an 82-year - old male , a retired teacher , presented as an outpatient with pains in his lower back and radiating down his left leg in the distribution of l4 , 5 dermatome , as well as tingling sensation in the affected region .
he rated his leg pain as 8 of 10 and his back pain as 3 of 10 .
he had a 15-year history of symptoms , which became aggravated over the previous year .
his leg pain resulted in a moderate impairment of activities of daily living , and his functional score on the oswestry disability index was 38% .
physical examination showed mild left lower extremity weakness , and motor strength testing revealed 4+/5 in left quadriceps and tibialis anterior muscle , suggesting pain - induced reduction of strength .
his sensations to light touch and pin prick were normal , his straight leg rising test results were negative , and his dorsalis pedis and tibial arterial pulsation were normal .
although he previously had no limitations in walking , he had recently experienced leg pain after walking for more than five minutes , with relief of pain after sitting or bending forward .
his lumbar x - rays showed grade i retrolisthesis at l1 - 2 - 3 - 4 - 5 and a multiple old compression fracture at l2 , l3 , and l4 .
he had been treated with celebrex ( 200 mg / day ) and ultracet ( 325 mg acetaminophen plus 37.5 mg tramadol ) , a durogesic patch ( 25 g / hr ) , and repeated epidural steroid injections ( seven injections of caudal and/or transforaminal epidural blockers ) . despite these injections and a further increase in analgesic dosage
, he complained of persistent symptoms , with only 10 - 20% improvement over 1 - 2 weeks , and there were no improvements in functional status and walking distance . after obtaining irb approval and
written informed consent from the patient , we performed a transforaminal balloon decompression procedure to alleviate his radicular pain and to extend the duration of pain relief .
the patient was placed in the prone position , and a pillow was placed under his abdomen to minimize lumbar lordosis . after sterile preparation of the surgical field , an 18 g r - k needle ( epimed international , gloversville , usa ) was introduced into the l5 intervertebral foramen , and its tip was confirmed as being in the anterior epidural space by injection of contrast medium ( fig .
1 ) . fluoroscopy was used to visualize the target during the procedure . a 3 fr fogarty catheter (
edward lifescience , irvine , ca , usa ) filled with contrast medium was introduced into the epidural space of the l5 inter - vertebral foramen , and placed in the medial portion of the stenotic area .
the needle was slightly withdrawn , and repeated balloon decompression and deballooning were performed throughout the affected region , from the lateral recess to the dural sleeve , with each ballooning session lasting less than 5 seconds .
l4 intervertebral transforaminal decompression was also performed in the same manner . after removing the fogarty catheter ,
the r - k needle was reinserted and then 3 ml of a mixture of 0.8% lidocaine , 20 mg triamcinolone , and 1,500 iu of hyaluronidase was administered .
after the procedure , however , the patient complained of pain for three days . for the next 15 weeks , the patient reported markedly reduced leg pain ( 2 - 3/10 ) , improved functional status ( 20 - 26% ) and increased claudication distance ( 40 minutes ) .
beginning 16 weeks after treatment , his symptoms recurred , but were more tolerable than those before the treatment .
a 65-year - old male , a farmer , presented with pains in his lower back and right leg in the distribution of l5 dermatome .
his symptoms had started 6 months earlier , but had become aggravated over the previous month .
physical examination showed no weakness in his lower extremities , normal reactions to light touch and pin prick , and normal arterial pulsations .
a lumbar mri scan for back pain one month earlier showed bilateral foraminal stenosis , l4 - 5 and l5-s1 , due to disc protrusion and bulging discs of the entire lumbar spine .
he had been treated with meloxicam 7.5 mg / day and repeated epidural steroid injections ( 4 injections of interlaminar and/or transforaminal epidural blockers ) , but the effects of this treatment persisted for only one month .
a 3 fr fogarty catheter was introduced into the epidural space of his right l5 intervertebral foramen , followed by serial balloon decompression .
after removal of the fogarty catheter , he was administered 3 ml of a mixture of 0.8% lidocaine , 20 mg triamcinolone , and 1,500 iu of hyaluronidase .
over the next 24 weeks , the patient reported no leg pain ( 0/10 ) , markedly improved functional status ( 4 - 8% ) and increased claudication distance ( no limitation to walking ) .
a 77-year - old male , a retired soldier , presented with pain in his lower back , radiating down his right leg in the distribution of l4 dermatome and his left leg in l4 , 5 dermatome .
he had a 3-year history of symptoms , which became aggravated during the previous three months .
motor strength testing showed 4/5 in both quadriceps and tibialis anterior muscles , suggesting pain - induced reduction of strength .
he had a tingling sensation and numbness in his lateral calf and experienced leg pain after walking more than 10 m , making him unable to go to the bathroom in his house .
a lumbar mri scan for back pain two years earlier showed degenerative spondylolisthesis of l4 on l5 , causing severe central stenosis , with the cross - sectional area of his dural sac at the narrowest point being 40.4 mm .
lumbar mri also showed stenosis of both lateral recesses and both neural foramens , as well as retrolisthesis of l5 on s1 with disc bulging and facet arthrosis causing left neural foraminal stenosis .
he had been treated with opalmon 15 mg / day , lyrica 150 mg / day , ultracet and a fentanyl patch ( 25 g / hour ) , and had received 17 epidural steroid injections of transforaminal epidural blockers and decompressive neuroplasty . despite these injections and a further increase in analgesic dosage , he reported no improvements in pain and functional status .
he was not indicated for surgery because of his poor general condition , but was regarded as a candidate for spinal cord stimulation .
a 3 fr fogarty catheter was introduced into epidural space of the left l4 , l5 and the right l4 intervertebral foramen , and balloon decompression and drug administration were performed serially .
, the patient reported moderately reduced leg pain ( 3 - 4/10 ) , improved functional status ( 38 - 40% ) and increased claudication distance ( 70 m ) .
an 82-year - old male , a retired teacher , presented as an outpatient with pains in his lower back and radiating down his left leg in the distribution of l4 , 5 dermatome , as well as tingling sensation in the affected region .
he rated his leg pain as 8 of 10 and his back pain as 3 of 10 .
he had a 15-year history of symptoms , which became aggravated over the previous year .
his leg pain resulted in a moderate impairment of activities of daily living , and his functional score on the oswestry disability index was 38% .
physical examination showed mild left lower extremity weakness , and motor strength testing revealed 4+/5 in left quadriceps and tibialis anterior muscle , suggesting pain - induced reduction of strength .
his sensations to light touch and pin prick were normal , his straight leg rising test results were negative , and his dorsalis pedis and tibial arterial pulsation were normal .
although he previously had no limitations in walking , he had recently experienced leg pain after walking for more than five minutes , with relief of pain after sitting or bending forward .
his lumbar x - rays showed grade i retrolisthesis at l1 - 2 - 3 - 4 - 5 and a multiple old compression fracture at l2 , l3 , and l4 .
he had been treated with celebrex ( 200 mg / day ) and ultracet ( 325 mg acetaminophen plus 37.5 mg tramadol ) , a durogesic patch ( 25 g / hr ) , and repeated epidural steroid injections ( seven injections of caudal and/or transforaminal epidural blockers ) . despite these injections and a further increase in analgesic dosage
, he complained of persistent symptoms , with only 10 - 20% improvement over 1 - 2 weeks , and there were no improvements in functional status and walking distance . after obtaining irb approval and
written informed consent from the patient , we performed a transforaminal balloon decompression procedure to alleviate his radicular pain and to extend the duration of pain relief .
the patient was placed in the prone position , and a pillow was placed under his abdomen to minimize lumbar lordosis . after sterile preparation of the surgical field , an 18 g r - k needle ( epimed international , gloversville , usa ) was introduced into the l5 intervertebral foramen , and its tip was confirmed as being in the anterior epidural space by injection of contrast medium ( fig .
1 ) . fluoroscopy was used to visualize the target during the procedure . a 3 fr fogarty catheter (
edward lifescience , irvine , ca , usa ) filled with contrast medium was introduced into the epidural space of the l5 inter - vertebral foramen , and placed in the medial portion of the stenotic area .
the needle was slightly withdrawn , and repeated balloon decompression and deballooning were performed throughout the affected region , from the lateral recess to the dural sleeve , with each ballooning session lasting less than 5 seconds .
l4 intervertebral transforaminal decompression was also performed in the same manner . after removing the fogarty catheter ,
the r - k needle was reinserted and then 3 ml of a mixture of 0.8% lidocaine , 20 mg triamcinolone , and 1,500 iu of hyaluronidase was administered .
after the procedure , however , the patient complained of pain for three days . for the next 15 weeks , the patient reported markedly reduced leg pain ( 2 - 3/10 ) , improved functional status ( 20 - 26% ) and increased claudication distance ( 40 minutes ) .
beginning 16 weeks after treatment , his symptoms recurred , but were more tolerable than those before the treatment .
a 65-year - old male , a farmer , presented with pains in his lower back and right leg in the distribution of l5 dermatome .
his symptoms had started 6 months earlier , but had become aggravated over the previous month .
physical examination showed no weakness in his lower extremities , normal reactions to light touch and pin prick , and normal arterial pulsations .
a lumbar mri scan for back pain one month earlier showed bilateral foraminal stenosis , l4 - 5 and l5-s1 , due to disc protrusion and bulging discs of the entire lumbar spine .
he had been treated with meloxicam 7.5 mg / day and repeated epidural steroid injections ( 4 injections of interlaminar and/or transforaminal epidural blockers ) , but the effects of this treatment persisted for only one month .
a 3 fr fogarty catheter was introduced into the epidural space of his right l5 intervertebral foramen , followed by serial balloon decompression .
after removal of the fogarty catheter , he was administered 3 ml of a mixture of 0.8% lidocaine , 20 mg triamcinolone , and 1,500 iu of hyaluronidase . there were no complications throughout the procedure . over the next 24 weeks , the patient reported no leg pain ( 0/10 ) , markedly improved functional status ( 4 - 8% ) and increased claudication distance ( no limitation to walking ) .
a 77-year - old male , a retired soldier , presented with pain in his lower back , radiating down his right leg in the distribution of l4 dermatome and his left leg in l4 , 5 dermatome .
he had a 3-year history of symptoms , which became aggravated during the previous three months .
motor strength testing showed 4/5 in both quadriceps and tibialis anterior muscles , suggesting pain - induced reduction of strength .
he had a tingling sensation and numbness in his lateral calf and experienced leg pain after walking more than 10 m , making him unable to go to the bathroom in his house .
a lumbar mri scan for back pain two years earlier showed degenerative spondylolisthesis of l4 on l5 , causing severe central stenosis , with the cross - sectional area of his dural sac at the narrowest point being 40.4 mm .
lumbar mri also showed stenosis of both lateral recesses and both neural foramens , as well as retrolisthesis of l5 on s1 with disc bulging and facet arthrosis causing left neural foraminal stenosis .
he had been treated with opalmon 15 mg / day , lyrica 150 mg / day , ultracet and a fentanyl patch ( 25 g / hour ) , and had received 17 epidural steroid injections of transforaminal epidural blockers and decompressive neuroplasty . despite these injections and a further increase in analgesic dosage , he reported no improvements in pain and functional status .
he was not indicated for surgery because of his poor general condition , but was regarded as a candidate for spinal cord stimulation .
a 3 fr fogarty catheter was introduced into epidural space of the left l4 , l5 and the right l4 intervertebral foramen , and balloon decompression and drug administration were performed serially . there were no complications throughout the procedure . over the next 24 weeks , the patient reported moderately reduced leg pain ( 3 - 4/10 ) , improved functional status ( 38 - 40% ) and increased claudication distance ( 70 m ) .
although little is known regarding the nonoperative management of spinal stenosis , conservative treatment usually includes physical therapy , nsaids , muscle relaxants and/or mild narcotics , as needed by individual patients .
in addition , local anesthetics and corticosteroids are usually administered to relieve symptoms of persistent pain .
although lumbar epidural corticosteroid injections have not consistently shown efficacy , they may relieve pain in patients with symptoms resulting from inflammation at the interface between the nerve root and the compressing tissues .
epidural injection of steroids is thought to reduce inflammatory edema of the injured nerve root and thus improve intraneural blood flow , decrease sensitization of the dorsal horn neurons and suppress the transmission of nociceptive c - fibers .
local anesthetics induce sympathetic nerve blockade and vasodilation , thereby improving blood flow to the ischemic neural element .
co - administration of hyaluronidase has also been used to enhance the effect of lysis of epidural adhesion .
epidural injection of steroids and local anesthetics in patients with spinal stenosis has been shown to result in only short - lived improvements in pain and function , because the symptoms of spinal stenosis reflect a combination of pathological processes caused by space occupying lesions or fibrosis , such as interruption of blood flow , venous congestion , ischemia , axonal damage and intraneural fibrosis . since serial injections of conventional epidural steroids into our three patients did not result in symptom relief , we utilized an alternative technique focused on resolving the underlying pathophysiology of spinal stenosis , consisting of percutaneous epidural foraminoplasty with 3 fr fogarty catheters , balloon decompression of the epidural space of the intervertebral foramina , and administration of drugs to the target region .
fogarty catheters were initially utilized in thrombectomy to remove fresh , soft emboli and thrombi from arteries and veins .
using its pliable distal tip , designed to minimize trauma to the venous valves , to manipulate around perineural structures enables a relatively safe procedure . instead of inflating with air , however , we used contrast medium , enabling visualization of ballooning and de - ballooning during the procedure .
several factors may be responsible for post - decompression pain relief and functional improvement in our patients .
for example , balloon distension of the epidural space may result in effective mechanical detachment of perineural adhesion , which may play a role in restoring the mobility of the nerve roots to some extent , thus contributing to long - term symptom relief .
moreover , mechanical ballooning of a narrow intervertebral foramen may reduce venous congestion and mechanical irritation .
venous congestion has been regarded essential in precipitating circulatory disturbance , thus inducing neurogenic claudication .
furthermore , initial improvements of symptoms after the decompressive procedure may be due to local anesthetics and steroids that reach the areas causing these symptoms .
balloon dilatation and adhesiolysis , however , may also contribute to the effective delivery of epidural injections to regions of spinal stenosis , thereby improving the effects of drugs in these target lesions .
we found that balloon decompression did not yield consistent results in our patients , which may be due to differences in disease severity and/or physical condition .
patient one achieved 4 months of modest symptom relief , whereas patient two had 6 months symptom - free .
patient three showed incomplete improvement , but this seemed acceptable because this patient was considered a candidate for a spinal cord stimulator .
additional studies involving more patients are needed to establish the proper criteria for selecting patients for balloon decompression .
patient safety should also be considered in the effects of acute compression on spinal nerves .
increasing pressure and its duration have been found to induce more pronounced effects such as intraneural edema .
the safe limits of nerve compression in vivo have not been established , however , transforaminal balloon decompression would be regarded as safe if the balloon pressure is increased slowly and the procedure is limited to less than 2 - 4 h .
there have been previous attempt to use various balloon catheter for epidural adhesiolysis in patients with failed back surgery syndrome . to our knowledge
, however , this is the first report describing the use of epidural balloon catheters to decompress the intervertebral foraminal space in the treatment of patients with spinal stenosis . over the past several years
, minimally invasive surgical techniques have been introduced , using smaller incisions and more limited removal of the innate structure , to achieve decompression .
although our case series provides only anecdotal evidence , the results suggest that transforaminal decompression using a balloon may have potential in the nonsurgical treatment of this condition by modifying the underlying pathophysiology of segmental stenosis .
ongoing randomized controlled trials with larger sample sizes will address the effects of this treatment on pain improvement , functional score and claudication distance .
 lumbar spinal stenosis is a commonly treated with epidural injections of local anesthetics and corticosteroids , however , these therapies may relieve leg pain for weeks to months but do not influence functional status . furthermore , the majority of patients report no substantial symptom change over the repeated treatment . utilizing balloon catheters , we successfully treated with three patients who complained persistent symptoms despite repeated conventional steroid injections . 
 our results suggest that transforaminal decompression using a balloon catheter may have potential in the nonsurgical treatment of spinal stenosis by modifying the underlying pathophysiology . 
CASE REPORT
1. Patient 1
2. Patient 2
3. Patient 3
DISCUSSION