Epidural Scar Research Articles

Bilateral synchronous UBE for unilateral laminotomy and bilateral decompression as a potentially effective minimally Invasive approach for two-level lumbar spinal stenosis

Currently, Unilateral biportal endoscopy is widely used in the surgical treatment of lumbar spinal stenosis. To investigate the feasibility of bilateral synchronous UBE to unilateral laminotomy and bilateral decompression(BS-UBE-ULBD) for treating two-level lumbar spinal stenosis (LSS). Sixty-four patients with two-level lumbar spinal stenosis (LSS) treated with BS-UBE-ULBD from October 2022 to January 2024 were retrospectively analyzed. All patients were treated with BS-UBE-ULBD. All 64 patients successfully underwent surgery, and the duration of surgery was 95–180 min, with an average of 119.92 ± 14.79 min. The average number of fluoroscopy was 3.02 ± 0.92. The average blood loss during the surgery was 73. 44 ± 36.70 ml. Postoperative lumbar CT showed that the spinal canal and bilateral nerve roots were fully decompressed. There were no postoperative complications, such as infection, severe nerve root injury, and lumbar instability. Complete follow-up data were obtained for all 64 cases. The VAS score of low back and leg pain and the ODI of lumbar function significantly (P < 0.05) improved at each follow-up time point. MacNab evaluation at 6 months after the surgery showed that the results were excellent in 48 cases, good in 14 cases, and fair in 2 cases. The excellent and good rate was 96. 88% (62/64). So BS-UBE-ULBD is a minimally invasive, highly effective, and safe procedure for 2-level LSS.Degenerative lumbar spinal stenosis (LSS) refers to clinical symptoms caused by the compression of the cauda equina, nerve root, and vascular complex. LSS can occur due to the abnormal shape and volume of the bony or fibrous structure after degenerative changes and the stenosis of the inner diameter of one or more lumens at a single level or multiple levels. It is a common cause of lumbago or lumbago and leg pain, which is common among middle-aged and elderly people1. LSS has become the most common cause of lumbar surgery among patients over 60 years of age2. However, traditional surgery necessitates extensive stripping of paraspinal muscles, which can easily lead to the ischemic injury of paraspinal muscles and atrophy after denervation. Therefore, traditional surgery may result in intractable back pain, stiffness, and discomfort after surgery3,4. Furthermore, as the posterior bone and soft tissue structures need to be extensively resected during the surgery, epidural scar and nerve compression are highly likely after the surgery. The high risk of general anesthesia cannot be ignored among elderly and weak patients2,5.Recently, with the rapid development of minimally invasive spine surgery, endoscopic surgery has been applied in the treatment of LSS6. Unilateral biportal endoscopy (UBE ) is more popular in treating LSS and is a more flexible operation, with small trauma, quick recovery, and a gentle learning curve. In addition, many studies have proven the good clinical efficacy of unilateral biportal endoscopy7. Multilevel spinal stenosis can be done simultaneously. Previously, the same operator decompressed multiple segments in turn8,9, but the operation lasted longer, and the corresponding problems, such as bleeding, high risk of anesthesia, and fluoroscopy frequency, increased.From October 2022 to June 2024, our hospital pioneered the use of Bilateral Synchronous UBE-unilateral Laminotomy and Bilateral Decompression (BS-UBE-ULBD) for two-level degenerative LSS. Sixty-four patients with two-segment LSS were treated with BS-UBE-ULBD, and the results were satisfactory.

Hydrogen-releasing magnesium hydrogel mitigates post laminectomy epidural fibrosis through inhibition of neutrophil extracellular traps

Epidural fibrosis is a primary contributor to the failure of laminectomy surgeries, leading to the development of failed back surgery syndrome (FBSS). Post-laminectomy, neutrophils infiltrate the surgical site, generating neutrophil extracellular traps (NETs) that contribute to epidural fibrosis. Reactive oxygen species (ROS) play a pivotal role in mediating NETs formation. Molecular hydrogen, recognized for its selective antioxidant properties and biosafety, emerges as a potential therapeutic gas in suppressing epidural fibrosis. In this study, we developed an in-situ hydrogen release hydrogel that inhibits the formation of NETs and mitigates epidural scarring. Biodegradable magnesium (Mg) microspheres served as a hydrogen source, coated with PLGA to regulate hydrogen release. These microspheres (Mg@PLGA) were then incorporated into a PLGA-PEG-PLGA thermosensitive hydrogel (Mg@PLGA@Gel), providing a surgical implant for sustained, long-term hydrogen release. In vitro experiments confirmed the biocompatibility of the system, demonstrating that hydrogen produced by Mg@PLGA effectively neutralizes neutrophil intracellular ROS and inhibits NETs formation. Histological analyses, including H&E staining, MRI, Masson staining, and immunohistochemistry, collectively indicate that Mg@PLGA@Gel is biocompatible and effectively inhibits epidural fibrosis post-laminectomy. Furthermore, Mg@PLGA@Gel inhibits ROS accumulation and NETs formation at the surgical site. These findings suggest that Mg@PLGA@Gel ensures continuous, therapeutic hydrogen concentration, providing relief from epidural fibrosis in a laminectomy mouse model. Statement of significance•The hydrogen-releasing hydrogel combines the therapeutic effects of a physical barrier with immunomodulation.•In situ-generated molecular hydrogen scavenges ROS caused by surgical stress and suppresses NETs formation.•The hydrogen-releasing hydrogel is demonstrated to exhibit high biocompatibility and inhibit epidural scar formation in vivo.

Prior Hypermobile Spinal Cord Stimulator Removal With Difficult Reimplantation due to Epidural Scarring Provides Relief in Postlaminectomy Syndrome

BACKGROUND: When spinal cord stimulation (SCS) therapy fails for postlaminectomy syndrome (PLS), oftentimes the device is not removed or explanted, or rarely, it is reimplanted with the hopes of success with a new implant. CASE REPORT: Our patient is a 52-year-old man with a history of PLS treated with L5-S1 discectomy who presented with refractory chronic low back pain. He underwent an initial SCS implant with significant pain relief, but was limited due to unwanted abdominal stimulations with movement and explanted 8 months later. Despite his prior experience, a second SCS was implanted but with great difficulty due to widespread epidural scarring leading to a positional headache, which self-resolved. Fortunately, the second implant provided &gt; 50% pain relief. CONCLUSIONS: Our case highlights the importance of reconsidering an SCS reimplantation which may benefit a select group of individuals, though more research is required to define this subset of patients. KEY WORDS: Hypermobile, unwanted stimulations, explant, reimplantation, spinal cord stimulator

Ligamentum Flavum Flap Technique in Lumbar Microdiscectomy.

Microdiscectomy has been the gold-standard technique for the treatment of lumbar disc herniation. A potential reason for suboptimal symptom resolution following microdiscectomy is postoperative epidural fibrosis1. Preservation of the ligamentum flavum through the use of the ligamentum flavum flap technique reduces postoperative epidural fibrosis and leads to a favorable long-term prognosis. The L5-S1 interlaminar space on the operative side is exposed with use of a standard microsurgical approach, and the level is confirmed. The ligamentum flavum is held taut with use of tooth forceps, holding onto superficial layers, and a flap with its base on the lateral side is created. Initial separation is made at the midline (where the flavum is very thin) with use of a no.-15-blade scalpel. The flap is elevated by detaching the ligamentum flavum between the lower border of the L5 lamina and sacrum with use of a 1-mm Kerrison rongeur. The detachment of the ligamentum flavum is performed carefully, preserving the attachments on the lateral border. Having a thin base allows the flap to be elevated and rotated, and the flap thus can be tucked into the muscle above the facet joint. The nerve root is retracted, and discectomy is performed according to the location and size of the disc. After achieving good hemostasis, the ligamentum flavum flap is gently rotated back to its normal position. In most cases, the flap can be returned back to its original position without any gap and without any need for suture. Closure is performed in layers. Nonoperative treatment yields good pain relief in more than 80% of patients with disc herniation. However, if surgery is required, the primary concern for the surgeon is the prevention of postoperative scarring and fibrosis around the nerve root. Previous attempts to mitigate this potential complication have revolved around the placement of a subcutaneous fat graft over the nerve root; however, no firm evidence exists to support this technique. Synthetic materials such as expanded polytetrafluoroethylene, Adcon-L gel (Wright Medical Technologies), and sodium hyaluronate have also been utilized to prevent epidural scarring; however, the ligamentum flavum is a natural biological solution. Postoperative fibrosis may occur if there is a dead space as a result of the excision of the ligamentum flavum or due to inflammation. Restoration of native tissue anatomy with use of the ligamentum flavum technique can prevent such fibrosis, as has been reported previously. In addition to reducing scar formation, preserving the ligamentum flavum can make revision surgery (which is rarely required) safer, as there is less or no epidural fibrosis or nerve root scarring. Patients undergoing this procedure have shown good improvement in the Oswestry Disability Index (ODI) and a clinically notable reduction in visual analog scale (VAS) pain scores in the immediate postoperative period as well as on long-term follow-up. The chances of epidural fibrosis have been shown to be significantly decreased over long-term follow-up. Li et al. reported substantially lower VAS and ODI scores among patients who underwent the ligamentum flavum flap technique compared with a control group, as well as a significantly lower grade of epidural fibrosis at 6 months postoperatively2. In a similar study, Özay et al. highlighted significant clinical improvement and reduced chances of postoperative epidural fibrosis in 51 patients who underwent the ligamentum flavum flap technique3. Additionally, Li et al. showed that patient age and the area of the laminar space were the 2 important factors that determine the preservation of the ligamentum flavum, as the failure rate was significantly higher in elderly patients (>43.5 years) and those with small interlaminar space (<1.95 cm2). ODI and VAS scores were substantially better, and fibrosis formation, as assessed on computed tomography (CT) scans with intravenous iopamidol injection, was significantly reduced in patients with preserved ligamentum flavum4. Properly set up the operating microscope and fluoroscopy unit in order to ensure accurate starting points.Utilize minimal cautery at all levels of dissection.Hold the ligamentum flavum taut superficially while incising with use of a no.-15 scalpel.Detach the ligamentum flavum while safely preserving the attachments on the lateral border.Perform proper repositioning of the ligamentum flavum after achieving hemostasis. ODI = Oswestry Disability IndexVAS = visual analog scaleCT = computed tomographyLF = ligamentum flapSLRT = straight leg raise testAP = anteroposteriorMRI = magnetic resonance imagingASIS = anterior superior iliac spineCSF = cerebrospinal fluid.

Evaluation of Lumbar Adhesiolysis Using a Radiofrequency Catheter During Epiduroscopy in the Treatment of Failed Back Surgery Syndrome (FBSS).

Failed back surgery syndrome (FBSS) is a complication of spinal surgery that results in severe and disabling back/leg pain. Epiduroscopy is a percutaneous minimally invasive surgical technique used in the treatment of lumbar radicular pain that enables both direct visualization of epidural adhesions in patients with FBSS and the mechanical release of fibrotic scars in the epidural space. Although the use of a balloon catheter during epiduroscopy can usually remove adhesions between the dura and the vertebrae, in the thickest areas of fibrosis, the use of a catheter with a molecular quantum resonance radiofrequency generator may resect hard epidural fibrotic obstructions. The aim of this study was to evaluate the efficacy and safety of this radiofrequency catheter in the treatment of severe epidural fibrotic scars. Ninety-three patients with FBSS were enrolled in this study. In 49 cases, a thick area of fibrosis was visualized during epiduroscopy and the use of a balloon catheter could not remove the fibrotic scars. In all of these cases, we used a molecular quantum resonance radiofrequency catheter to remove dense fibrotic areas. Intraoperatively during epiduroscopy, we could directly visualize lysis of the fibrotic scars. Immediately after the procedure and at 1-month and 6-month follow-up, the patients reported significant pain reduction. Pain reduction and patient satisfaction were also reported at 12 months in all but 5 cases. This study found a clinically relevant reduction of pain at 1 and 6 months after epiduroscopy in patients with FBSS. The use of a radiofrequency catheter is safe and effective in resection of hard and thick epidural scars.

Fulminant Cervical Epidural Hematomas: Why Do They Happen, How Can We Minimize Their Occurrence, and What Can We Do When They Do Occur? A Perspective

BACKGROUND: Epidural hematomas after appropriately performed cervicothoracic interlaminar epidural injections have been associated with the rapid onset of neurological symptoms and devastating outcomes, despite prompt identification and treatment. Anticoagulation issues were initially felt to be the problem, but the occurrence of fulminant hematomas in patients without coagulation forced a reassessment of the causes and responses to this problem. OBJECTIVES: To evaluate why fulminant epidural hematomas occur after cervicothoracic epidural injections, with a literature review to survey knowledge about them in the surgical literature, and to offer comments as to what the interventional pain physician can do to minimize their occurrence. STUDY DESIGN: A perspective piece with a literature review. SETTINGS: Interventional pain management practices. METHODS: A perspective on the issue of fulminant cervical hematomas and an associated literature review. RESULTS: Anatomical studies show that there are no meaningful arteries in the posterior epidural spaces which would explain hematomas. There is a dense posterior intravertebral epidural venous plexus at C1 and also at C6-C7 extending caudally to the upper thoracic region. A venous origin has been questioned because venous pressure was felt to be too low to explain the bleeding. The surgical literature, going back 80 years, contains numerous reports of engorged epidural veins causing radiculopathy and myelopathy. These engorged veins can occur in the presence or absence of spinal pathology. There is no known means of reliably identifying these engorged veins; they have been mistaken for disc protrusions. At least one report documents massive bleeding from these veins. Studies done on a feline model of cervical stenosis suggest that the epidural pressure can reach arterial levels. LIMITATIONS: No direct documentation of arterialized posterior intravertebral epidural venous pressures has been made. While anatomical anomalies and degeneration contribute to epidural scarring, we do not have a full understanding as to the cause of arterialization of veins, particularly in younger patients with no obvious intraspinal pathology. CONCLUSION: Fulminant cervicothoracic epidural hematomas after an epidural injection appear to arise from the unintentional and unavoidable puncture of arterialized veins with sharp needles. A technique to open a path out from the foramen so that the blood can escape is described. Alternatively, providers should consider injecting more cephalad, between C2-C3 and C6-C7 in the cervical spine, or an alternative procedure, such as a selective nerve root injection. A cervical transforaminal approach should only be attempted with a blunt needle, which cannot enter an artery. Should symptoms occur, cervical flexion rotation maneuvers should be implemented while awaiting prompt transfer to a facility where an appropriate diagnosis and treatment can be provided. KEY WORDS: Cervical epidural hematoma, cervical epidural injection, posterior intravertebral venous plexus, arterialized epidural veins, pressurized epidural veins

A Clinical Study on Functional Outcome of Percutaneous Transforaminal Endoscopic Discectomy under Local Anesthesia

Abstract Background: Many surgical approaches from conventional open discectomy, microdiscectomy, percutaneous endoscopic interlaminar discectomy, and transforaminal endoscopic discectomy have been used for the treatment of prolapsed intervertebral disc. Transforaminal endoscopic discectomy through a Kambin’s triangle is a minimally invasive procedure which can be done under local anesthesia, without muscle splitting, with short hospital stay and minimal complications compared to other techniques used. Aim: The aim of this study was to evaluate the functional outcomes following percutaneous transforaminal endoscopic discectomy (PTED) under local anesthesia for lumbar disc herniations. Materials and Methods: This interventional study was conducted between November 2020 and October 2021 in our Orthopaedics Department after the clearance of the Ethical Committee. This study included 54 patients with radicular pain for at least 3 weeks with a positive nerve root compression sign and who underwent PTED under local anesthesia. The Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) have been used for pre- and postoperative clinical assessment of the patients, and follow-up was done at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Results: Maximum patients were in the age group of 61–70 years, and 65.2% of the patients were male. 68.2% of patients had lumbar disc herniation at L4-L5 level. The mean operative time of PTED was 70.6 min. Out of 16 cases of L5-S1 disc prolapse, 1 case was operated by making an iliac bone window due to the inaccessibility of disc space because of highly placed iliac crest. The mean preoperative VAS and ODI scores were 8.1 and 56.6, respectively. The postoperative VAS and ODI scores were dramatically improved at each follow-up interval (P &lt; 0.0001). Out of 66 patients who underwent operation, 4 patients developed surgical site infection and 2 were found to have dysesthesia, and no serious complications were noted. Conclusion: PTED has been shown to be a safe, effective, and minimally invasive alternative for the treatment of lumbar disc herniation. PTED found to be favorable because it had a shorter operational time and less epidural scarring, allowing for simple revision procedures as needed. As a result, this points to a greater acceptability of endoscopic procedures and their possible widespread use in the future.

MicroRNA-29a Mitigates Laminectomy-Induced Spinal Epidural Fibrosis and Gait Dysregulation by Repressing TGF-β1 and IL-6.

Spinal epidural fibrosis is one of the typical features attributable to failed back surgery syndrome, with excessive scar development in the dura and nerve roots. The microRNA-29 family (miR-29s) has been found to act as a fibrogenesis-inhibitory factor that reduces fibrotic matrix overproduction in various tissues. However, the mechanistic basis of miRNA-29a underlying the overabundant fibrotic matrix synthesis in spinal epidural scars post-laminectomy remained elusive. This study revealed that miR-29a attenuated lumbar laminectomy-induced fibrogenic activity, and epidural fibrotic matrix formation was significantly lessened in the transgenic mice (miR-29aTg) as compared with wild-type mice (WT). Moreover, miR-29aTg limits laminectomy-induced damage and has also been demonstrated to detect walking patterns, footprint distribution, and moving activity. Immunohistochemistry staining of epidural tissue showed that miR-29aTg was a remarkably weak signal of IL-6, TGF-β1, and DNA methyltransferase marker, Dnmt3b, compared to the wild-type mice. Taken together, these results have further strengthened the evidence that miR-29a epigenetic regulation reduces fibrotic matrix formation and spinal epidural fibrotic activity in surgery scars to preserve the integrity of the spinal cord core. This study elucidates and highlights the molecular mechanisms that reduce the incidence of spinal epidural fibrosis, eliminating the risk of gait abnormalities and pain associated with laminectomy.

Full endoscopic spine surgery

BackgroundWith a dramatic increase in elderly population worldwide, the prevalence of degenerative spine disease is steadily rising. Even though the entire spinal column is affected the problem is more commonly seen in the lumbar, cervical spine and to some extent the thoracic spine. The treatment of symptomatic lumbar disc or stenosis is primarily conservative with analgesics, epidural steroids and physiotherapy. Surgery is advised only if conservative treatment is ineffective. Conventional open microscopic procedures even though are still a gold standard, have the disadvantages of excessive muscle damage and bone resection, epidural scarring along with prolonged hospital stay and increased need of postoperative analgesics. Minimal access spine surgeries minimize surgical access related injury by minimizing soft tissue and muscle damage and also bony resection thus preventing iatrogenic instability and unnecessary fusions. This leads to good functional preservation of the spine and enhances early postoperative recovery and early return to work. Full endoscopic spine surgeries are one of the more sophisticated and advanced form of MIS surgeries. PurposeFull endoscopy has definitive benefits over conventional microsurgical techniques. These include better and clear vision of the pathology due to presence of irrigation fluid channel, minimal soft tissue and bone trauma, better and relatively easy approach to deep seated pathologies like thoracic disc herniations and a possibility to avoid fusion surgeries. The purpose of this article is to describe these benefits, give an overview of the two main approaches - transforaminal and interlaminar, their indications, contraindications and their limitations. The article also describes about the challenges in overcoming the learning curve and its future prospectives. ConclusionFull endoscopic spine surgery is one of the fastest growing technique in the field of modern spine surgery. Better intraoperative visualization of the pathology, lesser incidence of complications, faster recovery time, less postoperative pain, better relief of symptoms and early return to activity are the main reasons behind this rapid growth. With better patient outcomes and reduced medical costs, the procedure is going to be more accepted, relevant and popular procedure in future.

The Role and Future of Endoscopic Spine Surgery: A Narrative Review.

Many types of surgeries are changing from conventional to minimally invasive techniques. Techniques in spine surgery have also changed, with endoscopic spine surgery (ESS) becoming a major surgical technique. Although ESS has advantages such as less soft tissue dissection and normal structure damage, reduced blood loss, less epidural scarring, reduced hospital stay, and earlier functional recovery, it is not possible to replace all spine surgery techniques with ESS. ESS was first used for discectomy in the lumbar spine, but the range of ESS has expanded to cover the entire spine, including the cervical and thoracic spine. With improvements in ESS instruments (optics, endoscope, endoscopic drill and shaver, irrigation pump, and multiportal endoscopic), limitations of ESS have gradually decreased, and it is possible to apply ESS to more spine pathologies. ESS currently incorporates new technologies, such as navigation, augmented and virtual reality, robotics, and 3-dimentional and ultraresolution visualization, to innovate and improve outcomes. In this article, we review the history and current status of ESS, and discuss future goals and possibilities for ESS through comparisons with conventional surgical techniques.

Paddle-Lead Spinal-Cord Stimulation Surgeries for Chronic Neuropathic Pain: A Single Surgeon Case-Series Outcome Analysis in Indian Population.

Background Spinal-cord stimulation (SCS) for relief of chronic neuropathic pain is well established. Objective The inherent limitations with conventional percutaneous lead SCS are lead migration, positional variations in stimulation, as well as possible nonreplication of benefits after permanent SCS implantation, which were experienced during a positive trial period. To circumvent these limitations, we analyzed five consecutive cases of chronic intractable neuropathic pain who underwent direct SCS paddle lead placement during the trial period for pain relief. In addition, during the process of placing a permanent paddle lead, the impediment created by prior epidural scarring in such chronic patients can be obviated mechanically thereby increasing the efficacy of the procedure. Material and Methods The demographic details, diagnosis, preoperative visual analogue scale score (VAS), and follow-up VAS were recorded. Surgical procedure consisted of a standard dorsal laminotomy followed by placement of permanent paddle leads. Results All patients reported significant improvement in their VAS scores. Mean duration of follow-up was 23.6 months (9-35 months). Mean preoperative VAS was 9.4 and 1.4 at the last follow-up. No major complications were found. Conclusion With careful patient selection and appropriate surgical strategy, it was possible to implant permanent paddle leads during SCS trial itself in our five patients thereby replicating and sustaining the trial period pain relief. We argue that this can be a new cost-effective and reliable technique for the placement of SCS leads achieving excellent and sustained pain relief.

Intra-arterial injection of particulate corticosteroids: mechanism of injury.

Mechanism of neurologic complications after epidural spinal injections (ESI) of particulate steroids at the cervical spine include intrathecal injection, epidural hematoma, direct spinal cord injury, and brain stem or cord infarction due to an arterial spasm or inadvertent intra-arterial injection of particulate steroids. At the lumbar spine, there is evidence that a spinal cord infarction secondary to an inadvertent intra-arterial injection of particulate steroids through a transforaminal approach is the leading mechanism.Variations in the arterial supply of the spinal cord help to understand how a lumbar ESI may lead to a spinal cord infarction at the thoracic level. A radiculomedullary artery arising from the lumbar or sacral spine may participate to the supply of the spinal cord. All radicular and radiculomedullary arteries penetrate the spinal canal through the intervertebral foramen. Therefore, its catheterization carries a risk of inadvertent intraarterial injection. An ex vivo animal study has shown that particulate steroids injected in the blood stream produce an immediate and unexpected change of red blood cells into spiculated cells which aggregate and cause arterioles obstruction, while no particulate steroid macroaggregates or vascular spasm were observed. Rare instances of neurologic complications also occurred after ESI performed through a posterior approach. All occurred in previously operated on patients suggesting a pathologic role for the epidural scar.

Percutaneous endoscopic lumbar discectomy via the medial foraminal and interlaminar approaches: A comparative study with 2-year follow-up.

The purpose of this study was to analyze the clinical effect of percutaneous endoscopic medial foraminal discectomy (PEMFD) in the treatment of lumbar disc herniation (LDH). We retrospectively examined and compared clinical data from 39 single-level LDH patients who underwent PEID and 47 who underwent PEMFD. All the patients were diagnosed with single-level LDH and were treated in Xuzhou Central Hospital for single-segmental lumbar disc herniation between June 2017 and December 2019. Collect and count surgical-related indicators, intraoperative bleeding volume and 24-hour postoperative drainage volume, lower extremity numbness Visual Analogue Scale (VAS), the pain VAS and lumbar Oswestry Disability Index (ODI) scores. Intraoperative bleeding volume and 24-hour postoperative drainage volume were significantly lower in the PEMFD group (p < 0.05). Operation time and length of hospital stay did not significantly differ between the groups. Transient spinal cord injury and surgical site infection did not occur. Recurrence occurred in two patients in each group. Repeat surgery in these patients demonstrated remarkable epidural scarring in the PEID group patients; no scarring was evident in the PEMFD group patients. The numbness VAS score 72 h after surgery and the pain VAS and ODI scores 1 month after surgery significantly differed between groups; however, pain VAS and ODI scores 6, 12, and 24 months after surgery did not. At last follow-up, the modified MacNab criteria outcome did not significantly differ between the groups. PEMFD and PEID have similar short- and medium-term outcomes. However, PEMFD has several advantages: simplicity, lower bleeding volume, and preservation of the LF.

PO146 / #1032 ENDOSCOPIC LATERAL APPROACH FOR DORSAL ROOT GANGLION BURST STIMULATION AFTER FAILED SPINAL CORD STIMULATION – PROSPECTIVE COHORT STUDY: E-POSTER VIEWING

Traditional dorsal root ganglion stimulation is an established therapy option in cases of monoradicular pain which is one of the most common conditions in spine clinics and patients with persistent spinal pain syndrome type II, i. e. after spinal surgery. However, due to epidural scarring its application remains not recommended. Recently, we presented a technical note depicting the endoscopic placement of cylindrical leads for dorsal root ganglion stimulation via a lateral approach. Here we present data of a prospective cohort study.

Manual therapy interventions in the management of adults with prior cervical spine surgery for degenerative conditions: a scoping review

ObjectiveCervical spine surgeries for degenerative conditions are rapidly increasing. Cervical post-surgery syndrome consisting of chronic pain, adjacent segment disease, recurrent disc herniation, facet joint pain, and/or epidural scarring is common. Repeat surgery is regularly recommended, though patients are often unable to undergo or decline further surgery. Manual therapy is included in clinical practice guidelines for neck pain and related disorders, however clinical guidance for utilization of manual therapy in adults with prior cervical spine surgery is lacking. This study aimed to synthesize available literature and characterize outcomes and adverse events for manual therapy interventions in adults with prior cervical spine surgery due to degenerative conditions.MethodsPreferred reporting items for systematic reviews and meta-analyses extension for scoping reviews was followed. PubMed, Cumulative Index of Nursing and Allied Health Literature, physiotherapy evidence database, and Index to Chiropractic Literature were searched from inception through October 2021. English-language literature comprised of randomized clinical trials (RCT), case–control, cohort, and case report designs were included. Adults undergoing manual therapy, with or without combination of other interventions, with prior cervical spine surgery due to degenerative conditions were included.ResultsTwelve articles were identified, including 10 case reports, 1 low-quality RCT, and 1 acceptable-quality RCT. Eight case reports described 9 patients with history of fusion surgery. Two case reports described 2 patients with history of discectomy. One case report described one patient with separate operations of a discectomy at one level and a fusion at another level. One case report described 2 patients with history of cervical disc replacement surgery. The two RCTs included 63 and 86 participants, respectively. Use of manual joint mobilization/manipulation, table/instrument assisted mobilization/manipulation, and multimodal interventions were described in eligible studies. Favorable clinical outcomes were reported in 10 studies. Six case reports/series involving 8 patients described use of unclassified forms of manual therapy. Eight studies described the use of multimodal interventions along with manual therapy. One study described high patient satisfaction. Two studies, accounting for 3 patients, reported serious adverse events.ConclusionsThere is a lack of literature informing evidence related to clinical outcomes, patient satisfaction, and adverse events associated with manual therapy for patients with prior cervical spine surgery due to degenerative conditions. High-quality studies of higher-level hierarchical study design are needed to understand the clinical utility and safety profile of manual therapy for this population.

Endoscopic Lateral Approach for Dorsal Root Ganglion Burst Stimulation: Technical Note and Illustrative Case Series

IntroductionDorsal root ganglion (DRG) stimulation demonstrated superiority over traditional spinal cord stimulation with better pain relief and greater improvement of quality of life. However, leads specifically designed for DRG stimulation are difficult to implant in patients who previously underwent spinal surgery and show epidural scarring at the desired site of implantation because of the reduced stiffness of the lead. Nevertheless, recurrent leg or arm pain after spinal surgery usually manifests as a single level radiculopathy, which should theoretically be amenable to DRG stimulation. Materials and MethodsWe present the percutaneous transforaminal placement of cylindrical leads through a lateral endoscopic approach for DRG stimulation in burst mode. ResultsWe could successfully show that percutaneous transforaminal lead placement is feasible in three illustrative cases. ConclusionThis technical note combines two innovations, one linked to the other. The first innovation involves a novel endoscopic lateral transforaminal approach to insert a cylindrical lead to the DRG. Because this electrode is compatible with burst stimulation-enabled devices, a second innovation consists of the application of burst stimulation on the DRG.

LncRNA-COX2 inhibits Fibroblast Activation and Epidural Fibrosis by Targeting EGR1.

Rationale: Epidural fibrosis is one of the contributors to failed back surgery syndrome (FBSS) with a high incidence of about 80,000 cases per year. The fibrosis spreads from the operative region to the dura mater or the nerve root and results in functional incapacity and pain after laminectomy. Our previous study showed that down-regulation of lncRNA-COX2 is involved in the epidural scar formation. However, it remains unknown whether lncRNA-COX2 participate in the fibroblast activation and epidural fibrogenesis.Methods: LncRNA-COX2 and EGR1 expression were assessed by qRT-PCR and western blotting. Fibroblasts differentiation, proliferation and migration was determined by Collagen I/ɑ-SMA, 5-ethynyl-2'-deoxyuridine (EdU) and Transwell Assay respectively. Luciferase reporter assay was performed for the verification of target of LncRNA-COX2. Laminectomy was performed to establish the model of epidural fibrosis in mice. Epidural scar was evaluated by hematoxylin and eosin (HE) staining and Masson Trichrome staining.Results: Based on the result of transcriptome profiling, we found LncRNA-COX2 was significantly decreased in epidural tissues after laminectomy and in activated fibrotic fibroblasts. In vitro, overexpression of LncRNA-COX2 suppressed epidural fibrogenesis by inhibiting fibroblasts differentiation, proliferation and migration. Mechanistically, LncRNA-COX2 functioned as competing endogenous RNA (ceRNA) of EGR1. Gain of LncRNA-COX2 significantly decreased the expression of EGR1 and showed anti-fibrotic effect while EGR1 was markedly increased after loss of LncRNA-COX2. In vivo, LncRNA-COX2 attenuated laminectomy-induced epidural fibrosis in mice.Conclusion: In summary, the results demonstrated that LncRNA-COX2 showed anti-fibrotic effect by targeting EGR1 and identified LncRNA-COX2 as therapeutic molecule for preventing aberrant epidural fibrosis.

Repair of dural defects with electrospun bacterial cellulose membranes in a rabbit experimental model.

To evaluate the advantages and mechanisms involved in repairing rabbit dural defect with a novel electrospun bacterial cellulose (EBC) membrane, a series of experiments were carried out in vitro and in vivo. Compared with common bacterial cellulose (BC) membrane, a more dispersed and regular fiber structure and a better porosity and water holding capacity were found in the EBC membrane, which also had superior degradability. However, the biomechanical properties were slightly decreased. The results demonstrated that BC and EBC membranes had little effect on proliferation and apoptosis of mouse fibroblast cells. There were no complications such as infection, cerebrospinal fluid leakage, epilepsy and brain swelling after BC and EBC membrane repairs in rabbit models. Using real-time quantitative polymerase chain reaction (RT-qPCR) and western blot, the early inflammatory reactions in the EBC group were shown to be lower than in the BC group, and were close to the autologous dura mater group. Histological observations and western blot revealed more collagen fibers evenly distributed on the outer side of EBC membranes than in the BC and unpatched groups, and fewer brain tissue adhesions and epidural scars were found in the EBC group. Compared with common BC membrane, the EBC membrane had better biophysical properties and biocompatibility. It is expected to be a suitable alternative material for the repair of damaged dura mater.

Full endoscopic interlaminar discectomy (FEID) for recurrent lumbar disc herniation: surgical technique, clinical outcome, and prognostic factors.

The objective of this study is to determine the effectiveness and prognostic factors of revisional full endoscopic interlaminar discectomy (FEID) for recurrent herniation after conventional open disc surgery. The major concerns of the repeated discectomy for recurrent lumbar disc herniation (RLDH) are the epidural scar and postoperative segmental instability. Compared to open discectomy, endoscopic method has advantages of less tissue traumatization, clearer visualization and better tissue identification. With the improvement of endoscopic technique and instrument, the problems related to adhesive scar tissues or postoperative instability could be overcome. From June 2014 to December 2016, FEID was performed in consecutive 24 patients for RLDH. The age ranged from 25 to 60 years (mean 44.6 years). The level operated was L5-S1 in 16 cases and L4-5 in 8 cases. To avoid injury to the neural tissue, we started with the bony structure. A small part of facet or lamina might be resected in severe stenotic or adhesive condition. Aggressive separation of the scar from the neural tissue might lead to dural tear and should be avoided. The herniated disc material was removed after neural tissue had been clearly identified and protected. The follow-up period was at least 24 months. The visual analog scale (VAS) for leg pain and back pain, and Oswestry disability index (ODI) showed significant improvement after treatment. Excellent or good outcome by the modified Macnab's criteria was obtained in 22 of 24 patients at two years follow-up. Excellent outcome was noted in 100 percent patients younger than 50 years. Small durotomy occurred in 2 patients and no visible cerebrospinal fluid (CSF) leakage was detected despite repair was not performed. Two additional surgery was performed including one repeated FEID for re-recurrence of disc herniation and one fusion surgery for postoperative back pain. FEID is a safe and effective alternative for recurrent disc herniation. The successful rate was greater than 90 percent, especially in the younger patients with the advantages of early recovery and no need for fusion.

Flipped Reposition Laminoplasty for Excision of Intradural Extramedullary Tumors in the Thoracolumbar Spine: A Case Series of 14 Patients.

Study DesignA retrospective study was done to assess the outcome of the new technique of flipped reposition laminoplasty for excision of intradural extramedullary (IDEM) spinal tumors of the thoracolumbar region.PurposeTo describe flipped reposition laminoplasty technique and evaluate its outcomes. Overview of LiteratureLaminectomy has been the conventional approach for the surgical excision of IDEM spinal tumors, but it has potential postoperative complications. Laminoplasty maintains the posterior arch of the spine and avoids complications seen in Laminectomy, such as instability, epidural scarring, and kyphotic deformity.MethodsFourteen patients (nine females and five males) diagnosed with IDEM tumors of the thoracolumbar region operated between 2016 and 2018 were included in this study. Pathologically, five cases were schwannomas; four cases were meningiomas; two cases were ependymomas; and one case each was lymphoma, neurofibroma, and teratoma. All patients had their neurological deficits documented using the American Spinal Injury Association (ASIA) impairment scale. After completion of all preanesthetic formalities, the patients were operated upon by a single surgeon using the flipped reposition laminoplasty technique. Follow-up was done at 1, 3, 6, and 12 months post operation and yearly thereafter.ResultsThe mean age of the patients was 35.28 years (14–65 years), and the mean follow-up duration was 17 months (6–26 months). Two patients were assessed with ASIA grade A neurology, one patient improved to ASIA grade B, whereas the other did not improve. Two patients improved from ASIA grade B to ASIA grade D, and seven patients with ASIA grades C and D improved to ASIA grade E. Fusion at the osteotomy site was seen in 92.85% (13 out of 14) cases on one side within 6 months post operation. Fusion was seen in all the cases within 1 year post operation.Conclusions Flipped reposition laminoplasty is an excellent technique providing adequate exposure and additional stability postoperatively.