Percutaneous epidural balloon decompression and neuroplasty by ZiNeu catheter in lumber spinal stenosis patient in Bangladesh: A case report
Authors
- Rajat Shuvra DasDepartment of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (currently, Bangladesh Medical University), Dhaka, Bangladesh
- Sanjoy Kumar SahaDepartment of Anaesthesia, Analgesia and Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (currently, Bangladesh Medical University), Dhaka, Bangladesh
- Panna Lal SahaDepartment of Anaesthesiology, Critical Care and Pain Medicine, National Institute of Burn and Plastic Surgery, Dhaka, Bangladesh
. - Jin-Woo ShinDepartment of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, South Korea
.
DOI:
Keywords
percutaneous epidural balloon decompression, lumbar spinal stenosis, ZiNeu catheter
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Correspondence
Publication history
Received: 15 Jan 2025
Accepted: 24 Apr 2025
Published online: 14 May 2025
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Funding
None.
Ethical approval
Ethical approval was not sought because this is a case report. However, written informed consent was obtained from the patient for publication of this case report and any accompanying images.
Trial registration number
Not applicable
Copyright
© The Author(s) 2025; all rights reserved
Published by Bangabandhu Sheikh
Mujib Medical University (currently, Bangladesh Medical University)
Published by Bangabandhu Sheikh
Mujib Medical University (currently, Bangladesh Medical University)
Key messages
This case demonstrates the efficacy of percutaneous epidural balloon neuroplasty with a zineu catheter for lumbar spinal stenosis in patients unresponsive to conservative treatment. This procedure facilitates adhesiolysis, reduces venous congestion, and enables localised drug delivery, resulting in pain relief and functional improvement. It may also serve as an alternative to surgical intervention or conventional epidural steroid injections.
Introduction
Introduction
Epidural adhesions, often resulting from surgery, spinal stenosis, or disc herniation, restrict spinal nerve movement and increase neural sensitivity causing pain. Percutaneous epidural adhesiolysis (PEA), particularly beneficial for patients resistant to conservative treatments, breaks these adhesions and delivers drugs directly to the affected area [1]. Utilising Racz or ZiNeu catheters, PEA enhances drug distribution effectiveness hindered by adhesions [2]. PEA proves more effective than traditional epidural steroid injections in lumbar spinal stenosis [3]. Percutaneous epidural balloon neuroplasty (PEBN), combining balloon decompression and neuroplasty, has shown significant pain reduction and functional improvement with minimal complications [4]. We report a case of percutaneous balloon decompression and neuroplasty with a ZiNeu catheter for lumbar spinal canal stenosis, confirming its safety and effectiveness. So far literature search, no cases of combined balloon decompression and epidural neuroplasty with the ZiNeu catheter have been reported in our country.
Case description and management
Case description and management
..
A 22-year-old female presented with a three-year history of lower back pain and right leg tingling that worsened after walking for 5 minutes and improved with rest or forward flexion. Physical examination revealed bilateral sacroiliac joint tenderness, positive straight leg raise, at right side, Patrick's, sacral thrust, and Kemp tests. Laboratory findings showed elevated erythrocyte sedimentation rate(40 mm/hr) and C-reactive protein 8, pelvic radiography (modified Ferguson view) indicated bilateral grade 2 sacroiliitis.
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MRI showed L4-L5 right paracentral disc protrusion and L5-S1 diffuse disc bulge, compressing L4-L5 traversing nerve roots, resulting in right-sided foraminal stenosis at L4-L5 and bilateral neural foraminal stenosis at L5-S1. The diagnosis was lumbar spinal canal stenosis at L4-L5 and L5-S1 caused by right paracentral disc protrusion and spondyloarthropathy. The patient received oral ibuprofen, acetaminophen, pantoprazole, and duloxetine, along with oral tofacitinib and physical exercise based on specialists' recommendations.
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After one month, with minimal improvement, the patient underwent percutaneous epidural balloon decompression and neuroplasty. The procedure performed under C-arm guidance with American Society of Anesthesiologists Monitoring System, involved an 18-gauge IV line in the right arm and a 10-gauge caudal epidural needle from the ZiNeu (02) 1.55 mm catheter set up to S3 in caudal epidural space. The skin was infiltrated with 1% lidocaine before needle insertion. A mixture of 10 ml iohexol contrast dye and 1% lidocaine (1:1) identified filling defects at L5-S1 anterior epidural space and bilateral foramen and L4-L5 anterior epidural space (Figure-1a). A ZiNeu balloon catheter was guided to both the anterior and posterior epidural space at the sites of the filling defect mentioned above and, ballon was inflated with 0.1 ml iohexol dye for adhesiolysis and repeated for up to a maximum of 5 seconds at each site (Figure 1). Dexamethasone (3 mg) was injected into L4-L5 and L5-S1. Severe adhesions in the L5-S1 anterior epidural space necessitated 1500 units of hyaluronidase.
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Although an epidurogram showed dye spread to the anterior epidural space and right L5-S1 neural foramen, balloon decompression could not be done at the L4-L5 anterior epidural space. An epidural catheter was placed in the right L4-L5 lateral canal, and 5 ml of plain 1% lidocaine was administered postoperatively. Thirty minutes later, 4 ml of 5.0% NaCl was injected after confirming the absence of motor block. The patient was discharged after one hour of satisfaction. Follow-ups over one month showed reduced pain, tingling, numbness, and improved mobility, with scores of 2/11 on the numerical rating scale, 8/35 on Paindetect, and 4 on PHQ9. The patient was able to walk for 30-40 minutes without neurogenic claudication. Physical examination revealed negative straight leg raise, and Kemp tests on the right side.
Categories | Number (%) |
Sex |
|
Male | 36 (60.0) |
Female | 24 (40.0) |
Age in yearsa | 8.8 (4.2) |
Education |
|
Pre-school | 20 (33.3) |
Elementary school | 24 (40.0) |
Junior high school | 16 (26.7) |
Cancer diagnoses |
|
Acute lymphoblastic leukemia | 33 (55) |
Retinoblastoma | 5 (8.3) |
Acute myeloid leukemia | 4 (6.7) |
Non-Hodgkins lymphoma | 4 (6.7) |
Osteosarcoma | 3 (5) |
Hepatoblastoma | 2 (3.3) |
Lymphoma | 2 (3.3) |
Neuroblastoma | 2 (3.3) |
Medulloblastoma | 1 (1.7) |
Neurofibroma | 1 (1.7) |
Ovarian tumour | 1 (1.7) |
Pancreatic cancer | 1 (1.7) |
Rhabdomyosarcoma | 1 (1.7) |
aMean (standard deviation) | |
Categories | Number (%) |
Sex |
|
Male | 36 (60.0) |
Female | 24 (40.0) |
Age in yearsa | 8.8 (4.2) |
Education |
|
Pre-school | 20 (33.3) |
Elementary school | 24 (40.0) |
Junior high school | 16 (26.7) |
Cancer diagnoses |
|
Acute lymphoblastic leukemia | 33 (55) |
Retinoblastoma | 5 (8.3) |
Acute myeloid leukemia | 4 (6.7) |
Non-Hodgkins lymphoma | 4 (6.7) |
Osteosarcoma | 3 (5) |
Hepatoblastoma | 2 (3.3) |
Lymphoma | 2 (3.3) |
Neuroblastoma | 2 (3.3) |
Medulloblastoma | 1 (1.7) |
Neurofibroma | 1 (1.7) |
Ovarian tumour | 1 (1.7) |
Pancreatic cancer | 1 (1.7) |
Rhabdomyosarcoma | 1 (1.7) |
aMean (standard deviation) | |
Pain level | Number (%) | P | ||
Pre | Post 1 | Post 2 | ||
Mean (SD)a pain score | 4.7 (1.9) | 2.7 (1.6) | 0.8 (1.1) | <0.001 |
Pain categories | ||||
No pain (0) | - | 1 (1.7) | 31 (51.7) | <0.001 |
Mild pain (1-3) | 15 (25.0) | 43 (70.0) | 27 (45.0) | |
Moderete pain (4-6) | 37 (61.7) | 15 (25.0) | 2 (3.3) | |
Severe pain (7-10) | 8 (13.3) | 2 (3.3) | - | |
aPain scores according to the visual analogue scale ranging from 0 to 10; SD indicates standard deviation | ||||
Figure 1 a) Epidurogram before percutaneous balloon decompression, b) Epidurogram after percutaneous balloon decompression, c) Zineu catheter at posterior epidural space with inflated balloon.
Discussion
The Lower back and lower extremity pain unresponsive to conservative treatments is often linked to post-surgery syndrome, spinal stenosis, or disc herniation [5]. For patients unsuitable for or unresponsive to surgery and epidural injections, percutaneous adhesiolysis may be an effective alternative [6]. PEA alleviates pain and improves function by disrupting epidural adhesions and restoring nerve mobility.
Studies show PEA's efficacy in managing lumbar spinal stenosis, chronic disc herniation, and post-lumbar surgery syndrome [7]. The ZiNeu catheter's balloon technology aids adhesiolysis and decompression, enhancing epidural drug delivery and expanding stenotic areas. This intervention increases nerve root mobility and reduces neurogenic claudication symptoms [8].
Epidurography is crucial for identifying filling defects from adhesions and assessing procedural efficacy. A study reported transforaminal balloon treatment increased epidural space in the intervertebral foramen by 28% and lumbar foraminal canal volume by 98% [9]. Research shows significant pain relief and functional improvement with balloon decompression. In our case, improvement confirmed the safety and effectiveness of this minimally invasive procedure.
The combined balloon decompression and adhesiolysis approach using the ZiNeu catheter offers a promising alternative for managing chronic lumbar spinal stenosis, providing long-term relief and functional recovery while minimising risks.
Acknowledgements
This procedure was performed at the Social Islami Bank Limited Hospital, Panthapath, on 12 November 2024. We are thankful to the hospital authority, operation theatre, and post-surgery care unit staff of the hospital and the Bangladesh Pain Management and Research Center for their uneventful support in performing this case. Furthermore, we are grateful to the patient for his willingness to cooperate and consent to this procedure at the first intention after discussion..
Author contributions
Manuscript drafting and revising it critically: RSD, SKS, AKMA. Approval of the final version of the manuscript: RSD, SKS, PLS, JWS, AKMS. Guarantor accuracy and integrity of the work: RSD, SKS, PLS, JWS, AKMA..
Conflict of interest
We do not have any conflict of interest.
Data availability statement
We confirm that the data supporting the findings of the study will be shared upon reasonable request.
Supplementary file
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