Junior Journal Club Peridural Fibrosis

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Junior Journal ClubPeridural Fibrosis

• Jens François
• BSS
• Gent, 1.03.2008

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European Spine Journal

• Preventing peridural fibrosis with nonsteroidal
  anti-inflammatory drugs
• Manuel A. Sandoval Daniel Hernandez-Vaquero
• E-pub january 2008

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Introduction

• Peridural fibrosis formation of extradural
  fibrous tissue, which produces an adherence of
  the dura mater and the nerve roots to the erector
  muscles of the spinal column in the posterior
  part and to the disc and vertebral body in the
  anterior part.
• This scar formation may be compressive and at the
  same time restricts the mobility of the nerve
  root that is most vulnerable against new discal
  protrusions and favors the presence of a stenosis
  of the neural canal.
• Peridural fibrosis originates from the bleeding
  surface of the deep layer of the posterior
  paravertebral muscles.
• LaRocca H, MacNab I (1974) The laminectomy
  membrane studies in its evolution,
  characteristics, effects and prophylaxis in dogs.
  J Bone Joint Surg 56B545550

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Introduction

• Established peridural fibrosis
• clinical relevance ???
• no effective treatment known
• Ceviz A, Arslan A, Ak HE, Inaloz S (1997) The
  effect of urokinase in preventing the formation
  of epidural fibrosis and/or leptomeningeal
  arachnoiditis. Surg Neurol 47124127
• symptomatic analgesics, NSAID, fysiotherapy
• surgery ???
• Kuivila TE, Berry JL, Bell GR, Steffee AD (1988)
  Heparinized materials for control of the
  formation of the laminectomy membrane in
  experimental laminectomies in dogs. Clin Orthop
  Relat Res 236166174
• Senegas J, Vital JM, Riojas A, Richard O, Caille
  JM (1988) Diagnosis of recurrent herniated disk
  using discographic scanning. Rev Chir Orthop
  Reparatrice Appar Mot 74(Suppl 2)9194

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Introduction

• Established peridural fibrosis
• surgery
• LaRocca H, MacNab I (1974) The laminectomy
  membrane studies in its evolution,
  characteristics, effects and prophylaxis in dogs.
  J Bone Joint Surg 56B545550
• MacKay MA, Fischgrund JS, Herkowitz HN et al
  (1995) The effect of interposition membrane on
  the outcome of lumbar laminectomy and discectomy.
  Spine 2017931796
• Robertson JT, Meric AL, Dohan Jr FC et al (1993)
  The reduction of postlaminectomy peridural
  fibrosis in rabbits by a carbohydrate polymer. J
  Neurosurg 798995
• Best treatment prevention of formation
• meticulous surgical technique
• careful hemostasis
• placement of barriers physical and/or chemical

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Materials Methods

• Aceclofenac
• Air-Tal, Biofenac
• systemic chemical barrier
• no foreign bodies
• 24 New Zealand white (NZW) rabbits
• all L4 laminectomie
• 12 im injection of 5 mg/kg/day aceclofenac for 7
  days
• 12 im injection physiological saline for 7 days
• animals sacrificed at 2 weeks and 4 weeks ( 4
  groups of 6 animals)
• blinded histological examination dural
  adherences, fibrous area, n fibroblasts, n
  inflammatory cells

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Results fibrous area
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Results fibroblasts
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Results inflammatory cells
same type of inflammatory cells in all groups
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Results dural adherences
less adherences in the study group significantly
less adherences grade 3 (gt 66 dural surface
area) in study group at 2 weeks
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Discussion

• Different barriers have been proposed ever since
  the first description of peridural fibrosis.
• Purpose impede migration of fibroblasts from
  musculature to (para)neural tissues.
• Recently
• expandable polytetrafluroethylene membrane
  (ePTFE)
• ADCON-L (bioresorbable gelatin and polyglycan
  gel)
• Complications !
• epidural fat necrosis, atrophy, cauda
  compression
• hemostatic gelfoam monoradicular paralysis
• ADCON-L CSF leak from microscopic dural
  lacerations
• Prospective studies no benefit from physical
  barriers !
• Chemical barriers (corticoids, activators of
  tissue plasminogen, mitomycin C, urokinase and
  elastase) are no longer used

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Conclusion

• NSAIDs are probably safer than physical and/or
  chemical barriers
• Aceclofenac seems effective
• However
• is peridural fibrosis an issue at all ?
• what about extensive decompressions and fusion
  procedures ?
• NSAID inhibit fusion process and lower fusion
  rates
• Questions
• Who thinks peridural fibrosis may be clinically
  relevant in discectomy/laminectomy/fusion
  procedures ?
• Does anyone actually use any modality to prevent
  peridural fibrosis ?
• Has anyone seen any adverse effects of these
  treatments ?