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Heo KY, Bonsu JM, Khawaja S, Karzon A, Rajan PV, Barber LA, Yoon ST. Database analysis comparing incidence and complication rates between inpatient and outpatient laminotomies for lumbar disc herniation. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100328. [PMID: 38966040 PMCID: PMC11222817 DOI: 10.1016/j.xnsj.2024.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 07/06/2024]
Abstract
Background Lumbar disc herniation (LDH) is a common condition that can be characterized with disabling pain. While most patients recover without surgery, some still require operative intervention. The epidemiology and trends of laminotomy for LDH have not been recently studied, and current practice patterns might be different from historical norms. This study aimed to investigate the trends of inpatient and outpatient laminotomies for LDH and compare complication rates between these two sites of service. Methods A large, national database was utilized to identify patients > 8 years old who underwent a laminotomy for LDH between 2009 and 2019. Two cohorts were created based on site of surgery: inpatient versus outpatient. The outpatient cohort was defined as patients who had a length of stay less than 1 day without any associated hospitalization. Epidemiologic analyses for these cohorts were performed by demographics. Patients in both groups were then 1:1 propensity-score matched based on age, sex, insurance type, geographic region, and comorbidities. Ninety-day postoperative complications were compared between cohorts utilizing multivariate logistic regressions. Results The average incidence of laminotomy for LDH was 13.0 per 10,000 persons-years. Although the national trend in incidence had not changed from 2009 to 2019, the proportion of outpatient laminotomies significantly increased in this time period (p=.02). Outpatient laminotomies were more common among younger and healthier patients. Patients with inpatient laminotomies had significantly higher rates of surgical site infections (odds ratio [OR] 1.61, p<.001), venous thromboembolism (VTE) (OR 1.96, p<.001), hematoma (OR 1.71, p<.001), urinary tract infections (OR 1.41, p<.001), and acute kidney injuries (OR 1.75, p=.001), even when controlling for selected confounders. Conclusions Our study demonstrated an increasing trend in the performance of laminotomy for LDH toward the outpatient setting. Even when controlling for certain confounders, patients requiring inpatient procedures had higher rates of postoperative complications. This study highlights the importance of carefully evaluating the advantages and disadvantages of performing these procedures in an outpatient versus inpatient setting.
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Affiliation(s)
- Kevin Y. Heo
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Janice M. Bonsu
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Sameer Khawaja
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Anthony Karzon
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Prashant V. Rajan
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Lauren A. Barber
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
| | - Sangwook Tim Yoon
- Department of Orthopaedic Surgery, Emory University School of Medicine, 21 Ortho Ln, Atlanta, GA 30329, United States
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Kelekis A, Bonaldi G, Cianfoni A, Filippiadis D, Scarone P, Bernucci C, Hooper DM, Benhabib H, Murphy K, Buric J. Intradiscal oxygen-ozone chemonucleolysis versus microdiscectomy for lumbar disc herniation radiculopathy: a non-inferiority randomized control trial. Spine J 2022; 22:895-909. [PMID: 34896609 DOI: 10.1016/j.spinee.2021.11.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Low back pain with or without radicular leg pain is an extremely common health condition significantly impacting patient's activities and quality of life. When conservative management fails, epidural injections providing only temporary relief, are frequently utilized. Intradiscal oxygen-ozone may offer an alternative to epidural injections and further reduce the need for microdiscectomy. PURPOSE To compare the non-inferiority treatment status and clinical outcomes of intradiscal oxygen-ozone with microdiscectomy in patients with refractory radicular leg pain due to single-level contained lumbar disc herniations. STUDY DESIGN / SETTING Multicenter pilot prospective non-inferiority blocked randomized control trial conducted in three European hospital spine centers. PATIENT SAMPLE Forty-nine patients (mean 40 years of age, 17 females/32 males) with a single-level contained lumbar disc herniation, radicular leg pain for more than six weeks, and resistant to medical management were randomized, 25 to intradiscal oxygen-ozone and 24 to microdiscectomy. 88% (43 of 49) received their assigned treatment and constituted the AS-Treated (AT) population. OUTCOME MEASURES Primary outcome was overall 6-month improvement over baseline in leg pain. Other validated clinical outcomes, including back numerical rating pain scores (NRS), Roland Morris Disability Index (RMDI) and EQ-5D, were collected at baseline, 1 week, 1-, 3-, and 6-months. Procedural technical outcomes were recorded and adverse events were evaluated at all follow-up intervals. METHODS Oxygen-ozone treatment performed as outpatient day surgeries, included a one-time intradiscal injection delivered at a concentration of 35±3 μg/cc of oxygen-ozone by a calibrated delivery system. Discectomies performed as open microdiscectomy inpatient surgeries, were without spinal instrumentation, and not as subtotal microdiscectomies. Primary analyses with a non-inferiority margin of -1.94-point difference in 6-month cumulative weighted mean leg pain NRS scores were conducted using As-Treated (AT) and Intent-to-Treat (ITT) populations. In post hoc analyses, differences between treatment groups in improvement over baseline were compared at each follow-up visit, using baseline leg pain as a covariate. RESULTS In the primary analysis, the overall 6-month difference between treatment groups in leg pain improvement using the AT population was -0.31 (SE, 0.84) points in favor of microdiscectomy and using the ITT population, the difference was 0.32 (SE, 0.88) points in favor of oxygen-ozone. The difference between oxygen-ozone and microdiscectomy did not exceed the non-inferiority 95% confidence lower limit of treatment difference in either the AT (95% lower limit, -1.72) or ITT (95% lower limit, -1.13) populations. Both treatments resulted in rapid and statistically significant improvements over baseline in leg pain, back pain, RMDI, and EQ-5D that persisted in follow-up. Between group differences were not significant for any outcomes. During 6-month follow-up, 71% (17 of 24) of patients receiving oxygen-ozone, avoided microdiscectomy. The mean procedure time for oxygen-ozone was significantly faster than microdiscectomy by 58 minutes (p<.0010) and the mean discharge time from procedure was significantly shorter for the oxygen-ozone procedure (4.3±2.9 hours vs. 44.2±29.9 hours, p<.001). No major adverse events occurred in either treatment group. CONCLUSIONS Intradiscal oxygen-ozone chemonucleolysis for single-level lumbar disc herniations unresponsive to medical management, met the non-inferiority criteria to microdiscectomy on 6-month mean leg pain improvement. Both treatment groups achieved similar rapid significant clinical improvements that persisted and overall, 71% undergoing intradiscal oxygen-ozone were able to avoid surgery.
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Affiliation(s)
- Alexis Kelekis
- University General Hospital Attikon, Athens, Haidari 12462, Greece
| | - Giuseppe Bonaldi
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Lombardia 24127, Italy
| | - Alessandro Cianfoni
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Lugano 6900, Switzerland; Department of Interventional and Diagnostic Neuroradiology, Inselspital University Hospital of Bern, Bern 3008, Switzerland
| | | | - Pietro Scarone
- Department of Neuroradiology, Neurocenter of Southern Switzerland, Lugano 6900, Switzerland; Department of Interventional and Diagnostic Neuroradiology, Inselspital University Hospital of Bern, Bern 3008, Switzerland
| | - Claudio Bernucci
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Lombardia 24127, Italy
| | | | - Hadas Benhabib
- Toronto Western Hospital, University Health Network, Toronto, Canada
| | - Kieran Murphy
- Toronto Western Hospital, University Health Network, Toronto, Canada.
| | - Josip Buric
- Casa di Cura San Camillo, Forte dei Marmi, Lucca 55042, Italy
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Hosseini S, Niakan A, Dehghankhalili M, Dehdab R, Shahjouei S, Rekabdar Y, Shaghaghian E, Shaghaghian A, Ghaffarpasand F. Effects of adhesion barrier gel on functional outcomes of patients with lumbar disc herniation surgery; A systematic review and meta-analysis of clinical trials. Heliyon 2021; 7:e07286. [PMID: 34189319 PMCID: PMC8220332 DOI: 10.1016/j.heliyon.2021.e07286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/21/2021] [Accepted: 06/07/2021] [Indexed: 11/09/2022] Open
Abstract
Failed Back Surgery Syndrome (FBSS) is persistent pain and disability following lumbar laminectomy which is associated with decreased quality of life and disability and has been reported in up to 40% of the patients undergoing lumbar laminectomy. Several approaches have been introduced to reduce the rate of the FBSS. Among these, applying anti-adhesive barrier gels have been studied with interest with controversial results. The aim of the current study was to determine the effects of anti-adhesive barrier gels on functional outcome and recurrence of patients undergoing lumbar disc surgery. We searched databases including EMBASE, PUBMED, Web of Science, Scopus, Cochrane Library, and scholar databases until November 2019. To assess the heterogeneity across included studies was used Cochran's Q and I-square (I2) statistics. Standardized mean difference (SMD) and 95% CI between were used to estimate pooled effect sizes. Out of 4507, 10 clinical trials found to be appropriate for current meta-analysis. The pooled results of included clinical trials indicated that adhesion barrier gel significantly decreased leg pain (LP) (SMD = −0.31; 95% CI, −0.60, −0.03; P = 0.032; I2: 59.2%) among patients with lumbar disc herniation surgery. Back pain (BP) (SMD = −0.03; 95% CI, −0.23, 0.16; P = 0.734; I2: 40.2%), and Oswestry disability index (ODI) (SMD = −0.11; 95% CI, −0.27, 0.05; P = 0.178; I2: 0.0%), were not significantly affected following adhesion barrier gel application. Application of adhesion barrier gel in single level lumbar disc surgery is associated with deceased leg pain. However, its application does not affect the low back pain, disability and gate. Further, larger randomized clinical trials are required.
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Affiliation(s)
- Seyedmorteza Hosseini
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Niakan
- Trauma Research Center, Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Reza Dehdab
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shima Shahjouei
- Neuroscience Institute, Geisinger Health System, Pennsylvania, USA
| | - Yasamin Rekabdar
- Young Researchers and Elite Club, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Elaheh Shaghaghian
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Fariborz Ghaffarpasand
- Research Center for Neuromodulation and Pain, Shiraz University of Medical Sciences, Shiraz, Iran
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Efficacy of Poly(D,L-Lactic Acid-co-Glycolic acid)-Poly(Ethylene Glycol)-Poly(D,L-Lactic Acid-co-Glycolic Acid) Thermogel As a Barrier to Prevent Spinal Epidural Fibrosis in a Postlaminectomy Rat Model. Clin Spine Surg 2017; 30:E283-E290. [PMID: 28323713 DOI: 10.1097/bsd.0000000000000221] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
STUDY DESIGN Experimental animal study. OBJECTIVE The authors conducted a study to determine the efficacy and safety of the poly(D,L-lactic acid-co-glycolic acid)-poly(ethylene glycol)-poly(D,L-lactic acid-co-glycolic acid) (PLGA-PEG-PLGA) thermogel to prevent peridural fibrosis in an adult rat laminectomy model. SUMMARY OF BACKGROUND DATA Peridural fibrosis often occurs after spinal laminectomy. It might cause persistent back and/or leg pain postoperatively and make a reoperation more difficult and dangerous. Various materials have been used to prevent epidural fibrosis, but only limited success has been achieved. MATERIALS AND METHODS The PLGA-PEG-PLGA thermogel was synthesized by us. Total L3 laminectomies were performed on 24 rats. The PLGA-PEG-PLGA thermogel or chitosan (CHS) gel (a positive control group) was applied to the operative sites in a blinded manner. In the control group, the L3 laminectomy was performed and the defect was irrigated with the NS solution 3 times. All the rats were killed 4 weeks after the surgery. RESULTS The cytotoxicity of this thermogel was evaluated in vitro and the result demonstrated that no evidence of cytotoxicity was observed. The extent of epidural fibrosis, the area of epidural fibrosis, and the density of the fibroblasts and blood vessel were evaluated histologically. There were statistical differences among the PLGA-PEG-PLGA thermogel or CHS gel group compared with the control group. Although there was no difference between the PLGA-PEG-PLGA thermogel and CHS gel, the efficiency of the PLGA-PEG-PLGA thermogel was shown to be slightly improved compared with the CHS gel. CONCLUSIONS The biocompatibility of the PLGA-PEG-PLGA thermogel was proven well. The application of this thermogel effectively reduced epidural scarring and prevented the subsequent adhesion to the dura mater. No side effects were noted in the rats.
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Nevzati E, Berberat J, Soleman J, Coluccia D, Muroi C, Schöpf S, Lukes A, Fischer I, Remonda L, Fandino J, Marbacher S. Magnetic Resonance Imaging Signal Characteristics of Medishield: Early Postoperative Profile in a Rabbit Interlaminotomy Model. World Neurosurg 2016; 98:704-710.e3. [PMID: 27965076 DOI: 10.1016/j.wneu.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/30/2016] [Accepted: 12/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Application of Medishield to the nerve root is common during spinal surgery to create a mechanical barrier from pain mediators and reduce scar formation. However, Medishield's signal characteristics on magnetic resonance imaging (MRI) have not yet been examined. METHODS Microsurgical interlaminotomy was performed on 2 lower lumbar segments in 17 adult New Zealand white rabbits. After dural exposure, applications of 1 mL (autologous blood clot or Medishield) were randomized for each level. On postoperative days 1 through 3, various MRI sequences in 1.5T were performed including T1-weighted, T2-w, T1-gadolinium-weighted, susceptibility-weighted and turbo inversion recovery magnitude (TIRM) sequence. Signaling characteristics were analyzed by 3 blinded observers. Inter-rater agreement was calculated using Fleiss's kappa coefficient (κ). Positive and negative likelihood ratios in detecting Medishield by MRI were determined. RESULTS Of 24 MRIs performed, TIRM sequence identified Medishield with the highest likelihood ratio. Medishield's positive likelihood ratio was highest (5.8) on postoperative day 1 with interobserver agreement of 93% (κ = 0.75); these rates declined to 2.5 and 1.4 on postoperative days 2 and 3 with interobserver agreements of 71% (κ = 0.43) and 83% (κ = 0.67), respectively. Medishield adherence was confirmed in each rabbit by histologic examinations. CONCLUSION Understanding that radiologic detection of Medishield diminished over time as its signal characteristics became less distinguishable from a blood clot is essential in clinical practice. Medishield was detected on postoperative day 1 but not 2 days later after hemodynamic changes had occurred. These results may provide a guide for postoperative findings, such as differential diagnosis of hematoma.
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Affiliation(s)
- Edin Nevzati
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland.
| | - Jatta Berberat
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Daniel Coluccia
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Carl Muroi
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Salome Schöpf
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Anton Lukes
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Ingeborg Fischer
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Luca Remonda
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aurau, Aarau, Switzerland
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Reduction of Leg Pain by Oxiplex Gel After Lumbar Discectomy in Patients With Predominant Leg Pain and Elevated Levels of Lower Back Pain: A Prospective, Randomized, Blinded, Multicenter Clinical Study. ACTA ACUST UNITED AC 2016; 28:301-7. [PMID: 23897052 DOI: 10.1097/bsd.0b013e3182a35590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN A prospective, randomized, blinded, multicenter clinical study. OBJECTIVE To evaluate carboxymethylcellulose/polyethylene oxide gel (Oxiplex) in improving clinical outcomes in subjects having predominant leg pain and elevated low back pain undergoing first-time lumbar discectomy for disk herniation. SUMMARY OF BACKGROUND DATA Clinical studies in the United States and Italy found that Oxiplex reduced leg pain after decompression surgery. METHODS A total of 68 subjects with herniated lumbar disk were enrolled and randomized into treatment (surgery plus gel) or surgery-only control groups. A prospective statistical analysis assessed the effect of gel in the severe back pain subgroup (prespecified as greater than or equal to median baseline back pain of the population studied). All subjects except 2 controls lost to follow-up completed the study. Preoperative and postoperative visual analogue scale leg pain scores were analyzed and compared between groups at 60 days after surgery. RESULTS There were no serious adverse events or neurological safety concerns reported in any patients. Gel-treated patients had statistically significantly lower visual analogue scale leg pain scores at study end compared with controls (P=0.0240), representing a 21% additional reduction in leg pain compared with surgery alone in the severe baseline back pain subgroup (P=0.0240). The proportion of subgroup patients experiencing zero leg pain at study end was significantly higher in the gel treatment group (60%) than in the control group (23%) (P=0.0411). CONCLUSIONS The data from this study confirm and extend results of 2 previous studies in Italy and the United States that reported statistically significantly greater reductions in leg pain in gel-treated patients with severe preoperative low back pain compared with patients who only underwent decompression surgery.
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Tos P, Crosio A, Pellegatta I, Valdatta L, Pascal D, Geuna S, Cherubino M. Efficacy of anti-adhesion gel of carboxymethylcellulose with polyethylene oxide on peripheral nerve: Experimental results on a mouse model. Muscle Nerve 2015; 53:304-9. [PMID: 26082205 DOI: 10.1002/mus.24739] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2015] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Perineural scar formation is responsible for pain and loss of function after surgical procedures. Neurolysis and application of anti-adhesion gels are required to restore a gliding surface. We tested a carboxymethylcellulose (CMC) and polyethylene oxide (PEO) gel on mouse sciatic nerve to describe its safety and efficacy. METHODS Adult mice underwent a surgical procedure in which we burned the muscular bed of the sciatic nerve bilaterally (Burned group) and applied anti-adhesion gel to 1 of the nerves (Burned+gel group). After 3 weeks, we studied scar tissue by biomechanical and histological evaluation. RESULTS Both histological and biomechanical analysis showed that the gel reduced perineural scarring. The difference between the Burned and Burned+gel groups was statistically significant. CONCLUSIONS CMC-PEO gel can reduce perineural scar tissue. In histological section, scar tissue was present in both groups, but in the Burned+gel group a gliding surface was identified between scar and nerve.
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Affiliation(s)
- Pierluigi Tos
- Reconstructive Microsurgery Unit, Traumatology Department, CTO Hospital, Via Zuretti 29, 10100 Turin, Italy
| | - Alessandro Crosio
- Reconstructive Microsurgery Unit, Traumatology Department, CTO Hospital, Via Zuretti 29, 10100 Turin, Italy
| | - Igor Pellegatta
- Plastic Surgery Unit, Department of Biotechnologies and Sciences of Life, University of Insubria/Varese, Varese, Italy
| | - Luigi Valdatta
- Plastic Surgery Unit, Department of Biotechnologies and Sciences of Life, University of Insubria/Varese, Varese, Italy
| | - Davide Pascal
- Human Anatomy Laboratory, Clinical and Biological Sciences Department, University of Turin, AOU San Luigi Gonzaga, Orbassano, Italy
| | - Stefano Geuna
- Human Anatomy Laboratory, Clinical and Biological Sciences Department, University of Turin, AOU San Luigi Gonzaga, Orbassano, Italy
| | - Mario Cherubino
- Plastic Surgery Unit, Department of Biotechnologies and Sciences of Life, University of Insubria/Varese, Varese, Italy
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Ji GY, Oh CH, Moon BG, Yi S, Han IB, Heo DH, Kim KT, Shin DA, Kim KN. Efficacy and Safety of Sodium Hyaluronate with 1,4-Butanediol Diglycidyl Ether Compared to Sodium Carboxymethylcellulose in Preventing Adhesion Formation after Lumbar Discectomy. KOREAN JOURNAL OF SPINE 2015. [PMID: 26217381 PMCID: PMC4513167 DOI: 10.14245/kjs.2015.12.2.41] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Gyu Yeul Ji
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea. ; Department of Neurosurgery, Guro Teun Teun Hospital, Seoul, Korea
| | - Chang Hyun Oh
- Department of Neurosurgery, Guro Teun Teun Hospital, Seoul, Korea
| | - Byung Gwan Moon
- Department of Neurosurgery, Eulji Hospital, Eulji University College of Medicine, Seoul, Korea
| | - Seong Yi
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - In Bo Han
- Department of Neurosurgery, Bundang CHA Medical Center, CHA University College of Medicine, Sungnam, Korea
| | - Dong Hwa Heo
- Department of Neurosurgery, The Leon Wiltse Memorial Hospital, Suwon, Korea
| | - Ki-Tack Kim
- Department of Orthopedic Surgery, Kyung Hee University College of Medicine, Seoul, Korea
| | - Dong Ah Shin
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Keung Nyun Kim
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
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Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J 2015; 15:1461-77. [PMID: 24412033 DOI: 10.1016/j.spinee.2013.08.049] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 07/09/2013] [Accepted: 08/23/2013] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Ruth A Lewis
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP.
| | - Nefyn H Williams
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP; North Wales Organisation for Randomised Trials in Health (NWORTH), Bangor University, The Normal Site, Holyhead Road, Gwynedd, UK LL57 2PZ
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, UK LE1 6TP
| | - Kim Burton
- Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH
| | - Nafees Ud Din
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Hosam E Matar
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Herries Road, Sheffield, UK S5 7AU
| | - Maggie Hendry
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Ceri J Phillips
- School of Human and Health Sciences, Swansea University, Singleton Park, Swansea, UK SA2 8PP
| | - Sadia Nafees
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
| | - Deborah Fitzsimmons
- Spinal Research Institute, University of Huddersfield, Queensgate, Huddersfield, UK HD1 3DH
| | - Ian Rickard
- Green Oak, Dolydd Terrace, Betws-Y-Coed, UK LL24 0BU
| | - Clare Wilkinson
- North Wales Centre for Primary Care Research, College of Health & Behavioural Sciences, Bangor University, Gwenfro Unit 4-8, Wrexham Technology Park Wrexham, UK LL13 7YP
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Wu CY, Jou IM, Yang WS, Yang CC, Chao LY, Huang YH. Significance of the mass-compression effect of postlaminectomy/laminotomy fibrosis on histological changes on the dura mater and nerve root of the cauda equina: an experimental study in rats. J Orthop Sci 2014; 19:798-808. [PMID: 25074653 DOI: 10.1007/s00776-014-0590-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 05/18/2014] [Indexed: 02/09/2023]
Abstract
PURPOSE The precise mechanism and pathological role of postlaminectomy/laminotomy fibrosis (PLF) in postoperative neurological deficits have not been established. Many studies use magnetic resonance imaging (MRI) to prove that there is no consistent correlation between PLF and postoperative neurological deficits and back pain (PNDBP). Therefore, we assumed that the direct-compression effect may not be the only factor but that other neurological deficits associated with pathological mechanisms should exist and need more investigation. The purpose of this study was to compare over time the differences and changes in histopathological properties of PLF in rats. METHODS We used a rat model with walking-track analysis for neurologic evaluation, grading scale to evaluate PLF, histomorphometric measurements of dura sac diameter, and histological tissue reactions (dura mater and spinal rootlets) juxtaposed to the postlaminectomy/laminotomy defect. The 54 adult Sprague-Dawley rats were divided into laminotomy (n = 18), laminectomy (n = 18), and sham-operation groups (n = 18). All groups were subdivided into three equal subgroups based on different postoperative time points (1, 2, and 3 months). All sections of vertebral column were stained with hematoxylin and eosin and with Masson's trichrome. RESULTS The results showed that only a slight compression effect reflected by nonsignificant changes in the maximum anterior-posterior diameters within the dura sac, in the walking tract test, and increased grades of PLF over time. In addition, significant pathological inflammatory changes, such as thickening of the dura mater, axonal swelling, and neovascularization, were found in the post-laminectomy/laminotomy groups at each time point. CONCLUSION Laminectomy-/laminotomy-related inflammation may lead to PLF, and these pathological changes may be the main cause of postoperative neurological deficits. These findings show that research on preventing PLF should include perioperative modulation of inflammatory reactions induced by laminectomy/laminotomy.
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Affiliation(s)
- Cheng-Yi Wu
- Department of Orthopaedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, 539 Jhongsiao Rd, Chia-Yi City, Taiwan
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11
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Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S, Cho CH, DePalma MJ, Dougherty P, Fernand R, Ghiselli G, Hanna AS, Lamer T, Lisi AJ, Mazanec DJ, Meagher RJ, Nucci RC, Patel RD, Sembrano JN, Sharma AK, Summers JT, Taleghani CK, Tontz WL, Toton JF. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J 2014; 14:180-91. [PMID: 24239490 DOI: 10.1016/j.spinee.2013.08.003] [Citation(s) in RCA: 337] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 08/14/2013] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- D Scott Kreiner
- Ahwatukee Sports and Spine, 4530 E. Muirwood Dr, Suite 110, Phoenix, AZ 85048-7693, USA.
| | - Steven W Hwang
- Department of Neurosurgery, Tufts Medical Center, 800 Washington St, Boston, MA 02111-1552, USA
| | - John E Easa
- The College of Human Medicine, Michigan State University, 12662 Riley St, Suite 120, Holland, MI 49424-8023, USA
| | - Daniel K Resnick
- Department Neurosurgery, University of Wisconsin Medical School, K4/834 Clinical Science Center, 600 Highland, Madison, WI 53792-0001, USA
| | - Jamie L Baisden
- Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226-3522, USA
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine, 2055 High St, Suite 130, Denver, CO 80205-5504, USA
| | - Charles H Cho
- Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115-6110, USA
| | | | | | | | - Gary Ghiselli
- Denver Spine, 7800 E. Orchard Rd, Suite 100, Greenwood Village, CO 80111-2584, USA
| | | | - Tim Lamer
- Mayo Clinic Rochester, 200 1st St SW, Eisenberg 8G, Rochester, MN 55905-0001, USA
| | - Anthony J Lisi
- VACT Healthcare System, 950 Campbell Ave., Bldg 2, Floor 4, West Haven, CT 06516-2770, USA
| | - Daniel J Mazanec
- Cleveland Clinic Spine Institute, 9500 Euclid Ave., C21, Cleveland, OH 44195-0001, USA
| | | | | | - Rakesh D Patel
- University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5000, USA
| | - Jonathan N Sembrano
- University of Minnesota, 2450 Riverside Ave. S., Suite R200, Minneapolis, MN 55454-1450, USA
| | - Anil K Sharma
- Spine and Pain Medicine, 2 Mockingbird Drive, Colts Neck, NJ 07722-2228, USA
| | - Jeffrey T Summers
- NewSouth NeuroSpine, 2470 Flowood Drive, Flowood, MS 39232-9019, USA
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12
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Affiliation(s)
- Jin Woo Shin
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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13
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Di Spiezio Sardo A, Spinelli M, Bramante S, Scognamiglio M, Greco E, Guida M, Cela V, Nappi C. Efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel in prevention of intrauterine adhesions after hysteroscopic surgery. J Minim Invasive Gynecol 2011; 18:462-9. [PMID: 21777835 DOI: 10.1016/j.jmig.2011.04.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Revised: 04/20/2011] [Accepted: 04/22/2011] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVES To assess the efficacy of a polyethylene oxide-sodium carboxymethylcellulose gel (Intercoat; Gynecare, division of Ethicon, Inc., Somerville, NJ) in preventing the development of de novo intrauterine adhesions (IUAs) after hysteroscopic surgery and to rate the patency of the internal uterine ostium at 1-month follow-up diagnostic hysteroscopy. DESIGN Randomized controlled study (Canadian Task Force classification I). SETTING University hospital. PATIENTS One hundred ten patients diagnosed during office hysteroscopy as having single or multiple lesions suitable for surgical treatment or resistant dysfunctional uterine bleeding requiring endometrial ablation. INTERVENTIONS Patients were randomized to 2 groups. Group 1 underwent hysteroscopic surgery plus intrauterine application of Intercoat gel, and group 2 underwent hysteroscopic surgery only (control group). Follow-up office hysteroscopy was performed at 1 month after surgery to assess the rate and severity of IUA formation and to rate the patency of the internal uterine ostium after the surgical intervention. MEASUREMENTS AND MAIN RESULTS Compared with the group 2, group 1 demonstrated a significant reduction in the incidence (6% vs 22%; p <.05) of de-novo IUAs. Application of the gel seemed to reduce the severity of IUAs, with fewer moderate and severe IUAs at follow-up in group 1 in comparison with group 2 (33% vs 92%). Furthermore, group 1 demonstrated significant improvement in the degree of patency of the internal uterine ostium (41.9% of cases) in comparison with diagnostic office hysteroscopy performed at enrollment (p <.05). In contrast, in group 2, worsening of patency of the internal uterine ostium was recorded in 18.2% of cases (p <.05). CONCLUSIONS Intercoat gel seems to prevent de novo formation of IUAs and to improve the patency of the internal uterine ostium at follow-up hysteroscopy. However, larger studies are needed to confirm these findings.
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Affiliation(s)
- Attilio Di Spiezio Sardo
- Department of Gynaecology and Obstetrics, and Pathophysiology of Human Reproduction, University of Naples Federico II, Naples, Italy
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Brochhausen C, Schmitt VH, Rajab TK, Planck CNE, Krämer B, Wallwiener M, Hierlemann H, Kirkpatrick CJ. Intraperitoneal adhesions--an ongoing challenge between biomedical engineering and the life sciences. J Biomed Mater Res A 2011; 98:143-56. [PMID: 21548063 DOI: 10.1002/jbm.a.33083] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 01/12/2011] [Accepted: 01/20/2011] [Indexed: 01/29/2023]
Abstract
Peritoneal adhesions remain a relevant clinical problem despite the currently available prophylactic barrier materials. So far, the physical separation of traumatized serosa areas using barriers represents the most important clinical strategy for adhesion prevention. However, the optimal material has not yet been found. Further optimization or pharmacological functionalization of these barriers could give an innovative input for peritoneal adhesion prevention. Therefore, a more complete understanding of pathogenesis is required. On the basis of the pathophysiology of adhesion formation the main barriers currently in clinical practice as well as new innovations are discussed in the present review. Physiologically, mesothelial cells play a decisive role in providing a frictionless gliding surface on the serosa. Adhesion formation results from a cascade of events and is regulated by a variety of cellular and humoral factors. The main clinically applied strategy for adhesion prevention is based on the use of liquid or solid adhesion barriers to separate physically any denuded tissue. Both animal and human trials have not yet been able to identify the optimal barrier to prevent adhesion formation in a sustainable way. Therefore, further developments are required for effective prevention of postoperative adhesion formation. To reach this goal the combination of structural modification and pharmacological functionalization of barrier materials should be addressed. Achieving this aim requires the interaction between basic research, materials science and clinical expertise.
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Affiliation(s)
- Christoph Brochhausen
- REPAIR-Lab, Institute of Pathology, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany.
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Fransen P. Reduction of postoperative pain after lumbar microdiscectomy with DuraSeal Xact Adhesion Barrier and Sealant System. Spine J 2010; 10:751-61. [PMID: 20542472 DOI: 10.1016/j.spinee.2010.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 03/30/2010] [Accepted: 05/02/2010] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT An excessive amount of scar tissue after lumbar microdiscectomy may increase postoperative pain. Several fibrosis inhibitors have been used in the past in an endeavor for better functional outcome. PURPOSE The goal of this study was to evaluate DuraSeal Xact Adhesion Barrier and Sealant System (DSX), a polyethylene glycol-based synthetic fibrosis inhibitor, for its ability to reduce postoperative pain after lumbar microdiscectomy. STUDY DESIGN This is a prospective randomized controlled study. PATIENT SAMPLE Twenty patients between 19 and 71 years of age about to undergo elective lumbar single-level discectomy were randomized into two groups of 10. OUTCOME MEASURES Assessments included the visual analog scale (VAS) pain score, the short form (SF)-36 questionnaire, and the Oswestry low back pain scale, preoperatively and at discharge, and 30, 90, and 180 days after surgery. METHODS One group was treated with DSX, and the control group received the local standard of care. DSX was applied as a thin layer on the nerve root and surrounding area after microdiscectomy. RESULTS The VAS pain scale was lower at all time points in the DSX treatment group than in the control group. The reductions at 30, 90, and 180 days for DSX and control groups, respectively, were 43.9% versus 35.6%, 64.3% versus 44.8%, and 75.4% versus 59.6%. The SF-36 scores in the DSX treatment group showed more improvement than in the control group as soon as 30 days for physical functioning, general health, vitality, social functioning, mental health, and emotional patterns, and by 90 days for bodily pain and general health. The Oswestry pain score was lower at all time points in the DSX treatment group than in the control group. The reductions at 30, 90, and 180 days for DSX and control groups, respectively, were 41.5% versus 34.3%, 68.2% versus 42.4%, and 73.3% versus 55.4%. Wound healing was normal in the DSX treatment group, there were no complications related to DSX use, and no patient in either group required reoperation. CONCLUSIONS Although this study is too small to have conclusions of efficacy and will need confirmation by larger trials, treatment of a microdiscectomy site with DSX for fibrosis prevention shows promising results in terms of safety, reduction of postoperative pain and functional results when compared to control with the additional advantage of being suitable for use in the presence of a dural tear.
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Affiliation(s)
- Patrick Fransen
- Brussels Neurosurgery Center, Clinique du Parc Léopold, 1040 Brussels, Belgium.
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Use of Temporary Implantable Biomaterials to Reduce Leg Pain and Back Pain in Patients with Sciatica and Lumbar Disc Herniation. MATERIALS 2010. [PMCID: PMC5445914 DOI: 10.3390/ma3053331] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The principle etiology of leg pain (sciatica) from lumbar disc herniation is mechanical compression of the nerve root. Sciatica is reduced by decompression of the herniated disc, i.e., removing mechanical compression of the nerve root. Decompression surgery typically reduces sciatica more than lumbar back pain (LBP). Decompression surgery reduces mechanical compression of the nerve root. However, decompression surgery does not directly reduce sensitization of the sensory nerves in the epidural space and disc. In addition, sensory nerves in the annulus fibrosus and epidural space are not protected from topical interaction with pain mediators induced by decompression surgery. The secondary etiology of sciatica from lumbar disc herniation is sensitization of the nerve root. Sensitization of the nerve root results from a) mechanical compression, b) exposure to cellular pain mediators, and/or c) exposure to biochemical pain mediators. Although decompression surgery reduces nerve root compression, sensory nerve sensitization often persists. These observations are consistent with continued exposure of tissue in the epidural space, including the nerve root, to increased cellular and biochemical pain mediators following surgery. A potential contributor to lumbar back pain (LBP) is stimulation of sensory nerves in the annulus fibrosus by a) cellular pain mediators and/or b) biochemical pain mediators that accompany annular tears or disruption. Sensory fibers located in the outer one-third of the annulus fibrosus increase in number and depth as a result of disc herniation. The nucleus pulposus is comprised of material that can produce an autoimmune stimulation of the sensory nerves located in the annulus and epidural space leading to LBP. The sensory nerves of the annulus fibrosus and epidural space may be sensitized by topical exposure to cellular and biochemical pain mediators induced by lumbar surgery. Annulotomy or annular rupture allows the nucleus pulposus topical access to sensory nerve fibers, thereby leading to LBP. Coverage of the annulus and adjacent structures in the epidural space by absorbable viscoelastic gels appears to reduce LBP following surgery by protecting sensory fibers from cellular and biochemical pain mediators.
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Richards PJ, Turner AS, Gisler SM, Kraft S, Nuss K, Mark S, Seim HB, Schense J. Reduction in postlaminectomy epidural adhesions in sheep using a fibrin sealant-based medicated adhesion barrier. J Biomed Mater Res B Appl Biomater 2010; 92:439-46. [PMID: 19927336 DOI: 10.1002/jbm.b.31533] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Epidural adhesion formation is believed to be a central governing factor in the prevalence of pain after spinal surgery and is regarded as being the primary instigator of neural tethering, leading to complications during revision surgery. In this study, we assess the effectiveness and safety of fibrin sealant supplemented with tributyrin, termed Medicated Adhesion Barrier (MAB), as an alternative means of reducing the incidence of posterior spinal epidural adhesion formation. Laminectomy defects in sheep were treated with MAB, fibrin sealant alone, ADCONGel, or remained untreated. At 12 weeks postoperatively, the extent of fibrosis and epidural adhesion formation was evaluated using magnetic resonance imaging (MRI), peel-off testing, and histological examination. Initial invitro analysis revealed that tributyrin was retained in fibrin gel in a time-dependent manner and was an effective inhibitor of fibroblast proliferation. Treatment of sheep with MAB significantly reduced both the prevalence (p < 0.05) and tenacity (p < 0.05) of epidural adhesions. The effectiveness of MAB in preventing epidural adhesions was found to be comparable with that of ADCONGel. No adverse events were reported after the use of MAB. The MAB preparation seems to be an effective resorbable barrier for the prevention of epidural adhesions.
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Schonman R, Corona R, Bastidas A, De Cicco C, Mailova K, Koninckx PR. Intercoat gel (oxiplex): efficacy, safety, and tissue response in a laparoscopic mouse model. J Minim Invasive Gynecol 2009; 16:188-94. [PMID: 19249707 DOI: 10.1016/j.jmig.2008.12.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Revised: 12/12/2008] [Accepted: 12/18/2008] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE To study the efficacy and safety of Intercoat gel in a laparoscopic mouse model with pneumoperitoneum-enhanced adhesion formation. DESIGN Randomized controlled trial. Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I). SETTING University laboratory research center. SUBJECTS Balb\c female mice 9 to 10 weeks old. INTERVENTIONS Two laparoscopic mouse models for adhesion formation were used. In the first model, adhesions following bipolar opposing lesions in the pelvis were enhanced by 60 minutes of carbon-dioxide pneumoperitoneum. In the second model, adhesions were further enhanced by bowel manipulation. The first experiment evaluated the efficacy of Intercoat in both models. The second experiment evaluated the efficacy of Intercoat in the first model, when applied immediately on the lesion, when applied at the end of the pneumoperitoneum, and when applied in the upper abdomen. Biopsy specimens were taken after 7 days and were evaluated after hematoxylin-eosin and CD45 staining. MEASUREMENTS AND MAIN RESULTS Qualitative and quantitative adhesion scoring. Morphology was evaluated by standard light microscopy. In both models, Intercoat decreased adhesion formation whether applied immediately on the lesion or at the end of the pneumoperitoneum (qualitative and quantitative scoring p <.0001 and p <.0001, respectively). Intercoat application is associated with tissue redness, vascular congestion, and cellular edema but without an inflammatory reaction. Applied in the upper abdomen, Intercoat does not increase adhesions, but decreases adhesions at higher doses (p =.0024). Intercoat in high doses had a toxic effect (p =.0058). CONCLUSION Intercoat is an effective antiadhesion product. It is associated with tissue edema and vasodilatation as observed after 7 days both macroscopically and by histology.
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Affiliation(s)
- Ron Schonman
- Departments of Obstetrics and Gynecology at University Hospital Leuven, Belgium.
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Mo F, Yue J, Zhang J, Howk K, Williams A. Evaluation of Perivascular Adhesion Formation in New Zealand White Rabbits Using Oxiplex and DuraSeal Xact Adhesion Barrier System. SAS JOURNAL 2009. [DOI: 10.1016/s1935-9810(09)70009-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Comparison of Oxiplex and Gore-Tex effectivity in an experimental peridural fibrosis model. Neurocirugia (Astur) 2009; 20:360-6. [DOI: 10.1016/s1130-1473(09)70155-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Evaluation of Perivascular Adhesion Formation in New Zealand White Rabbits Using Oxiplex and DuraSeal Xact Adhesion Barrier System. Int J Spine Surg 2009; 3:68-76. [PMID: 25802630 PMCID: PMC4365594 DOI: 10.1016/sasj-2009-0006-nt] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Accepted: 05/27/2009] [Indexed: 11/21/2022] Open
Abstract
Background Adhesion formation after spine surgery is a result of normal wound healing that may place patients at increased risk for complications during revision surgery. Preventing adhesions could reduce the risk of complications during revision surgery, and possibly reduce the need for revision procedures. This study evaluates the ability of DuraSeal Xact Adhesion Barrier System (DSX) (Covidien, Mansfield, Massachusetts) and Oxiplex/SP gel (OX) (FzioMed, San Luis Obispo, California) to affect the extent and severity of postoperative perivascular adhesion development in an anterior spinal surgical rabbit model. Methods We determined the extent and severity of postoperative adhesion development 34 days after surgery in 12 male New Zealand White rabbits randomly assigned to intraoperative treatment with either DSX or OX, or to an untreated control group. Adhesion severity and extent were scored on scale from 0 (none) to 3 (severe). Results The extent and severity of adhesions in the DSX group were significantly less than in the untreated control group. The DSX group mean extent score was 1.3 ± 0.5 (vs 2.5, P = .01) and the mean severity score was 1.25 ± 0.5 (vs 2.8, P = .005). The extent and severity of adhesions in the OX group were not significantly different from the control group. Conclusion In this study, we found DSX to be the most effective compound in preventing adhesion formation after anterior spine surgery. Clinical Relevance Extrapolating these results in rabbits to humans, less scarring between the major blood vessels could decrease the rate of complications in revision spine procedures.
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Fransen P. Safety of carboxymethylcellulose/polyethylene oxide for the prevention of adhesions in lumbar disc herniation--consecutive case series review. ANNALS OF SURGICAL INNOVATION AND RESEARCH 2008; 2:2. [PMID: 18513413 PMCID: PMC2423360 DOI: 10.1186/1750-1164-2-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2007] [Accepted: 05/30/2008] [Indexed: 11/10/2022]
Abstract
BACKGROUND Epidural fibrosis is regarded as a cause of failed back surgery syndrome (FBSS) when excessive adhesional/fibrotic scar tissue causes compression, pain or discomfort by tethering of nerve tissue to the surrounding muscle or bone. Fibrosis inhibitors could therefore increase the success rate of spinal surgery and decrease the need for reoperations. In recent years, bio-resorbable gels or films for the prevention of peridural fibrosis and post-operative adhesions have been developed that look clinically promising. This included a 100% synthetic, sterile, absorbable gel combinations of carboxymethylcellulose (CMC) and polyethylene oxide (PEO) used to coat the dura to reduce scarring after discectomy which became available in Europe in 2002. However, given the burden of the problem and unfavorable experience with other types of adhesion-reduction agents, our unit decided to evaluate the safety of CMC/PEO in a large population of patients undergoing spinal microdiscectomy for herniation. METHODS To determine the safety and assess efficacy of carboxymethylcellulose/polyethylene oxide (CMC/PEO) gel as an anti-adhesion gel, a consecutive series of 396 patients undergoing lumbar discectomy performed by one surgeon had CMC/PEO gel administered at the end of surgery. The patients were followed up in accordance with standard clinical practice and records reviewed for side effects, such as skin reactions, general reactions or local fluid collections. Reoperations for recurrent herniation included an evaluation of fibrosis reduction. RESULTS No product related complications were observed. Five patients needed reoperations for recurrent herniation. Significant but subjective reduction in fibrosis was observed in these patients. CONCLUSION The findings provide confidence that CMC/PEO gel is well tolerated as an agent to achieve reduction of fibrosis in lumbar disc surgery. Further formal prospective study is recommended in this area of unmet need.
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Affiliation(s)
- Patrick Fransen
- Department of Neurosurgery, Clinique du Parc Léopold, Bruxelles, Belgium.
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Yildiz KH, Gezen F, Is M, Cukur S, Dosoglu M. Mitomycin C, 5-fluorouracil, and cyclosporin A prevent epidural fibrosis in an experimental laminectomy model. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16:1525-30. [PMID: 17387523 PMCID: PMC2200739 DOI: 10.1007/s00586-007-0344-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/09/2006] [Revised: 02/21/2007] [Accepted: 03/01/2007] [Indexed: 11/25/2022]
Abstract
This study examined the preventive effects of the local application of mitomycin C (MMC), 5-fluorouracil (5-FU), and cyclosporine A (CsA) in minimizing spinal epidural fibrosis in a rat laminectomy model. Thirty-two 2-year-old male Wistar albino rats, each weighing 400 +/- 50 g, were divided into four equal groups: sham, MMC, 5-FU, and CsA. Each rat underwent laminectomy at the L5-L6 lumbar level. Cotton pads (4 x 4 mm2) soaked with MMC (0.5 mg/ml), 5-FU (5 ml/mg), or CsA (5 mg/ml) were placed on the exposed dura for 5 min. Thirty days after surgery, the rats were killed and the epidural fibrosis, fibroblast density, inflammatory cell density, and arachnoid fibrosis were quantified. The epidural and arachnoid fibroses were reduced significantly in the treatment groups compared to the sham group. Fibroblast cell density and inflammatory cell density were decreased significantly in the MMC and 5-FU groups, but were similar in the sham and CsA groups. The decreased rate of epidural fibrosis was promising. Further studies in humans are needed to determine the short- and long-term complications of the agents used here.
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Affiliation(s)
- Kartal Hakan Yildiz
- Department of Neurosurgery, School of Medicine, Duzce University, 81620 Konuralp, Duzce, Turkey
| | - Ferruh Gezen
- Department of Neurosurgery, School of Medicine, Duzce University, 81620 Konuralp, Duzce, Turkey
| | - Merih Is
- Department of Neurosurgery, School of Medicine, Duzce University, 81620 Konuralp, Duzce, Turkey
| | - Selma Cukur
- Department of Pathology, Izzet Baysal State Hospital, Bolu, Turkey
| | - Murat Dosoglu
- Department of Neurosurgery, School of Medicine, Duzce University, 81620 Konuralp, Duzce, Turkey
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Bendebba M, Dizerega GS, Long DM. The Lumbar Spine Outcomes Questionnaire: its development and psychometric properties. Spine J 2007; 7:118-32. [PMID: 17197345 DOI: 10.1016/j.spinee.2006.06.382] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2006] [Revised: 05/19/2006] [Accepted: 06/08/2006] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTENT There are currently a number of generic and disease-specific instruments for assessing complaints of low back pain (LBP). None provide the comprehensive coverage of the wide range of factors that are considered essential in evaluating treatment outcomes. PURPOSE To develop and evaluate the psychometric properties of a comprehensive, disease-specific questionnaire for characterizing complaints of LBP and evaluating the outcomes of treatments for these complaints. STUDY DESIGN A clinical-cohort study of a large, convenience sample of LBP patients. METHODS We have developed a comprehensive, disease-specific questionnaire for characterizing complaints of LBP and evaluating the outcomes of treatments for these complaints. A large group of patients who sought treatment for LBP (n=2539) completed the Lumbar Spine Outcomes Questionnaire (LSOQ) before treatment, and at 12 and 24 months after treatment. For each subject and for each evaluation period, scores on six composite measures were derived from the subjects' responses to the questionnaire: a LBP severity score, a leg pain severity score, a functional disability score, a psychological distress score, a physical symptoms score, and a health-care utilization score. These scores were used to evaluate the reliability, validity, and responsiveness of the questionnaire. RESULTS Test-retest reliability of the LSOQ was evaluated by correlating the subject's 12-month scores on each composite measure with the corresponding 24-month scores. Intraclass coefficients of correlation were used. The obtained coefficients of correlation [(a) LBP severity, 0.87; (b) leg pain severity, 0.85; (c) functional disability, 0.87; (d) psychological distress, 0.88; (e) physical symptoms other than pain, 0.82; and (f) health-care utilization, 0.76] indicate good test-retest reliability for the LSOQ. Construct validity was evaluated by correlating scores on the composite measures derived from the LSOQ with scores on measures of the same constructs derived from the Oswestry Low Back Pain Disability Questionnaire and the Short Form 36-Item Health Survey. The coefficients of correlation were relatively high (mostly between .7 and .9), indicating good construct validity. Construct validity was also evaluated by comparing the scores of groups of subjects who were known to differ or not to differ on the composite measures, using multivariate analyses of variance. Significant multivariate and univariate differences were obtained between groups who were expected to differ (ie, surgically and nonsurgically treated patients). No significant differences were found for groups who were not expected to differ (ie, patients with similar diagnosis, but different surgical treatments). Responsiveness was assessed by evaluating differences in the 24-month change scores between improved and unimproved subjects. Large and significant differences were obtained between improved and unimproved subjects for all composite measures derived from the LSOQ. The observed effect sizes ranged from .68 to 1.17 indicating that the LSOQ is highly responsive. CONCLUSION The LSOQ appears to be acceptable to patients, easy to administer, highly reliable, valid, and responsive. It provides information on demographics, pain severity, functional disability, psychological distress, physical symptoms, health-care utilization, and satisfaction. It should be considered for use in both clinical and research applications as well as regulatory review involving patients with LBP complaints.
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Affiliation(s)
- Mohammed Bendebba
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
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Young P, Johns A, Templeman C, Witz C, Webster B, Ferland R, Diamond MP, Block K, diZerega G. Reduction of postoperative adhesions after laparoscopic gynecological surgery with Oxiplex/AP Gel⁎ ⁎Oxiplex/AP Gel, FzioMed, Inc., San Luis Obispo, California.: a pilot study. Fertil Steril 2005; 84:1450-6. [PMID: 16275243 DOI: 10.1016/j.fertnstert.2005.04.055] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2004] [Revised: 04/20/2005] [Accepted: 04/20/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine whether Oxiplex/AP Gel (FzioMed, San Luis Obispo, CA) was safe and preliminarily effective in reducing postsurgical adhesions after adnexal surgery by laparoscopy. DESIGN Prospective, multicenter, double-blind, randomized, U.S. Food and Drug Administration-monitored feasibility study. SETTING University and private clinics. PATIENT(S) Patients undergoing laparoscopic surgery with pelvic adhesions, tubal occlusion, endometriosis, and/or dermoids were randomized to receive Oxiplex/AP Gel or no further treatment after surgery. INTERVENTION(S) A blinded, parallel-group design was conducted at six centers. Patients (aged 18-46 years) underwent laparoscopic surgery, with second-look surgery 6-10 weeks later. Surgeries were videotaped. Oxiplex/AP Gel was used to cover adnexa and adjacent tissue. MAIN OUTCOME MEASURE(S) Blinded reviews of videotapes were quantitated with the American Fertility Society adhesion score (AFS score). RESULT(S) In 18 treatment patients, surgery was performed on 29 adnexa. Application of Oxiplex/AP Gel required approximately 90 seconds. In 10 control patients, surgery was performed on 18 adnexa. The mean baseline AFS score for each group was 8.0. At second look, treated adnexa had the same score (8.1), whereas in control adnexa the score increased (from 8.0 to 11.6). Thirty-four percent of treated adnexa increased in adhesion score, in contrast to 67% of control adnexa. There were no device-related adverse events. CONCLUSION(S) In this pilot study, Oxiplex/AP Gel was safe, easy to use with laparoscopy, and produced a reduction in the increase of adnexal adhesion scores.
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Affiliation(s)
- Phil Young
- IGO Medical Group, San Diego, California, USA
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Kato T, Haro H, Komori H, Shinomiya K. Evaluation of hyaluronic acid sheet for the prevention of postlaminectomy adhesions. Spine J 2005; 5:479-88. [PMID: 16153573 DOI: 10.1016/j.spinee.2005.01.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Accepted: 01/26/2005] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Various materials have been tested for their ability to maintain a barrier between muscles and epidural space in order to physically or chemically inhibit scar ingrowths. Hyaluronic acid (HA) solution and gel have been reported to be effective in preventing adhesions postlaminectomy; however, neither has been used clinically after spinal surgery. PURPOSE To determine the efficacy of HA sheet for the prevention of postlaminectomy adhesions compared with that of HA gel or another sheet. STUDY DESIGN/SETTING An animal model of lumbar laminectomy in rabbits was used to study postoperative scar tissue formation around the spinal cord. The histologic effects of HA sheet were compared with those of Gelfoam (GF) and further evaluated by an inflammation model using rhTNF-alpha. PATIENT SAMPLE Rabbit. OUTCOME MEASURES Histologic examination. METHODS Five rabbits were killed at 2, 4, 8, and 24 weeks after laminectomy, respectively. Another 18 rabbits were examined in an environment of active inflammation experimentally induced by rhTNF-alpha to compare the effects of HA sheet with those of GF or HA gel. Histologic examination was performed to quantitatively assess invasive scar formation or inflammation postlaminectomy, and then, the histologic effects of HA sheet were compared with those of GF or HA gel. RESULTS In the HA group, significantly, the area of subarachnoid space was larger, distance from the surface of dura to scar tissues was greater, the number of inflammatory cells in the scar tissues at the site of laminectomy was less, and enlargement of dura was suppressed. Using an inflammation model, we also demonstrated the efficacy of HA sheet treatment. CONCLUSIONS In an experimental laminectomy model, HA sheet formed a solid interpositional membrane barrier and exhibited anti-inflammatory activity. Further investigations will be needed for HA sheet to be used clinically.
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Affiliation(s)
- Tsuyoshi Kato
- Department of Spinal and Orthopaedic Surgery, Tokyo Medical and Dental University, Graduate School of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-5819, Japan
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Mastronardi L, Pappagallo M, Tatta C. The Oxiplex/SP gel-morphine compound after lumbar microdiscectomy in the management of postoperative pain. Report of 20 cases. ACTA ACUST UNITED AC 2005; 64:75-8; discussion 78-9. [PMID: 15993192 DOI: 10.1016/j.surneu.2004.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2004] [Accepted: 09/07/2004] [Indexed: 11/16/2022]
Abstract
OBJECT Morphine-based compounds are used epidurally after lumbar microdiscectomy to minimize postoperative pain. After the withdrawal of ADCON-L we started to use Oxiplex (Oxiplex/SP Gel) as a barrier against epidural fibrosis and as a vehicle for morphine delivery. METHODS We administered epidurally morphine (1 mg) dissolved in Oxiplex gel to 20 consecutive patients after lumbar microdiscectomy, evaluating safety and analgesic effectiveness. Outcome measures adopted were (1) visual analog scale (VAS) of back and radicular pain, (2) straight leg raising (SLR) maneuver to assess evoked pain, (3) postoperative time to comfortable ambulation, (4) postoperative hospitalization, (5) postoperative request of analgesics, and (6) postoperative work time loss. RESULTS No complications, such as urinary retention, respiratory disturbances, or wound infections, were observed. During the first 24 hours the mean VAS was lower than the preoperative one (12.5 vs 77.3 mm, respectively; P < .01). The mean postoperative SLR was 62.25 degrees vs 38.74 degrees of preoperative period (P < .05). After a mean of 29.8 hours, patients were discharged. Twelve patients (60%) had low back and radicular pain relapse 36 to 72 hours after operation, requiring assumption of analgesics. At that time, 2 patients reported a level of pain higher than the preoperative one. At 1- and 2-week follow-up visits, mean VAS scores were 33.5 and 12.0 mm, respectively. The 2-week overall treatment satisfaction rating was excellent for 60% and good for 40%. Finally, the mean postoperative work time loss was 27 days. CONCLUSIONS The epidural application of Oxiplex-morphine compound after lumbar microdiscectomy was found to be safe. Regarding postoperative pain control, it was found to be effective only during the first 36 hours.
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Lundorff P, Donnez J, Korell M, Audebert AJM, Block K, diZerega GS. Clinical evaluation of a viscoelastic gel for reduction of adhesions following gynaecological surgery by laparoscopy in Europe. Hum Reprod 2005; 20:514-20. [PMID: 15591082 DOI: 10.1093/humrep/deh651] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Commonly used adhesion prevention devices either cannot be applied or are difficult to use via laparoscopy. A viscoelastic gel was developed specifically for adhesion prophylaxis during minimally invasive surgery. METHODS Randomized, third party-blinded, parallel-group design conducted at four centres. Patients (18-46 years old) underwent laparoscopic surgery with second look 6-10 weeks later. Viscoelastic gel coated adnexa and adjacent tissues. Blinded reviews of videotapes were quantified by American Fertility Society (AFS) adhesion scores. RESULTS In 25 treatment patients, surgery was performed on 45 adnexa. Coverage of surgical sites at risk for adhesions was typically accomplished with approximately 15 ml of viscoelastic gel which was delivered in approximately 90 s. In 24 control patients, surgery alone was performed on 41 adnexa. Treated adnexa showed a decrease in AFS score (11.9-9.1). In contrast, control adnexa showed an increase in AFS score (8.8-15.8). This difference in second-look AFS scores (42% reduction) is significant (P<0.01). Ninety-three per cent of treated adnexa did not have a worse adhesion score in contrast to 56% of control adnexa. Combining scores into prognostic categories also show significant treatment effect of the viscoelastic gel (P<0.01). CONCLUSION Viscoelastic gel was easy to use via laparoscopy and produced significant reduction in adnexal adhesions. It provides benefits to patients undergoing gynaecological surgery.
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Affiliation(s)
- P Lundorff
- Department of Obstetrics and Gynecology, Viborg Hospital, Viborg, Denmark
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Kim KD. Peridural fibrosis. J Neurosurg 2004; 100:400-1; author reply 401. [PMID: 15070156 DOI: 10.3171/spi.2004.100.4.0400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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