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epidural_fibrosis

Epidural fibrosis

Postoperative epidural fibrosis (PEF) localized around the exposed dura and nerve roots is a known radiologic entity seen after lumbar spine surgery. Although excessive PEF is associated with residual and new lumbar pain and radiculopathy, its role as the generator of the pain is still discussed. Various materials acting as an adhesion barrier have been tested. There is no undebated class I evidence that any one of them is suitable to reduce or avoid PEF and provide a better clinical outcome.

Dural fibrosis and epidural adhesion after laminectomy are developed from adjacent dense scar tissue, which is a natural wound healing process 1) 2) 3) 4). , and ranked as the major contributor for postoperative pain recurrence after laminectomy or discectomy, and has been implicated as an important cause of failed back surgery syndrome.

The epidural hyperplasia can extend to the spinal canal and adhere to the dura and nerve root, which lead to the periodic recurrent symptoms including radicular pain 5) 6) 7) 8) 9).

At the same time, dural fibrosis made the risk of nerve root injury, dural laceration and Iatrogenic injury greatly improved, which challenging doctors for exploring the operation technology 10) 11) 12).

Although the epidural scar tissue adhesion can be removed and the adhered nerve root can also be released, but this need second operation 13) 14) 15).

A reoperation on the scar can produce more scarring 16) 17).

Prevention

Researchers tried to reduce scar formation through various operation techniques such as minimally invasive discectomy, application of local anti-inflammatory drugs, but the effects of these methods were not uniform 18) 19) 20) 21) 22).

A study has clearly demonstrated the fact that the use of suction drainage alone or combined with only fat grafts, fats grafts and local steroids application, or only local steroids application significantly improved patient outcome with respect to pain relief and functional outcome and significantly reduced EF as measured by an MRI 23).


Recently, CCN5 exhibited an inhibitory effect on connective tissue growth factor (CTGF)/CCN2 (a critical regulator for fibrotic disease)‑mediated fibrogenesis. However, its function in epidural fibrosis and the underlying mechanisms involved remain to be determined. In this study, an obvious downregulation of CCN5 was observed in scar tissues from laminectomized rats, concomitant with a marked upregulation of CCN2, suggesting a potential negative regulatory role of CCN5 in fibrogenesis. Furthermore, CCN5 overexpression notably mitigated transforming growth factor‑β1-enhanced fibroblast viability and proliferation. Of note, CCN5 upregulation inhibited the switch of fibroblasts into myofibroblasts as its overexpression abrogated the expression of the myofibroblast marker, α-smooth muscle actin (α-SMA). CCN5 upregulation also reduced an increase in collagen type I, α1 (COL1A1) and total collagen concentrations. Additionally, CCN5 over-expression decreased CCN2 expression and increased Smad6 phosphorylation. Mechanism analysis revealed that blocking Smad6 signaling significantly ameliorated the inhibitory effect of CCN5 on the CCN2 levels, accompanied by the reduction in cell proliferation and collagen production. These results confirm that CCN5 exerts an anti-fibrotic function by regulating the Smad6-CCN2 pathway, thereby indicating a potential approach for ameliorating epidural fibrosis after laminectomy 24).

Treatment

Epiduroscopic laser neural decompression (ELND) provides a new view of the epidural space as well as an alternative treatment for a herniated disc and epidural fibrosis.

1)
Alkalay RN, Kim DH, Urry DW, Xu J, Parker TM, Glazer PA. Prevention of postlaminectomy epidural fibrosis using bioelastic materials. Spine (Phila Pa 1976) 2003;28:1659–1665.
2)
Hsu CJ, Chou WY, Teng HP, Chang WN, Chou YJ. Coralline hydroxyapatite and laminectomy-derived bone as adjuvant graft material for lumbar posterolateral fusion. J Neurosurg Spine. 2005;3:271–275.
3)
Temel SG, Ozturk C, Temiz A, Ersozlu S, Aydinli U. A new material for prevention of epidural fibrosis after laminectomy: oxidized regenerated cellulose (interceed), an absorbable barrier. J Spinal Disord Tech. 2006;19:270–275.
4)
Yu CH, Lee JH, Baek HR, Nam H. The effectiveness of poloxamer 407-based new anti-adhesive material in a laminectomy model in rats. Eur Spine J. 2012;21:971–979.
5)
Yakovlev AE, Resch BE. Treatment of multifocal pain with spinal cord stimulation. Neuromodulation. 2012;15:210–213. discussion 213.
6)
Seo DH, Yoon KW, Lee SK, Kim YJ. Microsurgical excision of symptomatic sacral perineurial cyst with sacral recapping laminectomy: a case report in technical aspects. J Korean Neurosurg Soc. 2014;55:110–113.
7)
Bartynski WS, Petropoulou KA. The MR imaging features and clinical correlates in low back pain-related syndromes. Magn Reson Imaging Clin N Am. 2007;15:137–154. v.
8)
Liu J, Ni B, Zhu L, Yang J, Cao X, Zhou W. Mitomycin C-polyethylene glycol controlled-release film inhibits collagen secretion and induces apoptosis of fibroblasts in the early wound of a postlaminectomy rat model. Spine J. 2010;10:441–447.
9)
Sizer PS Jr, Phelps V, Dedrick G, Matthijs O. Differential diagnosis and management of spinal nerve root-related pain. Pain Pract. 2002;2:98–121.
10)
Brzezicki G, Jankowski R, Blok T, Klimczak A, Szymas J, Huber J, Szukala A, Siemionow M, Nowak S. Postlaminectomy osteopontin expression and associated neurophysiological findings in rat peridural scar model. Spine (Phila Pa 1976) 2011;36:378–385.
11)
Su C, Yao C, Lu S, Zhang A, Cao X, Teng G, Zang F. Study on the optimal concentration of topical mitomycin-C in preventing postlaminectomy epidural adhesion. Eur J Pharmacol. 2010;640:63–67.
12)
Yakovlev AE, Timchenko AA, Parmentier AM. Spinal cord stimulation and sacral nerve stimulation for postlaminectomy syndrome with significant low back pain. Neuromodulation. 2014;17:763–5.
13)
Rigoard P, Jacques L, Delmotte A, Poon K, Munson R, Monlezun O, Roulaud M, Prevost A, Guetarni F, Bataille B, Kumar K. An Algorithmic Programming Approach for Back Pain Symptoms in Failed Back Surgery Syndrome Using Spinal Cord Stimulation with a Multicolumn Surgically Implanted Epidural Lead: A Multicenter International Prospective Study. Pain Pract. 2015;15:195–207.
14)
Rahimzadeh P, Sharma V, Imani F, Faiz HR, Ghodraty MR, Nikzad-Jamnani AR, Nader ND. Adjuvant hyaluronidase to epidural steroid improves the quality of analgesia in failed back surgery syndrome: a prospective randomized clinical trial. Pain Physician. 2014;17:E75–82.
15)
Kim SB, Lee KW, Lee JH, Kim MA, An BW. The effect of hyaluronidase in interlaminar lumbar epidural injection for failed back surgery syndrome. Ann Rehabil Med. 2012;36:466–473.
16)
Jinkins JR, Osborn AG, Garrett D, Jr, Hunt S, Story JL. Spinal nerve enhancement with Gd-DTPA: MR correlation with the postoperative lumbosacral spine. AJNR Am J Neuroradiol. 1993;14:383–394.
17)
LaRocca H, Macnab I. The laminectomy membrane. Studies in its evolution, characteristics, effects and prophylaxis in dogs. J Bone Joint Surg Br. 1974;56B:545–550.
18)
Bolat E, Kocamaz E, Kulahcilar Z, Yilmaz A, Topcu A, Ozdemir M, Coskun ME. Investigation of efficacy of mitomycin-C, sodium hyaluronate and human amniotic fluid in preventing epidural fibrosis and adhesion using a rat laminectomy model. Asian Spine J. 2013;7:253–259.
19)
Yan L, Li X, Wang J, Sun Y, Wang D, Gu J, He J, Hu H, Chen G, Wang Q, Feng X. Immunomodulatory effectiveness of tacrolimus in preventing epidural scar adhesion after laminectomy in rat model. Eur J Pharmacol. 2013;699:194–199.
20)
Preul MC, Campbell PK, Garlick DS, Spetzler RF. Application of a new hydrogel dural sealant that reduces epidural adhesion formation: evaluation in a large animal laminectomy model. J Neurosurg Spine. 2010;12:381–390.
21)
Sun Y, Wang L, Sun S, Liu B, Wu N, Cao X. The effect of 10-hydroxycamptothecine in preventing fibroblast proliferation and epidural scar adhesion after laminectomy in rats. Eur J Pharmacol. 2008;593:44–48.
22)
Liu LM, Song YM, Duan H, Ding YL, Lu B. Effect of polylactic acid glue in preventing epidural scar adhesion after laminectomy in rabbits. Chin J Traumatol. 2006;9:146–151.
23)
Mohi Eldin MM, Abdel Razek NM. Epidural Fibrosis after Lumbar Disc Surgery: Prevention and Outcome Evaluation. Asian Spine J. 2015 Jun;9(3):370-85. doi: 10.4184/asj.2015.9.3.370. Epub 2015 Jun 8. PubMed PMID: 26097652; PubMed Central PMCID: PMC4472585.
24)
Xu H, Liu C, Sun Z, Guo X, Zhang Y, Liu M, Li P. CCN5 attenuates profibrotic phenotypes of fibroblasts through the Smad6-CCN2 pathway: Potential role in epidural fibrosis. Int J Mol Med. 2015 Apr 21. doi: 10.3892/ijmm.2015.2190. [Epub ahead of print] PubMed PMID: 25901787.
epidural_fibrosis.txt · Last modified: 2017/05/25 13:34 by administrador