A Novel Balloon-Inflatable Catheter for Percutaneous Epidural Adhesiolysis and Decompression
A 75-year-old man presented to our clinic with pain in his back, both thighs, and calves that had persisted for seven months. He had a medical history of well-controlled hypertension and a depressive disorder. When he walked for 10 minutes, his pain was aggravated and accompanied by dysesthesia of the feet, and these symptoms were relieved by bending over. His pain score was 8 on the 11-point Numeric Rating Scale (NRS; 0 = no pain, 10 = worst pain imaginable), and his Oswestry Disability Index (ODI; ranging from 0-100; 0 = no disability) score was 56. No abnormal signs were seen on physical examination. Magnetic resonance imaging (MRI) of his lumbar spine revealed central stenosis at the L4-5 level due to a bulging disc, facet arthrosis, and thickening of the ligamentum flavum (). For two years, he had been treated with oral medication, a fentanyl patch, and five sets of epidural steroid injections. In addition, PEA had been performed three times (once with the NaviCath and twice with the Racz catheter). However, the therapeutic effect of these procedures did not last for more than three weeks, and the duration of pain relief was further shortened after a series of procedures. His functional status was worsening, and his ODI score increased to 72.\nAfter obtaining the patient's written informed consent, we performed PEA and decompression with the inflatable balloon neuroplasty catheter to reduce his pain and extend the duration of pain relief. The patient was placed in the prone position with a pillow under his abdomen to minimize lumbar lordosis. After sterile preparation for the procedure, a 10 G guide needle, which was specially designed to prevent cutting and skiving of the catheter, was inserted into the epidural space through the sacral hiatus. The epidural space was identified by injection of contrast medium (Omnipaque, Nycomed Imaging AS, Oslo, Norway) under fluoroscopy. A caudal epidurogram, checked before planning the PEA, showed a filling defect from the central epidural space at the L5-S1 level to both L5 intervertebral foramina (). We performed mechanical adhesiolysis and decompression of the intervertebral foramina with the inflatable balloon neuroplasty catheter in order of precedence (i.e., central anterior epidural space, lateral recess area, and each intervertebral foramen). PEA and decompression were conducted by gentle side-to-side movement of the catheter with ballooning. The balloon was filled with 0.13 ml of contrast agent, and each ballooning process was limited to 5 seconds () []. The extent of balloon inflation was adjusted by the degree of pain; if moderate to severe pain was noted during balloon inflation, no further attempt at treatment was made for safety reasons. The catheter moved only in the deflated state. After PEA and decompression, the contrast agent in the anterior epidural space spread upward above the level of L5-S1, suggesting that successful adhesiolysis had been achieved (). Before removal of the catheter, 6 ml of a mixture of 1% preservative-free lidocaine, 20 mg triamcinolone, and 1,500 IU hyaluronidase was administered via the catheter. There were no complications during the procedure such as bleeding or damage to the dura. On follow-up monitoring after one month, the patient's pain had been reduced from an NRS of 8 to 4. The patient could walk without pain for more than 20 minutes, and his ODI score had decreased to 36. The effect has been sustained for more than 14 months, and the patient is currently being monitored on follow-up.