Clinical experiences of performing transforaminal balloon adhesiolysis in patients with failed back surgery syndrome: two cases report
A 62-year-old female presented at our hospital complaining of pain in the left buttock and a tingling sensation in the left L5 dermatome. Eight months prior, the patient's left leg pain did improve after undergoing discectomy at the L5-S1 level, but her pain recurred and she still had the tingling sensation in her left leg. Her visual analogue scale (VAS) score for pain was 8 out of 10 and her functional score on the Oswestry Disability Index was 56%. Examination revealed normal motor power and sensation in the lower extremities, and normal pulsation of the dorsalis pedis and tibial arteries. The results of the straight leg raise test of the left leg were negative. She complained of leg pain after walking for 20 meters, and an epidurogram performed after discectomy indicated filling defects in her left side at the L5-S1 level. She was treated with 900 mg/day of gabapentin and a transdermal fentanyl patch (25 µg/hr). We performed percutaneous epidural adhesiolysis at the left L5 level using a Navigation catheter (Epimed International, Gloversville, USA), and, for the next 2 months, the patient demonstrated reduced leg pain (VAS 3 of 10) and increased walking distance (100 meters). Three months after treatment, her symptoms worsened to a degree similar to that before the procedure, so we decided to perform transforaminal balloon adhesiolysis.\nWe obtained approval from our institutional review board and written informed consent from the patient. The patient was placed in the prone position, and a pillow was placed under her abdomen to minimize lumbar lordosis. After sterilizing the insertion site, an 18-gauge R-K needle (Epimed International, Gloversville, USA) was inserted into the left L5 intervertebral foramen. The filling defects in her left side at the L5-S1 level and the positioning of the tip in the anterior epidural space was confirmed by fluoroscopy with the aid of a contrast medium. A 3-Fr Fogarty catheter (Edward Lifescience, Irvine, CA, USA) filled with the contrast medium was introduced into the epidural space of the L5 intervertebral foramen and placed into the medial portion of the fibrotic area. Inflation of the balloon using 0.13 ml of the contrast medium followed by deflation was repeatedly performed throughout the affected region, from the lateral recess to the dural sleeve, with each inflation session lasting less than 5 seconds. If the patient complained of moderate discomfort during inflation of the balloon, the volume of the balloon was reduced. After removing the Fogarty balloon catheter, lysis of fibrosis was confirmed by fluoroscopy with the contrast medium, and 3 ml of a mixture of 0.8% lidocaine, 20 mg triamcinolone, and 1500 IU of hyaluronidase was administered (). There were no complications such as bleeding or severe pain throughout the procedure. The pain in her left leg (VAS 3 of 10) and functional status (40%) improved over the next 4 weeks and the patient reported no left leg pain (VAS 0 of 10), an improved functional status (32%), and increased claudication distance (200 meters) for the next 24 weeks.