Peridural scar and its relation to clinical outcome: a randomised study on surgically treated lumbar disc herniation patients

Evaluation of the effectiveness of oxytocin and enalapril in the prevention of epidural fibrosis developed after laminectomy in rats

INTRODUCTION

Except for methylprednisolone, there is no current low-cost and low-side-effect drug/barrier method to prevent epidural fibrosis after spine surgery. However, the use of methylprednisolone has led to substantial controversy because of its serious side effects on wound healing. This study aimed to evaluate the effects of enalapril and oxytocin on preventing the development of epidural fibrosis in a rat laminectomy model.

MATERIALS

Under sedation anesthesia, T9, T10, and T11 laminectomy was performed on 24 Wistar Albino male rats. The animals were then separated into four groups; Sham group (only laminectomy was performed; n = 6), MP group (laminectomy was performed and 10 mg/kg/day methylprednisolone was administered intraperitoneally (ip) for 14 days; n = 6), ELP group (laminectomy was performed and 0.75 mg/kg/day enalapril was administered ip for 14 days; n = 6), OXT group (laminectomy was performed and 160 µg/kg/day oxytocin was administered ip for 14 days; n = 6). Four weeks after the laminectomy, all the rats were euthanised, and the spines were removed for histopathological, immunohistochemical, and biochemical examinations.

RESULTS

Histopathological examinations revealed that the degree of epidural fibrosis (X²=14.316, p = 0.003), collagen density (X²=16.050, p = 0.001), and fibroblast density (X²=17.500, p = 0.001) was higher in the Sham group and lower in the MP, ELP, and OXT groups. Immunohistochemical examinations showed that collagen type 1 immunoreactivity was higher in the Sham group and lower in the MP, ELP, and OXT groups (F = 54.950, p < 0.001). The highest level of α-smooth muscle actin immunoreactivity was seen in the Sham and OXT groups, and the lowest was in the MP and ELP groups (F = 33.357, p < 0.001). Biochemical analysis revealed that tissue levels of TNF-α, TGF-β, IL-6, CTGF, caspase-3, p-AMPK, pmTOR, and mTOR/pmTOR were higher in the Sham group and lower in MP, ELP, and OXT groups (p < 0.05). The GSH/GSSG levels were lower in the Sham group and higher in the other three groups (X²=21.600, p < 0.001).

CONCLUSION

The study results showed that enalapril and oxytocin, which are known to have anti-inflammatory, antioxidant, anti-apoptotic, and autophagy-related regenerative properties, could reduce the development of epidural fibrosis after laminectomy in rats.

Analysis of Long-Term Results of Lumbar Discectomy With and Without an Interspinous Device

BACKGROUND

Discectomy is the surgical treatment of choice for disc herniation. However, discectomy can lead to disc degeneration and vertebral instability over time. Interspinous devices (ISDs), added to conventional surgery, constitute a low-invasive alternative that attempts to prevent these complications. The aim of this study is to compare the long-term clinical and functional outcomes of patients undergoing conventional discectomy with those who had an ISD added during surgery.

METHODS

This analytical-descriptive, retrospective, and transversal studyinvestigated outcomes of 114 patients who underwent surgery for a lumbar disc herniation between 2008 and 2011. The results were evaluated with a minimum follow-up of 8 years (mean, 10 years) by means of different questionnaires: visual analog scale (VAS), Oswestry Disability Index (ODI), consumption of analgesic medication, work status, degree of satisfaction, and complications and reinterventions during the follow-up period.

RESULTS

At the end of the follow-up, an overall improvement of VAS of 5 points (71%) and ODI of 36 points (77%) was observed, with a degree of satisfaction of 76% with disc surgery. The analysis between both groups showed a better behavior in VAS and ODI in the implant group, with a pre- and postsurgery difference of 73% and 79% compared to 66% and 77% in the control group, respectively, though this finding was not statistically significant. The current analgesic consumption and the degree of satisfaction were also better in the group with an implant. Compared with the non-implant group, the number of reinterventions at the end of the follow-up was lower (7% vs 15.5%) and the time until the second intervention was higher (81.5 vs 41 months) in the group with an implant, but the differences were not statistically significant.

CONCLUSIONS

Lumbar discectomy proved to be a safe technique for the treatment of disc herniation, and results are maintained over time. The additional gesture of adding an ISD to conventional discectomy improves clinical outcomes overall, but not in a statistically significant way. The lower number of reinterventions and the longer period without surgery being required may mean a certain protective effect of the ISD on the intervertebral disc being operated on.

Effect of Previous Caudal Block to Predict Successful Outcome after Adhesiolysis using a Steerable Catheter in Lumbar Failed Back Surgery Syndrome: A Retrospective Study

Adhesiolysis is minimally invasive and commonly used for pain associated with adhesion after lumbar spine surgery. Caudal epidural block may be used for radiating pain due to failed back surgery syndrome. We evaluated the predictive value of response to caudal block performed prior to adhesiolysis in failed back surgery syndrome. Between January 1, 2013 and June 30, 2020, 150 patients with failed back surgery syndrome were treated with adhesiolysis using a steerable catheter at the pain clinic of a tertiary hospital after failed conservative treatment (including caudal block). Patient demographics, pain duration, and lumbar magnetic resonance imaging findings were examined. Response to previous caudal block was determined as a binary result (yes or no). Patients were followed up 3 months after adhesiolysis. Successful outcome was defined as a ≥2-point reduction in the numeric rating scale scores for radicular pain 3 months after adhesiolysis, evident in 81/150 (46%) patients. Multivariable logistic regression analysis revealed that caudal block response was an independent predictor of successful adhesiolysis (odds ratio = 4.403; p = 0.015). Response to prior caudal block is a positive predictor of successful adhesiolysis.

Posterior Floating Laminotomy as a New Decompression Technique for Posterior Cervical Spinal Fusion Surgery

Objective

In the cervical spine, many surgical procedures have been developed to achieve optimal results for various disorders, including degenerative diseases, traumatic injury, and tumor. In this study, we report our experience and follow-up results with a new surgical technique for cervical spine entitled posterior floating laminotomy (PFL) in comparison with conventional laminectomy and fusion (LF).

Methods

Data for 85 patients who underwent conventional LF (n=66) or PFL (n=19) for cervical spine disorders between 2012 and 2019 were analyzed. Radiological parameters, including cervical lordosis (CL), T1 slope (T1S), segmental lordosis (SL), and C2–7 sagittal vertical axis (SVA), were measured with lateral spine X-rays. Functional outcomes, comprising the modified Japanese Orthopaedic Association (mJOA), neck disability index (NDI), and visual analog scale (VAS) scores, were also measured. For the patients who underwent PFL, postoperative magnetic resonance image (MRI) was performed in a month after the surgery, and the degree of decompression was evaluated at the T2-weighted axial image, and postoperative computed tomography (CT) was conducted immediately and 1 year after the operation to evaluate the gutter fusion.

Results

There was no difference in CL, T1S, SL, and C2–7 SVA between the groups but there was a difference in the preoperative and postoperative SL angles. The mean difference in the preoperative SL angle compared with that at the last follow-up was -0.3° after conventional LF and 4.7° after PFL (p=0.04), respectively. mJOA, NDI, and VAS scores showed significant improvements (p<0.05) during follow-up in both groups. In the PFL group, postoperative MRI showed sufficient decompression and postoperative CT revealed gutter fusion at 1 year after the operation.

Conclusion

PFL is a safe surgical method which can preserve postoperative CL and achieve good clinical outcomes.

The impact of posterior epidural adipose tissue on postoperative outcomes after posterior decompression surgery for lumbar spinal stenosis: A prospectively randomized non-inferiority trial

STUDY DESIGN

The present study is a prospectively randomized study.

OBJECTIVE

The objective of the study was to evaluate the impact of posterior epidural adipose tissue (PAT) on postoperative outcome following lumbar decompression surgery for lumbar spinal stenosis (LSS) by whether PAT was removed or preserved during the surgical procedure.

SUMMARY OF BACKGROUND DATA

In posterior decompression surgery for LSS, PAT is routinely removed without knowledge of its role and significance. However, considering adipose tissue has regenerative properties of damaged neighboring tissues or itself, PAT, which is adipose tissue located at peridural space, might also have a potential to regenerate the neighboring damaged tissue, including dura and nerve root in the lumbar spine, but this has not been thoroughly studied.

METHODS

Of the 185 eligible patients screened for the current study, 181 patients were enrolled and randomly allocated into either group A (PAT removal, n = 90) or group B (PAT retention, n = 91). The primary outcome measure was pain intensity on the lower back and lower extremity. The secondary outcome measures were functional outcome based on the Oswestry disability index (ODI) and walking distance, complications during the surgical procedure, and surgical outcomes.

RESULTS

Postoperative pain intensity on the lower back and lower extremity was greater in group A than in group B. Functional status on ODI and walking distance was also worse in group B than in group A (64.9% in group A and 66.2% in group B). The number of patients with aggravated pain intensity and deteriorated functional status in postoperative follow-up times was significantly greater in group A than in group B. There were no significant differences in surgical outcome and complications between the groups.

CONCLUSION

Preserving epidural fat may be favorable in postoperative outcomes of posterior decompression surgery for LSS compared to removing epidural fat.

Differences in beliefs about pain control after surgery due to lumbar or cervical discopathy and degenerative spine disease

BACKGROUND

Clinical, psychological and demographic variables have been investigated to determine factors involved in quality of life of patients with chronic pain. It has been stressed that chronic pain is more associated with beliefs about pain, than with pain intensity.

OBJECTIVE

The main aim of this retrospective cross-sectional study was to examine differences between postoperative beliefs about pain control, perception of pain and mood disturbances in patients treated operatively due to neck or lumbar discopathy and degenerative spine disease.

METHODS

Forty-four patients treated operatively due to lumbar and forty-one patients treated surgically due to cervical discopathy filled in the Visual Analogue Scale (VAS), The Beck Depression Inventory (BDI-PL) and Beliefs about Pain Control Questionnaire (BPCQ-PL). Patients with lumbar and cervical discopathy additionally completed disease-specific outcome measures.

RESULTS

The patient groups do not differ significantly in regards to BPCQ-PL, BDI-PL or VAS. Both study samples differ in regards to dependencies related to beliefs that pain is controlled by powerful others and about internal control of pain.

CONCLUSIONS

Cognitive-behavioral interventions, concerning depression and beliefs about pain control, may be appropriate for both lumbar and cervical surgical populations, to improve post-surgical functioning.

A New Grading of Epidural Hematoma or Scar Formation after Posterior Cervical Spine Surgery: Evaluation of Perioperative Related Factors, Distributions, and Clinical Outcomes after Surgery

Introduction

The purpose of this study was to evaluate surgical outcomes using a new grading of postoperative epidural hematoma (EH) or epidural scar formation after posterior cervical spine surgery.

Methods

Postoperative EH or epidural scar formation after cervical laminoplasty (LP) or posterior decompression and fusion (PDF) were graded into Grades 1-5 by magnetic resonance imaging at 24 hours, 2 weeks, 6 months, and one year after surgery. The patients were divided into the Mild group (Grades 1-3) and the Severe group (Grades 4, 5). Perioperative factors were compared between the two groups at 24 hours after surgery. Distribution of EH or scar formation was investigated according to two surgeries. The recovery rate of Japanese Orthopedic Association (JOA) scores and the improvements of neck disability index (NDI) were compared between the two groups at one year postoperatively.

Results

Of the postoperative factors, posterior shift of the cervical spinal cord at C4 and C7 significantly differed between the two groups. Patients in the Severe group at 24 hours after surgery (17%) increased to 41% at 2 weeks and subsequently decreased to 16% at 6 months after LP. After PDF, 3% in the Severe group at 24 hours after surgery increased to 15% at 2 weeks and then decreased to 3% at 6 months postoperatively. Only one (3%) patient remained in the Severe group at 1 year after PDF. The recovery rate of JOA score (47.5%) of the patients in the Mild group showed trend larger than that of the Severe group (34.7%) after LP. Preoperative NDI (15.6 points) significantly improved postoperatively to 12.1 points in only the Mild group after LP.

Conclusions

The patterns of distribution of EH or scar formation did not differ between the two surgical methods. The severity of postoperative scar formation related to surgical outcomes after LP.

The Dural Tube Continues to Expand after Muscle-Preserving Cervical Laminectomy

Introduction

The purpose of this study was to elucidate the duration for which the dural tube continues to expand after muscle-preserving cervical laminectomy and the extent to which the expansion affects surgical outcomes.

Methods

We analyzed 83 patients with cervical myelopathy who underwent muscle-preserving selective laminectomy of three consecutive laminae between C4 and C6. On the lateral radiographs, parameters considered were C2-7 Cobb angles, range of flexion-extension neck motions, and C2-7 sagittal vertical axis. Neck alignment was classified into four types with lateral radiographs. Anteroposterior (AP) diameter of the dural tube was measured at mid-level of the C5 vertebral body on T2 sagittal image. Expansion ratio (ER) was defined as the extent of expansion at a particular time divided by the final extent of expansion of the dural tube diameter. Operative outcomes were examined using the Japanese Orthopaedic Association scores.

Results

The mean age was 62.3 years, and the mean follow-up period was 2 years and 9 months. AP diameter of the dural tube had been expanding until 1-year after surgery. ER in cases with kyphosis was lower at 6 months than that in cases without kyphosis, indicating that the speed of dural expansion was slower in cases with kyphosis. There was no correlation between the extent of expansion of the dural tube and neurological recovery.

Conclusions

The dural tube continued to expand for approximately 1-year after surgery. The dural tube of patients with kyphosis slowly expanded possibly because of the hardness of the dura mater. A small extent of dural expansion does not necessarily indicate bad surgical outcomes.

A review of the role of epidural percutaneous neuroplasty

Degeneration, whether from age or postsurgical, in the ventral and lateral epidural space can lead to irritation of both the nerve roots and of the nerves present in the epidural space, the peridural membrane and the posterior longitudinal ligament. This irritation is often accompanied by mild scarring. Neuroplasty is a specific procedure designed to relieve this irritation. The effectiveness of neuroplasty is not affected by the extent of spinal stenosis. Neuroplasty can be performed in the lumbar, thoracic and cervical spine, and using caudal, transforaminal and interlaminar approaches. Postprocedural home exercises are an integral part of the procedure. There are multiple high-grade studies positive for the effectiveness and safety of neuroplasty. Neuroplasty should be offered prior to surgery in patients with persistent back and/or extremity pain.

[Diagnosis and interventional treatment of pain syndromes after surgery for degenerative lumbar spine diseases]

Postoperative pain accompanies up to 20% of interventions for degenerative spine diseases (DSDs). The epidemiologic data are contradictory; clinical and radiological diagnostics is often low efficient; capabilities of interventional diagnosis and treatment techniques are poorly understood.

PURPOSE

The study purpose was to investigate the structure of pain syndromes after surgery for DSDs of the lumbar spine, based on complex diagnostics, as well as to evaluate the capabilities of interventional treatment.

MATERIAL AND METHODS

We examined 310 patients with postoperative pain syndromes. Patients with obvious indications for repeated surgery were excluded from the analysis; the remaining patients underwent selective diagnostic blockades followed by interventional (puncture) treatment. A positive outcome was defined as a reduction in pain by 50% on the numerical rating scale (NRS-11), by 20% in the Oswestry index (ODI), and by 8 points in the sciatica bothersomeness index (SBI), with the effect lasting for 12 months. Predictive factors for the risk of pain syndromes were analyzed.

RESULTS

Out of 310 patients, 162 (52.6%) patients had no obvious indications for surgery. Radicular pain was detected in 56 (18.6%) of 310 patients; the positive treatment outcome was achieved in 38 (67.86%) of 56 patients. Facet pain was present in 29 (9.35%) patients; the positive treatment outcome was achieved in 23 (79.31%) patients. Discogenic pain was found in 12 (3.87%) patients; the positive treatment outcome was achieved in 5 (41.63%) patients. sacroiliac joint (SIJ) pain was present in 42 (13.55%) patients; the positive treatment outcome was achieved in 36 (85.71%) patients. Myofascial and competing pain was detected in 12 (3.87%) patients; the causes were not identified in 11 (3.55%) cases. The main risk factors were sagittal balance parameters.

CONCLUSION

Complex diagnostics revealed postoperative pain not associated with surgical causes in 52.6% of cases; the origin of pain was identified in 49.95% of cases. Interventional treatment was effective in 64.81% of cases; failed back surgery syndrome was diagnosed in 16.13% of patients.

Effectiveness of the Biophysical Barriers to the Peridural Fibrosis in Rat Laminectomy Model

Purpose: Peridural fibrosis which could occur after the spinal surgery could adhere neural tissue closely and may cause to neural entrapment symptoms and require surgical reintervention. Aim of the study: Present study was designed to reduce occurrence of peridural fibrosis in rat laminectomy model by using biophysical barriers called hyaluronic acid (HAS) dural barrier, activated polyethylene glycol and polyethylene imine (PEG) dural barrier, and platelet-rich plasma (PRP). Materials and methods: In this study, 2 of 26 male Wistar albino rats (325-350 g body weight), which were not included into study groups were sacrificed by removing their total blood and their blood was used for preparation of PRP, and remaining rats were randomly delivered into four groups called SHAM, HAS, PEG, and PRP groups. Then L3-4-5 laminectomy was performed to all animals and experimental agents were administered to the selected groups mentioned above. Spinal colons of all animals were removed gross total after 6-week period and investigated histopathologically. Additionally, real-time-polymerase chain reaction was used to obtain collagen type I and type III, transforming growth factor-1β, and tumor necrosis factor-α gene expressions. Results: All results demonstrated that polyethylene glycol and polyethylene imine dural barrier and PRP could decrease peridural fibrosis formation efficiently in rat. Conclusion: Present study results suggested that to reduce or block formation of peridural fibrosis, either polyethylene glycol and polyethylene imine dural barrier or PRP could be used effectively in human subjects after they will be closely investigated in future studies.

Postlaminectomy membrane with dynamic spinal cord compression disclosed with computed tomographic myelography: a case report and literature review

INTRODUCTION

It has been hypothesized that postoperative epidural scar, postlaminectomy membrane, may be responsible for late neurological deterioration after cervical laminectomy in some cases, but there is a lack of radiological studies in the literature showing the clinical significance of postlaminectomy membrane. We describe a rare case with radiological evidence of dynamic spinal cord compression caused by the postlaminectomy membrane, which may have been related to neurological deterioration.

CASE PRESENTATION

A 73-year-old male developed recurrent cervical myelopathy 6 months after C4-C6 laminectomy. In addition to atlantoaxial subluxation and kyphotic deformity, dynamic spinal cord compression by the postlaminectomy membrane was identified on computed tomographic myelography. The patient underwent atlantoaxial fixation and C3-C7 posterior decompression and fixation combined with removal of the thick and firm postlaminectomy membrane adhering to the dura mater. Histopathological findings of the postlaminectomy membrane revealed chronic inflammation around exogenous materials, presumably surgical materials remaining after the first operation, in the thick fibrous tissue. The patient's symptoms improved without recurrence of symptoms and postlaminectomy membrane formation for 3 years.

DISCUSSION

Compared with cervical laminoplasty, cervical laminectomy entails several postoperative problems, including postlaminectomy membrane formation. Postlaminectomy membranes may cause dynamic effects related to late neurological deterioration, and the evaluation of dynamic factors is important for neurological recurrence after cervical laminectomy. In the present case, chronic inflammation caused by surgical materials remaining after the first operation might have contributed to the rapid development of the postlaminectomy membrane.

The Results of Treating Failed Back Surgery Syndrome by Adhesiolysis: Comparing the One- and Three-Day Protocols

Background

The optimal treatment of failed back surgery syndrome (FBSS) is controversial. Limited studies have demonstrated the satisfactory outcomes of percutaneous adhesiolysis in FBSS, which can be performed as a 1 day or 3 days procedure. In the current randomized clinical trial, we compared the clinical and functional outcomes of these 2 techniques.

Methods

In this study, 60 patients with FBSS were randomly assigned into 2 equal groups: 1 day group and 3 days group. Before and at 4 and 12 weeks after the procedure, pain intensity was measured using visual analogue scale (VAS). The Oswestry disability index (ODI) was also completed. Pain reduction of 50% or more was defined as treatment success.

Results

Significant pain relief and ODI improvement were obtained in the 2 groups with adhesiolysis (P < 0.001). However, pain intensity remained the same before and at 4 and 12 weeks after adhesiolysis. ODI score was significantly lower in 1 day group in the 1 month visit (P < 0.001). Treatment was successful in 76.7% and 83.3% of the patients in 1 day and 3 days groups, respectively (P = 0.519).

Conclusions

Adhesiolysis is an effective treatment for pain relief and functional improvement in FBSS. The results of 1 day and 3 days procedures are comparable. Based on these findings, the authors recommend using 1 day technique, which can potentially decrease the patients' discomfort, hospital stay, and cost of treatment.

High-contrast high-resolution imaging of posttraumatic mandibular nerve by 3DAC-PROPELLER magnetic resonance imaging: correlation with the severity of sensory disturbance

OBJECTIVE

Magnetic resonance neurography reveals abnormal morphologies of regenerated nerves and overgrown connective tissue in injured trigeminal nerves, suggesting neuroma formation. We hypothesized that such deformities and scar formation contribute to pain symptoms.

STUDY DESIGN

High-contrast high-resolution magnetic resonance imaging was utilized to evaluate the inferior alveolar nerve and lingual nerve following traumatic injury in 19 patients. The relationship between the morphologic classification and severity of the sensory disorder was assessed.

RESULTS

In all cases, 3-dimensional anisotropy contrast periodically rotated overlapping parallel lines with enhanced reconstruction (3DAC-PROPELLER) successfully revealed the inner structures within the lesion. The isolated type represented the normal course of the nerve isolated from scar-like tissue (8 cases), whereas the deformity type included the deformed nerve either within scar-like tissue or by itself, unassociated with surrounding scar-like tissue (9 cases). In the remaining 2 cases, the nerve tissue and scar-like tissue were incorporated. Patients with the deformity type exhibited significantly more severe pain symptoms compared with patients with the isolated type.

CONCLUSIONS

Overgrown connective tissue does not necessarily block regenerating nerves and itself may not cause pain. The morphologic findings on the 3DAC-PROPELLER were relevant to the severity of pain symptoms.

Efficacy of Percutaneous Adhesiolysis in the Treatment of Lumbar Post Surgery Syndrome

Context

Lumbar post-surgery syndrome is common and often results in chronic, persistent pain and disability, which can lead to multiple interventions. After failure of conservative treatment, either surgical treatment or a nonsurgical modality of treatment such as epidural injections, percutaneous adhesiolysis is often contemplated in managing lumbar post surgery syndrome. Recent guidelines and systematic reviews have reached different conclusions about the level of evidence for the efficacy of epidural injections and percutaneous adhesiolysis in managing lumbar post surgery syndrome. The objective of this systematic review was to determine the efficacy of all 3 percutaneous adhesiolysis anatomical approaches (caudal, interlaminar, and transforaminal) in treating lumbar post-surgery syndrome.

Evidence Acquisition

Data Sources: A literature search was performed from 1966 through October 2014 utilizing multiple databases. Study Selection: A systematic review of randomized trials published from 1966 through October 2014 of all types of epidural injections and percutaneous adhesiolysis in managing lumbar post-surgery syndrome was performed including methodological quality assessment utilizing Cochrane review criteria, Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment (IPM–QRB), and grading of evidence using 5 levels of evidence ranging from Level I to Level V. Data Extraction: The search strategy emphasized post-surgery syndrome and related pathologies treated with percutaneous adhesiolysis procedures.

Results

The search criteria yielded 16 manuscripts on percutaneous adhesiolysis assessing post-surgery syndrome. Of these, only 4 randomized trials met inclusion criteria for methodological quality assessment, 3 of them were of high quality; and the fourth manuscript was of low quality. Based on these 3 randomized controlled trials, 2 of them with one-day procedure and one with a 3-day procedure, the level of evidence for the efficacy of percutaneous adhesiolysis is Level II based on best evidence synthesis.

Conclusions

Based on this systematic review, percutaneous adhesiolysis is effective in managing patients with lumbar post-surgery syndrome after the failure of conservative management including fluoroscopically directed epidural injections.

Treatment of lumbar disc herniation with radiculopathy. Clinical practice guidelines endorsed by The Polish Society of Spinal Surgery

INTRODUCTION

Herniated lumbar disc (HLD) is arguably the most common spinal disorder requiring surgical intervention. Although the term is fairly straightforward, the exact pathology and thus the clinical picture and natural history may vary. Therefore, it is immensely difficult to formulate universal guidelines for surgical treatment.

AIM

The aim of this paper is to organize the terminology and clear the inconsistencies in phraseology, review treatment options and gather available published evidence to address the clinical questions to create a set of clinical guidelines in relevant to the topic.

METHODS AND RESULTS

Twelve queries, addressing optimal surgical treatment of the HLD have been formulated. The results, based on the literature review are described in the present work. The final product of the analysis was a set of guidelines for the surgical treatment of symptomatic HLD. Categorized into four tiers based on the level of evidence (I-III and X), they have been designed to assist in the selection of optimal, effective treatment leading to the successful outcome.

CONCLUSIONS

The evidence based medicine (EBM) is becoming ever more popular among spinal surgeons. Unfortunately this is not always feasible. Lack of uniform guidelines and numerous conflicts of interest introduce flaws in the decision making process. The key role of experts and professional societies is to provide high value recommendation based on the most current literature. Present work contains a set of guidelines for the surgical treatment of HLD officially endorsed by the Polish Spine Surgery Society.

Effects of Radiation on Spinal Dura Mater and Surrounding Tissue in Mice

PURPOSE

Spinal surgery in a previously irradiated field carries increased risk of perioperative complications, such as delayed wound healing or wound infection. In addition, adhesion around the dura mater is often observed clinically. Therefore, similar to radiation-induced fibrosis--a major late-stage radiation injury in other tissue--epidural fibrosis is anticipated to occur after spinal radiation. In this study, we performed histopathologic assessment of postirradiation changes in the spinal dura mater and peridural tissue in mice.

MATERIALS AND METHODS

The thoracolumbar transition of ddY mice was irradiated with a single dose of 10 or 20 Gy. After resection of the irradiated spine, occurrence of epidural fibrosis and expression of transforming growth factor beta 1 in the spinal dura mater were evaluated. In addition, microstructures in the spinal dura mater and peridural tissue were assessed using an electron microscope.

RESULTS

In the 20-Gy irradiated mice, epidural fibrosis first occurred around 12 weeks postirradiation, and was observed in all cases from 16 weeks postirradiation. In contrast, epidural fibrosis was not observed in the nonirradiated mice. Compared with the nonirradiated mice, the 10- and 20-Gy irradiated mice had significantly more overexpression of transforming growth factor beta 1 at 1 week postirradiation and in the late stages after irradiation. In microstructural assessment, the arachnoid barrier cell layer was thinned at 12 and 24 weeks postirradiation compared with that in the nonirradiated mice.

CONCLUSION

In mice, spinal epidural fibrosis develops in the late stages after high-dose irradiation, and overexpression of transforming growth factor beta 1 occurs in a manner similar to that seen in radiation-induced fibrosis in other tissue. Additionally, thinning of the arachnoid barrier cell layer was observed in the late stages after irradiation. Thus, consideration should be given to the possibility that these phenomena can occur as radiation-induced injuries of the spine.

Efficacy and Safety of Sodium Hyaluronate with 1,4-Butanediol Diglycidyl Ether Compared to Sodium Carboxymethylcellulose in Preventing Adhesion Formation after Lumbar Discectomy

OBJECTIVE

Epidural injection of hyaluronic acid may prevent adhesion formation after spine surgery, but the compounds used to stabilize hyaluronidase could interfere with its anti-adhesion effects. The present study was conducted as a clinical trial to evaluate the efficacy and safety of an experimental medical gel in preventing adhesion formation.

METHODS

This study was designed as a multicenter, randomized, double-blind, and comparative controlled clinical trial with an observation period of 6 weeks. Subjects were randomly assigned into two groups: group A with sodium hyaluronate + 1,4-butanediol diglycidyl ether (BDDE) and group B with sodium hyaluronate + sodium carboxymethylcellulose (CMC). Visual analogue scale (VAS) of back and leg pain and the Oswestry disability index (ODI) and scar score ratings were assessed after surgery.

RESULTS

Mean scar grade was 2.37±1.13 in group A and 2.75±0.97 in group B, a statistically significant difference (p=0.012). VAS of back and leg pain and ODI scores decreased significantly from baseline to 3 and 6 weeks postoperatively in both groups (p<0.001). However, VAS and ODI scores were not statistically different between groups A and B at baseline or at 3 and 6 weeks after operation (p>0.3). The number of adverse reactions related to the anti-adhesion gels was not statistically different (p=0.569), but subsequent analysis of nervous adverse reactions showed group B was superior with a statistically difference (p=0.027).

CONCLUSION

Sodium hyaluronate with BDDE demonstrated similar anti-adhesion properties to sodium hyaluronate with CMC. But, care should be used to nervous adverse reactions by using sodium hyaluronate with BDDE.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses

BACKGROUND

There are numerous treatment approaches for sciatica. Previous systematic reviews have not compared all these strategies together.

PURPOSE

To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.

STUDY DESIGN

Systematic review and network meta-analysis.

METHODS

We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.

RESULTS

We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.

CONCLUSIONS

For the first time, many different treatment strategies for sciatica have been compared in the same systematic review and meta-analysis. This approach has provided new data to assist shared decision-making. The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction. The issue of how best to estimate the effectiveness of treatment approaches according to their order within a sequential treatment pathway remains an important challenge.

Markers of inflammation and fibrinolysis in relation to outcome after surgery for lumbar disc herniation. A prospective study on 177 patients

PURPOSE

The role of inflammation and fibrinolysis for the development of back pain and sciatica has been discussed. The aim of this study was to assess the relationship between markers of inflammation and fibrinolysis, to predict the outcome after surgery for lumbar disc herniation.

METHODS

177 patients were recruited. High sensitive C-reactive protein (hsCRP), plasminogen activator inhibitor 1 (PAI-1), fibrinogen, and D-dimer were analyzed preoperatively. Visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), and EuroQol 5 Dimensions (EQ-5D) were assessed preoperatively and at 6 weeks, 6-, 12-, and 24- months postoperatively. Dichotomization was made at the median for the laboratory analyses, and between the worst quartile and the other three quartiles for the outcome variables. Logistic regression was used to determine the odds ratios (OR) and 95 % confidence intervals (CI).

RESULTS

The associations between PAI-1 and outcome seemed to be most prominent at the 6 and 12-month follow-up. When being in the upper half of PAI-1, the OR for being in the worst quartile of VAS back pain 12 months postoperatively was 3.33 (1.56-7.10). The corresponding OR for VAS leg pain was 2.46 (1.18-5.10), for ODI 2.83 (1.35-5.94) and for EQ-5D 2.73 (1.30-5.75). The OR for hsCRP was 2.10 (1.03-4.29) for being in the worst quartile of VAS back pain. Fibrinogen or D-dimer was not associated with any outcome variable.

CONCLUSIONS

High PAI-1, a marker of fibrinolysis, was fairly consistently associated with poor outcome, while hsCRP, fibrinogen, and D-dimer were not.

Does disk space degeneration according to Los Angeles and Modic scales have relation with recurrent disk herniation?

Background:

After single disk herniation operation, about 5–20% recurrences may occur. Different etiology may affect the prevalence of recurrence. Disk degeneration according to Modic and Los Angles scales could affect recurrence rate. This study wants to show the relationship between disk space degeneration according to these scales on severity, time, and prevalence of disk herniation recurrence.

Materials and Methods:

Thirty-four patients presented with radicular pain (with or without back pain) and history of lumbar disk surgery was included in this prospective study. Pre- and postoperative T2-weighted sagittal magnetic resonance imaging (MRI) compared for Modic and Los Angeles disk degeneration grading, then, data analysis on SPSS (version 20) software, paired t-test, and others.

Results:

The result of study shows for first operation that grade (II) Los Angeles is the most common, but, for second procedure grade (IV) was less common and the mostly decreased (from 14.7 to 9.2%). In addition, Wilcoxon test shows no change of Los Angeles grading for both first and second surgery (P = 0.06). Whereas; based on Modic criteria grading was different from first operation, in other words, grade (I) (41.2%) in first operation was changed to 20.6% in second operation (P = 0.007).

Conclusion:

Our study showed that the Los Angeles criterion is more practical and useful for prediction of recurrence and in the patients with Los Angles grade III and IV and grade II and III on Modic scale, the chance of recurrence is less than patients with lower grades.

Does improvement in epidurography following percutaneous epidural neuroplasty correspond to patient outcome?

OBJECTIVE

The positive effects of percutaneous epidural neuroplasty (PEN) likely result from elimination of fibrous tissue. However, a direct link between epidural adhesions and pain symptoms is debatable. We tested the hypothesis that epidurographic improvements correspond to improved patient outcome.

METHODS

In this prospective study, patients with a filling defect on initial epidurography underwent PEN. Two weeks later, contrast agent distribution around the target area was assessed with repeat epidurography. A successful treatment was defined as over a 50% reduction in visual analog scale (VAS) score 2 weeks postprocedure. The demographic data, history of lumbar spine operation, target nerve, diagnosis, VAS scores, degree of epidurographic improvement, and patient satisfaction were compared between the successful treatment group (Group I) and unsuccessful treatment group (Group II).

RESULTS

Seventy-nine patients were included. Epidurographic findings improved in 67.1% of patients 2 weeks after the procedure. Following PEN, the mean VAS scores of all patients were significantly decreased at 2 weeks (4.12 ± 2.34), 1 month (3.56 ± 2.30), 3 months (3.84 ± 2.45), and 6 months (4.13 ± 2.71) compared with the initial scores (7.82 ± 1.78). In the comparison between Groups I and II, the rate of epidurographic improvement in Group I was higher than in Group II (P = 0.022). Satisfaction in patients that had epidurographic improvement (median satisfaction: 4) was higher than in patients that did not have epidurographic improvement (median satisfaction: 3; P = 0.003).

CONCLUSION

The epidurographic changes following PEN correlate with patient-assessed pain relief and satisfaction.

Epidural lysis of adhesions for failed back surgery and spinal stenosis: factors associated with treatment outcome

BACKGROUND

Failed back surgery syndrome (FBSS) is a challenging problem. One treatment advocated to treat FBSS is epidural lysis of adhesions (LOA). The results of studies examining LOA for FBSS have been mixed, but are limited because no study has ever sought to identify factors associated with outcomes.

METHODS

We performed this multicenter, retrospective study in 115 patients who underwent LOA for FBSS (n = 104) or spinal stenosis (n = 11) between 2004 and 2007. Twenty-seven demographic, clinical, and procedural variables were extracted from medical records and correlated with the outcome, defined as ≥50% pain relief lasting ≥1 month. Univariable analysis was performed, followed by multivariable logistic regression.

RESULTS

Overall, 48.7% (95% confidence interval [CI], 39.3%-58.1%) of patients experienced a positive outcome. In univariable analysis, those who had a positive outcome were older (mean age 64.1 years; 95% CI, 59.7-68.6 vs 57.2; 95% CI, 53.0-61.4 years; P = 0.02), while higher baseline numerical rating scale pain scores were associated with a negative outcome (mean 6.7 years; 95% CI, 6.0-7.3 vs 7.5; 95% CI, 6.9-8.0; P = 0.07). Use of hyaluronidase did not correlate with outcomes in univariable analysis (odds ratio [OR], 1.2; 95% CI, 0.6-2.5; P = 0.65). In multivariable analysis, age ≥81 years (OR, 7.8; 95% CI, 1.4-53.7), baseline numerical rating scale score ≤9 (OR, 4.4; 95% CI, 1.4-16.3, P = 0.02), and patients on or seeking disability or worker's compensation (OR, 4.4; 95% CI, 1.1-19.5, P = 0.04) were significantly more likely to experience a positive outcome.

CONCLUSIONS

Considering our modest success rate, selecting patients for epidural LOA based on demographic and clinical factors may help better select treatment candidates. Procedural factors such as the use of hyaluronidase that increase risks and costs did not improve outcomes, so further research is needed before these become standard practice.

Postoperative spine complications

Imaging of the postoperative spine is common, although it remains a difficult task for radiologists. This article presents an overview of common surgical approaches and spinal hardware, and specific complications that may be associated with each procedure. In addition, expected postoperative changes and complications that are common among procedures, with their differential diagnosis and imaging features, are discussed.

Epidural lysis of adhesions

As our population ages and the rate of spine surgery continues to rise, the use epidural lysis of adhesions (LOA) has emerged as a popular treatment to treat spinal stenosis and failed back surgery syndrome. There is moderate evidence that percutaneous LOA is more effective than conventional ESI for both failed back surgery syndrome, spinal stenosis, and lumbar radiculopathy. For cervical HNP, cervical stenosis and mechanical pain not associated with nerve root involvement, the evidence is anecdotal. The benefits of LOA stem from a combination of factors to include the high volumes administered and the use of hypertonic saline. Hyaluronidase has been shown in most, but not all studies to improve treatment outcomes. Although infrequent, complications are more likely to occur after epidural LOA than after conventional epidural steroid injections.

An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy

BACKGROUND CONTEXT

The objective of the North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of lumbar disc herniation with radiculopathy. The guideline is intended to reflect contemporary treatment concepts for symptomatic lumbar disc herniation with radiculopathy as reflected in the highest quality clinical literature available on this subject as of July 2011. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.

PURPOSE

To provide an evidence-based educational tool to assist spine specialists in the diagnosis and treatment of lumbar disc herniation with radiculopathy.

STUDY DESIGN

Systematic review and evidence-based clinical guideline.

METHODS

This guideline is a product of the Lumbar Disc Herniation with Radiculopathy Work Group of NASS' Evidence-Based Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. A literature search addressing each question and using a specific search protocol was performed on English-language references found in Medline, Embase (Drugs and Pharmacology), and four additional evidence-based databases to identify articles. The relevant literature was then independently rated using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were developed via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Level I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

RESULTS

Twenty-nine clinical questions were formulated and addressed, and the answers are summarized in this article. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence.

CONCLUSIONS

The clinical guideline has been created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with symptomatic lumbar disc herniation with radiculopathy. The entire guideline document, including the evidentiary tables, suggestions for future research, and all the references, is available electronically on the NASS Web site at http://www.spine.org/Pages/PracticePolicy/ClinicalCare/ClinicalGuidlines/Default.aspx and will remain updated on a timely schedule.

Skin, fascias, and scars: symptoms and systemic connections

Every element or cell in the human body produces substances that communicate and respond in an autocrine or paracrine mode, consequently affecting organs and structures that are seemingly far from each other. The same also applies to the skin. In fact, when the integrity of the skin has been altered, or when its healing process is disturbed, it becomes a source of symptoms that are not merely cutaneous. The skin is an organ, and similar to any other structure, it has different functions in addition to connections with the central and peripheral nervous system. This article examines pathological responses produced by scars, analyzing definitions and differences. At the same time, it considers the subcutaneous fascias, as this connective structure is altered when there is a discontinuous cutaneous surface. The consequence is an ample symptomatology, which is not limited to the body area where the scar is located, such as a postural or trigeminal disorder.

Long-term follow-up of standard microdiscectomy versus minimal access surgery for lumbar disc herniations

BACKGROUND

Surgery of lumbar disc herniations is one of the most common neurosurgical procedures. New surgical approaches and techniques are constantly evolving. We present our long-term follow-up results comparing standard open microdiscectomy (SOMD) and minimal access microdiscectomy (MAMD) for single-level lumbar disc herniations.

METHODS

Patients were randomized in two groups receiving either MAMD or SOMD. Physical and mental health and pain relief were assessed (ODI, SF-36 questionnaire, VAS leg and back pain). In addition, all patients received MR imaging for morphological evaluation of postoperative peridural scar tissue formation.

RESULTS

Of the 60 initial patients (SOMD: 30 pts, MAMD: 30 pts), 38 were available for long-term follow-up. Mean follow-up time was 33 months. Long-term follow-up revealed significant postoperative pain relief in both groups. Good to excellent results concerning physical and mental health and pain relief were achieved in both groups. Significantly less peridural scar tissue formation was observed in the MAMD patients, but without clinical impact.

CONCLUSION

MAMD is a feasible alternative to the standard open approach. Both groups show significant and long-lasting pain relief and good to excellent results regarding health-related quality of life. Congruent to our short-term results, we observed slightly but not statistically significant better clinical results in the MAMD group when compared to the SOMD group.

Investigation of efficacy of mitomycin-C, sodium hyaluronate and human amniotic fluid in preventing epidural fibrosis and adhesion using a rat laminectomy model

Study Design

A retrospective study.

Purpose

The aim of this study was to evalute the effects of mitomycin-C, sodium hyaluronate and human amniotic fluid on preventing spinal epidural fibrosis.

Overview of Literature

The role of scar tissue in pain formation is not exactly known, but it is reported that scar tissue causes adhesions between anatomic structures. Intensive fibrotic tissue compresses on anatomic structures and increases the sensitivity of the nerve root for recurrent herniation and lateral spinal stenosis via limiting movements of the root. Also, neuronal atrophy and axonal degeneration occur under scar tissue.

Methods

The study design included 4 groups of rats: group 1 was the control group, groups 2, 3, and 4 receieved antifibrotic agents, mitomycin-C (group 2), sodium hyaluronate (group 3), and human amniotic fluid (group 4). Midline incision for all animals were done on L5 for total laminectomy. Four weeks after the surgery, the rats were sacrificed and specimens were stained with hematoxylin-eosin and photos of the slides were taken for quantitive assesment of the scar tissue.

Results

There was no significant scar tissue in the experimental animals of groups 2, 3, and 4. It was found that there was no significant difference between drug groups, but there was a statistically significant difference between the drug groups and the control group.

Conclusions

This experimental study shows that implantation of mitomycin-C, sodium hyaluronate and human amniotic fluid reduces epidural fibrosis and adhesions after spinal laminectomy in rat models. Further studies in humans are needed to determine the complications of the agents researched.

Epidural steroids: a comprehensive, evidence-based review

Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.

Conservative management of recurrent lumbar disk herniation with epidural fibrosis: a case report

OBJECTIVE

A retrospective case report of a 24-year-old man with recurrent lumbar disk herniation and epidural fibrosis is presented. Recurrent lumbar disk herniation and epidural fibrosis are common complications following lumbar diskectomy.

CLINICAL FEATURES

A 24-year-old patient had a history of lumbar diskectomy and new onset of low back pain and radiculopathy. Magnetic resonance imaging revealed recurrent herniation at L5/S1, left nerve root displacement, and epidural fibrosis.

INTERVENTION AND OUTCOMES

The patient received a course of chiropractic care including lumbar spinal manipulation and rehabilitation exercises with documented subjective and objective functional and symptomatic improvement.

CONCLUSION

This case report describes chiropractic management including spinal manipulative therapy and rehabilitation exercises and subsequent objective and subjective functional and symptomatic improvement.

Magnetic resonance imaging in follow-up assessment of sciatica

BACKGROUND

Magnetic resonance imaging (MRI) is frequently performed during follow-up in patients with known lumbar-disk herniation and persistent symptoms of sciatica. The association between findings on MRI and clinical outcome is controversial.

METHODS

We studied 283 patients in a randomized trial comparing surgery and prolonged conservative care for sciatica and lumbar-disk herniation. Patients underwent MRI at baseline and after 1 year. We used a 4-point scale to assess disk herniation on MRI, ranging from 1 for "definitely present" to 4 for "definitely absent." A favorable clinical outcome was defined as complete or nearly complete disappearance of symptoms at 1 year. We compared proportions of patients with a favorable outcome among those with a definite absence of disk herniation and those with a definite, probable, or possible presence of disk herniation at 1 year. The area under the receiver-operating-characteristic (ROC) curve was used to assess the prognostic accuracy of the 4-point scores regarding a favorable or unfavorable outcome, with 1 indicating perfect discriminatory value and 0.5 or less indicating no discriminatory value.

RESULTS

At 1 year, 84% of the patients reported having a favorable outcome. Disk herniation was visible in 35% with a favorable outcome and in 33% with an unfavorable outcome (P=0.70). A favorable outcome was reported in 85% of patients with disk herniation and 83% without disk herniation (P=0.70). MRI assessment of disk herniation did not distinguish between patients with a favorable outcome and those with an unfavorable outcome (area under ROC curve, 0.48).

CONCLUSIONS

MRI performed at 1-year follow-up in patients who had been treated for sciatica and lumbar-disk herniation did not distinguish between those with a favorable outcome and those with an unfavorable outcome. (Funded by the Netherlands Organization for Health Research and Development and the Hoelen Foundation; Controlled Clinical Trials number, ISRCTN26872154.).

Inhibition of epidural fibrosis after microendoscopic discectomy with topical application of mitomycin C: a randomized, controlled, double-blind trial

OBJECT

The authors conducted a study to evaluate the effects and the safety of locally applied mitomycin C (MMC) on epidural fibrosis after microendoscopic discectomy (MED).

METHODS

Seventy-five patients undergoing single-level unilateral MED for lumbar disc herniation were randomly assigned to receive cotton wool impregnated with either 0.5 mg/ml MMC or saline applied at the site of discectomy for 5 minutes. Outcome measures included degrees of pain severity, functional disability, physical symptoms, and quantitative evaluation of postoperative epidural fibrosis shown on follow-up lumbar contrast-enhanced MRI.

RESULTS

Sixty-two patients completed the follow-up. Neither serious drug adverse effects nor clinically significant laboratory adverse effects were observed. Patients in both groups showed similar clinical recoveries postoperatively. A statistically significant difference (p < 0.05) between the 2 treatments was shown in a quantitative evaluation of postoperative MRI-documented epidural fibrosis in the MMC group and the saline group using a modified grading system. The mean cross-sectional areas of epidural fibrosis were 7.32-70.06 mm(2) in the MMC group and 22.94-90.48 mm(2) in the saline group. The epidural fibrosis index ranged from 0.0296 to 0.3267 in the MMC group and from 0.1191 to 0.3483 in the saline group. A significant difference was also observed using the Ross grading system to evaluate postoperative MR images.

CONCLUSIONS

Although no benefit was observed clinically, the authors observed a notable reduction of epidural fibrosis after MED radiologically, with 0.5 mg/ml MMC locally applied and no clinical side effects.

Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing post lumbar surgery syndrome: 2-year follow-up of a randomized, controlled trial

Background

The literature is replete with evaluations of failed surgery, illustrating a 9.5%–25% reoperation rate. Speculated causes of post lumbar surgery syndrome include epidural fibrosis, acquired stenosis, recurrent disc herniation, sacroiliac joint pain, and facet joint pain among other causes.

Methods

Patients (n = 120) were randomly assigned to two groups with a 2-year follow-up. Group I (control group, n = 60) received caudal epidural injections with catheterization up to S3 with local anesthetic (lidocaine 2%, 5 mL), nonparticulate betamethasone (6 mg, 1 mL), and 6 mL of 0.9% sodium chloride solution. Group II (intervention group, n = 60) received percutaneous adhesiolysis of the targeted area, with targeted delivery of lidocaine 2% (5 mL), 10% hypertonic sodium chloride solution (6 mL), and nonparticulate betamethasone (6 mg). The multiple outcome measures included the Numeric Rating Scale, the Oswestry Disability Index 2.0, employment status, and opioid intake with assessments at 3, 6, 12, 18, and 24 months posttreatment. Primary outcome was defined as 50% improvement in pain and Oswestry Disability Index scores.

Results

Significant improvement with at least 50% relief with pain and improvement in functional status was illustrated in 82% of patients at the 2-year follow-up in the intervention group compared to 5% in the control group receiving caudal epidural injections. The average number of procedures over a period of 2 years in Group II was 6.4 ± 2.35 with overall total relief of approximately 78 weeks out of 104 weeks.

Conclusion

The results of this study show significant improvement in 82% of patients over a period of 2 years with an average of six to seven procedures of 1-day percutaneous adhesiolysis in patients with failed back surgery syndrome.

The grading model for the assessment of the total amount of epidural fibrosis in postoperative lumbar spine

Purpose

To present a new model derived from Ross’s model for the assessment of the total amount of epidural fibrosis and to present inter- and intravariability study.

Methods

Two readers blinded to each other and blinded to their first and second reading retrospectively evaluated the magnetic resonance examinations in 32 postoperative spine surgery patients using this model.

Results

Paired and unpaired two-sided t tests showed no significant difference between the first and second reading, and interclass correlation coefficient revealed good interobserver reliability.

Conclusion

The proposed model enables estimation of the amount of epidural fibrosis in postoperative lumbar spine and does not require any additional software or hardware. It is designed for multi-centered clinical studies where it is necessary to compare the values of epidural fibrosis between the tested and control group. The use of the proposed model is fast and practical and helps to avoid complications arising from image format, calibration and software, which are often encountered in multi-centered studies.

Alpha-lipoic acid reduces peridural fibrosis after laminectomy of lumbar vertebrae in rabbits

BACKGROUND

Peridural fibrosis is an inevitable healing process causing failed back surgery syndrome after lumbar spinal operations. In this study, alpha-lipoic acid (ALA), reported to reduce fibrosis in liver, oral mucosa, and peritoneum, investigated as a potential candidate for prevention of peridural fibrosis.

METHOD

Twelve adult New Zealand white male rabbits were divided into control (n = 5) and ALA groups (n = 7). Laminectomy of lumbar spine was performed and ALA was applied on the exposed dura mater topically in ALA group.

RESULTS

According to histological peridural grading, the ALA group (median grade 1) showed significantly less peridural fibrosis than the control group (median grade 3, p = 0.005).

CONCLUSIONS

ALA is a promising substance in the prevention of peridural fibrosis, especially in early preoperative and postoperative period.

Remarkable epidural scar formation compressing the cervical cord after osteoplastic laminoplasty with hydroxyapatite spacer

The authors report on an 81-year-old woman whose condition deteriorated 2 months after undergoing osteoplastic laminoplasty with placement of hydroxyapatite spacers. Magnetic resonance imaging showed postlaminectomy scar formation compressing the cervical spinal cord. The patient underwent laminectomy and removal of remarkably thick epidural scar tissue, which resulted in resolution of her symptoms. Histological diagnosis of the scar was fibrous granulation tissue with foreign body granuloma, characterized by multinucleated giant cells and marked increases of capillary vessels, fibroblasts, and collagen fibers. This case of symptomatic postlaminectomy scar formation after osteoplastic laminoplasty suggests that osteoplastic laminoplasty cannot always prevent laminectomy membrane formation.

Effectiveness of the biophysical barriers on the peridural fibrosis of a postlaminectomy rat model: an experimental research

PURPOSE

Long term results after surgical treatment of disc herniation have shown that epidural and/or peridural fibrosis formed during the healing process after surgical intervention. We conducted this experimental study to evaluation of the effectiveness of the bioresorbable barriers (ADCON-L and Seprafilm(®) Adhesion Barrier) on formation of the peridural fibrosis in rat model performed laminectomy.

METHODS

Thirty-two male Wistar albino rats 250-350g body weight were distributed into three groups (CONTROL, AL group received ADCON-L; SAB group received Seprafilm(®) Adhesion Barrier). A dorsal laminectomy at L3, L4, L5 was performed, and then except those of the CONTROL group, the experimental material was left on the dura mater. Six weeks later spinal column of all rats was totally removed between the T10 and L5 levels, and peridural fibrosis, and dural adhesions were evaluated histologically and graded. The results were compared statistically by using the chi-square (χ(2)) test. Also three random regions were examined, and the fibroblast cells were counted. The fibroblast count results were statistically analysed by using the One-Way ANOVA test.

RESULTS

The variation of histopathological grades was statistically significant regarding the comparison of the all groups obtained from the χ(2) test (χ(2)=16.40; p=0.003). However, the variation in the mean values of the fibroblast count result was not statistically significant obtained from the One-Way ANOVA test (F=2.114; p>0.05).

CONCLUSION

Our study results suggest that Seprafilm(®) Adhesion Barrier and ADCON-L can be effective in reducing the prevalence of the postoperative peridural adhesions in rat laminectomy model. On the other hand, the fibroblast densities of the experimental groups were not different between groups. So, we could say that these materials can act as a foreign body in long term period in rat.

[Imaging of the postsurgical spine]

Some early complications (hematoma, spondylodiscitis, pseudomeningocele) can occur with all types of surgery while late complications vary with the type of surgery. After discectomy, postsurgical changes (osseous and ligamentous defects, scar tissue, granulation tissue) should be distinguished from postsurgical complications or recurrent disease (recurrent disc herniation, arachnoiditis, spondylodiscitis). Following spinal decompression and fusion procedures, standard radiographs and CT can confirm the adequate position of the fusion devices, the presence of fusion, and the development of late osseous complications: pseudarthrosis, instability and recurrent stenosis.

Recurrent lumbar disk herniation

Recurrent lumbar disk herniation is the most common complication following primary open diskectomy. It is defined as recurrent back and/or leg pain after a definite pain-free period lasting at least 6 months from initial surgery. Careful neurologic examination is critical, and laboratory tests should be ordered to evaluate for infection. Imaging demonstrates disk herniation at the previously operated level. It is important to differentiate recurrent disk herniation from postoperative epidural scar because the latter may not benefit from reoperation. Treatment of recurrent lumbar disk herniation includes aggressive medical management and surgical intervention. Surgical techniques include conventional open diskectomy, minimally invasive open diskectomy, and open diskectomy with fusion. Fusion is necessary in the presence of concomitant segmental instability or significant foraminal stenosis resulting from disk space collapse.

Clinical factors of importance for outcome after lumbar disc herniation surgery: long-term follow-up

Factors as age, sex, smoking, duration of leg pain, working status, type/level of disc herniation and psychosocial factors have been demonstrated to be of importance for short-term results after lumbar discectomy. There are few studies with long-term follow-up. In this prospective study of lumbar disc herniation patients undergoing surgery, the result was evaluated at 2 and 5-10 (mean 7.3) years after surgery. Predictive factors for satisfaction with treatment and objective outcome were investigated. Out of the included 171 patients undergoing lumbar discectomy, 154 (90%) patients completed the 2-year follow-up and 140 (81%) completed the long-term follow-up. Baseline data and questionnaires about leg- and back pain intensity (VAS), duration of leg pain, disability (Oswestry Disability Index), depression (Zung Depression Scale), sick leave and employment status were obtained preoperatively, at 2-year- and long-term follow-up. Primary outcome included patient satisfaction with treatment (at both time points) and assessment of an independent observer at the 2-year follow-up. Secondary outcomes at 2-year follow-up were improvement of leg and back pain, working capacity and the need for analgesics or sleeping pills. In about 70% of the patients excellent or good overall result was reported at both follow-ups, with subjective outcome measurements. The objective evaluation after 2 years was in agreement with this result. Time on sick leave was found to be a clinically important predictor of the primary outcomes, with a potential of changing the probability of a satisfactory outcome (both objective and subjective) from around 50% (sick leave >3 months) to 80% (sick leave <2 months). Time on sick leave was also an important predictor for several of the secondary outcomes; e.g. working capacity and the need for analgesics.