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PubMed1990

Use of Vicryl (polyglactin 910) mesh to limit epidural scar formation after laminectomy.

A variety of substances have been used at laminectomy sites to prevent postoperative epidural scarring. Free grafts of autologous subcutaneous fat are commonly used both clinically and experimentally. The free fat grafts usually survive, but decrease in size by about 50%. Postoperatively, subcutaneous seroma has been observed with the use of fat grafts, as well as recurrent symptoms of neural compression by the graft that required additional operations. When compared to the use of free grafts after laminectomy in dogs, Vicryl mesh produced slightly more scarring, but consistently less than that observed in control animals. The Vicryl mesh was resorbed by a minimal chronic inflammatory response over about 45 days. Seven of 11 fat-grafted zones showed signs of necrosis, at times with a greater collection of inflammatory cells than that associated with the Vicryl mesh. Of the 4 fat-grafted zones that showed good survival, 2 had gross evidence of neural compression. No surgical zone treated with Vicryl mesh exhibited evidence of neural compression. In view of these results, the use of Vicryl mesh at laminectomy sites may be a safer method of limiting postoperative epidural scar formation.

Animals↗
PubMed1999

Inhibition of peridural fibrosis after laminectomy using low-dose external beam radiation in a rat model.

OBJECTIVE: Clinical studies have revealed a significant association between the presence of extensive postlumbar discectomy peridural scar formation and the reoccurrence of low back and radicular pain. Low-dose perioperative radiation therapy has been shown to inhibit scar formation. Its effect on peridural fibrosis, however, has not been studied. METHODS: Thirty male Sprague-Dawley rats underwent L5 laminectomies. Ten rats each received a single fraction of 700-cGy external beam radiation to the lumbar spine 24 hours before surgery; 10 rats each received 700 cGy 24 hours after surgery. The remaining 10 rats served as a control group. All of the rats were killed 30 days after surgery. The spines were harvested, and axial histological sections through the laminectomy defect were evaluated. Each specimen was scored for extent, density, and arachnoidal involvement by fibrosis. RESULTS: There was a statistically significant difference between the treatment and control groups regarding the extent of fibrosis along the dura (P < 0.001), the density of fibroblasts (P < 0.005), and the arachnoid involvement (P < 0.01). There was no difference in fibrosis reduction between the groups receiving pre- and postlaminectomy radiation. CONCLUSION: Low-dose external beam radiation therapy administered before or after laminectomy in a rat model significantly decreases the extent, density, and arachnoidal involvement of peridural fibrosis. This technique may improve the outcome of patients who undergo reoperations for recurrent radicular and/or low back pain after successful lumbar discectomy in whom there is a significant amount of peridural fibrosis.

Animals↗
PubMed1999

Cervical spondylotic myelopathy: functional and radiographic long-term outcome after laminectomy and posterior fusion.

OBJECTIVE: To evaluate the long-term efficacy of cervical laminectomy with posterior lateral mass fusion/fixation in the treatment of patients with cervical spondylotic myelopathy (CSM). METHOD: Twenty-five patients treated for CSM by laminectomy and lateral mass fusion at the Division of Neurosurgery at The Ohio State University between 1989 and 1994 were studied retrospectively. Only patients with longer than 2-year postoperative follow-up durations were included. At follow-up examination, each patient completed an SF36 questionnaire, underwent a physical examination, underwent plain radiography showing the spinal curvature with plate and screw position, and underwent magnetic resonance imaging of the cervical spine, which evaluated dural sac decompression and spinal cord abnormalities. Patient-generated data were used for outcome measurements. RESULTS: The mean follow-up duration was 47.5 months. Good outcome was defined by the presence of three criteria: ability to walk unassisted (Grade IIIA or better), ability to write unassisted, and ability to manage buttons and/or zippers unassisted. The inability to meet these criteria was defined as a poor outcome. Two patients (8%) experienced complications that resulted from the surgery. There was no instability or progression to significant kyphosis. Lesions that were hyperintense on magnetic resonance images did not correlate with outcome. Eighty percent of the patients achieved good outcomes, and 76% had improved myelopathy scores. None of the patients had late neurological deterioration. Patients with better neurological statuses at the time of surgery (Grade IIIA or better) were more likely to improve (P < 0.0001); the likelihood of a change in status for those starting with poorer grades (IIIB or worse) was not statistically significant (P < 0.08). CONCLUSION: Cervical laminectomy with posterior fusion/fixation proved useful in the treatment of patients with CSM with straight or lordotic spines and multilevel compression. This therapy addresses the dynamic and compressive forces that are important in the pathogenesis of CSM, resulting in minimal complications and possible improvement in long-term outcomes.

Adult↗
PubMed2000

Inhibition of peridural fibrosis after laminectomy using low-dose external beam radiation in a dog model.

OBJECTIVE: Clinical studies have demonstrated a significant association between the presence of extensive postlumbar discectomy peridural scar formation and the recurrence of low back and radicular pain. Low-dose perioperative radiation therapy has previously been demonstrated to inhibit peridural fibrosis after laminectomy in a rat model. The current study was designed to measure the effect of low-dose radiation on postlaminectomy peridural fibrosis development in a larger animal model. METHODS: Three dogs underwent a total of 12 lumbar hemilaminectomies. For each animal, two levels received 1) external beam radiation 24 hours before surgery, 2) surgery alone, or 3) radiation alone. Radiation was administered in a single fraction of 700 cGy using computed tomographic guidance for dosimetry planning. The isodose distribution was such that the dose conformed to the posterior epidural space with minimal exit dose to normal tissue. Port films were used to confirm the correct levels. Gadolinium-enhanced magnetic resonance imaging (MRI) of the lumbar spines was obtained before the animals were killed 12 weeks after surgery. The spines were harvested, and axial sections through the laminectomy defect were stained with hematoxylin and eosin and Masson's trichrome. All specimens were evaluated for extent of fibrosis along the dura, density of fibrosis, nerve root entrapment, and sublaminar fibrosis. RESULTS: There were no complications from the surgery, and no new neurological deficits were noted. There was a statistically significant difference between the irradiated and nonirradiated groups regarding the extent of fibrosis (P = 0.001) and the density of fibroblasts (P = 0.001). There was also a marked difference in nerve root entrapment (P = 0.182) and the presence of sublaminar fibrosis (P = 0.061) between the treatment and control groups. MRI revealed less gadolinium enhancement at the irradiated levels compared with the nonirradiated levels, confirming the usefulness of MRI in predicting the degree of epidural fibrosis. CONCLUSION: Low-dose external beam radiation therapy administered 24 hours before laminectomy in a dog model significantly decreased the extent and density of peridural fibrosis as well as nerve root entrapment and sublaminar fibrosis. This treatment strategy may be efficacious in patients with recurrent radicular pain after lumbar discectomy that is thought to be secondary to peridural fibrosis on the basis of gadolinium-enhanced MRI studies, and who might benefit from reoperation for nerve root decompression.

Animals↗
PubMedDate not supplied

Prevention of nerve root adhesions after laminectomy.

In repeat lumbar surgery for failure of the original operation to provide lasting relief, well-organized fibrous tissue is often noted binding together the dura, nerve roots, and erector spinae muscles. Lumbar laminectomy was carried out in 46 dogs and seven groups of animals studied. Gelfoam failed to prevent fibrosis. Free fat grafts prevented fibrosis whether the graft was placed at the laminectomy site or around the nerve roots. Vascularization of the grafts was demonstrated by injection of India ink before sacrifice. Ligamentum nuchae, which is similar to ligamentum flavum in its high elastic content, was also effective in preventing scar formation. The operative biopsy findings at reexploration in four patients who had free fat grafts following laminectomy are presented.

Adipose Tissue↗
PubMedDate not supplied

Atlantoaxial rotatory fixation after decompressive laminectomy. A case report.

A case of atlantoaxial rotatory fixation and kyphosis in an 8.5-year-old boy following decompressive laminectomy for spinal cord tumor is described. Halo gravity traction was used to reduce the deformity, and then stabilization was performed from C1 through C5 via the anterior approach and with the use of iliac and fibular bone graft. The case is unique in that anterolateral rotatory fixation was combined with kyphosis in the upper cervical spine. It is reemphasized that all children who undergo decompressive laminectomy be observed closely or stabilized at the time of laminectomy.

Atlanto-Axial Joint↗
PubMed1986

The injudicious laminectomy.

This report is an attempt to point out a hazard of what would be otherwise competent treatment of acquired spinal stenosis, namely laminectomy and facetectomy, in a small group of patients who are osteoporotic and who also have a "minor" compression fracture in the area in which the surgery is contemplated. Three patients who had such laminectomies, with disastrous results, are presented, along with one patient who, instead, had internal fixation and fusion at the time of laminectomy with an excellent result. The latter approach is recommended in such cases.

Aged↗
PubMed1989

Analysis of cervical instability resulting from laminectomies for removal of spinal cord tumor.

Thirty-four patients with cervical cord tumor were followed in order to investigate the incidence of postoperative deformity or instability after laminectomies. Seven cases (20%) presented cervical instability, including three cases that required spinal fusion. Analysis of these cases revealed the identification of some risk factors that are involved in the pathogenetic mechanism of cervical instability, which are: age at operation, preoperative curvature in neutral position, number of removed laminas, C2 laminectomy, and destruction of facet joints. The number of these risk factors present in each case was shown to be directly related to the incidence of cervical instability. Patients who had not developed instability demonstrated 1.2 factors on average, while patients who had developed instability showed a mean of 2.5 factors. Patients who had additionally required spinal fusion presented 3 risk factors, including C2 laminectomy and destruction of facet joints.

Adult↗
PubMed1990

Postoperative lumbar spinal instability occurring or progressing secondary to laminectomy.

The manifestations and pathomechanism of postoperative lumbar spinal instability, occurring or progressing secondary to laminectomy, was clarified by means of functional radiographic analysis in a series of 46 patients over 40 years of age. The relation between instability and the clinical symptoms also is discussed. In patients under 60 years of age, instability at the operated level tended to appear in cases of wide laminectomy more often than in cases of partial laminectomy. Occurrence or progress of instability seems to be promoted by resection of the posterior spinal elements rather than the disc. It is further considered that the postoperative aggravation of clinical symptoms may be influenced not only by instability, but also by the other factors.

Age Factors↗
PubMed1993

The effect of multilevel laminectomy on the cervical spine of growing cats. An experimental study.

This experiment was undertaken to observe the effect of multilevel laminectomy on the cervical spine of growing cats. Wide cervical laminectomy was done from C3 to C6 on 24 immature cats and 24 mature cats. Cervical kyphosis gradually developed in the growing cats postoperatively after 4 months; normal cervical curves were maintained in the mature cats. Corporal subluxation at the kyphotic segment was detected postoperatively after 4 months, but the characteristic wedge-shaped deformity of the vertebral body of the swan-neck deformity was not detected using serial radiographs during the 12-month observation period. Histologically, there was no evidence of thinning or early fusion of the anterior part of the physis throughout the observation period. Post-laminectomy kyphosis developed as the result of forward subluxation of vertebral bodies because of the destabilizing surgery.

Aging↗
PubMed1993

Effects of laminectomy and retained extradural foreign body on cauda equina adhesion.

The histologic effects of posterior lumbar surgery and retained extradural foreign bodies on the cauda equina were investigated in rats over time. The following four groups of rats were provided: Group 1, sham operation (laminar exposure alone); Group 2, laminectomy alone; Group 3, laminectomy with retained extradural silk thread; Group 4, laminectomy with extradural kaolin; and the control. Histological study was performed on the transverse sections of laminectomized (L5) and nonlaminectomized (L4) areas. In Group 1, adhesive changes involving the cauda equina, consisting of dilatation of nutrient vessels, and eosinophilic exudative changes between the adhering cauda rootlets were seen the day after surgery, but the fibrinous adhesion was resolved spontaneously in all rats after 1 week without permanent sequelae. In Groups 2 and 3, postoperative adhesion of the cauda equina roots was conspicuous, but it resolved by 6 weeks. In Group 4, obvious adhesion persisted through the 12th week after surgery. Destruction of the myelin sheath and axonal loss of the cauda equina occurred in the first week after surgery in all the experimental groups except in the sham group. The severity and extent of the neural degeneration were mostly parallel to the severity of inflammatory changes in the epidural areas. At the nonlaminectomized area (L4) in each group, the arachnoid and cauda equina tended to congregate the day after surgery, but these changes were all transitory. The severity and persistency of the arachnoiditis and neural degeneration directly corresponded to the magnitude of the inflammation and wound healing processes. This seems to imply that careful surgical intervention with no use of foreign bodies is necessary to reduce postoperative adhesive arachnoiditis.

Animals↗
PubMed1995

The use of expanded polytetrafluoroethylene as an interpositional membrane after lumbar laminectomy.

STUDY DESIGN: Prevention of post-laminectomy membrane formation was evaluated in a canine model. Fat graft, Silastic sheeting and expanded polytetrafluoroethylene were compared with nonimplanted control sites. OBJECTIVES: The development of an effective barrier to peridural scar invasion is of major importance in optimizing results after lumbar laminectomy. SUMMARY OF BACKGROUND DATA: Postoperative peridural fibrosis represents a normal biologic response after lumbar spinal surgery. A variety of biologic and nonbiologic interpositional materials have been studied. Expanded polytetrafluoroethylene has been shown to limit scar adhesion in the pericardium and peritoneum and has not been studied previously as a postlaminectomy interpositional membrane. METHODS: Eleven adult female cross-bred hounds underwent multilevel standardized laminotomies. Three materials--fat graft, Silastic sheeting, and expanded polytetrafluoroethylene--were compared with nonimplanted controls. The animals were killed 12 weeks after surgery and were evaluated histologically and using gadolinium-enhanced magnetic resonance imaging. RESULT: The magnetic resonance imaging studies were inconclusive in assessing peridural scar extension or identifying the implanted membranes. Histology revealed dense scar tissue at all control sites and replacement of all fat grafts by scar. Scar density was significantly less for the expanded polytetrafluoroethylene membrane surgical sites than for the control, fat graft, and Silastic sheeting sites. CONCLUSIONS: Expanded polytetrafluoroethylene membrane is biocompatible, maintains its structural integrity, and is impervious to fibrous ingrowth. These findings support further investigation of expanded polytetrafluoroethylene membrane as an interpositional material to prevent post-laminectomy peridural fibrosis.

Adipose Tissue↗
PubMed1995

The effect of interposition membrane on the outcome of lumbar laminectomy and discectomy.

STUDY DESIGN: This study evaluated clinical and magnetic resonance imaging differences of patients treated surgically for lumbar disc herniation. Clinical follow-up and magnetic resonance imaging evaluation of epidural fibrosis were used to assess patient outcome. OBJECTIVES: The purpose of this study was to evaluate the difference in clinical outcome with either free-fat graft, Gelfoam, or no interposition membrane placed in the laminectomy defect after nerve root decompression. SUMMARY OF BACKGROUND DATA: Epidural fibrosis has been considered a cause of recurrent symptoms after lumbar laminectomy, and numerous materials have been evaluated for prophylaxis of the "laminectomy membrane." These have been mainly histologic and animal studies with no data correlating clinical symptoms and postoperative epidural scar formation. METHODS: One hundred fifty-six patients who were treated surgically for lumbar disc herniation were randomly assigned to one of three groups and followed prospectively for at least 1 year. Thirty-three of these patients were received magnetic resonance imaging evaluations after 6 months by an independent radiologist who graded the amount of epidural scar formation. The patients were assessed at 1 year and given a rating of excellent, good, fair, or poor, and the scar was graded as none, minimal, or moderate. RESULTS: Although 97% of all patients improved, 83% were rated excellent or good. There were no statistical differences between the three groups clinically and radiographically. Patients with workers compensation had a statistically significant lower success rate (P < 0.001). CONCLUSIONS: Clinical outcome after lumbar disc surgery does not correlate with the use or type of interposition membrane used to prevent epidural fibrosis.

Adolescent↗
PubMed2005

Effect of preemptive gabapentin on postoperative pain relief and morphine consumption following lumbar laminectomy and discectomy: a randomized, double-blinded, placebo-controlled study.

Synergism between gabapentin and morphine in treating incisional pain has been demonstrated in animal experiments and clinical studies. The efficacy of gabapentin for treatment of perioperative pain remains controversial. This study was designed to detect the influence of gabapentin premedication on morphine consumption in the immediate postoperative period in patients undergoing lumbar laminectomy and discectomy. Either gabapentin 800 mg (in two equally divided doses) or placebo was given preoperatively to 60 adult patients undergoing elective lumbar laminectomy or discectomy in a double-blinded, placebo-controlled, randomized study. Standard general anesthesia was given to all the patients. Morphine was administered via patient-controlled analgesia pump in the immediate postoperative period for first 8 hours. Pain at rest and on movement was assessed using a Verbal Rating Scale (VRS) every 2 hours for the first 8 postoperative hours. There were no differences in demographics or surgical duration between the two groups. The amount of fentanyl administered in the intraoperative period was similar between the two groups. In the postoperative period, the VRS score for pain at 0, 2, 4, 6, and 8 hours was not significantly different between the two groups. Highest median VRS score was recorded at 0 hours postoperatively in both groups (VRS: rest = 6, movement = 8 in placebo group; rest = 6, movement = 8 in gabapentin group). Total morphine consumption and side effects were similar in the two groups. Gabapentin does not decrease the morphine requirement or morphine side effects in the immediate postoperative period following lumbar laminectomy and discectomy.

Adolescent↗
PubMed2003

Prevention of cerebrospinal fistulae and reduction of epidural scar with new surgical hemostat device in a porcine laminectomy model.

STUDY DESIGN: In a porcine laminectomy model, a standard dural/arachnoid incision was made and tested for cerebrospinal fluid leak after material application. Sites were graded for scar formation and healing response at 3 weeks. OBJECTIVE: This study compares effectiveness of CoStasis, Tissucol, and suture for prevention of cerebrospinal fluid leaks and epidural scar formation after spinal dural incisions. SUMMARY OF BACKGROUND DATA: Cerebrospinal fluid leaks following cranial and spinal surgery are potentially serious complications. Epidural scar formation is exacerbated by improper control of hemostasis. A hemostatic agent with dural sealant properties may be advantageous. METHODS: Total laminectomy was performed at three levels in seven pigs. At each level, a uniform 1.5 cm incision was made in the dura and arachnoid. A single suture was placed to approximate the edges and sites were treated with one of three methods: CoStasis, Tissucol, or no treatment. At sacrifice, 3 weeks later, epidural scar was graded, pressure testing of some sites was done, and tissue for histologic sections was harvested. RESULTS: CoStasis and Tissucol produced immediate dural sealing when the valsalva maneuver was applied. One suture-only site leaked. At sacrifice, all sites were sealed. CoStasis and Tissucol had less scar formation than control sites. Pressure testing results were similar at CoStasis and Tissucol sites. CONCLUSION: CoStasis and Tissucol have comparable effectiveness in sealing CSF leaks immediately and at 3 weeks after complete laminectomy. CoStasis demonstrated comparable performance to Tissucol with less epidural scar formation than primary suture alone.

Animals↗
PubMed2004

Relation between laminectomy and development of adjacent segment instability after lumbar fusion with pedicle fixation.

STUDY DESIGN: A retrospective study of 101 patients who had undergone posterolateral lumbar fusion, to analyze the association between adjacent instability and the extent of laminectomy. OBJECTIVES: To investigate the hypothesis that the integrity of the posterior complex (spinous process/supraspinous ligament/spinous process) between the fused segments and the neighboring motion segments significantly influences lumbar spine stability. SUMMARY OF BACKGROUND DATA: Spinal fusion with pedicle fixation accelerates the degeneration of adjacent motion segments. The lowest cranial motion segment is the most common level for the development of adjacent instability. Laminectomy, including removal of the spinous process, supraspinous ligament, interspinous ligament, lamina and ligamentum flavum, jeopardizes the integrity of the posterior complex of the spine. METHODS: This study enrolled 101 patients, followed up for at least 6 years, who had been treated with posterolateral lumbar fusion with pedicle fixation because of lumbar spondylolisthesis. The diagnosis of adjacent instability depended on the dynamic lateral views of the lumbosacral spine during each follow-up. The integrity of the posterior complex was based on the extent of laminectomy and the fusion level. RESULTS: At the cranial adjacent motion segment, 2 of 31 (6.5%) patients with preserved posterior complex integrity between the fused segment and motion segment developed adjacent instability, compared with 17 of 70 (24.3%) without preserved posterior complex integrity. At the caudal adjacent motion segment, none of 13 patients (0%) with preserved integrity developed adjacent instability, compared with 3 of 54 (5.6%) without preserved integrity. CONCLUSIONS: Damaging the integrity of the posterior complex between the fused segments and the neighboring motion segments may jeopardize lumbar spine stability. Sacrificing either the supraspinous ligament or the tendon insertion points on the spinous processes leads to an accelerated development of adjacent instability.

Adult↗
PubMed2005

Long-term outcome of laminectomy for spinal stenosis in octogenarians.

STUDY DESIGN: Cohort study with follow-up after at least 1.5 years. OBJECTIVES: The purpose of this study was to determine long-term safety and efficacy of laminectomy in octogenarians. SUMMARY OF BACKGROUND DATA: This is the first study evaluating the outcome in octogenarians with well-defined lumbar spinal stenosis. This study was designed to provide some guidance in clinical-practical decisions in the treatment of aged patients with lumbar stenosis. METHODS: We evaluated long-term outcome after laminectomy in 23 consecutive patients affected by lumbar spinal stenosis. Comorbidity was assessed using the Cumulative Illness Rating Scale for Geriatrics. At follow-up, all patients completed a questionnaire containing the Visual Analog Pain Scale and the Oswestry Disability Index. The use of analgesics was assessed from chart review of their family physician. RESULTS: The average age at the time of surgery was 82.2 +/- 2.6 years; the mean follow-up was 2.7 +/- 1.2 years. The mean of the Cumulative Illness Rating Scale for Geriatrics total score was 7.7 +/- 4.3, reflecting the normative comorbidity-values of octogenarians. At follow-up, 4 patients had died. The Oswestry Disability Index for the remaining patients was 36.4 +/- 28%. The daily nonsteroidal anti-inflammatory medication had decreased from 1.9 to 0.1 equivalent analgesic doses and the amount of morphine from 0.6 to 0.2 equivalent narcotic doses. The Pain Score on the Visual Analog Pain Scale decreased from 85 to 39. After surgery no patient had claudication. CONCLUSION: On the long-term, decompressive laminectomy in selected octogenarians results in decreased disability, decline of analgesics usage, and increased quality of life.

Aged, 80 and over↗
PubMed2006

Anti-adhesion properties of a thrombin-based hemostatic gelatin in a canine laminectomy model: a biomechanical, biochemical, and histologic study.

STUDY DESIGN: An in vivo study on the effects of an agent for scar prevention in a dog laminectomy model. OBJECTIVE: To examine the anti-adhesion properties of a thrombin-based hemostatic gelatin (FLOSEAL; Baxter International Inc., Deerfield, IL). SUMMARY OF BACKGROUND DATA: Postlaminectomy dural adhesion sometimes causes symptomatic problems. Although a new type of hemostatic agent, a thrombin-based hemostatic gelatin, has been developed, its effect on postlaminectomy scar prevention is unknown. METHODS: A 4-level lumbar laminectomy was performed on 11 adult mongrel dogs. There were 2 levels randomly chosen to receive the thrombin-based hemostatic gelatin treatment, while the remaining levels were untreated (control). Dogs were euthanized 8 weeks after surgery. To assess the tenacity of adhesion between the dura and scar, peel-off testing was performed. Gross, biochemical, and histologic analyses were then used to examine the samples. RESULTS: Peel-off stiffness was significantly decreased in the treatment group (64.8% of the control, P = 0.032; 2-tailed unpaired t test). Histologically, there was significantly less scar tissue formation in the treatment group (P = 0.04). The gross analyses showed a trend toward a smaller amount of scar tissue and tenacity of adhesion between the dura and scar in the treatment group. Biochemically, there was a trend toward a lower collagen cross-links content in the treatment group (P = 0.07). CONCLUSIONS: The thrombin-based hemostatic gelatin decreases the tenacity of adhesion between the dura and scar at laminectomy sites.

Animals↗