Cyberknife treatment of refractory Cluster Headache.
Download
Report
Transcript Cyberknife treatment of refractory Cluster Headache.
Intrathecal Therapies:
Local and National Trends and
Complications
NANS 2010
Nandan Lad, MD, PhD; Robert T. Arrigo, MS;
Melanie Hayden,MD; Paul Kalanithi, MD; Chirag G. Patil,
MD; , Maxwell Boakye, MD, Jaimie Henderson,MD
Stanford University Medical Center
Dept of Neurosurgery; Outcomes Research Lab;
Biodesign Surgical Innovation Program;
Disclosure
Conflict of Interest:
None
Grants:
NIH, AHA, NCIIA
Consultant for:
Neurofluidics, Inc.
I will discuss the following investigational use
in my presentation:
Future Directions-NeuroApheresis
2
Outcomes Research
Rationale:
Trusted resource to improve health
through the best use of neurosurgical
modalities.
Advance the optimal use of medical
devices, procedures and biological
products, by:
-Developing knowledge
-Managing risk
-Improving practice
-Informing policy makers
Spine
Stereotac
tic/Functi
onal
Tumor
Outcomes
Research
Critical
Care
Vascular/
Endovascular
Peripheral
Nerve
Pediatrics
3
Intrathecal therapies
Current treatment for:
Spasticity, Cancer/Nonmalignant pain
Reduces need for high-dose opioid therapy and
systemic toxicity.
Continuous infusion or bolus trial
Determine dosing, responsiveness and increase long-term
success.
Currently a last resort, used only for medically refractory
patients.
4
Methods
A retrospective cohort study was performed by using the
California State and Nationwide Inpatient Sample over a six
year period (2003-2008).
The NIS is a nationwide database of hospital inpatient stays.
Largest all-payer inpatient care database, representing
approximately 20% of all inpatient admissions to nonfederal
hospitals in the United States.
Data from approximately 8 million annual discharges from 1004
hospitals in 37 states.
We filtered all-listed diagnoses for only neuro-related diagnoses
and icd9 procedure code 03.90 (placement of intrathecal
catheter/pump)
We examined trends, cost, demographics and short-term
complications associated with intrathecal therapies for pain and
spasticity.
5
Results
The national sample included a total of 33,187 procedures
performed.
There was a nearly 35% decrease in the annual number
of procedures over this period with 6920 procedures in
2003 and 4492 in 2008.
6
Results
Hospital geography- Percentage of US Procedures:
7
Results
National demographics for the procedure included:
67% less than 65 years of age,
55% female,
64% Caucasian,
Comorbidities
(0: 33%, 1: 27%, 2: 20%, 3: 11%, 4+:7%)
Insurance status
(39% private, 44% Medicare/Medical, 17% other)
8
Results
Any Complications
(Acute)
Cardiac
6.2%
0.33%
Infection
0.93%
Neurologic
0.52%
Pulmonary
2.1%
Renal
1.5%
Venous Thromboembolism
1.1%
Wound Complication
0.58%
Several studies with 1-3 year followup from institutional studies have reported
overall complication rates ranging from 15-40%, including catheter malfunction,
pump failure and infection (Fluckiger 2008, Borowski 2008, Ward 2009)
9
Conclusions
Intrathecal therapy has improved over the last several
decades, and implantable drug delivery devices have
become increasingly sophisticated and safe.
Morbidity rates are in-range as those previously reported
in large single institution series.
Physicians and patients currently have many options for
treating pain and spasticity with various old and new
agents and their combination.
Where do we go from here? What’s next?
10
Biodesign Process: Invention & Innovation
11
Biodesign Process: Invention & Innovation
Surgeons are in a unique position to be that link
12
Intrathecal Therapies: Future Directions
Certain biological
components
• Cells (RBC, T/B-cell)
• Soluble factors (cytokine, Ab)
when present in CSF
Neuroinflammatory &
Neurodegenerative
Conditions
Emerging
Concept
13
Future Directions
Unmet Need
Neurotoxic
Components
in CSF
Current Therapy
TYSABRI
IV IgG
Steroids/
Interferon
Plasmapheresis
RBC
Lumbar
Drainage
Needed
Therapy
X
T-cell
X
X
X
B-cell
(X)
X
X
Antibody
Inflammation
/Cytokines
X
X
X
X
Rapid, broad spectrum approach to treat
neurological disorders via removal of all classes of
neurotoxic agents
14
Future Directions
Direct removal of pathogens from CSF
Targeted drug delivery and circulation
Versatile platform that can treat a
spectrum of CNS diseases*
Customized, Integrated
Disposable/Implantable System
Acute-Subacute-Chronic
Initial target: Multiple Sclerosis (MS)
*Neurofluidics, Inc.
15
Thank You.
Manuscript in progress.
[email protected]
Intrathecal Therapies:
Local and National Trends and Complications
16