Yuku free message boards

www.reddinganesthesia.com/radio_frequency_lesioning_faq.htm

www.users.bigpond.com/metspinal/rfd.html

The Dutch Masters' Approaches to Chronic Pain Management:

www.asahq.org/NEWSLETTERS/1998/07_98/Dutch_0798.html

From one of the sites above:

The Dutch Masters' Approaches to Chronic Pain Management
Thomas G. Johans, M.D.

Editor's Note: Additional articles on topics related to pain management appeared in the May and June issues of the ASA NEWSLETTER.

There are few pain-relieving modalities more rewarding than alcohol neurolysis of the celiac plexus for pancreatic carcinoma. Placing a needle, performing a neurolysis and removing the needle have a certain elegance. Moreover, there are no long-term concerns about infection, catheter electrode-induced spinal cord damage, opioid tolerance, home health care usage and battery changes. Unfortunately, because of the rare occurrence of neuropathic and myelopathic complications, chronic pain patients are rarely offered these modalities. However, because of its simplicity and resultant profound analgesia, the use of neuroablative techniques to relieve intractable chronic pain compels physicians to seek a comparable but safer technique.

It is not surprising, then, to see the explosive interest in radiofrequency (RF) procedures, which produce a very reliable and accurate lesion. This technique provides safer, more effective neuroablation and has helped many patients who otherwise had no further options. As with any new innovation, additional training and education are mandatory through postgraduate training at regional anesthesia meetings, cadaver dissection laboratories and radiofrequency hands-on workshops.

In spite of these excellent educational opportunities, nothing compares to the educational advantages of proctorship. After attending a radiofrequency meeting conducted by Mennos Sluijter, M.D., from Amsterdam, I was im-pressed with the Dutch approach to chronic pain management and their clinical paradigms. After a number of years of using these RF techniques, I felt compelled to visit the "Dutch Masters" to hone my skills and improve my results.

Understanding what a burden it can be to have a visitor during a busy practice, I was amazed at the gracious response of Maarten van Kleef, M.D., from Maastricht, Netherlands. Not only did he personally set up three days for me to spend in his pain practice, but he also helped me to meet with Dr. Sluijter and Olav Rohof, M.D., from Gelene. This hospitality was pervasive throughout my experience in Holland and at times was overwhelming. Unlike many physicians in the United States who are reluctant to teach their methods for fear of competition, this act of kindness reflects an incredible professional maturity that was refreshing to experience. Whereas I gobbled up countless pearls about radiofrequency techniques, I felt there were some thought-provoking differences in medicine between the Dutch and the United States that the ASA membership would find interesting and worthwhile.

My host, Dr. van Kleef, is Vice Chair of the Department of Anesthesiology at the Academic Ziekenhuis Maastricht (AZM), which is a full-service academic hospital. Dr. van Kleef's expertise lies in his ability to teach a student to place a hair-like needle through six inches of fat and muscle and through a bony target no larger than the hub of the needle.

Dr. Rohof is in private practice as a consultant to a pain clinic in Koln, Germany, and is a staff pain physician at the Maasland Ziekenhuis, which is a community hospital in Gelene. Dr. Rohof is a superb clinician and a master in radiofrequency techniques. While visiting him that day in Gelene, he performed a radiofrequency cordotomy as if it were a stellate ganglion block and smoothly completed 20 other procedures to finish his morning before starting his afternoon in the office.

Dr. Sluijter is the grand master of the radiofrequency technique. He has a private pain practice at the Boven Hospital in Amsterdam. Dr. Sluijter is world-renowned for his work in radiofrequency techniques. Most of the newest innovations in this field are a result of his work. One of the most popular radiofrequency cannula was designed by him and bears his name. His quiet demeanor acts like a sedative as he also visits 20 patients in the morning, taking in stride two radiofrequency gasserian ganglionolyses.

These anesthesiologists would perform invasive procedures in the morning, then see new and chronic patients in the afternoon pain clinic. The diagnostic blocks are performed in the first part of the morning, then the radiofrequency procedures in the second half of the morning. There is no dictation unless for referral. Charts are small and neat. The initial history and physical are comprehensive but to the point. There are no outcome studies unless linked to a protocol study. Patients are assessed clinically, and there is little use for routine MRI or CT scanning.

All of the hospitals were meticulously clean and neat. Everything and everyone had a place and purpose. There was very little waste or inefficiency. The hospitals were arranged in poli, or clinics, offices and hospital. The flow of patients was very well-organized. The family doctor is the gatekeeper and will send the patient to the specialist polis such as the surgery clinic or internal medicine clinic. Cross-reference between poli to other specialists is common and seamless. Once patients have completed the care plan set up by the specialist clinics, they cannot re-enter unless at the request of the family doctor. This would not go over very well in the United States with our seemingly "revolving door" patients.

The pijnbestrijding ("pain conquering") clinics were very well-run. The patients undressed to their underwear and walked into a very small operating room in a same-day surgery unit or outpatient area. There was little or no discussion between the anesthesiologist and the patient about their pain management. Any lengthy discussion was done in the poli (clinic) at a different appointment. The anesthesiologist never left the procedure suite. There was almost no "downtime." Nothing was resterilized between cases. There were two nurses and a radiology technician in the room at all times. Patients positioned themselves on a simple, four-legged radiolucent table.

Unlike the anesthesiologists at the AZM who performed diagnostic blocks prior to any neuroablative technique, Drs. Rohof and Sluijter did not, as they thought the results of the diagnostic blocks were unreliable and the risks of the radiofrequency procedures were small. At the AZM, after four to five diagnostic blocks, the anesthesiologist would meet those patients outside of the operating room and assess the block. Depending on the results of the block, the anesthesiologist would then write a prescription for the next step in their clinical paradigm. Drs. Rohof and Sluijter would assess the patient clinically and perform the neuroablative procedure at the same visit.

Perhaps the most fascinating aspect of Dutch medical care was their standard of care. The patients of Holland are treated according to rather strict protocols set up and standardized throughout the country by the Dutch government. These are adhered to since payment is directly linked to following the protocols. What I thought was fascinating was the process they used to adopt a new protocol. When a new protocol is proposed, it is reviewed by a governmental board (ziekenfondsraad) that is not made up of M.B.A. bureaucrats, but of physicians. If this board approves the protocol, it will also appropriate sufficient state monies to perform the clinical trials. These randomized, blinded studies follow strict guidelines. Only the investigators of the study are allowed to perform protocol procedures. After the study is completed, the board decides if the results warrant full-scale adoption. If so deemed, then the government will allow all practitioners the opportunity to offer this to their patients and pay for the treatment. If not allowed, then the patient would either pay for it out of personal funds or it is simply not offered.

I was impressed with the well-thought-out protocols and the clearness of the paradigms used in the pain clinic. I was also impressed with the national pride of the Dutch physician. When I would offer an American alternative to one of their Dutch protocols, the response was either, "Do you have solid data to support the use of that modality?" if they had never attempted the alternative, or if they had, "A study we performed clearly showed that it was ineffective." The Dutch are scrupulously honest not only to their patients, but to themselves as well.

I was unhappy to leave this incredible learning experience. These physicians tolerated my incessant inquisitiveness and technical clumsiness. Rest assured, they will be rewarded in knowing that my patients will be made better using their techniques.
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Thomas G. Johans, M.D., practices pain management at St. John's Mercy Pain Management Center, St. Louis, Missouri.

Links to sites in Switzerland and other German speaking countries:

www.tpiweb.com/NewsBox/NB...13002.html

www.schmerzzentrum.ch/therapien/

Here is from one of the sites:

2. Radiofrequenz-Neurolysen

Bei dieser Methode wird der schmerzleitende Nerv gezielt mit radiofrequentem Strom behandelt. Dabei handelt es sich im Prinzip um Mikrowellen, durch welche der Nerv soweit erhitzt wird, bis er nicht mehr in der Lage ist, Schmerzimpulse zu leiten. Andere Qualitäten des Nerven wie Sensibilität und Motorik bleiben weitgehend unbeeinflusst.

Unter Röntgenkontrolle wird eine spezielle Nadel direkt an den Nerv geführt. Meist genügt dafür eine örtliche Betäubung.

Bei der Behandlung gewisser Kopfschmerzarten ist jedoch eine Kurznarkose notwendig.

Der Erfolg der Behandlung tritt meist verzögert innert 6 Wochen ein und hält zwischen 6 und 18 Monaten an.

Nach dieser Zeit kann die Therapie problemlos wiederholt werden.

Read about the experience from a Klinik Zürich:

Die gepulste Radiofrequenz-Therapie:

Unsere Erfahrungen sind sehr gut und decken sich mit bereits publizierten holländischen und deutschen Veröffentlichungen.

Dr. Menno E. Sluijter has written a book called "Radiofrequency, part I".

The book offers a comprehensive survey of all aspects of radiofrequency treatment for spinal pain in the lumbosacral region. It explains all the RF procedures with X-ray pictures, diagrams and many more illustrations and models. Much attention is given to optimal radiological projections and to techniques for reducing the discomfort to the patient to minimum.

The book is a must for doctors who start radiofrequency treatment and a valuable adjunct for those who are experienced in the field.

www.flivopress.com/ourboo...ideos.html

www.lowbackpain.com/radiofrequency.htm

www.thepaininstitute.com/...quency.htm

Sacroiliac joint pain and radiofrequency denervation:

www.wrh.org/physicians_me..._pain.html

irmi.gel.ulaval.ca/abstra...c_cryo.pdf

Didn't the clinic tell you about side effects the first weeks? All kind of RF treatments use puls, but not all of them use heat. I know it is more short-term side effects when using heat. But you really should tell the doctor about your experience. It can be an infection, although I don't think it happens often.
Mosken