May 16, 2016

laser epiduroscopy for low back pain

I continue to be very interested in laser epiduroscopy. Epiduroscopy is a procedure in which we put a fiberoptic scope into the epidural space. It is approved for visualization of the epidural space and for putting medications into the epidural space.
I believe that the greatest benefit of epiduroscopy, particularly laser epiduroscopy, is in the treatment of low back pain. Low back pain has many causes, including the musculoskeletal sprain and strain, lumbar facet disease and sacroiliac joint dysfunction. Another cause is disease within the lumbar intervertebral disc. Intervertebral disc disease occurs when the outer part of the disc, the annulus, becomes injured. Think of a tear in the inner part of a Michelin tire. The body tries to heal this tear and in the process produces a variety of substances which happen to have a side effect of irritating nerves which are growing into the injured area. These irritated nerves can cause low back pain.
We have tried many ways of treating low back pain. The best studied apply heat across the annulus to so that the nerves no longer hurt, as the heat has destroyed their ability to produce pain. The best of these technologies, biacuplasty, gives about40% of people 40% relief.
There are many other approaches to treating intradiscal disorder, including injecting stem cells, ozone and methylene blue. These treatments may work, but they need to be subjected to high quality studies comparing them to either placebo treatment or an active alternative treatment before we can answer whether they do work.
Another treatment for intradiscal disorder is fusion or disc replacement. There are many, many approaches to lumbar fusion, from the back, the front, the back and the front and the side. Many different means of fusing the disc have been developed. The major problem with fusion is that it does not work well. For some people, it is the best thing they have done. For others, fusion surgery can mark the end of their ability to function. The rule of thumb is that one-third of people get better after fusion, one-third have no change and one-third are worse. Fusion is expensive, has a long recovery time and an uncertain outcome. I recently read a deposition in which the spine surgeon said he made $1500 an hour operating. We need a technique which benefits the patient.
I believe that the reason why the various efforts to treat intradiscal disorder have been frustrating is because they do not treat scarring in the epidural space, between the back part of the vertebral bodies and the front of the dural sac which contains the cerebral spinal cord and the spinal cord and/or inflammation of the membranes in the space where the nerve roots exit the spinal column. It is easy to imagine how this scarring and inflamed tissue can cause pain.
Laser epiduroscopy is uniquely situated to treat both the pain from the intradiscal disorder and from the epidural scarring and inflamed tissue.
We can easily and safely use the laser to heat the annulus, treating the inflamed nerves there.
We can use the epiduroscope to break up the anterior and foraminal scarring and inflammation.
Some people think you cannot lyse, or break up, scars because if you lyse them, they simply return. Others think you cannot lyse them because the scarring is too dense. These arguments do not appreciate that there are two types of epidural scarring. One is the very dense scarring that occurs in the part of the epidural space after surgery. These scars cannot be broken up. The other is the fibrous scarring that occurs in the front of the epidural space, which connects the dura with the back of the vertebral body. These scars are filamentous and can easily be broken up mechanically with the epiduroscope. Also, the inflammation of the peridural membrane in the foramen can be broken up mechanically with the epiduroscope.
Some have used a laser to try to break up these scars. Use of a laser for this purpose is unnecessary and dangerous.
The epiduroscope is uniquely positioned to offer a better, faster, cheaper means of treating discogenic low back pain. We are in the process of a randomized controlled trial to prove this claim. While waiting for the results of the trial, I look forward to being able to offer this procedure to patients outside of the trial.