Lumbosacral Radicular Syndrome. Are interventions useful?
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1 Lumbosacral Radicular Syndrome Are interventions useful? Koen Van Boxem, MD, PhD, FIPP Anesthesiology Multidisciplinary pain unit St-Jozefkliniek Bornem, Belgium Maastricht Universitair Medisch Centrum, Netherlands
2 Lumbosacral radicular pain I. Epidemiology II. Are Interventions useful? conservative Epidural steroïds (epidural) anti-tnf, NGF surgery PRF Neurostimulation
3 Lumbosacral radicular pain I. Epidemiology
4 Herniated disc Van Boxem RAPM 2014 Li Anesthesiology 2007, Li RAPM 2011 Rogier Trompert Medical Art Van Boxem RAPM Cohen
5 Herniated disc Li Anesthesiology 2007, Li RAPM 2011 Van Boxem RAPM Cohen
6 Herniated disc Inflammation Neuropathic pain Ischemia - compression Li Anesthesiology 2007, Li RAPM 2011 Van Boxem RAPM Cohen
7 Epidemiology Definition? No consensus : sciatica, ischias, nerve root entrapment, radicular pain, radiculopathy, pain in the leg, nerve root pain Lumbosacral Radicular Syndrome (LRS) Merksey, Bogduk IASP Press 1994 Juan Valverde, 1568, Museum Plantin-Moretus, Belgium
8 Epidemiology Spontaneous evolution : Peul Pain 2008
9 Epidemiology Annual incidence : 9/1000 (Nl) Point prevalence : % 30-64j prevalence : 5% Most occuring form of neuropathic pain Heliovaara 1987 Van der Linden 2004,Dworkin Pain 2007 Bala Epidemiology of pain in the Netherlands 2011
10 Low QOL Doth Pain 2010
11 Conclusion epidemiology Spontaneous evolution : 75 % recovery 3 months but 25 % : unfavorable, female High recurrence 2 years, 2 nd line : 40 % not successful ¼ out of work Most frequent neuropathic pain Low quality of life Ropper NEJM 2015 Balague 1999, Vroomen 2002, Pinto 2012 Dworkin 2007 Suri 2012, Haugen 2012, Grovle 2013
12 Lumbosacral radicular pain II. Are interventions useful?
13 Therapy EBM In God we trust, all others must bring data Demming
14 Therapy EBM In God we trust, all others must bring data - Expert opinion Demming
15 Therapy EBM In God we trust, all others must bring data - Expert opinion - retrospective Demming
16 Therapy EBM In God we trust, all others must bring data - Expert opinion - retrospective - Prospective Demming
17 Therapy EBM In God we trust, all others must bring data - Expert opinion - retrospective - Prospective - Randomized controlled trial Demming
18 Therapy EBM In God we trust, all others must bring data - Expert opinion - retrospective - Prospective - Randomized controlled trial Demming
19 Lumbosacral radicular pain II. Are interventions useful? Conservative
20 Therapy EBM Bedrest vs stay active : - Goldberg JAMA 2015, Dahm Cochrane 2010 Luijsterburg 2007, Verwoerd Physical Therapy 2015 Santilli 2006
21 Therapy EBM Bedrest vs stay active : - Medication Paracetamol :? NSAID : - Morphine : - MPA IV 500mg, oral 60mg : not clinically relevant Nortryptylline, gabapentin, pregabalin, : - Goldberg JAMA 2015, Dahm Cochrane 2010 Luijsterburg 2007, Verwoerd Physical Therapy 2015 Santilli 2006
22 Therapy EBM Bedrest vs stay active : - Medication Paracetamol :? NSAID : - Morphine : - MPA IV 500mg, oral 60mg : not clinically relevant Nortryptylline, gabapentin, pregabalin, : - Physiotherapy : + 1 j, only when fear of movement? Goldberg JAMA 2015, Dahm Cochrane 2010 Luijsterburg 2007, Verwoerd Physical Therapy 2015 Santilli 2006
23 Therapy EBM Bedrest vs stay active : - Medication Paracetamol :? NSAID : - Morphine : - MPA IV 500mg, oral 60mg : not clinically relevant Nortryptylline, gabapentin, pregabalin, : - Physiotherapy : + 1 j, only when fear of movement? Spinal manipulation : + 45d Goldberg JAMA 2015, Dahm Cochrane 2010 Luijsterburg 2007, Verwoerd Physical Therapy 2015 Santilli 2006
24 Lumbosacral radicular pain II. Are interventions useful? conservative Epidural steroïds
25 Van Boxem RAPM 2014 Li Anesthesiology 2007, Li RAPM 2011 Cohen 2013
26 Epidural steroids Route : TF > IL, caudal Ackerman 2007, Cohen 2013 Kennedy Pain Medicine 2014 Kamble Eur Spine J 2015
27 Prevention of surgery? 1. Primaire outcome : Herniated disc or SS TF steroïd+bupi vs TF bupi 1->2j : surgery 28,6% vs 66,7% 5j : majority not operated Bicket Spine J 2015 Riew 2000, Riew 2006
28 Prevention of surgery? 2. Secundaire outcome : cross-over to surgery? No surgery sparing effect 3. ESI vs surgery +: 1/3 tot ½ prevention of surgery Bicket Spine J 2015 Radcliff 2012, Radcliff 2013, Butterman 2004, Gerszten 2010
29 Efficiency ESI? Conclusion : + subacute effect ( 3 months, longer?) + cost-effective Limited prevention of surgery short-term Bicket 2015, Pinto 2012 Fitzsimmons Pain 2014, Spuiker Huiges 2014
30 Safety? USA 2012: fungal contamination : 39 lethal Neurological complications : particulate steroids Cohen 2013
31 US response? American Academy of Pain Medicine ASA, ISIS American association neurological surgeons American Academy of Physical Medicine and rehabilitation American college of radiology American pain society American Society of Regional Anesthesia Pain Medicine e.g. first injection lumbar TF : dexamethasone Rathmell Anesthesiology 2015
32 Benelux response? working group : - Vlaamse Anesthesie Vereniging Pijnbestrijding - GRID - BPS - Nederlandse Vereniging Anesthesie, sectie pijn - World Institute of Pain, section Benelux - Dutch Pain Society Rathmell Anesthesiology 2015
33 Lumbosacral radicular pain II. Are interventions useful? conservative Epidural steroïds (epidural) anti-tnf, NGF
34 Anti-TNF, NGF Anti TNF-α insufficient proof, SE : - Anti NGF small positive effect, SE : - Nefyn SR Eur Spine J 2013, Leite SR Pain Physician 2014
35 Lumbosacral radicular pain II. Are interventions useful? conservative Epidural steroïds (epidural) anti-tnf, NGF surgery
36 Therapy EBM Surgery : 1 j >6-12 weken Progressive neurological paresis or sudden very severe paresis Faster motor recovery after surgery 3 months - 1 year : no difference (resp ESI, conserv care) Short-term : faster and better pain relief Long-term : conflicting evidence Butterman 2004, Peul NEJM 2007 Jacobs 2011, Overdevest Spine J 2014
37 Lumbosacral radicular pain II. Are interventions useful? conservative Epidural steroïds (epidural) anti-tnf, NGF surgery Pulsed Radiofrequency (PRF)
38 Two methods of RF application Continuous radiofrequency (CRF) Pulsed radiofrequency (PRF) Burst of RF No RF
39 Biological effect? 20 msec, 2 Hz, 45 V Δ myeline, mitochondrien, Max 42 C microfilamenten, microtubuli Van Boxem RAPM 2014
40 Dorsal horn : C-Fos Met-enkephalinen ERK, TNF-α OX-42,p38 (microglia) 5HT en NA Dorsal root ganglion : Δ myeline, mitochondria, microfilamenta, microtubuli ATF-3, voltage channels Van Boxem RAPM 2014
41 Clinical effect? Retrospective Prospective : unclear inclusion Van Boxem Pain Medicine 2011
42 Clinical effect? Prospective study F.U. : 6 months - Chronic LSR, unilateral - 1 dermatome until big toe or lateral side of foot Van Boxem Pain Medicine 2015
43 Results Clinical success : 55,4% NRS neuropathic component (DN4) QOL (physical component RAND-36) Van Boxem Pain Medicine 2015
44 Results Predictors : Older age ( 55y) + diagnostic blok Limited disability (ODI) fair predictive value (AUC : 0,73) Van Boxem submitted
45 Lumbosacral radicular pain II. Are interventions useful? conservative Epidural steroïds (epidural) anti-tnf, NGF surgery Pulsed Radiofrequency Neurostimulation
46 Neurostimulation Failed back surgery syndrome : + (low to moderate evidence) KCE 2012 Neuromodulation
47 Summary interventions LRS 1. Prevalence 5%, low QOL 2. Useful interventions? conservative : limited Epidural steroïds + subacute effect ( 3 months, longer?) + cost-effective Limited prevention of surgery short-term Rathmell Anesthesiology 2015
48 Summary interventions LRS surgery : faster relief, 1y PRF : Clinical success : 55% neuropathic, physical QOL diagn block,low disab., age 55 Spontaneous evolution? Neurostimulation : + : FBSS
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