Epidural Fibrosis after Lumbar Disc Surgery: Prevention and Outcome Evaluation

STUDY DESIGN: This is a prospective, randomized, controlled study designed and conducted over 10 years from 2002 to 2012. PURPOSE: The study aimed to monitor the effect of suction drains (SD) on the incidence of epidural fibrosis (EF) and to test, if the use of SD alone, SD with local steroids application, SD combined with fat grafts and local steroids application, or SD combined with fat grafts and without local steroids application, would improve outcome. OVERVIEW OF LITERATURE: EF contributes to significant unsatisfactory failed-back syndrome. Efforts have been tried to reduce postoperative EF, but none were ideal. METHODS: Between September 2002 and 2012, 290 patients with symptomatic unilateral or bilateral, single-level lumbar disc herniation were included in the study. Two groups were included, with 165 patients in group I (intervention group) and 125 patients in group II (control group). Group I was subdivided into four subgroups: group Ia (SD alone), group Ib (SD+fat graft), group Ic (SD+local steroids), and group Id (SD+fat graft+local steroids). RESULTS: The use of SD alone or combined with only fat grafts, fats grafts and local steroids application, or only local steroids application significantly improved patient outcome and significantly reduced EF as measured by magnetic resonance imaging (MRI). CONCLUSIONS: This 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. A simple grading system of EF on MRI was described.

Missed breast carcinoma; why and how to avoid?

Despite the advances in mammography techniques, it still has a number of limitations. It is estimated that about 10 to 25% of lesions are overlooked in mammograms out of which about two thirds are detected retrospectively by radiologists and oncologists. Causes of missed breast cancer on mammography can be secondary to many factors including those related to the patient [whether inherent or acquired], the nature of the malignant mass itself, poor mammographic techniques, provider factors or interpretive skills of radiologists and oncologists [including perception and interpretation errors]. The aim of this study is to investigate the aforementioned factors hindering early breast cancer detection and in turn lowering mammographic sensitivity and to outline the major guidelines to overcome these factors aiming to an optimum mammographic examination and interpretation by radiologists and oncologists. We conducted this multicenter study over a two-year interval. We included 152 histopathologicaly proven breast carcinomas that were initially missed on mammography. The cases were subjected to mammography, complementary US, MRI and digital mammography in some cases and all cases were histopathologically proven either by FNAB, CNB or open biopsy. Revision of the pathological specimens of these 152 cases revealed 121 infiltrating ductal carcinomas, 2 lobular, 4 mucinous, 14 inflammatory carcinomas, 6 carcinomas in situ [3 of which were intracystic], 2 intraductal papillary carcinomas and 3 cases with Paget's disease of the nipple. In analyzing the causes responsible for misdiagnosis of these carcinomas we classified them into 4 causative factors; patient, tumor, technical or provider factors. Tumor factors were the most commonly encountered, accounting for 44.1%, while provider factors were the least commonly encountered in 14.5%. Carcinomas were detected using several individual or combined complementary techniques. These techniques mainly included double reading, additional mammography views, ultrasound and MRI examinations. Forty four carcinomas were detected on double and re-reading by more experienced radiologists. Additional mammographic views were recommended in 35 [23%] cases. Complementary ultrasound examination was performed for all 152 cases [100%] and showed a higher sensitivity than mammography in carcinoma detection. It was diagnostic in 138 [90.8%] cases only. In the remaining 14 cases, further MRI and biopsy were performed. Why can breast carcinoma be missed? Four main factors are responsible for missing a carcinoma: [1] Patient factors [Inherently dense breasts or acquired dense breasts]. [2] Tumor factors [subtle carcinoma, masked carcinoma, multifocal carcinoma and multicentric carcinoma]. [3] Technical factors [bad exposure factors, malpositioned breasts and bad processing quality]. [4] Provider factors [bad perception and misinterpretation]. How to avoid missing a breast carcinoma? Review clinical data and use US and other adjunct techniques as MRI and biopsy to assess a palpable or mammographically detected mass. Be strict about positioning and technical factors. Try to optimize image quality. Be alert to subtle features of breast cancers. Always consider the well defined carcinoma. Compare current images with multiple prior studies to look for subtle increases in lesion size. Look for other lesions when one abnormality is seen. Judge a lesion by its most malignant features. Double reading and the use of computer aided diagnosis [CAD] and finally FFDM [Full Field Digital Mammography]. Close cooperation between the oncologist, radiologist and pathologist is essential to avoid missing any case of breast carcinoma

Approaches to minimize the risk of epidural fibrosis after lumbar disc surgery: [clinical - and MRI-based outcome evaluation]

Epidural fibrosis [EF] after lumbar disc surgery is a consequence of normal wound healing. Previous clinical studies have demonstrated a significant association between the presence of extensive post-lumbar discectomy EF formation and the recurrence of low-back and radicular pain with poor surgical outcomes in 5% up to 60%; in the nearly absent curable surgical solutions. Moreover, the presence of fibrosis may lead to nerve root tethering and renders reoperations risky. Theoretical approaches to minimizing the risk of developing EF include decreasing the chance of its development by decreasing the amount of postoperative hematoma by suction drainage [SD] and hence its invasion of by dense fibrous tissue; providing a barrier like autogenous fat between the exposed dura and the healing connective tissues; or applying a drug locally which is supposed to decrease scar tissue formation as steroids. In the present study, we aimed to evaluate the results of these theoretical approaches in the clinical and imaging outcomes of patients after lumbar disc surgery. The present study is a prospective, pragmatic, cohort study conducted and designed to evaluate the clinical outcome and efficacy of SD alone and combined with local application of fat grafts and/or steroids in prevention of post-lumbar discectomy EF. These outcomes were compared with outcomes in patients in whom neither the drain nor the barrier or steroids was implanted. A total of 58 patients [25 women, 33 men] indicated for surgery for a symptomatic, unilateral or bilateral, single-level lumbar disc herniation was included in this study. All patients underwent randomization and surgery. Patients were divided into 2 major groups with 33 patients in Group I [intervention group] and 25 patients in Group II [control group]. Group II served as the control, with decompressive surgery of their symptomatic nerve root alone without SD, local fat or steroid application. Group I was subdivided into 4 subgroups [Ia, Ib. Ic, and Id] according to the procedure done, whether decompressive surgery followed by SD alone or SD combined with local fat and/or steroid application. The barrier tested was autogenous fat graft. Thirty one patients underwent surgery at L4-5, and twenty-seven at L5-S1. Clinical outcome was assessed pre-and postoperatively by evaluating pain intensity, and patients' functional outcome. Pain intensity was evaluated in our study by numeric verbal rating [NVR] scale; and the patients' functional clinical outcome was measured by the range of motion and straight leg raising [SLR] tests. Imaging outcome was assessed on the basis of follow-up magnetic resonance imaging [MRI] findings. We proposed an MRI-based grading system for the extent of EF. No operative or early post operative complications were reported, and no new neurological deficits occurred. A significant proportion of patients in group I showed pain relief compared to the control group, as well as compared to the baseline findings. Analysis of functional outcome showed significant improvements in the intervention group compared to the baseline, as well as the control group at intervals of 3 months, 6 months, and 12 months. The results of pain relief and recovery of the functional status at the end of the study [12m] was best in group Id [SD + fat graft + steroids], followed by group Ib [SD + fat graft], group Ic [SD + steroids], and group Ia [SD alone] respectively. The worst results were obtained in the control group II. Based on the definition that less than 6 months of relief is considered short-term and longer than 6 months of relief is considered long-term, a significant number of patients obtained long-term relief with improvement in pain and functional status. At 1-year follow-up MRI examination, there was a trend toward better outcome in the intervention group. Both suction drainage and fatlsteroid combinations consistently reduced the frequency and the extent of epidural fibrosis on MRI. We conclude that, in patients operated on for unilateral, single-level lumbar disc herniations, implantation of suction drainage into the operation site results in less formation of EF radiologically and yields better clinical outcome. Fat grafts further reduced epidural fibrosis and did not impair normal healing. Local steroid is an effective adjuvant in a significant number of patients without adverse effects. Thus, the use of SD with addition of peridural fat barrier and steroids may improve outcome in these patients