Targeted methylprednisolone acetate/hyaluronidase/clonidine injection after diagnostic epiduroscopy for chronic sciatica: a prospective, 1-year follow-up study

Abstract

Background and objectives: It has been claimed that epiduroscopy offers an ideal combination of diagnostic and therapeutic interventions in one session. We prospectively evaluated whether abnormalities at the lumbar level as diagnosed by magnetic resonance imaging (MRI) are confirmed by epiduroscopy, and assessed if targeted epidural injection of medication alleviates sciatic pain.

Methods: A flexible, 0.9-mm fiberoptic endoscope was introduced through a disposable steering shaft into the caudal epidural space and advanced until the targeted spinal nerve was identified. Adhesions were mechanically mobilized under direct vision, and a mixture of 120 mg methylprednisolone acetate, 600 IU hyaluronidase, and 150 microg clonidine was applied locally. Pain scores were measured by visual analog scale (VAS) and global subjective efficacy rating.

Results: Nineteen of 20 patients studied showed adhesions via epiduroscopy. In 8 patients, 6 of whom had never undergone surgery, these were not detected with earlier magnetic resonance imaging. Six patients showed concomitant signs of active root inflammation. Of 20 patients treated with a targeted epidural injection, 11 patients (55%) experienced significant pain relief at 3 months. This was maintained at 6, 9, and 12 months for 8 (40%), 7 (35%), and 7 (35%) patients, respectively. Mean VAS at 3 months was significantly reduced (n = 20; DeltaVAS = 3.55; P <.0001), and this persisted at 12 months (DeltaVAS = 1.99, P =.0073).

Conclusions: Epiduroscopy is of value in the diagnosis of spinal root pathology. In sciatica, adhesions unreported by MRI can be identified. Targeted epidural medication, administered near the compromised spinal nerve, results in substantial and prolonged pain relief.