The disease that most causes loss of employment: Low back pain
Low back pain is among the most important health problems that significantly affects a person's social life and reduces the quality of life. If a herniated disc is diagnosed early and appropriate treatment is applied, full recovery can be achieved by preventing it from becoming chronic or causing irreversible damage. Let's talk about the treatment of herniated disc (lumbar disc herniation), which is the most troubling disease that most often accompanies low back pain after temporary cramps and stiffness, with epiduroscopy, which is a closed technique: What is epiduroscopy? Epiduroscopy is a diagnosis and treatment method developed in the early 1990s. The procedure can be performed with technical equipment consisting of an endoscopy monitor, a fiber optic camera connected to it, and an epiduroscopy catheter set.
Where is the epidural area (distance)? At the back of the spine, there is a canal containing the spinal cord and nerves extending from top to bottom. The spinal cord and nerves in this canal are surrounded by a strong membrane called dura. The outer part of this strong membrane is called the epidural area. With epiduroscopy, the nerve roots in the epidural distance, whether there is a problem around the fatty tissue surrounding these roots, and adhesions around the nerve roots can be seen.
Which patients are suitable for epiduroscopy? Epiduroscopy can be performed on patients who do not require microsurgical surgery and on patients whose daily activities such as walking and sitting are restricted and who complain of pain. The method was developed mostly for patients who do not benefit from physical therapy practices and drug treatments. In addition, it can be applied successfully in patients with common and especially small and medium-sized herniated discs at more than one distance in the lumbar region.
What is the role of epiduroscopy in low back pain? Epiduroscopy has two main purposes: to identify and treat the problem. Relieving chronic sciatica pain (pain radiating from the hip to the leg) is based on the principle of relieving adhesions in the epidural area. Adhesions can occur around the lower lumbar nerve roots after decompressive surgery for disc disease (herniated disc, lumbar disc surgery and stenosis surgery), or after inflammatory sciatica without surgery. They get older. Epidural adhesion can usually be detected with an advanced MRI scan using intravenous gadolinium. Uneven distribution of contrast can be seen on the epidurogram. By injecting depo-steroid and local anesthetic mixtures around the edematous nerve roots through the epiduroscopy catheter, pain mediators that cause inflammation are removed from around the nerve root, and if appropriate equipment is available, protrusion-extrusion hernias can be intervened mechanically or with laser shots.
What are the steps of the epiduroscopy procedure? Epiduroscopy is performed under local anesthesia, with intravenous sedation if necessary, in a face-down position, in an operating room to minimize infection, and using C-arm fluoroscopy. Local anesthetic is injected into the sacral hiatus and surrounding area to numb the procedure area. A small needle is inserted into the epidural space through the sacral (tail) hiatus. A thin metal guide wire is then passed through this needle. The small needle guide wire is withdrawn, leaving it in the epidural space. A series of dilators are passed over the guidewire until the sacral membrane reaches a level that will accept a sheath cannula. Once the sheath is placed, the guidewire is removed. A steerable catheter connected to a fiberoptic epiduroscope is inserted through the center of its sheath until it enters the epidural space. The path of the steerable catheter is widened using a saline flush system connected to a side port on the sheath. The fiberoptic epiduroscope is advanced upwards under X-ray guidance until it reaches the area where epidural adhesions are detected by MRI. Once the correct area is reached, the epidural adhesions are slowly opened using the tip of the epiduroscope. Next, depot steroids and local anesthetic can be injected around any inflamed nerve roots. The procedure is completed by placing a single stitch at the intervention site.
Who, where and how is epiduroscopy performed? This procedure can be performed by neurosurgeons who are trained and have sufficient experience, and algologists who perform interventional pain treatments. The procedure is performed under local anesthesia in the operating room. The procedure takes approximately 45 minutes. A thin camera system is placed through the opening in the coccyx area. By entering into the spinal canal through a cannulated fiberoptic catheter, herniations that compress the nerve root in the lumbar region and/or adhesions in the healing tissue of the body, called granulation, can be opened with laser shots or mechanically and medication can be applied to the distance. The goal is to reduce or eliminate patients' pain between 6 months and 1 year. During this period, the patient, whose pain subsides, will be able to strengthen his back muscles with exercises. The procedure is started with the help of a scopy, that is, a mobile x-ray device, and after the intervention, the area to be treated is reached through the camera and the procedure is completed. A single stitch is placed at the intervention site. The patient is discharged on the same day. The patient can return to work the next day, and after 1 week, the stitches are removed and he/she can return to a completely normal life.
What are the contraindications of epiduroscopy and its complications? Although epiduroscopy is a much safer procedure than open surgery in selected cases, it is contraindicated in some cases and may cause complications: Epiduroscopy is not recommended in the presence of altered coagulation (coumadin use, liver or hematological disease). The elderly cannot tolerate the increase in intracerebral pressure caused by the saline irrigation system. Direct nerve root damage is possible during epiduroscopy, but is minimized by keeping the patient awake and communicating verbally with the operator. A small hole in the dural membrane can sometimes be created by the epiduroscope. This causes a post-dural puncture (spinal) headache that usually resolves within a few days, but in a small number of cases it may continue to be a problem for several weeks. Spinal headaches are treated by using an epidural blood patch to close the hole. Macular hemorrhages, or bleeding into the inner layers of the eye, can occur when excessive amounts of saline flush are used during the procedure. Excessive saline causes a sudden and rapid increase in intracranial pressure, leading to bleeding in the eyes. This can be prevented by limiting the volume of wash used during the process.
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