Effectiveness of Sacral Epidural Laser Discectomy in Patients with chronic low back Resistant to Conservative Treatment

Effectiveness of Sacral Epidural Laser Discectomy in Patients with chronic low back Resistant to Conservative Treatment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of Sacral Epidural Laser Discectomy in Patients with chronic low back Resistant to Conservative Treatment bora uzuner, dursun türköz, dilek durmuş This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6134295/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Aim This study aimed to evaluate the effect of sacral epidural laser discectomy (SELD) on clinical parameters in patients with chronic low back and/or leg pain (CLBLP) resistant to conservative treatment. Methods A total of 75 patients with CLBLP who received SELD treatment were included in the study retrospectively. Patients were assessed for pain (numeric rating scale-NRS), and disability (Oswestry Disability Index-ODI). NRS and ODI scores were recorded before the operation and 1, 6, and 12 months after the operation. Results Of the 75 patients, the mean age was 52.00 ± 11.28 years (range: 30–78 years), and 45 (60.0%) were female and 35 (40.0%) were male. Baseline pain intensity (7.43 ± .774) and pain intensities obtained at three time points following the surgeries (1 month [3.93 ± 1.571], 6 months [4.36 ± 1.591], 12 months [5.00 ± 1.716]) showed statistically significant differences (p < .001). The baseline pain-related disability (2.92 ± .539) and the data obtained at three subsequent time points (1 month [1.76 ± .883], 6 months [1.85 ± .896], and 12 months [2.01 ± .923]) showed a statistically significant difference in pain-related disability (p < .001). The most common complications were headache (5 patients) and incisional pain (5 patients). Conclusion As a result of this study, we found that SELD, a relatively new technique, reduces pain and disability and has a low complication rate in patients with resistant CLBLP. Chronic Low Back Pain Epiduroscopy Laser Discectomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction In the last decade, human lifespan has significantly increased. However, the quality of life related to health has not kept pace with the extension of lifespan, leading to an increase in morbidity. Low back pain is the most common cause of disability worldwide (1). Approximately 84% of individuals experience low back pain at least once in their lives (2). Unfortunately, the treatments applied for chronic low back pain (CLBP) demonstrate limited effectiveness. The methods most frequently preferred by physicians for treatment include medications, exercise, and manipulation, which generally have only a 10 to 20-point improvement on a 100-point visual analog scale compared to placebo in large-scale studies. For this reason, in many cases, physicians often combine multiple treatment methods with the hope of achieving sufficient analgesic effect. Among the many existing treatment methods, epidural injections are commonly utilized for pathological conditions such as lumbar disc herniation, spinal stenosis, discogenic pain, and post-laminectomy syndrome (3). In cases of persistent disc herniation or post-laminectomy syndrome that do not respond to epidural injections, the adhesiolysis procedure is frequently employed (4, 5). The adhesiolysis procedure can be performed using a soft catheter or a flexible epiduroscope. The goal of the adhesiolysis procedure is to release adhesions surrounding the nerve that are compressing or pulling on it. By improving blood circulation around the nerve, the aim is to restore the flow of nutrients from the cerebrospinal fluid to the nerve root. However, adhesiolysis using a soft catheter has limitations including the inability of treatment to address pathologies with dense fibrous tissue or protruded disc tissue effectively. Epiduroscopy is a percutaneous minimally invasive procedure used for the diagnosis and treatment of low back pain. It is based on visualizing the epidural space through the sacral hiatus using a flexible epiduroscope. When necessary, it allows for various therapeutic treatment options such as the administration of therapeutic medications, adhesiolysis, and laser decompression of the herniated disc. Over the years, the applications of epiduroscopy have expanded in parallel with technological advancements. In the early 2000s, the technique of sacral epiduroscopic laser decompression (SELD) was developed using fiber-optic flexible cameras, light sources, and laser technology. SELD has found wide application in the diagnosis and treatment of various pathologies such as adhesions, spinal stenosis, disc herniations, CLBP, and failed back syndrome in the last three decades (6–13). The possible mechanisms of action of SELD can be explained by the decompression of the annulus following laser vaporization of the ruptured disc, adhesiolysis of adhesions around the nerve root and surrounding structures, ablation of the sinuvertebral nerve, and the removal of inflammatory cells and mediators from the environment through saline irrigation. The clinical outcomes of SELD were published previously in a limited number of articles (14). We aimed to review the effects of SELD treatment on both short-term and long-term pain and disability in a population of patients with CLBP (lasting more than 6 months) and/or leg pain who were resistant to conservative treatment and had previously undergone interventional procedures. METHOD Participants This study retrospectively identified patients who underwent SELD operations at Education and Research Hospital pain medicine clinic between January 11, 2016, and May 31, 2017 (ethical committee approval no: TUEK 31-2019BADK/7–60). Patients who had been suffering from lower back and/or leg pain for at least 6 months, and had undergone various treatments (non-pharmacological methods [physical therapy modalities, etc.], medical treatments [non-steroidal drugs, muscle relaxants, antidepressants and antiepileptic agents, opioids, etc.], interventional procedures [spinal-caudal injections, radiofrequency therapies, etc.]) prior to SELD operation but still had complaints and therefore had SELD operation planned as the next step, were retrospectively evaluated. Exclusion criteria were: being under 18 years old; having significant cognitive impairment and/or psychiatric illness that would impede communication; having cancer; and refusing to participate in the study. Preoperative Protocol Preoperative Protocol Prior to the operation, all patients were provided with detailed information about the possible advantages, disadvantages, and complications, and their consent was obtained. Detailed physical examinations were performed, and basic characteristics obtained from spinal magnetic resonance imaging (MRI) were recorded for each patient. Sociodemographic Form and Scales Participants were asked to provide information about their age, gender, presence of additional diseases, and pain areas (they were recommended to mark them on a prepared diagram). Previously applied interventional procedures and surgical methods were checked in the digital health record system, along with patient statements. Numeric rating scale (NRS) was used to evaluate pain intensity. Participants were asked to choose a number that best reflects the intensity of their pain (0 = no pain and 10 = the most severe pain imaginable). Higher scores indicate greater pain intensity. NRS scores were recorded before the operation (baseline pain intensity) and 1, 6, and 12 months after the operation (15). Oswestry Disability Index (ODI) was used to measure disability associated with back pain. It assesses how the patient's back pain affects their daily tasks and activities, and consists of 10 items. Each item is scored from 0 to 5, and higher values are associated with greater disability (16). ODI results were recorded before the operation (baseline disability) and 1, 6, and 12 months after the operation in the study. Surgical technique The surgical technique of epiduroscopy was performed under sterile operating room conditions and with hemodynamic and respiratory monitoring, following administration of preoperative antibiotics. Communication with the patient should be maintained during the procedure, and deep sedation should be avoided in order to ensure full neurological monitoring (17). Before the procedure, the caudal and sacral areas were wiped with antiseptic solution. Local anesthetics were administered to the skin and subcutaneous tissue. The skin incision was made above the sacral hiatus. A trocar was inserted through the incision site into the sacrum, and C-arm fluoroscopy was used to confirm that the trocar was in the midline with lateral and anteroposterior views. Then, a Spinnaut-V video-guided catheter (IMEDICOM Co. Ltd, Gyeonggi-do, Korea) was inserted into the trocar. The V video-guided catheter was manipulated to the anterior epidural space at the level of S2-S4 vertebrae with fluoroscopic lateral view. An anterior epidurogram was performed using non-ionic contrast agent to visualize the dyeing of the anterior epidural space and the outline of its pathology (Fig. 1 ). The vertebral level where the catheter tip is located was determined with fluoroscopy. Mechanical adhesiolysis was performed with a video-guided catheter that can be directed and is washed with saline through the side arm of the cannula for better visualization. L5-S1, L4-5, and L3-4 levels were viewed using video imaging. After the herniated disc pathology was observed, a 400 µm diameter Ho: YAG laser probe (ACCU-Tech Co., Ltd, Beijing, China) was advanced to the tip of the video-guided catheter. The lateral view and catheter placement (within the posterior longitudinal ligament [PLL] at the lowest level of the target disc) were confirmed with fluoroscopy and epiduroscopy, aided by video imaging of the anterior epidural space. Using the Ho:YAG laser at 5 W (0.5 J, 10 Hz), a hole was made in the PLL. Then, a fiber video cable was inserted under the herniated intervertebral disc through the hole in the PLL, and the herniated disc was ablated using the Ho: YAG laser at 8 W (0.8 J, 10 Hz). The decompression of the ruptured disc was subsequently confirmed epiduroscopically, demonstrating its decompression from the nerve root (Fig. 2 ). At the end of the procedure, 16 mg dexamethasone was applied to the epidural region and then the catheter was removed. Patients without any complaints were sent to the postoperative care room (18). Postoperative Protocol All major complications occurring during or after the surgery were documented. Surgical outcomes were assessed at the patients' most recent follow-up using Odom's criteria. This 4-point grading system evaluates clinical results following spinal surgery as excellent (no symptoms related to lumbar disc disease and no functional limitations), good (occasional discomfort with minimal functional impact), satisfactory (noticeable improvement but with substantial functional restrictions), and poor (no improvement or a worsening of the condition) (19). Statistical Analysis Analysis was performed using Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY). Continuous variable data are expressed as median (min-max), while categorical variable data are presented as numbers (%). The normality of data was tested using the Kolmogorov-Smirnov test. For non-normally distributed data in comparisons between groups, the Kruskal-Wallis analysis of variance test and Mann-Whitney U test were used. The Friedman test was used to compare repeated measurements, and the Wilcoxon signed-rank test was used for pairwise comparisons of significant values. Bonferroni correction was applied for post-hoc analyses following comparisons of more than two groups. The chi-square test was used to compare categorical data. A significance level of p < .050 was considered statistically significant, except for post-hoc analyses. RESULTS Patient Characteristics A total of 106 patients were invited to the study, and 85 agreed to participate. Ten patients were lost to follow-up and excluded from the study, resulting in a final sample size of 75 patients. Of the 75 patients who completed the study, the mean age was 52.00 ± 11.28 years (range: 30–78 years), and 45 (60.0%) were female and 35 (40.0%) were male. The most common comorbidity among participants was diabetes mellitus (DM), with 24 (32%) participants reporting this condition. A total of 56 patients (74.7%; 37 [66.1%] female, 19 [33.9%] male) had a history of lumbar surgery. Pain locations were noted as follows: only in the lower back (without radiating pain) in 8 (10.7%) patients; only in the leg(s) (without back pain) in 22 (29.3%) patients; and both in the lower back and leg(s) in 45 (60.0%) patients. Preoperative MRI examinations of the patients revealed at least one pathological finding (bulging/protrusion/extruded disc herniation, central and/or lateral stenosis, granulation at the surgical site) at the L3-4 level in 17 (22.7%) patients, at the L4-5 level in 59 (78.7%) patients, and at the L5-S1 level in 55 (73.3%) patients. Bulging was observed in 10 (13.3%) patients, protrusion in 60 (80.0%) patients, and extruded disc herniation in 8 (10.7%) patients. Central disc involvement was present in 47 (62.7%) patients, foraminal disc involvement in 28 (37.3%) patients, lumbar stenosis in 43 (57.3%) patients, and granulation in 42 (56.0%) patients. Previously performed spinal interventional procedures were as follows: caudal epidural steroid injection (CESI) in 28 patients (37.3%); transforaminal epidural steroid injection (TESI) in 40 patients (53.3%); radiofrequency ablation (RFA) of medial branch nerves for the lumbar spine in 25 patients (33.3%); and dorsal root ganglion (DRG) pulsed radiofrequency (PRF) in 39 patients (52.0%). While 63 individuals (84.0%) underwent one or more of these four procedures, there were 4 individuals (5.33%) who underwent all of them. Assessment of Pain Intensity and Disability Pain intensity: Pain intensity was evaluated at four different time points within a one-year period. Baseline pain intensity (7.43 ± .774) and pain intensities obtained at three time points following the surgeries (1 month [3.93 ± 1.571], 6 months [4.36 ± 1.591], 12 months [5.00 ± 1.716]) showed statistically significant differences (χ2 = 163.39; p < .001) (Table 1). Table 1. Pairwise comparisons of pain intensity and pain disability. Baseline – 1. m Baseline – 6. m Baseline – 1. y 1. m – 6. m 1. m – 1. y 6. m- 1. y Pain intensity* Z -7.380 a -7.224 a -6.616 a -2.542 b -4.867 b -4.607 b Asymp. Sig. (2-tailed) < .001 < .001 < .001 .011 < .001 < .001 Pain disability** Z -6.610 a -6.373 a -5.930 a -1.400 b -3.043 b -3.207 b Asymp. Sig. (2-tailed) < .001 < .001 < .001 . 162 .002 < .001 Abbreviations: m, month; y, year. Wilcoxon Signed Ranks Test. a : Based on positive ranks. b : Based on negative ranks. *: Pain intensity was calculated using NRS. **: Pain-related disability was calculated using ODI. Disability: ODI (Oswestry Disability Index) values were obtained at four different time points within a one-year period. The baseline pain-related disability (2.92 ± .539) and the data obtained at three subsequent time points (1 month [1.76 ± .883], 6 months [1.85 ± .896], 12 months [2.01 ± .923]) indicated statistically significant differences in pain-related disability (χ2 = 115.489, p < .001) ( Figure 3 ). Clinical Outcomes Clinical outcomes were evaluated according to the Odom criteria. Accordingly, 4 (5.3%) participants achieved "excellent" outcomes, 29 (38.7%) participants achieved "good" outcomes, 27 (36.0%) participants achieved "satisfactory" outcomes, and 15 (20.0%) participants achieved "poor" outcomes. Additionally, 13 (17.3%) patients did not benefit from epiduroscopy and required surgical intervention. Complications The most common complications observed were headache (5 [6.7%] patients) and incisional pain (5 [6.7%] patients). Other observed complications included dural tear in 4 (5.3%) patients, motor loss in 2 (2.7%) patients (one of which was temporary), and infection in 1 (1.3%) patient. Some individuals experienced multiple complications, with a total of 10 (13.3%) individuals developing complications. Among these 10 patients, 8 had a history of lumbar surgery, and 6 had granulation tissue present. One patient who developed motor loss (foot drop) underwent surgical intervention. Intergroup Comparisons Demographic data: There was no significant difference in surgical outcomes (ODOM criteria) between females and males (p = .566). There was a negative and weak correlation between age and surgical outcomes (r = -0.207; p = .075). There were no notable differences between the groups concerning other demographic variables (p > .050). Pain areas: Surgical outcomes at the 12-month mark were statistically significant only in the patient group with leg pain only (without back pain) (χ2 = 6.572; p = .037). No statistically significant differences were identified between the groups regarding pain intensity and pain-related disability across the assessed pain areas (p > .050). Previous surgical history: Patients with and without a history of prior surgery showed no statistically significant differences in pain intensity, pain-related disability, clinical outcomes, or procedure-related complications (p > .050). Imaging findings: Patients with and without granulation tissue, spinal stenosis, and various pathologic findings detected on MRI (extrusion, herniation, bulging, etc.) were evaluated separately, and no significant differences were found between the groups (p > .050). Previous interventional procedures: The types and presence of prior spinal interventional procedures were analyzed, revealing no significant differences between the groups regarding pain, clinical outcomes, or complications (p > .050). Discussion Low back pain is an extremely common health problem affecting individuals of all age groups. In addition to being one of the leading causes of disability, it also causes significant socioeconomic burden (20). The majority of back pain episodes resolve on their own, regardless of treatment, and most individuals experiencing back pain do not pursue medical attention (21). Approximately 10% to 15% of back pain becomes chronic, and it can cause substantial disability for some in this group. Most patients with low back pain do well with conservativemanagement. However, there are some patients who do not respond to these conservative measures. Many percutaneous disk procedures are in use, and new ones are continually being developed to treat patients with discogenic pain that has failed to respond to more conservative management (22). None of these, however, has been definitively shown to provide better results than a surgical microdiscectomy . SELD is a minimally invasive procedure that allows for direct visualization and treatment of spinal disorders and can be conducted under local anesthesia (11,23). SELD offers several advantages, including the preservation of paravertebral muscles, protection of bony structures, and rapid recovery. Since Choy et al. (5) first described laser ablation of the intervertebral disc, the SELD technique has significantly advanced over the years (8,11,12,24,25). In our study, the long-term (1-year) effectiveness of SELD was retrospectively evaluated in patients with chronic low back pain who were unresponsive to conventional interventional pain treatments, such as transforaminal/interlaminar/caudal epidural steroid injections and percutaneous facet medial branch radiofrequency ablation. A recently published review reported a clinically significant reduction in pain scores, with an average decrease of 2.8 points and a 20% reduction in disability at 12 months following epiduroscopy treatment. The review suggested that this could be an effective treatment option for patients with failed back surgery syndrome (FBSS) (26). Similarly, in our study, when we compared baseline pain intensity with postoperative pain intensity at all time points, we found a statistically significant reduction in pain intensity. At 12 months, we calculated an average decrease of 2.43 points in pain intensity. Similarly, for disability, we obtained significant results across all time points and calculated a 31.1% change at 12 months. The majority of patients in our study (74.7%) had a history of prior lumbar surgery, and all patients had previously undergone conventional interventional treatments due to their pain. A total of 33 participants (44%) experienced significant benefit from the treatment (ODOM grades 4 and 3) at the end of one year. We believe this finding represents the most clinically important outcome of our study, particularly for patients unresponsive to conventional interventional pain treatments. Several previous studies showed that the clinical outcomes of SELD are favorable. These studies reported significant reductions in low back pain or radiating leg pain, with patient satisfaction rates exceeding 70%, and a low incidence of failure or recurrence (27-29). In our study, the one-year follow-up satisfaction rate appears lower compared to these studies in the literature. However, Seong Son et al. (24) reported a patient satisfaction rate of 58.5% and a reintervention rate of 17.1% in their retrospective study of 82 patients with a 6-month follow-up period. These findings are consistent with our results and align with the literature (11,26,29,30,31). In our study, a slight worsening in pain intensity and disability was observed over time, which is similar to findings reported in a recent study (32). Although the reformation of fibrosis following the epiduroscopy procedure is a significant cause of pain, ongoing pathological degenerative processes in the lumbar vertebrae can lead to the re-release of cytokines, subsequently triggering pain again and ultimately resulting in further adhesions. We could not establish a direct relationship between demographic data and clinical outcomes. We acknowledge that our sample size was not sufficiently large to allow for such comparisons and emphasize the need to evaluate other potential factors negatively affecting chronic pain with a larger cohort. The mean age of the participants was calculated as 52.00 years, which is consistent with previous studies (31, 33). Compared to those with axial pain, we found significantly better clinical outcomes at the 12-month follow-up in the group with radicular pain. This may be due to the presence of different mechanical causes of axial low back pain in our patients (such as facet arthrosis, instability, spondylolisthesis, or sacroiliac joint-related pain). In the literature, the relationship between the type of spinal surgery and epiduroscopy outcomes was examined. Compared to discectomy and laminectomy, clinical outcomes were found to be worse in patients undergoing stabilization surgeries and anterior or posterior lumbar interbody fusion (34,35). However, similar to two separate retrospective studies evaluating the effectiveness of SELD (36,37), we did not find a significant difference in clinical outcomes between patients with or without a history of surgery. The severity of fibrosis may depend on the surgical technique, frequency, and method used (38). Dense fibrous scar tissue that can form in the epidural space after surgery may cause adhesions on the dura mater and nerve roots, and is associated with FBSS (39,40). In epiduroscopy, therapeutic efficacy is linked to the endoscopic adhesiolysis of these lesions (26). Fibrous scar tissue was observed in 42 patients (56.0%); however, we did not find any difference in clinical efficacy between patients with or without fibrosis. Our study included a relatively small patient cohort compared to other studies, which may have prevented some results from reaching statistical significance (e.g., the clinical impact of fibrosis). We encountered several complications related to epiduroscopy, including transient headaches (n=5), pain at the site of scope insertion (n=5), dural tears (n=4), motor loss (n=2), and mild meningitis (n=1). With the exception of one patient, all symptoms resolved following bed rest and conservative treatment with medications. A single instance of foot-drop due to a laser complication required emergency surgery and was successfully managed. Various complications, such as postoperative headache, pain at the incision site, motor loss, and infection, have been reported with SELD (11), and the "60-limit rule" was optionally recommended for these complications (41). We performed our procedures in accordance with this recommendation. The most common complications we observed were headache and incision site pain (both in 5 [6.7%] patients). Among major complications, dural tears occurred in 4 (5.3%) of our patients. Dural tear rates associated with SELD were documented in the literature to range from 1.7% to 7% (7, 37). In patients with a history of previous surgery, the incidence of dural puncture is notably higher compared to those without surgical history. This increased rate may be associated with anatomical changes and adhesions resulting from prior surgeries, which complicate catheter guidance (41). In our patient population, 74.7% had prior surgical history, which may explain the relatively high rate of dural puncture. Notably, in patients who underwent epiduroscopy with laser application, a significant complication arises from thermal damage to the nerve roots, leading to motor nerve dysfunction. Therefore, special attention is required during the laser procedure (9). In our patient series, motor loss was observed in two patients following laser discectomy, and one of them required emergency surgery. This study has some limitations. The data were collected retrospectively, and comparisons with a control group could not be made. The study was conducted at a single center, and the results could not be compared to populations with different socioeconomic and cultural backgrounds. Moreover, sufficient information regarding pain-related emotional and cognitive processes that might influence clinical outcomes was not obtained. Further research involving larger and more diverse populations is required to better understand the factors influencing the outcomes of SELD. Conclusion We suggest that SELD, a relatively new technique for patients with back and/or leg pain, is an advanced and practical method with a low complication rate and notable efficacy when performed by experienced practitioners. However, most studies in the medical literature are retrospective, as in our study. We suggest that prospective studies with larger patient cohorts are necessary to evaluate the long-term effectiveness of SELD and to assess its associated complications. Declarations Author Contribution Conception or design of the work -------------------------B.U and D.T---------------------Data collection -----------------------------------------B.U and D.T-----Data analysis and interpretation ---------------------------B.U and D.T-------------------Drafting the article ----------------------------------------B.U and D.T------Critical revision of the article ----------------------------------B.U and D.T------------Other (study supervision, fundings, materials, etc ---------------D.D-- References Barr KP, Chrıstopher J. Standaert, Stephen C. Johnson, Neelwant S. Sandhu. Low Back Pain. In: Braddom RL, editor. Braddom’s Physical Medicine and Rehabilitation 6th ed. USA. Elsevier Inc.; 2016. p.651–689. https://doi.org/10.1016/B978-0-323-62539-5.18001-4. Walker BF: The prevalence of low back pain: a systematic review of the literature from 1966 to 1998, J Spinal Disord 13:205–217. doi: 10.1097/00002517-200006000-00003. 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Trans-Sacral Epiduroscopic Laser Decompression for Symptomatic Lumbar Disc Herniation: A Preliminary Case Series. Photomed Laser Surg. 2016 Mar;34(3):121-9. doi: 10.1089/pho.2015.4000. Anne E H Broekema, Rob Molenberg, Jos M A Kuijlen, Rob J M Groen, Michiel F Reneman, Remko Soer. The Odom Criteria: Validated at Last: A Clinimetric Evaluation in Cervical Spine Surgery. J Bone Joint Surg Am. 2019 Jul 17;101(14):1301-1308. doi: 10.2106/JBJS.18.00370. Manuela L Ferreira, Gustavo Machado, Jane Latimer, Christopher Maher, Paulo H Ferreira, Rob J Smeets. Factors defining care-seeking in low back pain--a meta-analysis of population based surveys. Eur J Pain. 2010 Aug;14(7):747.e1-7. doi: 10.1016/j.ejpain.2009.11.005. Wertli MM, Burgstaller JM, Weiser S, Johann Steurer, Reto Kofmehl, Ulrike Held. Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: a systematic review, Spine (Phila Pa 1976) 39:263–273, 2014. doi: 10.1097/brs.0000000000000110. Pomerantz SR, Hirsch JA: Intradiscal therapies for discogenic pain, Semin Musculoskelet Radiol 10:125–135, 2006. doi: 10.1055/s-2006-939030. Andreas Veihelmann, C Devens, H Trouillier, C Birkenmaier, L Gerdesmeyer, H J Refior. Epidural neuroplasty versus physiotherapy to relieve pain in patients with sciatica: a prospective randomized blinded clinical trial. J Orthop Sci. 2006 Jul;11(4):365-9. doi: 10.1007/s00776-006-1032-y. Seong Son, Sang Gu Lee, Yong Ahn, Woo Kyung Kim. Clinical Outcomes of Trans-Sacral Epiduroscopic Laser Decompression (SELD) in Patients with Lumbar Disc Herniation. Pain Res Manag. 2020 Jun 1:2020:1537875. doi: 10.1155/2020/1537875. Seong Son, Sang Gu Lee, Yong Ahn, Woo Kyung Kim, Tae Seok Jeong. Outcomes of epiduroscopic laser ablation in patients with lumbar disc herniation. Medicine (Baltimore). 2020 Dec 18;99(51):e23337. doi: 10.1097/MD.00000000000023337. Matthijs W Geudeke, Annelot C Krediet, Süleyman Bilecen, Frank J P M Huygen, Mienke Rijsdijk. Effectiveness of Epiduroscopy for Patients with Failed Back Surgery Syndrome: A Systematic Review and Meta-analysis. Pain Pract. 2021 Apr;21(4):468-481. doi: 10.1111/papr.12974. Jo D, Lee DJ. The extent of tissue damage in the epidural space by Ho /YAG laser during epiduroscopic laser neural decompression. Pain Physician 2016;19:E209–14. Kim SK, Lee SC, Park SW. Trans-sacral epiduroscopic laser decompression versus the microscopic open interlaminar approach for L5-S1 disc herniation. J Spinal Cord Med 2018;43:1–1. Kim SK, Lee SC, Park SW, Kim ES. Complications of lumbar disc herniations following trans-sacral epiduroscopic lumbar decompression: a single-center, retrospective study. J Orthop Surg Res 2017;12:187. doi: 10.1186/s13018-017-0691-z. Richardson J, McGurgan P, Cheema S, Prasad R, Gupta S. Spinal endoscopy in chronic low back pain with radiculopathy. A prospective case series. Anaesthesia. 2001 May;56(5):454-60. doi: 10.1046/j.1365-2044.2001.01524-3.x. Mert Akbas, Huseyin Babun, Haitham Hamdy Salem, Tamer Hussien Emara, Shereen Elmosly. One-year evaluation of epiduroscopy in chronic back pain with and without radiculopathy: a retrospective study. Egypt J Neurol Psychiatry Neurosurg 56, 4 (2020). https://doi.org/10.1186/s41983-019-0142-3. Derya Burcu Hazer, Arsal Acarbaş, Hans Eric Rosberg. The outcome of epiduroscopy treatment in patients with chronic low back pain and radicular pain, operated or non-operated for lumbar disc herniation: a retrospective study in 88 patients. Korean J Pain. 2018 Apr;31(2):109-115. doi: 10.3344/kjp.2018.31.2.109. Avellanal M, Diaz-Reganon G. Interlaminar approach for epiduroscopy in patients with failed back surgery syndrome. Br J Anaesth. 2008 Aug;101(2):244-9. doi: 10.1093/bja/aen165. Ayşegül Ceylan, İbrahim Aşık, Güngör Enver Özgencil, Burak Erken. Evaluation of the efficacy of epiduroscopic adhesiolysis in failed back surgery syndrome. Turk J Med Sci. 2019 Feb 11;49(1):249-257. doi: 10.3906/sag-1807-173. Gruyters I, De Vooght P, Puylaert M, Mestrum R, Van Zundert J, Vanelderen P. Outcome and extent of epidural adhesiolysis attainable with epiduroscopy in failed back surgery syndrome relates to the type of previous lumbar surgery: 14AP2-2. European Journal of Anaesthesiology| EJA. 2013 Jun 1;30:207-8. doi:10.1097/00003643-201306001-00647. Dae Hyun Jo, Eung Don Kim, Hyun Jin Oh. The Comparison of the Result of Epiduroscopic Laser Neural Decompression between FBSS or Not. Korean J Pain. 2014 Jan;27(1):63-7. doi: 10.3344/kjp.2014.27.1.63. Ali Metin Ülgen, Serbülent Gökhan Beyaz, Mustafa Erkan Inanmaz, Fatih Şahin. Evaluation of the Efficacy of Epiduroscopic Laser Neural Discectomy in Lumbar Disc Herniations: Retrospective Analysis of 163 Cases- Evaluation of the Efficacy of ELNP. Pain Res Manag. 2020.29:2020:7361691. doi: 10.1155/2020/7361691. Ross J S, Robertson J T, Frederickson R C, Petrie J L, Obuchowski N, Modic M T, deTribolet N. Association between peridural scar and recurrent radicular pain after lumbar discectomy: magnetic resonance evaluation. ADCON-L European Study Group. Neurosurgery. 1996 Apr;38(4):855-61. doi:10.1227/00006123-199604000-00053. Paulo Pereira, Antonio Avelino, Pedro Monteiro, Rui Vaz, Jose Manuel Castro-Lopes. New insights from immunohistochemistry for the characterization of epidural scar tissue. Pain Physician. 2014 Sep-Oct;17(5):465-74 Róbert Rapčan, Ladislav Kočan, Juraj Mláka, Miroslav Burianek, Hana Kočanová, Simona Rapčanová, Michael Hess, Anthony Hammond, Martin Griger, Michal Venglarčík, Miroslav Gajdoš, Janka Vašková. A Randomized, Multicenter, Double-Blind, Parallel Pilot Study Assessing the Effect of Mechanical Adhesiolysis vs Adhesiolysis with Corticosteroid and Hyaluronidase Administration into the Epidural Space During Epiduroscopy. Pain Med. 2018 Jul 1;19(7):1436-1444. doi: 10.1093/pm/pnx328. Maurizio Marchesini, Edoardo Flaviano, Valentina Bellini, Marco Baciarello, Elena Giovanna Bignami. Complication of epiduroscopy: a brief review and case report. Korean J Pain. 2018 Oct;31(4):296-304. doi: 10.3344/kjp.2018.31.4.296. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6134295","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":424295714,"identity":"429504ac-909d-499a-9894-bbad22170a1b","order_by":0,"name":"bora uzuner","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBACAygtB2EYWBCvxdiAgRnElSBeS+IGsBYGIrSYS6Q/ky6ouJe+nb3/6IYfBRIM/O3dCXi1WM5ISJOecaY4d2fPYbabPUCHSZw5uwG/w24kHJPmbUvI3XAjme0GD1CLgUQuIS2JbdK8/xLSDYBabv4hTksymzRvQ0ICiHGbKFsse54xW/McSzDccOaw2W0ZAwkegn4xZ09/eJunJkHe4Hjjs5tv/tjI8bf34teCAXhIUz4KRsEoGAWjACsAALofQt8iIm4+AAAAAElFTkSuQmCC","orcid":"","institution":"Ondokuz Mayıs University","correspondingAuthor":true,"prefix":"","firstName":"bora","middleName":"","lastName":"uzuner","suffix":""},{"id":424295716,"identity":"d73b3287-0f82-4ac2-ad0d-25d656de4db5","order_by":1,"name":"dursun türköz","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"dursun","middleName":"","lastName":"türköz","suffix":""},{"id":424295717,"identity":"36e956c1-480f-4486-be27-3d97179dbb22","order_by":2,"name":"dilek durmuş","email":"","orcid":"","institution":"Ondokuz Mayıs University","correspondingAuthor":false,"prefix":"","firstName":"dilek","middleName":"","lastName":"durmuş","suffix":""}],"badges":[],"createdAt":"2025-03-01 11:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6134295/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6134295/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78753241,"identity":"c7983ec4-0c9b-42f6-b582-1c6a59801ccc","added_by":"auto","created_at":"2025-03-18 12:14:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33716,"visible":true,"origin":"","legend":"\u003cp\u003e(A) A pre-procedure epidurogram obtained before performing SELD highlights the herniated nucleus pulposus and adhesions causing flow obstruction at the affected level. (B) A post-procedure epidurogram following SELD demonstrates reduced herniation outline and restored flow at the previously affected site.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6134295/v1/18163939acdf76ce60d76364.jpg"},{"id":78753653,"identity":"21ee5d45-5f73-4534-b176-93d19162d0fb","added_by":"auto","created_at":"2025-03-18 12:22:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":24213,"visible":true,"origin":"","legend":"\u003cp\u003eEpiduroscopic visualization: (A) The dura is compressed due to the protrusion of the posterior longitudinal ligament (PLL), beneath which lies a herniated nucleus pulposus (HNP). (B) Decompression of the ruptured HNP located beneath the PLL is achieved using the Ho:YAG laser. (C and D) Fibrosis and adhesion undergo adhesiolysis with the Ho:YAG laser, (E) increased vascularity.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6134295/v1/7da9a5d8974db1f88bbb6f31.jpg"},{"id":78753248,"identity":"318d653c-545a-4ee1-9d65-79f5843cb39f","added_by":"auto","created_at":"2025-03-18 12:14:19","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":10020,"visible":true,"origin":"","legend":"\u003cp\u003eAxial and sagittal magnetic resonance images (MRI) before (A and B) and after (C and D) SELD procedure performed for L5-S1 recurrent paramedian disc herniation in an operated lumbar herniated nucleus pulposus patient. Significant reduction in the paramedian disc herniation is observed.\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6134295/v1/a0069316d2034d3bdd35340b.jpg"},{"id":78753655,"identity":"9150fbee-8079-4382-b1f8-68bfb76c9303","added_by":"auto","created_at":"2025-03-18 12:22:19","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eNRS results before (baseline), and 1 month, 6 months, and one year after epiduroscopy (χ2 = 163.39, p \u0026lt; .010).\u003c/p\u003e","description":"","filename":"placeholderimage.png","url":"https://assets-eu.researchsquare.com/files/rs-6134295/v1/c30854d2e2d766dc93cb914d.png"},{"id":78754319,"identity":"08ea0a2a-a29e-494d-90ba-8dcfcf22639f","added_by":"auto","created_at":"2025-03-18 12:30:19","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":5713,"visible":true,"origin":"","legend":"\u003cp\u003eODI results before (baseline), and 1 month, 6 months, and one year after epiduroscopy (χ2 = 115.489, p \u0026lt; .001).\u003c/p\u003e","description":"","filename":"placeholderimage.png","url":"https://assets-eu.researchsquare.com/files/rs-6134295/v1/9c3adf3f5ba48ccbf9d4d14c.png"},{"id":79978082,"identity":"2bffaecc-3ec8-4a2c-8245-be324c5ffd39","added_by":"auto","created_at":"2025-04-06 01:01:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":640788,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6134295/v1/ae6e0ae4-2fb4-4fec-a6f3-676647b6d3c2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffectiveness of Sacral Epidural Laser Discectomy in Patients with chronic low back Resistant to Conservative Treatment\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the last decade, human lifespan has significantly increased. However, the quality of life related to health has not kept pace with the extension of lifespan, leading to an increase in morbidity. Low back pain is the most common cause of disability worldwide (1). Approximately 84% of individuals experience low back pain at least once in their lives (2). Unfortunately, the treatments applied for chronic low back pain (CLBP) demonstrate limited effectiveness. The methods most frequently preferred by physicians for treatment include medications, exercise, and manipulation, which generally have only a 10 to 20-point improvement on a 100-point visual analog scale compared to placebo in large-scale studies. For this reason, in many cases, physicians often combine multiple treatment methods with the hope of achieving sufficient analgesic effect. Among the many existing treatment methods, epidural injections are commonly utilized for pathological conditions such as lumbar disc herniation, spinal stenosis, discogenic pain, and post-laminectomy syndrome (3). In cases of persistent disc herniation or post-laminectomy syndrome that do not respond to epidural injections, the adhesiolysis procedure is frequently employed (4, 5). The adhesiolysis procedure can be performed using a soft catheter or a flexible epiduroscope. The goal of the adhesiolysis procedure is to release adhesions surrounding the nerve that are compressing or pulling on it. By improving blood circulation around the nerve, the aim is to restore the flow of nutrients from the cerebrospinal fluid to the nerve root. However, adhesiolysis using a soft catheter has limitations including the inability of treatment to address pathologies with dense fibrous tissue or protruded disc tissue effectively.\u003c/p\u003e \u003cp\u003eEpiduroscopy is a percutaneous minimally invasive procedure used for the diagnosis and treatment of low back pain. It is based on visualizing the epidural space through the sacral hiatus using a flexible epiduroscope. When necessary, it allows for various therapeutic treatment options such as the administration of therapeutic medications, adhesiolysis, and laser decompression of the herniated disc. Over the years, the applications of epiduroscopy have expanded in parallel with technological advancements. In the early 2000s, the technique of sacral epiduroscopic laser decompression (SELD) was developed using fiber-optic flexible cameras, light sources, and laser technology. SELD has found wide application in the diagnosis and treatment of various pathologies such as adhesions, spinal stenosis, disc herniations, CLBP, and failed back syndrome in the last three decades (6\u0026ndash;13).\u003c/p\u003e \u003cp\u003eThe possible mechanisms of action of SELD can be explained by the decompression of the annulus following laser vaporization of the ruptured disc, adhesiolysis of adhesions around the nerve root and surrounding structures, ablation of the sinuvertebral nerve, and the removal of inflammatory cells and mediators from the environment through saline irrigation.\u003c/p\u003e \u003cp\u003eThe clinical outcomes of SELD were published previously in a limited number of articles (14). We aimed to review the effects of SELD treatment on both short-term and long-term pain and disability in a population of patients with CLBP (lasting more than 6 months) and/or leg pain who were resistant to conservative treatment and had previously undergone interventional procedures.\u003c/p\u003e"},{"header":"METHOD","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eThis study retrospectively identified patients who underwent SELD operations at Education and Research Hospital pain medicine clinic between January 11, 2016, and May 31, 2017 (ethical committee approval no: TUEK 31-2019BADK/7\u0026ndash;60). Patients who had been suffering from lower back and/or leg pain for at least 6 months, and had undergone various treatments (non-pharmacological methods [physical therapy modalities, etc.], medical treatments [non-steroidal drugs, muscle relaxants, antidepressants and antiepileptic agents, opioids, etc.], interventional procedures [spinal-caudal injections, radiofrequency therapies, etc.]) prior to SELD operation but still had complaints and therefore had SELD operation planned as the next step, were retrospectively evaluated. Exclusion criteria were: being under 18 years old; having significant cognitive impairment and/or psychiatric illness that would impede communication; having cancer; and refusing to participate in the study.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePreoperative Protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003ePreoperative Protocol\u003c/div\u003e\n\u003cp\u003ePrior to the operation, all patients were provided with detailed information about the possible advantages, disadvantages, and complications, and their consent was obtained. Detailed physical examinations were performed, and basic characteristics obtained from spinal magnetic resonance imaging (MRI) were recorded for each patient.\u003c/p\u003e\n\u003ch3\u003eSociodemographic Form and Scales\u003c/h3\u003e\n\u003cp\u003eParticipants were asked to provide information about their age, gender, presence of additional diseases, and pain areas (they were recommended to mark them on a prepared diagram). Previously applied interventional procedures and surgical methods were checked in the digital health record system, along with patient statements. Numeric rating scale (NRS) was used to evaluate pain intensity. Participants were asked to choose a number that best reflects the intensity of their pain (0\u0026thinsp;=\u0026thinsp;no pain and 10\u0026thinsp;=\u0026thinsp;the most severe pain imaginable). Higher scores indicate greater pain intensity. NRS scores were recorded before the operation (baseline pain intensity) and 1, 6, and 12 months after the operation (15).\u003c/p\u003e\n\u003cp\u003eOswestry Disability Index (ODI) was used to measure disability associated with back pain. It assesses how the patient\u0026apos;s back pain affects their daily tasks and activities, and consists of 10 items. Each item is scored from 0 to 5, and higher values are associated with greater disability (16). ODI results were recorded before the operation (baseline disability) and 1, 6, and 12 months after the operation in the study.\u003c/p\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003eThe surgical technique of epiduroscopy was performed under sterile operating room conditions and with hemodynamic and respiratory monitoring, following administration of preoperative antibiotics. Communication with the patient should be maintained during the procedure, and deep sedation should be avoided in order to ensure full neurological monitoring (17). Before the procedure, the caudal and sacral areas were wiped with antiseptic solution. Local anesthetics were administered to the skin and subcutaneous tissue. The skin incision was made above the sacral hiatus. A trocar was inserted through the incision site into the sacrum, and C-arm fluoroscopy was used to confirm that the trocar was in the midline with lateral and anteroposterior views. Then, a Spinnaut-V video-guided catheter (IMEDICOM Co. Ltd, Gyeonggi-do, Korea) was inserted into the trocar. The V video-guided catheter was manipulated to the anterior epidural space at the level of S2-S4 vertebrae with fluoroscopic lateral view. An anterior epidurogram was performed using non-ionic contrast agent to visualize the dyeing of the anterior epidural space and the outline of its pathology (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe vertebral level where the catheter tip is located was determined with fluoroscopy. Mechanical adhesiolysis was performed with a video-guided catheter that can be directed and is washed with saline through the side arm of the cannula for better visualization. L5-S1, L4-5, and L3-4 levels were viewed using video imaging. After the herniated disc pathology was observed, a 400 \u0026micro;m diameter Ho: YAG laser probe (ACCU-Tech Co., Ltd, Beijing, China) was advanced to the tip of the video-guided catheter. The lateral view and catheter placement (within the posterior longitudinal ligament [PLL] at the lowest level of the target disc) were confirmed with fluoroscopy and epiduroscopy, aided by video imaging of the anterior epidural space. Using the Ho:YAG laser at 5 W (0.5 J, 10 Hz), a hole was made in the PLL. Then, a fiber video cable was inserted under the herniated intervertebral disc through the hole in the PLL, and the herniated disc was ablated using the Ho: YAG laser at 8 W (0.8 J, 10 Hz). The decompression of the ruptured disc was subsequently confirmed epiduroscopically, demonstrating its decompression from the nerve root (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). At the end of the procedure, 16 mg dexamethasone was applied to the epidural region and then the catheter was removed. Patients without any complaints were sent to the postoperative care room (18).\u003c/p\u003e\n\u003ch3\u003ePostoperative Protocol\u003c/h3\u003e\n\u003cp\u003eAll major complications occurring during or after the surgery were documented. Surgical outcomes were assessed at the patients\u0026apos; most recent follow-up using Odom\u0026apos;s criteria. This 4-point grading system evaluates clinical results following spinal surgery as excellent (no symptoms related to lumbar disc disease and no functional limitations), good (occasional discomfort with minimal functional impact), satisfactory (noticeable improvement but with substantial functional restrictions), and poor (no improvement or a worsening of the condition) (19).\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n \u003cp\u003eAnalysis was performed using Statistical Package for Social Sciences (SPSS) version 20 (IBM Corp., Armonk, NY). Continuous variable data are expressed as median (min-max), while categorical variable data are presented as numbers (%). The normality of data was tested using the Kolmogorov-Smirnov test. For non-normally distributed data in comparisons between groups, the Kruskal-Wallis analysis of variance test and Mann-Whitney U test were used. The Friedman test was used to compare repeated measurements, and the Wilcoxon signed-rank test was used for pairwise comparisons of significant values. Bonferroni correction was applied for post-hoc analyses following comparisons of more than two groups. The chi-square test was used to compare categorical data. A significance level of \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.050 was considered statistically significant, except for post-hoc analyses.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003ePatient Characteristics\u003c/p\u003e\n\u003cp\u003eA total of 106 patients were invited to the study, and 85 agreed to participate. Ten patients were lost to follow-up and excluded from the study, resulting in a final sample size of 75 patients. Of the 75 patients who completed the study, the mean age was 52.00 \u0026plusmn; 11.28 years (range: 30\u0026ndash;78 years), and 45 (60.0%) were female and 35 (40.0%) were male. The most common comorbidity among participants was diabetes mellitus (DM), with 24 (32%) participants reporting this condition. A total of 56 patients (74.7%; 37 [66.1%] female, 19 [33.9%] male) had a history of lumbar surgery. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePain locations were noted as follows: only in the lower back (without radiating pain) in 8 (10.7%) patients; only in the leg(s) (without back pain) in 22 (29.3%) patients; and both in the lower back and leg(s) in 45 (60.0%) patients. Preoperative MRI examinations of the patients revealed at least one pathological finding (bulging/protrusion/extruded disc herniation, central and/or lateral stenosis, granulation at the surgical site) at the L3-4 level in 17 (22.7%) patients, at the L4-5 level in 59 (78.7%) patients, and at the L5-S1 level in 55 (73.3%) patients. Bulging was observed in 10 (13.3%) patients, protrusion in 60 (80.0%) patients, and extruded disc herniation in 8 (10.7%) patients. Central disc involvement was present in 47 (62.7%) patients, foraminal disc involvement in 28 (37.3%) patients, lumbar stenosis in 43 (57.3%) patients, and granulation in 42 (56.0%) patients.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Previously performed spinal interventional procedures were as follows: caudal epidural steroid injection (CESI) in 28 patients (37.3%); transforaminal epidural steroid injection (TESI) in 40 patients (53.3%); radiofrequency ablation (RFA) of medial branch nerves for the lumbar spine in 25 patients (33.3%); and dorsal root ganglion (DRG) pulsed radiofrequency (PRF) in 39 patients (52.0%). While 63 individuals (84.0%) underwent one or more of these four procedures, there were 4 individuals (5.33%) who underwent all of them.\u003c/p\u003e\n\u003cp\u003eAssessment of Pain Intensity and Disability\u003c/p\u003e\n\u003cp\u003ePain intensity: Pain intensity was evaluated at four different time points within a one-year period. Baseline pain intensity (7.43 \u0026plusmn; .774) and pain intensities obtained at three time points following the surgeries (1 month [3.93 \u0026plusmn; 1.571], 6 months [4.36 \u0026plusmn; 1.591], 12 months [5.00 \u0026plusmn; 1.716]) showed statistically significant differences (\u0026chi;2 = 163.39; p \u0026lt; .001) (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1. Pairwise comparisons of pain intensity and pain disability.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 20.7921%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8812%;\"\u003eBaseline \u0026ndash; 1. m\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 11.8812%;\"\u003eBaseline \u0026ndash; 6. m\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 12.8713%;\"\u003eBaseline \u0026ndash; 1. y\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 13.8614%;\"\u003e1. m \u0026ndash; 6. m\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8614%;\"\u003e1. m \u0026ndash; 1. y\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8515%;\"\u003e6. m- 1. y\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7921%;\"\u003e\u003cstrong\u003ePain intensity*\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.8713%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.8614%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8614%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8515%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7921%;\"\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Z\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e-7.380\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e-7.224\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.8713%;\"\u003e-6.616\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.8614%;\"\u003e-2.542\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8614%;\"\u003e-4.867\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8515%;\"\u003e-4.607\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7921%;\"\u003eAsymp. Sig. (2-tailed)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.8713%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.8614%;\"\u003e.011\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8614%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8515%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7921%;\"\u003e\u003cstrong\u003ePain disability**\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.8713%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.8614%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8614%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8515%;\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7921%;\"\u003eZ\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e-6.610\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e-6.373\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.8713%;\"\u003e-5.930\u003csup\u003ea\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.8614%;\"\u003e-1.400\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8614%;\"\u003e-3.043\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8515%;\"\u003e-3.207\u003csup\u003eb\u003c/sup\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7921%;\"\u003eAsymp. Sig. (2-tailed)\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 11.8812%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 12.8713%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 13.8614%;\"\u003e. 162\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.8614%;\"\u003e.002\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.8515%;\"\u003e\u0026lt; .001\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviations: m, month; y, year.\u003c/p\u003e\n\u003cp\u003eWilcoxon Signed Ranks Test.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e: Based on positive ranks. \u003csup\u003eb\u003c/sup\u003e: Based on negative ranks. *: Pain intensity was calculated using NRS.\u003c/p\u003e\n\u003cp\u003e**: Pain-related disability was calculated using ODI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisability:\u003c/strong\u003e ODI (Oswestry Disability Index) values were obtained at four different time points within a one-year period. The baseline pain-related disability (2.92 \u0026plusmn; .539) and the data obtained at three subsequent time points (1 month [1.76 \u0026plusmn; .883], 6 months [1.85 \u0026plusmn; .896], 12 months [2.01 \u0026plusmn; .923]) indicated statistically significant differences in pain-related disability (\u0026chi;2 = 115.489, p \u0026lt; .001) (\u003cstrong\u003eFigure 3\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical outcomes were evaluated according to the Odom criteria. Accordingly, 4 (5.3%) participants achieved \u0026quot;excellent\u0026quot; outcomes, 29 (38.7%) participants achieved \u0026quot;good\u0026quot; outcomes, 27 (36.0%) participants achieved \u0026quot;satisfactory\u0026quot; outcomes, and 15 (20.0%) participants achieved \u0026quot;poor\u0026quot; outcomes. Additionally, 13 (17.3%) patients did not benefit from epiduroscopy and required surgical intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most common complications observed were headache (5 [6.7%] patients) and incisional pain (5 [6.7%] patients). Other observed complications included dural tear in 4 (5.3%) patients, motor loss in 2 (2.7%) patients (one of which was temporary), and infection in 1 (1.3%) patient. Some individuals experienced multiple complications, with a total of 10 (13.3%) individuals developing complications. Among these 10 patients, 8 had a history of lumbar surgery, and 6 had granulation tissue present. One patient who developed motor loss (foot drop) underwent surgical intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntergroup Comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eDemographic data:\u003c/strong\u003e There was no significant difference in surgical outcomes (ODOM criteria) between females and males (p = .566). There was a negative and weak correlation between age and surgical outcomes (r = -0.207; p = .075). There were no notable differences between the groups concerning other demographic variables (p \u0026gt; .050).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003ePain areas:\u003c/strong\u003e Surgical outcomes at the 12-month mark were statistically significant only in the patient group with leg pain only (without back pain) (\u0026chi;2 = 6.572; p = .037). No statistically significant differences were identified between the groups regarding pain intensity and pain-related disability across the assessed pain areas (p \u0026gt; .050).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003ePrevious surgical history:\u003c/strong\u003e Patients with and without a history of prior surgery showed no statistically significant differences in pain intensity, pain-related disability, clinical outcomes, or procedure-related complications (p \u0026gt; .050).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImaging findings:\u003c/strong\u003e Patients with and without granulation tissue, spinal stenosis, and various pathologic findings detected on MRI (extrusion, herniation, bulging, etc.) were evaluated separately, and no significant differences were found between the groups (p \u0026gt; .050).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003ePrevious interventional procedures:\u003c/strong\u003e The types and presence of prior spinal interventional procedures were analyzed, revealing no significant differences between the groups regarding pain, clinical outcomes, or complications (p \u0026gt; .050).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLow back pain is an extremely common health problem affecting individuals of all age groups. In addition to being one of the leading causes of disability, it also causes significant socioeconomic burden (20).\u003c/p\u003e\n\u003cp\u003eThe majority of back pain episodes resolve on their own, regardless of treatment, and most individuals experiencing back pain do not pursue medical attention (21). Approximately 10% to 15% of back pain becomes chronic, and it can cause substantial disability for some in this group. Most patients with low back pain do well with conservativemanagement. However, there are some patients who do not respond to these conservative measures. Many percutaneous disk procedures are in use, and new ones are continually being developed to treat patients with discogenic pain that has failed to respond to more conservative management (22).\u0026nbsp;None of these, however, has been definitively shown to provide better results than a surgical microdiscectomy\u003cem\u003e.\u003c/em\u003e SELD is a minimally invasive procedure that allows for direct visualization and treatment of spinal disorders and can be conducted under local anesthesia (11,23). SELD offers several advantages, including the preservation of paravertebral muscles, protection of bony structures, and rapid recovery. Since Choy et al. (5) first described laser ablation of the intervertebral disc, the SELD technique has significantly advanced over the years (8,11,12,24,25). In our study, the long-term (1-year) effectiveness of SELD was retrospectively evaluated in patients with chronic low back pain who were unresponsive to conventional interventional pain treatments, such as transforaminal/interlaminar/caudal epidural steroid injections and percutaneous facet medial branch radiofrequency ablation.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; A recently published review reported a clinically significant reduction in pain scores, with an average decrease of 2.8 points and a 20% reduction in disability at 12 months following epiduroscopy treatment. The review suggested that this could be an effective treatment option for patients with failed back surgery syndrome (FBSS) (26).\u0026nbsp;Similarly, in our study, when we compared baseline pain intensity with postoperative pain intensity at all time points, we found a statistically significant reduction in pain intensity. At 12 months, we calculated an average decrease of 2.43 points in pain intensity. Similarly, for disability, we obtained significant results across all time points and calculated a 31.1% change at 12 months. The majority of patients in our study (74.7%) had a history of prior lumbar surgery, and all patients had previously undergone conventional interventional treatments due to their pain. A total of 33 participants (44%) experienced significant benefit from the treatment (ODOM grades 4 and 3) at the end of one year. We believe this finding represents the most clinically important outcome of our study, particularly for patients unresponsive to conventional interventional pain treatments. Several previous studies showed that the clinical outcomes of SELD are favorable. These studies reported significant reductions in low back pain or radiating leg pain, with patient satisfaction rates exceeding 70%, and a low incidence of failure or recurrence (27-29). In our study, the one-year follow-up satisfaction rate appears lower compared to these studies in the literature. However, Seong Son et al. (24) reported a patient satisfaction rate of 58.5% and a reintervention rate of 17.1% in their retrospective study of 82 patients with a 6-month follow-up period. These findings are consistent with our results and align with the literature (11,26,29,30,31). In our study, a slight worsening in pain intensity and disability was observed over time, which is similar to findings reported in a recent study (32). Although the reformation of fibrosis following the epiduroscopy procedure is a significant cause of pain, ongoing pathological degenerative processes in the lumbar vertebrae can lead to the re-release of cytokines, subsequently triggering pain again and ultimately resulting in further adhesions.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;We could not establish a direct relationship between demographic data and clinical outcomes. We acknowledge that our sample size was not sufficiently large to allow for such comparisons and emphasize the need to evaluate other potential factors negatively affecting chronic pain with a larger cohort. The mean age of the participants was calculated as 52.00 years, which is consistent with previous studies (31, 33). Compared to those with axial pain, we found significantly better clinical outcomes at the 12-month follow-up in the group with radicular pain. This may be due to the presence of different mechanical causes of axial low back pain in our patients (such as facet arthrosis, instability, spondylolisthesis, or sacroiliac joint-related pain).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;In the literature, the relationship between the type of spinal surgery and epiduroscopy outcomes was examined. Compared to discectomy and laminectomy, clinical outcomes were found to be worse in patients undergoing stabilization surgeries and anterior or posterior lumbar interbody fusion (34,35). However, similar to two separate retrospective studies evaluating the effectiveness of SELD (36,37), we did not find a significant difference in clinical outcomes between patients with or without a history of surgery. The severity of fibrosis may depend on the surgical technique, frequency, and method used (38). Dense fibrous scar tissue that can form in the epidural space after surgery may cause adhesions on the dura mater and nerve roots, and is associated with FBSS (39,40). In epiduroscopy, therapeutic efficacy is linked to the endoscopic adhesiolysis of these lesions (26). Fibrous scar tissue was observed in 42 patients (56.0%); however, we did not find any difference in clinical efficacy between patients with or without fibrosis. Our study included a relatively small patient cohort compared to other studies, which may have prevented some results from reaching statistical significance (e.g., the clinical impact of fibrosis).\u003c/p\u003e\n\u003cp\u003eWe encountered several complications related to epiduroscopy, including transient headaches (n=5), pain at the site of scope insertion (n=5), dural tears (n=4), motor loss (n=2), and mild meningitis (n=1). With the exception of one patient, all symptoms resolved following bed rest and conservative treatment with medications. A single instance of foot-drop due to a laser complication required emergency surgery and was successfully managed.\u003c/p\u003e\n\u003cp\u003eVarious complications, such as postoperative headache, pain at the incision site, motor loss, and infection, have been reported with SELD (11), and the \"60-limit rule\" was optionally recommended for these complications (41). We performed our procedures in accordance with this recommendation. The most common complications we observed were headache and incision site pain (both in 5 [6.7%] patients). Among major complications, dural tears occurred in 4 (5.3%) of our patients. Dural tear rates associated with SELD were documented in the literature to range from 1.7% to 7% (7, 37). In patients with a history of previous surgery, the incidence of dural puncture is notably higher compared to those without surgical history. This increased rate may be associated with anatomical changes and adhesions resulting from prior surgeries, which complicate catheter guidance (41). In our patient population, 74.7% had prior surgical history, which may explain the relatively high rate of dural puncture. Notably, in patients who underwent epiduroscopy with laser application, a significant complication arises from thermal damage to the nerve roots, leading to motor nerve dysfunction. Therefore, special attention is required during the laser procedure (9). In our patient series, motor loss was observed in two patients following laser discectomy, and one of them required emergency surgery.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; This study has some limitations. The data were collected retrospectively, and comparisons with a control group could not be made. The study was conducted at a single center, and the results could not be compared to populations with different socioeconomic and cultural backgrounds. Moreover, sufficient information regarding pain-related emotional and cognitive processes that might influence clinical outcomes was not obtained. Further research involving larger and more diverse populations is required to better understand the factors influencing the outcomes of SELD.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u0026nbsp; We suggest that SELD, a relatively new technique for patients with back and/or leg pain, is an advanced and practical method with a low complication rate and notable efficacy when performed by experienced practitioners. However, most studies in the medical literature are retrospective, as in our study. We suggest that prospective studies with larger patient cohorts are necessary to evaluate the long-term effectiveness of SELD and to assess its associated complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConception or design of the work -------------------------B.U and D.T---------------------Data collection -----------------------------------------B.U and D.T-----Data analysis and interpretation ---------------------------B.U and D.T-------------------Drafting the article ----------------------------------------B.U and D.T------Critical revision of the article ----------------------------------B.U and D.T------------Other (study supervision, fundings, materials, etc ---------------D.D--\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBarr KP, Chrıstopher J. Standaert, Stephen C. Johnson, Neelwant S. Sandhu. Low Back Pain. In: Braddom RL, editor. Braddom\u0026rsquo;s Physical Medicine and Rehabilitation 6th ed. USA. Elsevier Inc.; 2016. p.651\u0026ndash;689. https://doi.org/10.1016/B978-0-323-62539-5.18001-4.\u003c/li\u003e\n\u003cli\u003eWalker BF: The prevalence of low back pain: a systematic review of the literature from 1966 to 1998, J Spinal Disord 13:205\u0026ndash;217. doi: 10.1097/00002517-200006000-00003.\u003c/li\u003e\n\u003cli\u003eManchikanti L, Abdi S, Atluri S, Ramsin M Benyamin, Mark V Boswell, Ricardo M Buenaventura, David A Bryce, Patricia A Burks, David L Caraway, Aaron K Calodney, Kimberly A Cash, Paul J Christo, Steven P Cohen, James Colson, Ann Conn, Harold Cordner, Sareta Coubarous, Sukdeb Datta, Timothy R Deer, Sudhir Diwan, Frank J E Falco, Bert Fellows, Stephanie Geffert, Jay S Grider, Sanjeeva Gupta, Haroon Hameed, Mariam Hameed, Hans Hansen, Standiford Helm 2nd, Jeffrey W Janata, Rafael Justiz, Alan D Kaye, Marion Lee, Kavita N Manchikanti, Carla D McManus, Obi Onyewu, Allan T Parr, Vikram B Patel, Gabor B Racz, Nalini Sehgal, Manohar Lal Sharma, Thomas T Simopoulos, Vijay Singh, Howard S Smith, Lee T Snook, John R Swicegood, Ricardo Vallejo, Stephen P Ward, Bradley W Wargo, Jie Zhu, Joshua A Hirsch. 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Korean J Pain. 2018 Oct;31(4):296-304. doi: 10.3344/kjp.2018.31.4.296.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic Low Back Pain, Epiduroscopy, Laser Discectomy","lastPublishedDoi":"10.21203/rs.3.rs-6134295/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6134295/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThis study aimed to evaluate the effect of sacral epidural laser discectomy (SELD) on clinical parameters in patients with chronic low back and/or leg pain (CLBLP) resistant to conservative treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 75 patients with CLBLP who received SELD treatment were included in the study retrospectively. Patients were assessed for pain (numeric rating scale-NRS), and disability (Oswestry Disability Index-ODI). NRS and ODI scores were recorded before the operation and 1, 6, and 12 months after the operation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 75 patients, the mean age was 52.00\u0026thinsp;\u0026plusmn;\u0026thinsp;11.28 years (range: 30\u0026ndash;78 years), and 45 (60.0%) were female and 35 (40.0%) were male. Baseline pain intensity (7.43\u0026thinsp;\u0026plusmn;\u0026thinsp;.774) and pain intensities obtained at three time points following the surgeries (1 month [3.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.571], 6 months [4.36\u0026thinsp;\u0026plusmn;\u0026thinsp;1.591], 12 months [5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.716]) showed statistically significant differences (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The baseline pain-related disability (2.92\u0026thinsp;\u0026plusmn;\u0026thinsp;.539) and the data obtained at three subsequent time points (1 month [1.76\u0026thinsp;\u0026plusmn;\u0026thinsp;.883], 6 months [1.85\u0026thinsp;\u0026plusmn;\u0026thinsp;.896], and 12 months [2.01\u0026thinsp;\u0026plusmn;\u0026thinsp;.923]) showed a statistically significant difference in pain-related disability (p\u0026thinsp;\u0026lt;\u0026thinsp;.001). The most common complications were headache (5 patients) and incisional pain (5 patients).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAs a result of this study, we found that SELD, a relatively new technique, reduces pain and disability and has a low complication rate in patients with resistant CLBLP.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Sacral Epidural Laser Discectomy in Patients with chronic low back Resistant to Conservative Treatment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-18 12:14:14","doi":"10.21203/rs.3.rs-6134295/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3198ccc6-350f-4d00-9cc4-68c51d83ea5f","owner":[],"postedDate":"March 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-06T00:53:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-18 12:14:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6134295","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6134295","identity":"rs-6134295","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}