Is the use of hemostatic matrix (Floseal) and alkylene oxide copolymer (Ostene) safe in spinal laminectomies? Peridural fibrosis assessment

Postoperative Epidural Fibrosis: Challenges and Opportunities - A Review

Postoperative epidural fibrosis (EF) is still a major limitation to the success of spine surgery. Fibrotic adhesions in the epidural space, initiated via local trauma and inflammation, can induce difficult-to-treat pain and constitute the main cause of failed back surgery syndrome, which not uncommonly requires operative revision. Manifold agents and methods have been tested for EF relief in order to mitigate this longstanding health burden and its socioeconomic consequences. Although several promising strategies could be identified, few have thus far overcome the high translational hurdle, and there has been little change in standard clinical practice. Nonetheless, notable research progress in the field has put new exciting avenues on the horizon. In this review, we outline the etiology and pathogenesis of EF, portray its clinical and surgical presentation, and critically appraise current efforts and novel approaches toward enhanced prevention and treatment.

Efficacy and Safety of Bioabsorbable Bone Hemostatic Agent in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Although a bioabsorbable bone hemostatic agent (BBHA) was developed approximately 20 years ago to overcome the shortcomings of conventional bone wax, its bleeding control capacity has not yet been studied. This study was aimed at investigating the efficacy and safety of BBHA in total knee arthroplasty (TKA). Sixty-two patients who underwent unilateral primary TKA for knee osteoarthritis were included and randomized to the control or BBHA group. Before releasing the tourniquet, BBHA was applied on the bone-cut surface that was not covered by implants. The primary variable was the drainage volume during the postoperative period. The secondary outcomes were total estimated blood loss (EBL), hemoglobin level, hematocrit level, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, range of motion (ROM), pain visual analog scale (VAS) score, and rate of complications. There were no significant differences in drainage volume or EBL between the 2 groups. Hemoglobin and hematocrit levels were higher in the BBHA group during the 4-week postoperative period; however, the intergroup differences were not significant. The ESR, CRP, ROM, and pain VAS scores in the BBHA group were not significantly different from the corresponding values in the control group. No specific complications were observed. Although BBHA was found to be safe without complications, it did not decrease bleeding after TKA in general cases. Further studies are necessary to evaluate the efficacy of BBHA in patients with coagulation problems.

Does prophylactic use of topical gelatin-thrombin matrix sealant affect postoperative drainage volume and hematoma formation following microendoscopic spine surgery? A randomized controlled trial

BACKGROUND CONTEXT

Microendoscopic spinal surgery has demonstrated efficacy and is increasingly utilized as a minimally invasive approach to neural decompression, but there is a theoretical concern that bleeding and postoperative epidural hematoma (PEH) may occur with increased frequency in a contained small surgical field. Hemostatic agents, such as topical gelatin-thrombin matrix sealant (TGTMS), are routinely used in spine surgery procedures, yet there has been no data on whether PEH is suppressed by these agents when administered in microendoscopic spine surgery.

PURPOSE

The purpose of this study was to investigate the effect of TGTMS on bleeding and PEH formation in lumbar micoroendoscopic surgery.

STUDY DESIGN

This is a randomized controlled trial (RCT) with additional prospective observational cohort.

PATIENT SAMPLE

Patients were registered from July 2017 to September 2018 and a hundred and three patients undergoing microendoscopic laminectomy for lumbar spinal stenosis at a single institution were enrolled in this study.

OUTCOME MEASURES

The primary outcome was the drainage volume within 48 hours after surgery. Secondary outcomes were the numerical rating scale (NRS) of leg pain on the second (NRS2) and seventh day (NRS7) after surgery and the hematoma area ratio (HAR) in horizontal images on magnetic resonance image (MRI).

METHODS

In the RCT, 41 cases that received TGTMS (F group) were compared with 41 control group cases (C group) that did not receive TGTMS at the end of the procedure. Drainage volume, NRS2, NRS7, and HAR on MRI were evaluated. Nineteen cases were excluded from the RCT (I group) due to difficulty of hemostasis during surgery and the intentional use of TGTMS for hemostasis. I group was compared with C group in the drainage volume and NRS of leg pain as a prospective observational study.

RESULTS

The RCT demonstrated no statistically significant difference in drainage volume between those receiving TGTMS (117.0±71.7; mean±standard deviation) and controls (125.0±127.0; p=.345). The NRS2 and NRS7 was 3.5±2.6 and 2.8±2.5 in the F group, respectively, and 3.1±2.6 and 2.1±2.3 in the C group, respectively. The HAR on MRI was 0.19±0.19 in the F group and 0.17±0.13 in the C group. There was no significant difference in postoperative leg pain and HAR (p=.644 for NRS2, p=.129 for NRS7, and p=.705 for HAR). In the secondary observational cohort, the drainage volume in the I group was 118.3±151.4, and NRS2 and NRS7 was 3.5±2.0 and 2.6±2.6, respectively. There were no statistically significant differences in drainage volume (p=.386) or postoperative NRS of leg pain between these two groups (p=.981 and .477 for NRS2 and NRS7, respectively).

CONCLUSIONS

The prophylactic use of TGTMS in patients undergoing microendoscopic laminotomy for lumbar spinal stenosis did not demonstrate any difference in postoperative bleeding or PEH. Nonetheless, for patients that had active bleeding that required the use of TGTMS, there was no evidence of difference in postoperative clinical outcomes relative to controls.

Effectiveness of Gelatin-Thrombin Matrix Sealants (Floseal®) on Postoperative Spinal Epidural Hematoma during Single-Level Lumbar Decompression Using Biportal Endoscopic Spine Surgery: Clinical and Magnetic Resonance Image Study

Background

Symptomatic postoperative spinal epidural hematoma (PSEH) is a devastating complication that could develop after lumbar decompression surgery. PSEH can also develop after biportal endoscopic spine surgery (BESS), one of the recently introduced minimally invasive spine surgery techniques. Gelatin-thrombin matrix sealant (GTMS) is commonly used to prevent PSEH. This study aimed at analyzing the clinical and radiological effects of GTMS use during BESS.

Methods

A total of 206 patients with spinal stenosis who underwent decompression by BESS through a posterior interlaminar approach from October 2015 to September 2018 were enrolled in this study. Postoperative magnetic resonance imaging (MRI) was performed in all patients for evaluation of PSEH. Patients in whom GTMS was not used during surgery were assigned to Group A, and those in whom GTMS was used were classified as Group B. In the clinical evaluation, the visual analog scale (VAS) of the leg and back, Oswestry Disability Index (ODI), and modified MacNab criteria were used. The incidence rate and degree of dural compression of PSEH on postoperative MRI were measured.

Results

The average age of the patients was 68.1 ± 11.2 (42–89) years. The overall incidence rate of PSEH was 20.9% (43/206). The incidence rates in Groups A and B were 26.4% and 13.6%, respectively, showing a significant difference (p = 0.023). The VAS-leg and ODI improvement was significantly different depending on the intraoperative use of GTMS. However, there was no statistically significant difference between the two groups in terms of the VAS-back improvement. Groups A and B showed “good” and “excellent” rates according to the modified MacNab criteria in 79.4% and 87.6% of patients, respectively, showing statistically significant difference (p = 0.049). In Group A, two patients underwent revision surgery due to PSEH, while none in Group B had such event.

Conclusion

Intraoperative use of GTMS during BESS may be related to reduction in the occurrence rate of PSEH. Specifically, patients with GTMS appliance showed marked decrease in the occurrence of PSEH and had better clinical outcomes.

A novel technique to develop thoracic spinal laminectomy and a methodology to assess the functionality and welfare of the contusion spinal cord injury (SCI) rat model

This study reports the advantage of a novel technique employing a motorised dental burr to assist laminectomy over the conventional manual technique at T10-T11 vertebra level in a rat model of spinal cord injury. Twenty-four female rats were randomly assigned to four groups: (1) conventionally laminectomised, (2) dental burr assisted laminectomised, (3) conventionally laminectomised with spinal cord contusion and (4) dental burr assisted laminectomised with spinal cord contusion. Basso Beattie Bresnahan (BBB) score, postoperative body weights, rat grimace scale (RGS), open cage activity and rearing was studied at 1, 7, 14, 21 and 28 days postoperatively, and area of spinal tissue affected was evaluated histologically. Laminectomised and spinal cord injured rats from dental burr groups showed significantly more weight gain and less weight loss respectively in comparison with respective conventionally laminectomised groups at various time points. Significantly higher RGS score was noticed in conventionally laminectomised animals on Day 1 in comparison to burr assisted laminectomy and presence of pain was evident until Day 7 in the conventionally spinal cord injured group. BBB score did not differ between techniques, whereas laminectomy groups showed more resting time than spinal injury groups. High rearing score was significantly higher in groups which underwent dental burr assisted technique at various time points with respect to their conventional counterparts. This study suggests that the use of dental burr assisted technique to perform laminectomy will bring refinement by producing less pain, aiding in better recovery, removing procedural artefacts without affecting the outcome of the model.

Translation of bone wax and its substitutes: History, clinical status and future directions

Bone wax, primarily composed of beeswax and softening agent, is a century-old material used to control bleeding of disrupted bone surfaces by acting as a mechanical barrier to seal the wound. The current bone wax products are commonly packed in easy-to-open foil in the form of sterile sticks or plates, with excellent malleability and smooth consistency, enabling cost-effective and easy handling approach for bleeding control. It has also been reported that the inert nature of bone wax causes complications including foreign body reaction, infection promotion and bone healing inhibition. With the advances in biomaterials and the market boost of bone haemostatic materials, the arena of bone wax substitute research has expanded to a wide spectrum of material formulations and forms. However, the development of substitutes of bone wax for translation is a pivotal yet challenging topic because currently a potential candidate is recommended to be just as simple to use, effective and inexpensive to produce as traditional bone wax but also be absorbable and osteogenic. This review provides an overview of bone wax including its history, clinical applications and associated complication. In addition, emerging substitutes of bone wax and outlooks of future directions including the standardised evaluation methods are also discussed as an effort to catalyse the innovation and translation of bone haemostatic agents in the near future. The translational potential of this article: Occurrence of osseous haemorrhage is common in surgically incised or traumatically fractured bone. It is essential to stop bone bleeding to avoid further pathologic consequences such as tissue necrosis and eventually mortalities due to blood loss. Medical sterile bone wax is a classical material for haemostasis of bone during orthopaedic surgeries, thoracic surgeries, neurological surgeries and so on. Along with its widespread use, complications such as foreign body reaction, bone healing inhibition and infection promotion associated with bone wax are observed. With the growing knowledge in biomaterials and the boost of market of bone haemostatic materials, bone wax substitute research is thriving. An overview of bone and its substitutes together with evolution of their design criteria is carried out in this work, providing information for the innovation and translation of bone haemostatic agents in the near future.

The effect of the new hemostatic agent Ostene® on bone healing: An experimental study in rabbits

Introduction: Ostene® is a water-soluble wax-like alkylene oxide copolymer preparation for use as a mechanical hemostatic agent. This study aims to evaluate the effects of Ostene® on bone healing. Materials and Methods: Twenty albino rabbits were divided into four groups according to post-treatment follow-up (24 hr, 3 days, 7 days, 14 days) with five rabbits in each group. Each rabbit in all groups was treated with two study materials (Ostene® and Gelfoam®). Three holes were made in the mandibular bone of each rabbit using 5mm surgical bur; two holes were made on right side: one for testing Ostene® and another for Gelfoam®. A third hole, on the left side of mandible, was not treated, and was used as a control. Finally, the incision was closed. The specimens were collected at different days post-treatment and examined by histopathology. Result and Discussion: This study showed that there is a significant difference (p-value≤ 0.05) between the Ostene® group and the other groups (Gelfoam® and control). At 24 hr post intervention, there is a significant difference in osteoblast cell formation (p-value=0.03), and osteoclast cell formation (p-value=0.05). New blood vessel formation, osteoblast and osteoclast cell formation for Ostene® group at 3 days post-intervention were also significantly different (p-values = 0.05, 0.03, 0.04, respectively). At 7 days post-intervention p-values were 0.05 for osteoblast formation and 0.04 for osteoclast formation, respectively. After 14 days of healing p-value for osteoblast cell formation in the Ostene® group was 0.05 and 0.04 for osteoclast cell formation. Conclusions: The bone hemostatic agent Ostene® is an effective at enhancing osteogenesis by initiating proliferation of osteoblast and osteoclast cells.