Southern Pain Specialists
Oh, your aching back
New procedure relieves many with chronic back pain
Lower back pain. Just the words can make you cringe.
That's because you either suffer from back pain or have friends and relatives who do. Maybe you've had to take care of them.
Back pain, often unabating, restricts movement. It makes sitting difficult. It prevents a good night's sleep. It makes people quit their jobs. It detracts from the quality of life. In short, it can make you miserable.
Many of those who experience such pain have what is called failed back syndrome. They've had surgery to remove a ruptured disc. Maybe they've had spinal fusion. They often feel better after months of recovery - but then the pain returns, sometimes more intense than before.
For many post-surgery patients, nothing seems to help. Not physical therapy, not pain medication, not epidural injections.
Some pain specialists are now turning to a procedure first described 72 years ago called epidural endoscopy, also called epiduroscopy. It was a crude way of looking into the spine in the 1930s and for decades afterward, but has evolved into a sophisticated yet simple procedure that utilizes tiny, flexible scopes with a camera and flashlight and modern radiological imaging.
"This is a minimally invasive form of surgery that enables us to bring pain relief when all other conservative treatments have failed," said Dr. Scott Berger, an anesthesiologist and medical director of the Delray (Fla.) Outpatient Surgery and Laser Center.
An experienced physician can do the procedure in 10 minutes in an operating room or surgical suite. A small incision is made at the base of the tailbone, and the area is numbed with Novocain. A needle is then inserted to show the pathway on a radiograph for a tiny, video-guided catheter, which is gently pushed up the back in a tiny space called the caudal canal. The scope is then "steered" into the epidural space, where valuable diagnostic information can be obtained in addition to scar tissue removal.
As the catheter advances, a color, fiber-optic camera at its tip captures a real-time image of the spinal canal's cavelike structure. A television monitor shows fat deposits as the camera moves forward. Then scar tissue, sometimes forming a formidable blockade to the device, appears on the screen. The assault begins.
"You use the catheter like a mini-battering ram," Berger said. Clearing a tunnel in the scar tissue can relieve pressure on nerve roots and reduce the pain. But that's only a first step.
As the camera advances, the surgeon can see inflamed nerves and areas where nerve roots have become encapsulated by scar tissue. The patient, who is awake but sedated, can tell the doctor when he feels pain. The doctor, in turn, can spray medication directly onto the inflamed and painful sites.
Berger, for example, uses a three-drug cocktail to stop the pain - lidocaine, which provides immediate relief for a short time; depomedrol, a steroid for longer relief, and hyaluronidase, an enzyme that might dissolve scar tissue. Once he administers the medication, he removes the scope and the catheter and closes the incision with a stitch or two.
Ronald Selinger, 70, of Delray Beach, Fla., said the procedure made him feel like a new person after more than two years of intense pain following back surgery.
"I was moving merchandise at a department store when I bent over and heard a rip. I had shattered a disc. They operated on me in December 2000, cleaned out the area, but left me with permanent damage," Selinger said. "The pain got to be immense. They gave me shots, electrical stimulation, all kinds of medicines - nothing worked."
Berger performed spinal endoscopy on him a few months ago, and he has been pain-free since.
"The next day, I was moving better than I did in years," Selinger said. "I got so carried away recently, I started walking fast like in the old days. There was no pain. It was amazing."
While epidural endoscopy can help some people who have never undergone back surgery, most candidates have the so-called failed back syndrome following an operation, said Dr. Kenneth Varley of Birmingham, Ala. He's among the most experienced doctors in performing the procedure - 378 cases, every one of them on videotape.
"Scar tissue is a huge problem following back surgery," Varley said. "It causes pain in a number of ways - by restricting epidural veins and encircling nerve roots and constricting over time. It also pulls on the nerve roots, inhibiting their ability to slide naturally. And it blocks steroidal solutions from getting to the precise site of the pain."
Using a scope, he said, enables doctors to spray pain-relieving medication directly onto inflamed nerves or close enough for the drugs to reach troubled areas and relieve pain.
Varley said he has achieved significant back pain relief in 75 percent of patients who have had one surgery, but only 25 percent success at the other end of the spectrum - patients who have had two or more surgeries at least two years before he sees them.
"The scar tissue can build up so severely that it's impossible to penetrate and get to the inflammation with just the scope," he said. "Ten-year-old scar tissue is like porcelain."
Relief can last anywhere from six months to several years. In some patients, the pain cycle is broken, and they don't experience a relapse, experts say.
Doctors who perform spinal endoscopy can receive some money from Medicare and managed-care companies. But these insurers will not pay for a procedure that uses the more sophisticated devices. So entering the spinal canal, in a way, remains somewhat crude. That frustrates Varley and Berger.
During one recent epidural endoscopy, Berger tried for almost 10 minutes to penetrate scar tissue - and reach the inflamed nerves - in a patient who had undergone two back operations. He could not and retreated.
"I could have kept trying to get through, but you don't want to be in the canal for any longer than I was for safety's sake," Berger said. "I always remember the most important thing they taught us in medical school: 'Do no harm.'"'
Taken from GrandForks.com on 5-11-03
By Glenn Singer, South Florida Sun-Sentinel