Clinical Significance of Epidurography Contrast Patterns after Adhesiolysis during Lumbar Percutaneous Epidural Neuroplasty

Sang-Hyuk Park, Gyu Yeul Ji, Pyung Goo Cho, Dong Ah Shin, Young Sul Yoon, Keung Nyun Kim, Chang Hyun Oh, Sang-Hyuk Park, Gyu Yeul Ji, Pyung Goo Cho, Dong Ah Shin, Young Sul Yoon, Keung Nyun Kim, Chang Hyun Oh

Abstract

Background: The correlation between epidurography contrast patterns and the clinical outcomes of percutaneous epidural neuroplasty (PEN) remains unclear.

Objective: To analyze the correlation between postadhesiolysis epidurography contrast patterns and the clinical outcomes of patients who undergo lumbar PEN.

Design: This study is a retrospective analysis of 78 consecutive patients who underwent lumbar PEN between April 2012 and March 2013.

Setting: The analysis was done in the university hospital center.

Method: The clinical outcomes of all patients were assessed before and 1, 3, 6, and 12 months after undergoing lumbar PEN. Specifically, the intensity of back and leg pain, quality of life, and procedural outcomes were evaluated using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and the 12-Item Short-Form Health Survey (SF-12).

Results: The VAS scores for back and leg pain, ODI score, and SF-12 score exhibited a significant improvement during the follow-up period (P < 0.01 versus preprocedural scores). At most follow-up time points, patients exhibiting extraforaminal contrast distribution (n=22) on postadhesiolysis epidurograms exhibited a similar improvement in VAS scores and a significantly better improvement in ODI and SF-12 scores compared with patients exhibiting intracanal contrast distribution (n=56).

Conclusion: Extraforaminal contrast distribution during lumbar PEN may be associated with better functional outcomes.

Figures

Figure 1
Figure 1
Modified classification of epidurography contrast patterns. (a) Grade 1: contrast spread to the medial or midline zone of the ipsilateral or contralateral epidural space, (b) grade 2: contrast spread to the lateral epidural space, proximal to the medial border of the neural foramen, (c) grade 3: contrast spread to the intraforaminal space, not extending to the lateral border of the neural foramen, (d) grade 4: contrast spread to the intraforaminal space, extending to but not crossing the lateral border of the neural foramen, and (e) grade 5: contrast spread beyond the lateral border of the neural foramen. Patients with grade 1, grade 2, and grade 3 patterns were assigned to a group exhibiting limited intracanal spread (IC group), while patients with grade 4 and grade 5 patterns were assigned to a group exhibiting extended extraforaminal spread (EF group).
Figure 2
Figure 2
Clinical outcomes of patients who underwent lumbar PEN. VAS, ODI, and SF-12 scores before and 1, 3, 6, and 12 months after lumbar PEN. All postprocedural clinical scores have significantly improved compared with preprocedural scores (P < 0.001). VAS: visual analog scale, ODI: Oswestry Disability Index, SF-12: 12-Item Short-Form Health Survey, and PEN: percutaneous epidural neuroplasty.
Figure 3
Figure 3
Correlation between epidurography contrast spread after adhesiolysis during PEN and clinical outcomes. Extraforaminal contrast spread (grades 4 and 5) is associated with a tendency for decreased pain and significantly better quality of life compared with intracanal spread (grades 1, 2, and 3). PEN: percutaneous epidural neuroplasty, VAS: visual analog scale, ODI: Oswestry Disability Index, and SF-12: 12-Item Short-Form Health Survey.
Figure 4
Figure 4
Representative case of a 60-year-old man with radicular pain in the left leg who underwent lumbar PEN. (a, b) Magnetic resonance imaging shows lumbar disc herniation and foraminal stenosis at the level of L4-5-S1 (asterisks). (c) The first epidurogram shows a filling defect at the left L5-S1 foramen. The catheter is inserted to the stenotic foramen, and mechanical adhesiolysis is attempted. (d) The final postadhesiolysis epidurogram shows excellent extraforaminal contrast spread. The patient exhibited significant pain relief and functional recovery after PEN. PEN: percutaneous epidural neuroplasty.

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