by the lack of a control group. CONCLUSIONS: We have described a new procedure for epiduroscopy via the transforaminal approach. It is a useful and safe approach to managing FBSS at the foraminal level and shows better long-term results than other endoscopic procedures. KEY WORDS: Epidural, epiduroscopy, chronic pain, spinal cord, back surgery.

Neuralgia del pudendo: algoritmo de manejo diagnóstico y terapéutico desde una unidad del dolor / Pudendal neuralgia: algorithm for diagnostic and therapeutic management in a pain unit

Objetivo. Presentar un algoritmo de manejo del dolor perineal crónico severo con sospecha de neuralgia del trigémino. Casos. Se presentan 3 casos clínicos con etiología y evolución clínica diversa. Discusión. Análisis de los criterios diagnósticos y tratamientos vigentes. Evaluación de los casos a la luz del algoritmo de diagnóstico y tratamiento propuesto (AU)

Objective. To describe a new algorithm for the management of severe chronic perineal pain/pudendal neuralgia. Cases. We report 3 clinical cases with different etiologies and outcomes. Discussion. We analyze the diagnostic criteria and treatments and evaluate the rational management of these patients according to the algorithm (AU)

One-year results of an algorithmic approach to managing failed back surgery syndrome.

BACKGROUND: Failed back surgery syndrome (FBSS) is a major clinical problem. Different etiologies with different incidence rates have been proposed. There are currently no standards regarding the management of these patients. Epiduroscopy is an endoscopic technique that may play a role in the management of FBSS. OBJECTIVE: To evaluate an algorithm for management of severe FBSS including epiduroscopy as a diagnostic and therapeutic tool. METHODS: A total of 133 patients with severe symptoms of FBSS (visual analogue scale score ≥7) and no response to pharmacological treatment and physical therapy were included. A six-step management algorithm was applied. Data, including patient demographics, pain and surgical procedure, were analyzed. In all cases, one or more objective causes of pain were established. Treatment success was defined as ≥50% long-term pain relief maintained during the first year of follow-up. Final allocation of patients was registered: good outcome with conservative treatment, surgical re-intervention and palliative treatment with implantable devices. RESULTS: Of 122 patients enrolled, 59.84% underwent instrumented surgery and 40.16% a noninstrumented procedure. Most (64.75%) experienced significant pain relief with conventional pain clinic treatments; 15.57% required surgical treatment. Palliative spinal cord stimulation and spinal analgesia were applied in 9.84% and 2.46% of the cases, respectively. The most common diagnosis was epidural fibrosis, followed by disc herniation, global or lateral stenosis, and foraminal stenosis. CONCLUSIONS: A new six-step ladder approach to severe FBSS management that includes epiduroscopy was analyzed. Etiologies are accurately described and a useful role of epiduroscopy was confirmed.

Anesthesia for pediatric gastroscopy: a study comparing the ProSeal laryngeal mask airway with nasal cannulae.

BACKGROUND: We tested the hypothesis that pediatric gastroscopy is more successful using the ProSeal laryngeal mask airway with the drain tube as a conduit to the stomach (ProSeal LMA group) than using nasal cannulae with conventional oral access to the stomach (NC group). METHODS: Sixty children were consecutively and randomly allocated into each group. Patients breathed spontaneously and were given sevoflurane/air/oxygen mixture with propofol 1 mg.kg-1 boluses, as required. Anesthesia was provided by experienced users of both techniques. The following data were collected by an unblinded observer: operation and anesthesia times; cardiorespiratory data; adverse events; and recovery scores. In addition, the surgeon scored the ease of performing the procedure. RESULTS: The mean (range) age and weight was 74 (24-144) months and 26 (10-61) kg. Operation (15 min vs 24 min, P<0.0001) and anesthesia (22 min vs 37 min, P<0.0001) times were shorter in the ProSeal LMA group, but propofol bolus requirements per unit time were similar. Oxygen saturation was higher in the ProSeal LMA group (100% vs 94%, P<0.0006), but other cardiorespiratory variables were similar. There were no differences in the ease of performing the procedure. Hypoxia occurred more frequently in the NC group (20% vs 0%). Recovery scores were similar. CONCLUSIONS: We conclude that pediatric gastroscopy is quicker and has fewer airway complications when performed through the ProSeal LMA than using nasal cannulae and a conventional approach by experienced users.