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The epidural space was first shown to be important in radicular pain states by Lindahl and Rexed in 1950.1 Subsequently, Goebert performed the first reported epidural steroid injection.2 Since that time physicians have used the epidural space to gain direct access to traversing nerve roots and indirect access to the intrathecal space for medication delivery.

Anatomically, the epidural space is tubular and exists as a potential space. This tubular three-dimensional structure surrounds the dura and spinal cord. It extends from the foramen magnum to the upper sacrum. When examined in transverse plane, its external boundaries are the ligamentum flavum posteriorly, lamina and pedicles laterally, and the vertebral body and intervertebral disc anteriorly. The internal boundary is the dura.

Medication administration into the epidural space has been used to treat both acute and chronic pain. Examples include regional anesthesia for surgery, trauma, and labor. Dilute local anesthetic infusions have been used to treat postherpetic neuralgia, complex regional pain states, and cancer-related pain. Opioids and sympathomimetics have been added for synergy. Epidural steroids have been used to treat inflammatory nerve root irritation. Volumemetric injections and flouroscopically guided catheters have been used to direct medication delivery, wash away inflammatory mediators, lyse epidural adhesions, and deliver anti-inflammatory medication.

Efficacy of epidural treatment for radiculopathy is determined by multiple factors. Medical factors influencing outcome include accuracy of diagnosis, presence of nerve root inflammation, symptom duration, previous surgical intervention, patient age, and clinician ability to place the epidural steroid at the level of pathology.3 Treatment outcome also depends on psychological and social issues. Abram delineated factors correlating with treatment failure at twice the rate expected. These factors include poor education, unemployment, pain constant in nature, sleep disturbance, nonradicular diagnosis, duration >6 months, change in recreational activities, and tobacco use.4

Epidural space endoscopy or spinal canal endoscopy may improve outcome by addressing some of the medical factors discussed above. The region of erythema that is likely related to inflammation is visually confirmed with the endoscope. Fluoroscopy is used to confirm the spinal level. The flexible steerable handle allows placement of medication in the lateral gutter adjacent to the nerve root. Reproduction of pain during the procedure while exploring pathology helps to confirm diagnosis.5

Psychological and social factors are more difficult to treat and unfortunately they are not amenable to procedural intervention. These factors cannot be ignored, however, because they are of equal or greater importance than the medical pathology.6 Therefore attempts to address these issues by modification of behavior, structured water or land exercise programs, tobacco cessation, and improved sleep hygiene need to be made. Interventions such as targeted pharmacologic therapy to enhance restful sleep and programs to structure daily activity to enhance self-esteem are no less important. Lastly, functional goals should be set. To focus on complete pain cessation in the patient suffering from chronic pain distracts from attainable goals and ultimately ...

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