Figure 1829

IDET, anteroposterior view.

FIGURE 18-30 IDET, lateral view.

Procedure A needle is introduced into the disc and advanced to a point lateral to the center (Figures 18-29 and 18-30). A catheter is introduced through the needle and advanced. The tip reflects on the inner annular wall and is advanced to an area beyond the annular tear or bulge. Part of the catheter has a thermal element that is heated to 90°C. At times it is necessary to repeat the procedure, introducing the needle into the opposite side in order to cover the entire posterior annular part with the thermal catheter. After the procedure there is usually low back pain for about three weeks. The patient should abstain from stressing the lower back and should use a brace temporarily.

Annuloplasty

Thermal energy is brought into the "painful" lumbar disc annulus and applied under controlled conditions near the annular tear.

Indications Annuloplasty is indicated in the case of a localized annular tear.

Procedure The procedure is similar to IDET, but the thermal catheter is navigated into the annulus near the painful tear.

Lyses of Adhesions

The adhesions around spinal nerves or the epidural space are "opened" and lysed via hydraulic and mechanical force applied by a catheter tip introduced via a needle.

Indications The indications for lyses of adhesions are the presence of fibrosis and scar tissue that entrap the spinal nerve root causing radicular pain and radiculopathy. An epidurogram is necessary prior to performing lyses of adhesions in order to localize the involved area and document at least one "patent" foramen. At least one patent foramen is necessary to allow decompression of the hydraulic pressure formed inside the epidural space during the procedure. This is especially important at the cervical spine that contains the "unforgiving" cervical spinal cord.

Procedure An epidurogram is performed initially to visualize adhesions or block (Figure 18-31). A 16-gage R-K—type needle is introduced into the epidural space through the sacral hiatus or the cervical interlaminar area. A catheter with a soft spring tip (Racz catheter) is passed through the needle and advanced near the suspected pathological site. Contrast is injected to obtain an epidurogram. The presence of excluded or "cut off" nerve root sleeves or epidural filling defects is noted. Hyaluronidase followed by 10% hypertonic saline solution are injected slowly to hydraulically dissect the scar tissue and open the obstructed areas in the epidural space, especially around the spinal nerves. See Figures 18-32 and 18-33.

Postprocedural pain can persist up to three weeks.

Racz catheter passed to blockage area.

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