Figure 1831

Epidurogram, lumbar, showing epidural adhesions.

Percutaneous Disc Decompression

Part of the vertebral disc nucleus is removed mechanically via a needle introduced percutaneously into the disc.

Indications The principal indication for therapeutic percutane-ouds discectomy is a small, contained disc herniation with a large annular tear. A CT discogram and nerve root confirmatory block should be done prior to the procedure in order to evaluate the annular tear and to confirm the painful disc and nerve root.

Procedure Sterility and use of antibiotics are strictly observed as in the case of performing a discogram. The disc is approached from the pathological side. A 17-gage needle trochar is introduced into the disc. A motorized augur tip cannula is passed through the trochar into the disc and advanced to the inner border of the anterolateral annulus. The motorized cannula is activated, and about 1 to 2 mL of nucleus pulposus is extracted.

Only the lumbar discs are sites for percutaneous disc decompression (Figures 18-34 and 18-35).

Spinal Cord Stimulation

The posterior spinal cord columns are stimulated by a lead introduced into the epidural space resulting in block of the pain pathways.

Indications Patients with neuropathic limb pain non controllable by medications or less invasive percutaneous procedures are candidates for spinal cord stimulation. Other indications are failed back surgery syndrome, painful arachnoiditis, and ischemic limb pain. A trial is done before the permanent implantation of the lead and stimulator. Many insurance companies request a psychiatric evaluation of the patient prior to the implant of the spinal cord stimulator.

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