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 Arnhem5 maart 2010 Veldhoven
2 Evidence Based Medicine Best available evidenceInterventional techniquesLargely lack valid comparators, such as no treatmentAre crippled by a lack of vigorous self-evaluation of its role in the treatment of chronic painEvidence-based medicine movement gives little guidance to practitioners whose tools are still under developmentAdvice:Monitor your outcomes using valid measuresBe more reflective and systematic in studying your own outcomes and patterns of careProvide this information to your patients as part of the decision-making processApply outcome instruments that are sensitive and precise enough to detect clinically significant change in the practical settingMerrill 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
10 Applications – Diagnostical Features Confirmation of presumed diagnoses unverifiable by conventional diagnostics (e.g., CT/MRI):epidural adhesionsinflammationtumorsanatomical abnormalitiesbiopsiesSupport & 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 Normal1Perineural adhesions (7) + inflammation (6)9Perineural adhesions10EpiduroscopyMRIPatients(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 studyEpiduroscopy: 95% fibrosis-MRI 16%fibrosisConcordant pain with fibrosis 84%
14 Applications – Therapeutic Features Targeted application of therapeutical agents, e.g.,anti-inflammatory agentsanalgesicsLADiluting inflammatoy mediatorsRemoval 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 criteriarefractory lumbosacral radicular painnot responding to conservative measures or other minimal invasive techniquesdermatome-like radiation patternVAS leg > VAS backVAS leg > 4,0Spinal stenosisExclusion criteriaprogressive signscoagulopathyinfectionincreased intracranial pressurespace-occupying CNS processescerebrovascular diseasepregnancymanifest bladder & bowel dysfunctionsensory disturbances S2-S4renal insufficencycancer, allergy, language problems, etc.
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 painModerate effect in spinal stenosis
27 Literature Study RA/P No. <3mn 3mn 6mn 12m St<3 Lt>3 Manc2005 DB3333%/90%0%/80%56%48%PIgar 20045/8SiSIGeur20022068%63%46%Richa200134Manc199960100%75%40%22%Manc20008577%52%21%
28 1 year follow up of epiduroscopy patients (n=58) with lumbar spinal stenosis Igarahashi et al.Brit J Anesth 2004; 93:monosegmentalmultisegmental
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 groupComment*In their study none of the patients had undergone back surgery in contrast to other studiesIn their study group very little scar tissue; in only 3pt adhesiolysis is performedRelatively 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 hospitals1 hospital development centre ( Alysis)Supported by government ( ZN/CVZ)
34 Protocol indications in-, exclusioncriteria treatment per protocol technique/materialsclassification & registration of datanumber of procedurespsychometric teststraining hands oninformed consentfollow upadv. eff./ complicationsdata ownershipfeedback of results & implementation (pilots)company independence
35 Conclusions ISpinal endoscopy has strong evidence for short term relief and moderate evidence for long term reliefThese 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 LANSET2 year follow up 500 patients ( results 2009)15 hospitals multicentre study ( )Prospective observational study 1000 patients (started)RCTQuality control
37 Conclusions 3 Technique development!!!!! Tools ( resaflex; laser etc.) 2007: start of European networkWe need to work together!!
38 DiscussionWhich place in the algorithm of treatment of radicular pain???Last option vs. early treatmentWe need more RCT’s
39 Anesthesiological Treatments Inhibition of excitation & Excitation of inhibition & Conduction blockAnesthesiological TreatmentsSpinal endoscopy is not THE solution,but might be A solutionAre you ready?Here I come...!