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Epiduroscopy in the 21th Century: State of the art

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Presentation on theme: "Epiduroscopy in the 21th Century: State of the art"— Presentation transcript:

1 Epiduroscopy in the 21th Century: State of the art
Jan Willem Kallewaard, Alysis zorggroep Arnhem 5 maart 2010 Veldhoven

2 Evidence Based Medicine
Best available evidence Interventional techniques Largely lack valid comparators, such as no treatment Are crippled by a lack of vigorous self-evaluation of its role in the treatment of chronic pain Evidence-based medicine movement gives little guidance to practitioners whose tools are still under development Advice: Monitor your outcomes using valid measures Be more reflective and systematic in studying your own outcomes and patterns of care Provide this information to your patients as part of the decision-making process Apply outcome instruments that are sensitive and precise enough to detect clinically significant change in the practical setting Merrill DG. Reg Anesth Pain Med 2003; 28: Rathnell & Carr. Editorial. Reg Anesth Pain Med 2003; 28: Praktische richtlijnen anesthesiologische pijnbestrijding 2009

3 Pain management EBM Short term effects>3mnth
Long term effects>6mnth

4 Current algorithm FBSS patient
Conservative therapy ( Med/FT/TENS) Epidural injection//PRF Neuroplasty ( RACZ) Epiduroscopy Neuromodulation

5 conclusion Short term effect ( 3 month) : strong evidence
Long term effect ( > 3 month): moderate evidence Limited literature concerning complications

6 Neuroplasty: why Epiduroscopy

7 History 1931 Burman visualisation spinal canal; s.o.
1936 Elias Stern; s.o.; animalexperiments. 1937 Pool 1th spinal endoscopy; pat. 1970 Ooi et al Fiberoptic scope; pat. 1970 Blomberg; s.o.; 10 pat.; rigid scope ± 1985 flexible scope Igarashi et al Thoracic en Lumbar age, pregnancy, :  epid structures Indication: spinal stenosis Diagnostic tool Adhaesive arachnoiditis 1991 Shimoji et al; diam. <<; fiber- flexible scoop;

8 Saberski et al Richardson et al
Hiatus sacralis: less chance of dura perforation 2 canals Richardson et al Epidural pressure monitoring I

9 Main Indications (2009) Chronic radiculopathic pain Spinal stenosis
Diagnostic tool

10 Applications – Diagnostical Features
Confirmation of presumed diagnoses unverifiable by conventional diagnostics (e.g., CT/MRI): epidural adhesions inflammation tumors anatomical abnormalities biopsies Support & facilitation of catheter placement and electrode implantation ? Postoperative assessment ? Electrical stimulation (case report: PRF through endoscope)

11 Spinal endoscopy vs. MRI
-Anatomy ++ -Vascularity - -Inflammation +/- -Sensitivity -Localisation -Fibrous tissue + -Therapeutic -Disc prolaps id -(ant) -Canal size

12 Applications – Diagnostical Features
Normal 1 Perineural adhesions (7) + inflammation (6) 9 Perineural adhesions 10 Epiduroscopy MRI Patients (20) Geurts et al, Region Anesth Pain Med 2002, 27,

13 Diagnostical features Epiduroscopy vs. MRI
Heavner 2009: Pain Practice: Incidence and severity of epidural fibrosis after back surgery: an endoscopic study Epiduroscopy: 95% fibrosis-MRI 16%fibrosis Concordant pain with fibrosis 84%

14 Applications – Therapeutic Features
Targeted application of therapeutical agents, e.g., anti-inflammatory agents analgesics LA Diluting inflammatoy mediators Removal of harmful epidural contents, e.g., EPIDURAL FIBROSIS (mechanical/laser/coablation) drain cysts ( case report) foreign bodies, e.g., torn epidural/spinal catheters ( case reports)

15 In- & Exclusion criteria
Inclusion criteria refractory lumbosacral radicular pain not responding to conservative measures or other minimal invasive techniques dermatome-like radiation pattern VAS leg > VAS back VAS leg > 4,0 Spinal stenosis Exclusion criteria progressive signs coagulopathy infection increased intracranial pressure space-occupying CNS processes cerebrovascular disease pregnancy manifest bladder & bowel dysfunction sensory disturbances S2-S4 renal insufficency cancer, allergy, language problems, etc.

16 Technique/Materials AND OTHERS…. Myelotec O.D. 2.7 mm/3,0mm
BIOMET EBI-Vue Cath O.D. 2.7 mm Epi-C polyDiagnost O.D. 2.4 mm AND OTHERS….

17 procedure In hospital Diagnostic Therapeutic Neural flossing

18 Developments 2010 Resascope 4 Directions Extra lumen
Adhesiolysis with tools ( foggerty/resaflex)



21 Complications & Adverse Effects
infection epidural hematoma retinal hemorrhage nerve root damage dural perforation & postpuncture headache inadvertent spinal injection of medication increase of preexisting pain pain at catheter insertion place (sacral hiatus)


23 Complications & Adverse Effects
infection epidural hematoma retinal hemorrhage nerve root damage dural perforation & postpuncture headache inadvertent spinal injection of medication increase of preexisting pain pain at catheter insertion place (sacral hiatus)


25 Systematic review of effectiveness and complications of adhesiolysis (2009)
Is spinal endoscopy superior over standard therapy?: Superior over epidural steroid injections, especially after failed percutaneous adhesiolysis, and in lumbar spinal stenosis.

26 Systematic review of effectiveness and complications of adhesiolysis (2009)
Strong evidence short and long term effect of spinal endoscopy in radicular pain Moderate effect in spinal stenosis

27 Literature Study RA/P No. <3mn 3mn 6mn 12m St<3 Lt>3 Manc2005
DB 33 33%/ 90% 0%/ 80% 56% 48% P Igar 2004 5/8 Si SI Geur2002 20 68% 63% 46% Richa2001 34 Manc1999 60 100% 75% 40% 22% Manc2000 85 77% 52% 21%

28 1 year follow up of epiduroscopy patients (n=58) with lumbar spinal stenosis
Igarahashi et al. Brit J Anesth 2004; 93: monosegmental multisegmental

29 BMC Anesthesiology 2005


31 Preliminary Results Rijnstate patients Primary Outcome Success=VAS-Leg Reduction of  50%
Time (months) T=3 T=6 T=9 T=12 T=24 Success (N) (%) 82/120 68.3% 76/120 63.3% 66/120 55.5% 56/120 46.7% 36/120 30%

32 Caudal epidural placement of steroid and spinal endoscopic placement of steroid are effective in patients with sciatica of 6-18 months with superior but not significantly superior results in the caudal epidural group Comment* In their study none of the patients had undergone back surgery in contrast to other studies In their study group very little scar tissue; in only 3pt adhesiolysis is performed Relatively short symptom duration compared to other studies (max 18mnth) * Richardson J, Kallewaard JW, Groen GJ (2005) Spinal endoscopy for chronic sciatica. Br J Anaesth 95:

33 Lanset study 2002 foundation Dutch quality system
15 licensed hospitals 1 hospital development centre ( Alysis) Supported by government ( ZN/CVZ)

34 Protocol indications in-, exclusioncriteria treatment per protocol
technique/materials classification & registration of data number of procedures psychometric tests training hands on informed consent follow up adv. eff./ complications data ownership feedback of results & implementation (pilots) company independence

35 Conclusions I Spinal endoscopy has strong evidence for short term relief and moderate evidence for long term relief These results seems to be better compared to classic epidural steroid injections and effective where percutaneous adhesiolysis fails. The benefits of therapeutic spinal endoscopy seems to be time-limited (note: results of re-do procedures produce the same results in most patients) Only one RCT setting so figures are only a strong indication

36 Conclusions 2: further research
LANSET 2 year follow up 500 patients ( results 2009) 15 hospitals multicentre study ( ) Prospective observational study 1000 patients (started) RCT Quality control

37 Conclusions 3 Technique development!!!!! Tools ( resaflex; laser etc.)
2007: start of European network We need to work together!!

38 Discussion Which place in the algorithm of treatment of radicular pain??? Last option vs. early treatment We need more RCT’s

39 Anesthesiological Treatments
Inhibition of excitation & Excitation of inhibition & Conduction block Anesthesiological Treatments Spinal endoscopy is not THE solution, but might be A solution Are you ready? Here I come...!

40 Thank You!

41 Literature Praktische richtlijnen Anesthesiologische pijnbestrijding (may 2009) ISBN: Epiduroscopy: G Schutze ( ISBN: )

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