Epiduroscopy in the 21 th Century: State of the art

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: 547-560 Rathnell & Carr. Editorial. Reg Anesth Pain Med 2003; 28: 498-501 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. Neuroplasty: why Epiduroscopy

6. 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;

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

8. Main Indications (2009) • Chronic radiculopathic pain • Spinal stenosis • Diagnostic tool

9. 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)

10. Spinal endoscopy vs. MRI

11. Patients (20) MRI Epiduroscopy 10 Perineural adhesions Perineural adhesions 9 Normal Perineural adhesions (7) + inflammation (6) 1 Normal Normal Applications – Diagnostical Features Geurts et al, Region Anesth Pain Med 2002, 27, 343-352

12. Diagnostical featuresEpiduroscopy 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%

13. 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)

14. 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. In- & Exclusion criteria

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

16. procedure • In hospital • Diagnostic • Therapeutic • Neural flossing

17. Developments 2010 • Resascope • 4 Directions • Extra lumen • Adhesiolysis with tools ( foggerty/resaflex)

20. 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) Complications & Adverse Effects

22. 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) Complications & Adverse Effects

24. 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.

25. 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

26. Literature

27. 1 year follow up of epiduroscopy patients (n=58) with lumbar spinal stenosis Igarahashi et al. Brit J Anesth 2004; 93: 181-187 monosegmental multisegmental

28. BMC Anesthesiology 2005

30. Preliminary Results Rijnstate patientsPrimary OutcomeSuccess=VAS-Leg Reduction of  50%

31. 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: 275-276

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

33. 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 Protocol

34. 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

35. Conclusions 2: further research LANSET • 2 year follow up 500 patients ( results 2009) • 15 hospitals multicentre study ( 2006-2009) • Prospective observational study 1000 patients (started) • RCT • Quality control

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

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

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

39. Thank You!

40. Literature 2009-2010 • Praktische richtlijnen Anesthesiologische pijnbestrijding (may 2009) ISBN: 978-90-77411-04-09 • Epiduroscopy: G Schutze ( ISBN: 978-3-540-87544-4)