Therapeutic Indications and Contraindications

The indications and contraindications for diagnostic epidurography with possible epidurolysis consist of one or more of the following:

1. Back or neck pain, with or without radicular pain of chronic duration

2. Unresponsiveness to conservative therapy

3. Lack of obvious source of pain pathology

4. Absence of focal neurological deficit

A good rule of thumb is to consider that the presence of a focal neurological deficit requires surgical decompression until another diagnosis is reached, while pain alone suggests a more conservative approach of injection therapy such as epidurolysis. This assumes that loss of function (focal neurological deficit) is most often due to compression while pain is most often inflammation. A compressed nerve root can be further compromised, perhaps permanently, with the potential barotrauma of an injection into a closed space (Figure 10.3A). Saberski et al. demonstrated that as little as 1 mL of injectate into a closed epidural space can produce 400 mmHg pressure.23 Careful and judicious epidurography can determine the presence of a loculated space that can be decompressed to allow a more normal and safe epidural spread following epidurolysis (Figure 10.3B, C).

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