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

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Presentation on theme: "Epiduroscopy in the 21 th Century: State of the art Jan Willem Kallewaard, Alysis zorggroep Arnhem 5 maart 2010 Veldhoven."— Presentation transcript:

1 Epiduroscopy in the 21 th 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 Elias Stern; s.o.; animalexperiments Pool 1th spinal endoscopy ; pat Ooi et al Fiberoptic scope; pat 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 –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 Normal 1 Perineural adhesions (7) + inflammation (6) Normal9 Perineural adhesions 10 EpiduroscopyMRIPatients (20) Geurts et al, Region Anesth Pain Med 2002, 27, Applications – Diagnostical Features

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 S 2 -S 4 renal insufficency cancer, allergy, language problems, etc.

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

17 procedure In hospital Diagnostic Therapeutic Neural flossing

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

19

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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)

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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)

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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 StudyRA/PNo.<3mn3mn6mn12mSt<3Lt>3 Manc 2005 RA, DB 3333%/ 90% 0%/ 80% 0%/ 56% 0%/ 48% PP Igar 2004 P5/8SiSISi PP Geur 2002 P2068% 63%46%PP Richa 2001 P34Si PP Manc 1999 P60100%75%40%22%PP Manc 2000 P85100%77%52%21%PP

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

30

31 Time(months)T=3T=6T=9T=12T=24 Success (N) (%)82/ %76/ %66/ %56/ %36/12030% Preliminary Results Rijnstate patients Primary Outcome Success=VAS-Leg Reduction of  50%

32 * Richardson J, Kallewaard JW, Groen GJ (2005) Spinal endoscopy for chronic sciatica. Br J Anaesth 95: 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)

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 Are you ready? Here I come...! Spinal endoscopy is not THE solution, but might be A solution

40 Thank You!

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


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