Anaesthesia Product News

Blood And Bones: Transfusion And Orthopaedic Surgery
Author: Dr Karen Stuart-Smith, Consultant Anaesthetist, Glan Clwyd Hospital, Denbighshire, Wales

A Role For Ultrasound In Paediatric Anaesthesia
Author: Steve Roberts, Consultant Anaesthetist, Alder Hey Hospital, Liverpool, UK, with a special interest in orthopaedics

RF Lesioning Techniques For Sacroilia Neurotomy And Intervertebral Disc Biacuplasty
Author: Dr A R Cooper, Causeway Hospital, Coleraine and Dr N Evans, District General Hospital, High Wycombe

Blood And Bones: Transfusion And Orthopaedic Surgery
Author: Dr Karen Stuart-Smith, Consultant Anaesthetist, Glan Clwyd Hospital, Denbighshire, Wales

This article arises from a report that I recently read in that well-known medical journal, The Daily Telegraph. It was a small paragraph tucked in a corner of page 2, describing a study published in Circulation which apparently demonstrated that blood transfusion had multiple adverse effects in surgical patients, including increased infection rates and prolonged lengths of stay. As an anaesthetist who plods through an elective orthopaedic list every week, acute surgical blood loss and its replacement both intra- and post-operatively occupies my mind a great deal, so I decided to read the original paper and assess its findings against the background of the general literature. As usual, I entered a complex minefield, and, as you will see, was unable to reach any firm conclusions based on the current evidence. Even worse, the evidence seems to be open to interpretation according to personal prejudices, with the same evidence being given an entirely different interpretation by different review writers. My most depressing discovery is that, in spite of the very long history of blood transfusion as a life-saving therapy, we really have no idea whether transfusion is good or bad for patients. The sensible unbiased science has not been done.

The research paper described in the Telegraph did not look at a general surgical population, but at patients undergoing cardiac surgery, a very discreet and unusual group¹. The design was a retrospective cohort study, which means in practice that the records of patients over a defined period of time are recalled from hospital databases, and compared according to specific criteria. In this case, the cohorts were patients undergoing routine cardiac surgery, and they were separated into two groups depending on

FIGURE 1
Figure 3. Kaplan-Meier “survival” curve showing the cumulative proportion of patients discharged from ICU/HDU and from hospital over time according to whether patients had had an RBC transfusion. Patients who died in hospital were censored at death. Figure 1 is taken from reference 1, from American Heart Association journal, Circulation

FIGURE 2
Figure 4. Kaplan-Meier survival curve showing the cumulative proportion of patients who died over time according to whether patients had had an RBC transfusion. Vertical dotted lines separate the epochs of follow-up time for which hazard ratios were estimated (ie, 0 to 30 days, 31 days to 1 year, and after 1 year). Figure 2 is taken from reference 1, from American Heart Association journal, Circulation

whether or not they received a blood transfusion in the postoperative period (intra-operative transfusion was excluded because of the potential confounding effects of cardiac bypass). The records of more than 8500 patients, who underwent cardiac surgery over an 8-year period, were examined-an impressive figure to be analysed in a single centre. The findings are impressive too, and in rather an alarming way. The two primary outcome measures, infection and ischaemia, were substantially more common in patients who received a blood transfusion, irrespective of lowest recorded haematocrit. In other words, if two post-cardiac surgery patients had a similar haematocrit, and one was transfused while the other was not, the transfused patient was more likely to experience severe infection or an ischaemic event (cardiac, neurological or renal) during their hospital stay. Even worse, transfused patients had an increased length of stay (figure 1) and a substantially increased post-discharge mortality, which rose with each passing year (figure 2).

At this point you are probably standing in the theatre sluice pouring that unit of blood you were about to give down the drain. Before you commit that ridiculously expensive crime, we should examine the paper more closely, and in the context of other studies. Because this is a retrospective study based entirely on collection of figures from hospital data bases, we know a lot less about the patients than you might think from the impressive array of data presented in the paper. Pre-operative co-morbidities are relatively easy to collect and are well-documented in this study. The bottom line appears to be that pre-operative medical status does not have an impact on transfusion-related adverse outcomes. For example, if two cardiac surgery patients had diabetes, the transfused patient was at greater risk of an adverse outcome than his non-transfused cohort colleague. The authors interpret this to mean that physiological condition does not influence outcome, i.e. the transfused patients were not sicker in the first place. What the study does not tell us is what

happened to the patient during their post-operative stay, which is a quite separate issue from their pre-operative status. There is an implicit presumption in this study that a falling haematocrit is the only transfusion trigger. This may be reasonable practice but is not common practice, and human nature is likely to confound the results here. It might be for example that patients with post-operative ischaemia were given a blood transfusion whether their haematocrit appeared to justify it or not, because they were hypotensive, had poor urine output or simply had a degree of ST segment depression that worried the staff and made transfusion more likely. Early signs of systemic infection might also prompt the on-call medical staff to administer a blood transfusion. I am not condoning blood transfusion as part of the management of this clinical scenario. What I am saying is that there is no information given in this paper as to when and why blood transfusions were given. Blood may have been given as part of the management of post–operative complications such as ischaemia and infection, and these types of complication do indeed prolong hospital stay and are a source of increased long-term mortality. A prospective cohort study, using data collection specifically geared to analyse the patients’ post-operative course, is the only way to properly answer this question. In my opinion, the study in its present form is inherently flawed in its conclusions.

FIGURE 3Figure 1. Summary odds ratio of an adverse clinical outcome (ie, cancer recurrence, death due to cancer recuurence, or overall mortality) across published observational studies comparing patients having or not having transfusion.
Figure 3 is taken from reference 2, with kind permission from the American Society of Hematology ©

FIGURE 4
Figure 3. Summary odds ratio of cancer recurrence derived from randomized controlled trials investigating the association of perioperative allogeneic blood transfusion with cancer recurrence in patients undergoing elective colorectal cancer resection.
Figure 4 is taken from reference 2, with kind permission from the American Society of Hematology ©

This brings us to the question of study design in general when looking at the effects of blood transfusion. For any clinical topic under investigation, the most robust form of test is generally held to be the randomised controlled trial (RCT). A study of this nature is inherently prospective of course, and involves dividing patients into untreated (control) and treated groups. Unfortunately it would probably be downright unethical to deliberately assign patients to either receive a blood transfusion or not, without regard to the clinical circumstances. The inevitable result of this difficulty is that modified study designs, with major flaws, have been used to investigate the potentially harmful effects of blood transfusion. The most common design is similar to the one described above, where two groups of patients, one of which received blood and the other did not, are analysed in either a prospective or, more commonly, a retrospective study. Such a study is effectively observational, even though it may be billed as an RCT. The statistical semantics are very important here. A proper randomised controlled trial has two groups which are comparable in every other way except for the intervention. This is not the case for studies of blood transfusion. A very careful analysis by Vamvakas² of all the then available RCTs and meta-analyses on the harmful consequences of blood transfusion clearly demonstrated huge variability in patient characteristics between RCTs included in the same meta-analysis. More damaging, the patients were not matched for illness severity, and more gravely ill patients predominated in the transfused groups. In other words, normal rigorous statistical rules were not applied. The result was that transfused patients appear in all of these studies to have a greater infection risk, and a greater incidence of cancer several years later. Vamvakas’ reanalysis of the data showed no clear difference between transfused and non-transfused patients with regard to infection or cancer rates (figures 3 and 4).

This suggests that the view, widely held amongst surgeons, that blood transfusion predisposes to perioperative infection and later cancer recurrence, may not have a justifiable basis in fact.

This brings us to the assumed mechanisms of increased infection risk with transfusion. There is of course the ever-present risk that a bag of blood may contain pathogens belonging to the donor. Parasites, viruses and prions have all been passed to transfusion recipients in this way³. Bacterial contamination is generally a result of poor handling of blood products during preparation, as reflected in the type of bacteria reported: Staphylococcus and Streptococcus spp. and E. coli being chief among these.³ Improved screening means that infection with these agents is very rare, and from this perspective, blood transfusion is very safe. Leukodepletion is assumed to further reduce the risk of cross infection between donor and recipient, on the assumption that donor white blood cells act as a Trojan Horse bringing sequestered pathogens into the patient. The evidence for this is extremely unclear, but many countries practice leukodepletion of donated blood as a precaution.³ It should be noted, however, that when trials comparing infection rates in patients who have been given non-leukodepleted versus leukodepleted blood are re-analysed to compensate for patient medical status, there is no evidence that leukodepletion improves postoperative infection rates.^3,4 The paper on cardiac surgery patients referred to above also confirms the lack of effect of leukodepletion.¹ Although this is presented as a new finding¹, in fact it is not surprising in view of the background literature.

A second way in which blood transfusion is thought to promote infection is through alteration in the characteristics of the patient’s own white blood cells, specifically T-lymphocytes.⁵ This is the phenomenon of Transfusion-related immunomodulation (TRIM).⁶ The reader is referred to a recent excellent review for a discussion of the mechanism of TRIM.⁶ Essentially the process is though to involve an up-regulation of suppressor T-cells and a down-regulation of natural killer (NK) cells, and accumulation of immune inhibitors in the blood unit while it sits in storage: histamine, eosinophil associated products, HL-antigens etc., although there is very limited evidence for any of these mechanisms in patients. The concept of TRIM arises from the observation made 30 years ago that renal transplant patients were less likely to reject allografts if they had a pre-operative transfusion of allogeneic blood. The presumed mechanism is a TRIM-related downregulation of the patient’s immune response. There is some laboratory evidence for this⁶, although a cynic might suggest these patients did better because their chronic anaemia was corrected. In any event, this isolated observation of an apparent immunosuppressive effect of blood transfusion led to the suggestion (only a suggestion) that similar immunosuppression in patients having surgery for cancer might be at risk of recurrence if they were transfused, because, it was suggested there might be prolonged suppression of T-lymphocyte activity.⁶ There seems to have been an immediate flurry of clinical activity, with rafts of surgeons rushing to conduct studies that conclusively ‘proved’ that blood transfusion was associated with an increased risk of tumour recurrence in cancer patients. This has now worked its way so deeply into the surgical psyche that it is almost impossible to remove. However, once all these studies are reanalysed to exclude confounding clinical factors: there is no clear evidence at all that blood transfusion promotes tumour recurrence in surgical cancer patients.⁶

Another recognised effect of blood transfusion on the immune profile of the recipient is transfusion-associated microchimerism (TA-MC).⁷ (Confusingly, some authors include this as part of TRIM, while others treat them separately). Transfusion-related microchimerism is the persistence of a donor’s leucocytes in the circulation of the recipient. Microchimerism may persist for many years, and seems to be particularly common in trauma patients who have received multiple transfusions.⁷ Even though the patient may have received units from several donors, typically only one donor’s white cells persist. This is probably due to a specific inability of the recipient to mount an immune response to that particular donor’s HLA-antigen profile. This phenomenon can occur even in leucodepleted blood, suggesting that very small numbers of donor white cells can survive in the patient. Transfusion-related microchimerism has been suggested as the basis for many different diseases (figure 5), but evidence is lacking. In the case of common diseases such as cancer and rheumatoid arthritis, it may prove very difficult to separate out the effects of transfusion from other confounding factors.⁷

FIGURE 5
Figure 1. A summary of current knowledge and unanswered questions regarding transfusion-associated microchimerism.
Figure 5 is taken from reference 7, with kind permission from Elsevier Ltd, 2007.

Overall, there is no conclusive evidence that allogeneic blood transfusion increases rates of infection or promotes cancer recurrence in the surgical patient. Does this mean that blood transfusion is a safe therapy? The general consensus seems to be that it probably is. The next question is, is it a necessary therapy? You will not be surprised to learn, weary reader, that there is no good research in this area to answer that question. It is often asserted that a low Hb does not affect outcome or hospital stay. I have no idea whether this is true and neither has anyone else because, frankly, an exhaustive (and tedious) search of the literature reveals no good studies on the issue. Of course, studies in ITU patients have suggested that a low Hb level is well-tolerated, and perhaps even desirable. However the ITU population is a very specific group, and even here there are caveats to the low Hb story. As we are dealing with the ordinary acute surgical patient here, I have decided to address the ITU group in a subsequent article. I am now (finally) going to focus on one patient group, for illustrative purposes. This is patients undergoing elective joint replacement surgery.

Patients undergoing orthopaedic surgery lose a lot of blood.⁸ Conversely, orthopaedic surgeons routinely underestimate intra and post-operative blood loss by an extraordinary amount.⁸ (You may wish to show reference 8 to your own orthopaedic surgeon). This study did also suggest that infection rates were lower with autologous than allogeneic blood, but it should be noted that the patients in this study who received allogeneic transfusions had significantly lower Hb to begin with-another example of an important confounding factor. Orthopaedic patients may be severely anaemic post-operatively.⁹ However, because of the (possibly unfounded) fear of the theoretical complications described above, and because of studies conducted in ITU and leukaemia patients (not orthopaedic patients) which suggest a low Hb is well-tolerated, it is not uncommon for these patients to go home with their acute anaemia uncorrected. Any GP in the country will confirm this, as they usually have to deal with the consequences. There are no current data on the effect of post-operative anaemia on mobilisation of orthopaedic patients¹⁰, and this research is urgently needed. Post-operative anaemia in general is typically is slow to correct and resistant to intravenous iron and erythropoietin.^9,11 It is disingenuous to say (as some do), that a low post-operative Hb does not delay discharge from hospital. In today’s NHS, patients are rapidly discharged into the community providing they still have a pulse, leaving primary care to sort it out. Length of stay is hardly a guide to good practice. There is evidence that at the very least, post-operative anaemia makes patients feel ill-they are tired, nauseated, hypotensive and dizzy.⁹ Because elective orthopaedic patients rarely receive post-operative ECGs, we cannot tell whether there are additional more serious effect of acute surgical anaemia, such as ST-segment depression. No population studies have followed these patients into the community, to determine whether the physiological stress of a low Hb has long-term sequelae. This is an elderly population with significant co-morbidities, and we know nothing about them.

So, should we give elective orthopaedic patients blood transfusions post-operatively? The answer at present is yes. There is no clear evidence of harm and there may be a considerable benefit in terms of an improved feeling of well-being in the patient and a reduced burden in the community. I cannot recommend a transfusion trigger, as there is no evidence to suggest what that should be. This is an urgently needed study, and would probably be best conducted as an observational design, following a large cohort of patients through their hospital journey in an effort to correlate post-operative Hb levels with clinical sequelae. If I had any money for this sort of thing, I’d do it.

In spite of all I have said above, there are two good reasons for not giving blood transfusions. These are that 1) blood is very expensive and 2) increasingly hard to get hold of. Having to transfuse blood considerably increases the cost of any operation. In orthopaedic surgery there is a very good strategy to avoid the necessity for blood transfusion10. Pre-operative erythropoietin and iron therapy is indicated to achieve an Hb of >12 g/dl. Use of cell salvage techniques in elective hip arthroplasty is, in my view, mandatory. In patients undergoing knee surgery, re-infusion of shed blood from a vacuum drain system will reduce the number of packed cell units required, but it should be noted that this type of blood salvage is not adequate replacement in this group of patients, and banked blood may still be required¹². Pre-operative optimisation of haemoglobin, good surgical technique, and meticulous use of salvage technology will significantly reduce the requirement for blood transfusion in orthopaedic patients. On the other hand, there is no value in leaving these elderly and vulnerable patients anaemic and ill post-operatively, so, if they need blood, GIVE IT.

Finally, a general observation. This has been one of the most difficult and frustrating articles I have ever had to write for Anaesthesia Product News. The whole subject of blood transfusion is surrounded by anecdote, prejudice, presumption and emotion. Most of the population have studies have been poorly conducted, and the statistics are weak. Laboratory evidence for the asserted deleterious effect of blood transfusion is almost non-existent. Anaesthetists frequently tell me that there is no research to do in anaesthesia, as it is such a ‘safe’ procedure. Well, anaesthetists give blood as well as anaesthetics, but we have no real idea what we are doing or why. It’s time we found out.

References

Murphy GJ et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007;116:2544-52
Vamvakas EC and Blajchman MA. Deleterious clinical effects of transfusion-related immunomodulation: fact or fiction? Blood 2001;97:1180-95. © the American Society of Hematology.
Dellinger EP and Anaya DA. Infectious and immunologic consequences of blood transfusion. Critical Care 2004;8 (Suppl 2):S18-S23
Vamvakas EC. Why have meta-analyses of randomized controlled trials of the association between non-white-blood-cell-reduced allogeneic blood transfusion and post-operative infection produced discordant results? Vox Sanguinis 2007;93:196-207
Raghavan M and Marik PE. Anemia, allogeneic blood transfusion, and immunomodulation in the critically ill. Chest 2005;127:295-307
Vamvakas EC and Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev 2007;21:327-48
Utter GH et al. Transfusion-associated microchimerism. Vox Sanguinis 2007;93:188-95
Rosencher N et al. Orthopaedic surgery transfusion haemoglobin European overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion 2003;43:459-69
Karkouti K et al. Intravenous iron and recombinant erythropoietin for the treatment of postoperative anaemia. Can J Anesth 2006;53:11-19
Blood conservation in elective orthopaedic surgery. British Orthopaedic Association, April 2005
Madi-Jehara SN et al. Post-operative intravenous iron used alone or in combination with low-dose erythropoietin is not effective for correction of anaemia after cardiac surgery. J Cardiothorac Vasc Anesth 2004;18:59-63
Munoz M et al. Which patients are most likely to benefit from postoperative shed blood salvage after unilateral knee replacement? An analysis of 581 consecutive procedures. Vox Sanguinis 2007;92:136-41

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As one of the largest children’s hospitals in Europe, the Alder Hey Hospital provides a broad range of specialist services for children, including most types of surgical procedure (with the exception of transplants). The hospital pioneered neonatal surgery and children’s cardiac surgery during the 1940s and 1950s, and its anaesthetists have made significant contributions towards modern day techniques for paediatric anaesthesia¹. Here, as in every hospital, every anaesthetist wants his or her methods to be as reliable as possible; failure can lead to a great deal of pain, distress, and complications potentially increasing the period of the child’s hospitalisation.

Over the past four years, Alder Hey anaesthetists have started using ultrasound guidance for line placement and regional nerve blocks and this has completely changed routine practice. Ultrasound imaging makes it possible to visualise the nerves and vessels while performing invasive procedures eg. nerve blockade and vascular access. With practice this allows quick and safe needle guidance. It is of particular help in children whose anatomy is distorted, as landmark techniques become unreliable. It is only since using ultrasound that many anaesthetists have really begun to appreciate the extent of the anatomical variability that exists across all patients.

Ultrasound guidance is particularly beneficial when placing central lines in babies: the team at Alder Hey has found that the technique significantly reduces failure rates, and keeps the time required to place a line to about five to ten minutes, where some difficult cases might previously have taken anything up to an hour or more. Similarly for nerve blocks, ultrasound is significantly speeding up procedures, and offers more benefits besides². Originally, nerve blocks were performed purely on the basis of anatomical landmarks, followed by the introduction of neurostimulation, which has been widely used for over ten years³. Neurostimulation can be far more precise than relying on anatomical landmarks alone, but there are inevitably some children with abnormal neurology who do not actually respond to the stimulator, even when the needle is positioned directly against the nerve. Alder Hey sees a considerable number of children with cerebral palsy, performing a variety of surgical procedures to help correct muscle and bone deformities such as hip reconstructions, tendon transfers and treating spasticity. These procedures aim to improve movement of the child’s joints and muscles, making hip and leg movements such as sitting and walking much easier for the child, and can also relieve pain in joints that are deformed or not functioning properly. In many ways for these children, anaesthesia is not always straightforward, particularly the difficulty of pain assessment. A failed nerve block can be particularly distressing and may result in the need to administer a variety of additional substances, such as morphine and sedatives. In the past, epidurals have often been the method of choice in these cases in preference to nerve blocks purely because they were more reliable.

The department now relies on a number of point-of-care ultrasound systems (including the SonoSite MicroMaxx®, TITAN® and 180PLUS ultrasound systems) for both vascular access and to guide regional anaesthesia in children of all ages. The high resolution of today’s point-of-care ultrasound systems means that the anaesthetists are able to place catheters very close to the relevant nerve in order to infuse local anaesthetic as required, with high accuracy and much greater success rates than before. Although these rates are similar to those of epidurals, using peripheral nerve catheters avoids the complications sometimes associated with epidurals, such as hypotension, urinary retention and infection. The compact size of these point-of-care systems is a key advantage, because anaesthetic rooms do not have enough space for the larger cart-based systems. The instruments are constantly on the move around the hospital, so their portability and durability are very important features, not only to anaesthetists but also to other hospital staff, such as neurologists and rheumatologists, who have, for example, borrowed them to use in clinics to guide joint injections.

The flexibility of these systems has led to them being used for a number of research projects within the department, investigating the uses of various anaesthetic techniques. Current projects for example include the investigation of caudal blocks in children, using ultrasound imaging to guide the needle and monitor the relative spread of anaesthetic up the spinal column according to the volume of anaesthetic given. The caudal block is similar to an epidural but is administered at the very base of the spine, at the sacral hiatus, to inject local anaesthetic upwards from there. The block is particularly useful in young children having bilateral lower limb surgery or in small babies with hernia repairs, but the procedure does have some associated risks, such as accidentally inserting the needle into the cerebrospinal fluid, or into a vein. Ultrasound imaging helps minimise these risks, making it possible to safely administer the anaesthetic, and has significantly helped with this particular project.

The portable ultrasound systems now available have extremely good imaging resolution and are purposely easy for users without previous experience of radiology to get to grips with. In theory almost anyone can pick up an ultrasound system and start scanning, however, the technique is very much operator-dependent, and it requires a great deal of effort and determination to learn to use the system properly and achieve competency. For example, learning to manipulate the needle and visualise it accurately under the ultrasound probe is much more difficult than at first appears to the casual observer. It is essential that anaesthetists are properly taught the necessary skills at the beginning, and that is a principle aim of ultrasound courses now held at Alder Hey twice yearly. There are very few paediatric ultrasound courses currently available and, as a consequence, these courses have attracted people from a variety of hospitals around the UK and Europe. Each two-day course is very hands-on, with very small group sizes, and only minimal lecturing, and aims to teach anaesthetists how to use ultrasound for both vascular access and regional anaesthesia. Rather than blinding the participants with a rapid overview of all the different possible procedures that can be done with ultrasound imaging, these courses concentrate on teaching just a few specific nerve blocks, thoroughly. As a result, the participants learn some skills that they can immediately apply when they return to their hospital.

For more information on the courses available at Alder Hey, please contact Dr Steve Roberts at steve.roberts@rlc.nhs.co.uk.

For further details on the full range of courses offered by SonoSite, Ltd., please email education@sonosite.com.

References

Royal Liverpool Children’s NHS Trust – Alder Hey, homepage: www.alderhey.com/RLCH/about_us.asp.
Tsui BCH (2007) Equipment for regional anesthesia in children. Techniques in Regional Anesthesia and Pain Management 11: 235-246.
Alo’ KM (2001) Recent advances in neurostimulation analgesia. Techniques in Regional Anesthesia and Pain Management 5: 142-151.

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Introduction
Disc biacuplasty is a safe and effective procedure for the treatment of axial discogenic low back pain. With good patient acceptability and a relatively straightforward placement, it is easier to perform than previous intradiscal procedures.

Sacroiliac neurotomy enables the capture of afferent lateral branches of the posterior rami which are responsible for relaying nociceptive signals from the sacroiliac (SIJ) joint and surrounding structures back to the CNS. There exists no correlation between nerve location and the bony landmarks identifiable under fluoroscopy. This variability presents a challenge for clinicians seeking to treat SIJ syndrome.

The Baylis Pain Management SInergy™ System makes use of Cooled-RF lesioning for effective denervation in the treatment of SIJ syndrome.

Education And Practice
BVM Medical researches and provides innovative, high quality disposable and implantable medical devices for the Specialist Interventionalist. The company markets a comprehensive solution to chronic pain management of certain structures in the back – The Baylis Cooled RF Pain Management System.

BVM also sponsors clinical research programmes, educational seminars and practical workshops to keep its’ customers at the forefront of technology, while building close, dependable working relationships with clinicians. Two of these, Dr Cooper and Dr Evans, are using their experience to run and host a hands-on cadaver workshop on 1 March 2008, for an invited, participating group of interested pain management specialists.

To be run at the Post Graduate Education Centre in Nottingham City Hospital, the workshop/seminar will encompass RF lesioning techniques for both Sacroiliac Neurotomy and Intervertebral Disc Biacuplasty. BVM will be demonstrating the SInergy™ System and TransDiscal™ System for use by the faculty and participants on this course.

Overview Of The Seminar
This one day seminar has been designed for pain management and spine physicians who want to learn the application of the TransDiscal™ and the SInergy™ System. The TransDiscal™ System is used to treat symptomatic patients with contained herniated discs which may have discogenic pain. The SInergy™ System is used to treat symptomatic patients with sacroiliac joint syndrome (SIJS). Presentations will focus on the equipment for the two systems and differentiate the probes and how they interact with the systems as well as the biophysical effects. Faculty will address the indications and clinical outcomes for the intervertebral disc biacuplasty and sacroiliac joint neurotomy and techniques that have proven successful in their practice. The practicum is the major portion of the seminar, where faculty will demonstrate intervertebral disc biacuplasty and sacroiliac joint neurotomy followed by attendee hands-on application. Safety and steps to avoid complications will also be addressed. The small group atomosphere will maximise faculty-participant interaction, and time for questions and answers. Reimbursement alternatives will be presented with follow-up assistance post meeting.

Objectives To Be Achieved
Upon completing this course, the physician should be able to:

Describe use of the RF Generator, pain pump unit and TransDiscal™ and Sacroiliac probes
Discuss patient indications for Intervertebral Disc Biacuplasty and Sacroiliac Joint Neurotomy
Demonstrate the application of device and instrument systems to perform Intervertebral Disc Biacuplasty using the TransDiscal™ System in a faculty guided cadaveric workshop
Demonstrate application of the SInergy™ Systems in performing SIJ neurotomy in a faculty guided cadaveric practricum
Identify steps for intraoperative safety and to avoid complications.
Discuss reimbursement alternatives for intervertebral disc biacuplasty and sacroiliac joint neurotomy

Preliminary Schedule Of The Seminar/Workshop
Saturday 1 March 2008

08.30 Registration and Coffee
09.00 Welcome

Presentations

09.05 Mr Naheed Visram : Physics of Cooled RF
09.20 Dr Cooper : TransDiscal™ Systems
09.40 Dr N Evans : SInergy™ Systems
10.00 Demonstration SInergy™ Systems and TransDiscal™ System – Group A
10.15 Cadavers Hands-on / Practicum – Session 1
11.15 Demonstration SInergy™ Systems and TransDiscal™ System – Group B
12.00 Cadavers Hands-on / Practicum – Session 2
13.30 Lunch
14.30 Additional Practicum Time and Wrap-up

Personal protective equipment will be provided.
Please bring you own eye wear.

This seminar is a non-CME event and is limited to 12 participants

Transferability Of Skills To Clinical Practice And Disclaimer
This educational seminar will provide opportunities to physicians to learn, discuss, observe and practice the application of new knowledge and skills on models during a faculty guided practicum. This course is not intended to prepare physicians for procedures or techniques in clinical practice. Attendance at this course does not imply clinical competence. Faculty recommend ongoing education and skill practice with experienced, qualified colleagues. It is the responsibility of an attendee to follow the process required by their healthcare organization to secure clinical privileges in the procedures taught during the course.

For more information
BVM offers a range of literature, DVDs and patient leaflets on the Baylis TransDiscal™ and SInergy™ Systems. Due to fast growing expansion of interest in this area of pain management relief and control, BVM will be organising and hosting further workshops and seminars on these techniques during 2008/09. For further interest, please telephone BVM Medical on 01455 614555, or visit www.baylismedical.com.

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