Arachnoiditis Extending Beyond Operative Site

Lumbar epidural fibrosis may occur after a lumbar discectomy, replacing normal epidural fat with non-physiologic scar tissue, binding the dura and nerve roots to the surrounding structures, and causing arachnoiditis. Lumbar arachnoiditis occurs in 6%-16% of postoperative surgeries in the lumbar region, usually at the site of the laminectomy into the spinal canal. This case report covers a 35-year-old male patient who underwent a discectomy with resulting arachnoiditis multiple levels cranial of the site of laminectomy. We illustrate the first reported case of diffuse arachnoiditis causing residual pain after a lumbar discectomy.

Retrospective analysis on correlation factors of preserving the ligamentum flavum in microendoscopic discectomy

OBJECTIVE

The present study was conducted to investigate the correlation factors of successful preservation of the ligamentum flavum (LF) in microendoscopic discectomy.

METHODS

This retrospective review was carried out on 78 consecutive patients who underwent single segment microendoscopic discectomy projecting to preserve the LF between January 2012 to January 2013. The demographic and clinical data including age, gender, duration of disease, area of interlaminar space, disc level and position type of lumbar disc herniation were recorded. Intraoperative outcomes including duration of operation and peri-operative bleeding were recorded. Clinical outcomes were assessed by Oswestry disability index (ODI) and visual analog scale (VAS), and fibrosis formation was detected using computed tomographic scans with IV iopamidol injection. The follow up lasted six months.

RESULTS

LF was successfully preserved in 54 patients (69.2%) and 24 patients (30.8%) underwent microendoscopic discectomy without preservation of LF. In multivariate logistic analysis, factors including age (OR, 1.17; 95% CI, 1.07-1.28; P<0.001) and area of the laminar space (OR, 0.09; 95% CI, 0.01-0.67; P=0.018) significantly associated with the preservation of LF. Other factors including gender, duration of ill course, disc level and position type seemed not associated with the preservation of the LF. In addition, there was no significant difference of the duration of the operation (P=0.689) as well as the peri-operative bleeding (P=0.147) between patients with preservation of the LF and patients without. However, patients with preservation of the LF showed significantly improved clinical outcomes (ODI: P=0.006, VAS: P=0.035) and less fibrosis formation than those without LF (P=0.018).

CONCLUSIONS

Microendoscopic discectomy with preservation of the LF could achieve better clinical outcomes and less epidural fibrosis, while elder patients with smaller area of the laminar space should be deliberated on the preservation of the LF during the microendoscopic discectomy.

Imaging of lumbar degenerative disk disease: history and current state

One of the most common indications for performing magnetic resonance (MR) imaging of the lumbar spine is the symptom complex thought to originate as a result of degenerative disk disease. MR imaging, which has emerged as perhaps the modality of choice for imaging degenerative disk disease, can readily demonstrate disk pathology, degenerative endplate changes, facet and ligamentous hypertrophic changes, and the sequelae of instability. Its role in terms of predicting natural history of low back pain, identifying causality, or offering prognostic information is unclear. As available modalities for imaging the spine have progressed from radiography, myelography, and computed tomography to MR imaging, there have also been advances in spine surgery for degenerative disk disease. These advances are described in a temporal context for historical purposes with a focus on MR imaging's history and current state.

Detection of postoperative granulation tissue with an ICG-enhanced integrated OI-/X-ray System

Background

The development of postoperative granulation tissue is one of the main postoperative risks after lumbar spine surgery. This granulation tissue may lead to persistent or new clinical symptoms or complicate a follow up surgery. A sensitive non-invasive imaging technique, that could diagnose this granulation tissue at the bedside, would help to develop appropriate treatments. Thus, the purpose of this study was to establish a fast and economic imaging tool for the diagnosis of granulation tissue after lumbar spine surgery, using a new integrated Optical Imaging (OI)/X-ray imaging system and the FDA-approved fluorescent contrast agent Indocyanine Green (ICG).

Methods

12 male Sprague Dawley rats underwent intervertebral disk surgery. Imaging of the operated lumbar spine was done with the integrated OI/X-ray system at 7 and 14 days after surgery. 6 rats served as non-operated controls. OI/X-ray scans of all rats were acquired before and after intravenous injection of the FDA-approved fluorescent dye Indocyanine Green (ICG) at a dose of 1 mg/kg or 10 mg/kg. The fluorescence signal of the paravertebral soft tissues was compared between different groups of rats using Wilcoxon-tests. Lumbar spines and paravertebral soft tissues were further processed with histopathology.

Results

In both dose groups, ICG provided a significant enhancement of soft tissue in the area of surgery, which corresponded with granulation tissue on histopathology. The peak and time interval of fluorescence enhancement was significantly higher using 10 mg/kg dose of ICG compared to the 1 mg/kg ICG dose. The levels of significance were p < 0.05. Fusion of OI data with X-rays allowed an accurate anatomical localization of the enhancing granulation tissue.

Conclusion

ICG-enhanced OI is a suitable technique to diagnose granulation tissue after lumbar spine surgery. This new imaging technique may be clinically applicable for postoperative treatment monitoring. It could be also used to evaluate the effect of anti-inflammatory drugs and may even allow evaluations at the bedside with new hand-held OI scanners.

A modern biomaterial for adhesion prevention

A biomaterial composed of carboxymethylcellulose, poly(ethylene oxide), and calcium can be prepared in a variety of ways to reduce fibrin deposition and adhesion formation. This biomaterial platform can be formulated into a flowable gel with tissue adherence appropriate for use in minimally invasive surgery. The device remains at the site of placement even in gravitationally dependent areas. A peridural formulation was shown in preclinical studies to be safe and effective in reducing adhesions to dura following spinal surgery. A peritoneal formulation used on pelvic organs following peritoneal cavity surgery was also shown to be safe and effective. A clinical feasibility study showed that patients with severe back pain and lower extremity weakness treated with the peridural formulation, applied over their nerve roots following laminectomy or laminotomy, experienced significantly reduced symptoms when compared with surgery-only controls. The peritoneal formulation was shown in two multicenter feasibility studies of women undergoing pelvic surgery to significantly reduce adhesion formation when compared with surgery-only controls. Confirmation of the feasibility studies awaits results from pivotal clinical trials. These formulations were safe, effective, and easy to use. This biomaterial provided a benefit to patients undergoing surgery where postsurgical adhesion formation is a concern.

Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery

OBJECTIVE

Postoperative fibrosis is one of the most important causes of failed back surgery syndrome after lumbar disc surgery. Numerous natural and synthetic materials have been investigated as means to prevent or reduce postoperative scarring after these operations. Preservation of the ligamentum flavum for this purpose has not been studied in depth. A prospective, randomized, controlled clinical study was conducted. The aim was to present a new technique for preserving the ligamentum flavum during lumbar discectomy, and to evaluate whether this helps prevent or diminish postoperative fibrosis.

METHODS

Twenty patients with unilateral L5-S1 disc herniation were randomly divided into two equal groups. Group A patients underwent classic microlumbar discectomy, and Group B patients underwent the same procedure but with preservation of the ligamentum flavum. Visual analog pain scale (VAPS) scores, Oswestry scale scores, and straight-leg raising angles were recorded preoperatively and at 6 months postoperatively. Differences between the pre-operative and postoperative findings for each group were statistically compared using the Wilcoxon test. Magnetic resonance imaging was also done at 6 months to assess the extent of postoperative fibrosis, and a "scarring grade" was recorded for each patient. The group findings for this were analyzed with Levene's test.

RESULTS

Both groups' clinical parameters were significantly improved at 6 months postsurgery. In Group A, the mean pre- and postoperative VAPS scores were 9.2 and 3.2, respectively (P < 0.05); the corresponding mean Oswestry scale scores were 88 and 28.2, respectively (P < 0.05); and the corresponding mean straight-leg raising angles were 290 and 630, respectively (P < 0.05). In Group B, the mean pre- and postoperative VAPS scores were 9.2 and 2.6, respectively (P < 0.05); the corresponding mean Oswestry scores were 85.2 and 22.2, respectively (P < 0.05); and the corresponding mean straight-leg raising scores were 260 and 710, respectively (P < 0.05). The mean scarring grades in Groups A and B were 1.8 and 1.0, respectively (P < 0.05).

CONCLUSION

The groups both showed satisfactory clinical outcomes and the improvements were comparable; however, the group with preserved ligamentum flavum showed significantly less local fibrosis at 6 months postoperatively. The authors speculate that this surgical technique provides a physical protective barrier that can reduce or even eliminate fibrosis-related complications after lumbar disc surgery.

Reduction of radiculopathy and pain with Oxiplex/SP gel after laminectomy, laminotomy, and discectomy: a pilot clinical study

STUDY DESIGN

Safety using Oxiplex/SP Gel during single-level discectomy for reduction of symptoms associated with unilateral herniation of the lumbar disc was investigated by self-assessment questionnaire and magnetic resonance imaging.

OBJECTIVE

To evaluate the safety and assess the efficacy parameters of Oxiplex/SP Gel.

SUMMARY OF BACKGROUND DATA

Animal studies demonstrated that Oxiplex/SP Gel (CMC/PEO) reduced epidural fibrosis after lumbar surgery.

METHODS

Surgeons examined spine and lower extremities of patients scheduled for discectomy to assess neurologic function and pain. Treated patients received sufficient Oxiplex/SP Gel (1-3 mL) to coat the nerve root and fill the epidural space. The control condition was surgery alone. At baseline, then 30 days, 90 days, and 6 months after surgery, patients completed self-assessment questionnaires concerning leg pain, lower extremity weakness, functional disability, daily living activities, symptoms, and radiculopathy. Magnetic resonance imaging was performed at baseline and 90 days after surgery. At 30 and 90 days after surgery, patients underwent physical examination, wound inspection, and laboratory tests.

RESULTS

The surgical procedures were well tolerated by the 23 patients treated with Oxiplex/SP Gel and the 11 control patients. There were no unanticipated adverse events, no clinically significant laboratory results, and no significant differences detected by magnetic resonance imaging. Treated patients had greater reduction in outcome measures at 30 days. The differences in scores were attenuated at 90 days and 6 months. A subgroup, the patients with significant leg pain and weakness at baseline (11 patients treated with Oxiplex/SP Gel and 7 control patients), had greater reduction in outcome measures than the control patients throughout the study.

CONCLUSIONS

Oxiplex/SP Gel was easy to use and safe for patients undergoing unilateral discectomy. Greater benefit in clinical outcome measures was seen in gel-treated patients, especially those with severe leg pain and weakness at baseline.

Reduction of peridural fibrosis after lumbar laminotomy and discectomy in dogs by a resorbable gel (ADCON-L)

STUDY DESIGN

A canine lumbar laminotomy and discectomy model was used to evaluate the effects of a resorbable gel, ADCON-L (Gliatech Inc., Cleveland, OH), in reducing peridural scar formation and to assess the healing progress of immediately adjacent normal structures.

OBJECTIVES

To compare peridural scar formation and anulus fibrosis healing with and without the use of ADCON-L in an animal model that closely replicates the common human surgical procedure.

SUMMARY OF BACKGROUND DATA

ADCON-L has been shown to reduce the development of peridural scars in rat, rabbit, and canine laminectomy models in previous investigations; discectomies were not performed in these previous studies, however, and thus anular healing could not be assessed.

METHODS

Seven adult mongrel dogs underwent a three-level unilateral lumbar hemilaminotomy and anular fenestration. In each dog, the ADCON-L was applied to two randomly assigned sites around the discectomy, the nerve roots, and the hemilaminotomy. The third site underwent surgery, but was left untreated (sham surgery only). The canines were killed 8 weeks after surgery, and a gross anatomic assessment of scar formation was done using microdissection by an observer blinded to treatment. A numerical rating system was developed to assess the relative amount and tenacity of the anterior scarring (discectomy site) and posterior scarring (hemilaminotomy site). The healing of the anular defect was assessed histologically.

RESULTS

ADCON-L significantly reduced peridural fibrosis in this lumbar discectomy model compared with the sham treated sites (p < 0.05). Further, the superficial layers, the posterior longitudinal ligament, and the anulus fibrosus healed well in the ADCON-L treated sites.

CONCLUSIONS

ADCON-L reduced local peridural fibrosis after lumbar laminotomy and discectomy without impacting the healing of the surrounding tissues.

Use of ADCON-L to inhibit postoperative peridural fibrosis and related symptoms following lumbar disc surgery: a preliminary report

STUDY DESIGN

This was a prospective, randomized, multicenter, double-blind study.

OBJECTIVES

The study evaluated the use of ADCON-L Anti-Adhesion Barrier Gel to inhibit peridural fibrosis and reduce fibrosis-related symptoms after first-time lumbar discectomy.

SUMMARY OF BACKGROUND DATA

Peridural scarring causes tethering of dura and nerve roots, contributing to pain and functional limitation, and that symptoms are evident by 6 months after surgery.

METHODS

Following discectomy, ADCON-L was applied to patients in the active treatment group. Outcome measures were reduction of peridural scar and postoperative pain.

RESULTS

There is an association between peridural scar and recurrent radicular pain. Patients having extensive peridural scar were three times more likely to experience recurrent radicular pain than those patients with less extensive scarring. ADCON-L inhibited peridural scar. Compared to the control group, there was a 23% reduction in the number of patients with extensive peridural scar and a 120% increase in the number of patients having minimal or no scar. ADCON-L reduced the incidence of activity-related pain. There was up to a 50% reduction in the number of patients reporting increased pain while doing typical activities of daily living.

CONCLUSIONS

ADCON-L is safe, reduces peridural fibrosis, and improves postoperative patient outcome.

Severe sciatica: a 13-year follow-up of 342 patients

This study involved 342 patients hospitalized because of severe, persistent sciatica suggestive of a lumbar intervertebral disc herniation. After standard clinical evaluation, EMG and myelography, 220 patients underwent lumbar discectomy. The remaining 122 patients were treated conservatively. Follow-up examinations were arranged after 1, 5 and 13 years. The study focused on the rehabilitation outcome in general and differences in outcome between the two treatment groups. Several indicators showed a rather poor outcome for sciatica patients during the 13-year follow-up period. In the operated group 16% had been re-operated because of lumbar disc herniation. True recurrence of herniation (same level and side) occurred in 8%. In the conservatively treated group 14% had undergone spinal surgery. Nearly 70% of the patients still reported sciatica. Self-assessed levels of low back pain were "no change/worse" for 19% in the operated group and for 44% in the conservatively treated group. In both the study groups, nearly 40% of the subjects had retired on disability pensions.