Spinal endoscopy is now providing additional proof that epidural fi-brosis is associated with the pathological changes of swollen, inflamed nerve roots responsible for radicular pain with or without evidence of disc disruption and neural compression. Direct visualization of the epidural space via spinoscopy (epiduroscopy) allows visualization of only the proximal nerve root as it exits the epidural space and enters the neuroforamen. A catheter placed transforaminally for purposes of decompressing a nerve root does not allow direct visualization, but still requires indirect visualization to verify catheter position, contrast spread and subsequent epidurolysis. Despite recent advances in our ability to visualize these pathological changes directly, indirect visualization by epidurography is still more widely utilized and is considered to be a superior method of treatment by most pain practitioners. However, this newfound ability to photograph epidural structures (both normal and pathological) adds diagnostic specificity to previously theoretical considerations of epidural fibrosis as a source of back and extremity pain.
It has also been proposed that a dual-catheter technique with both a posterior catheter (placed through the sacral hiatus or via the interlaminar space) and a ventral catheter (placed transforaminally) could be utilized with improved clinical efficacy.16 Detailed descriptions of this technique can be found in the literature20,33; however, published data are not available to validate any improvements in the efficacy of this approach. The relative increased risk of the transforaminal approach has not been quantified, but one must assume the risk to be greater with a neuroforaminal approach. For these reasons, this technique is not currently in widespread use.
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