Fibrosis epidural postquirúrgica: presentación de un caso con enfoque médico legal / Postsurgical epidural fibrosis: presentation of a case with a medical-legal approach

Resumen La fibrosis epidural es un hallazgo clínico y radiológico el cual se encuentra relacionado directamente en su génesis con los procedimientos quirúrgicos realizados en la columna vertebral. Esta patología es la causa más frecuente del síndrome de cirugía fallida de columna, manifestada clínicamente como un dolor equiparable en severidad al presentado previo a la intervención quirúrgica realizada. La fibrosis epidural es parte del proceso de cicatrización usual de los tejidos circundantes de la columna vertebral, en otras palabras, es esperable que esta suceda, sin embargo, solo una mínima cantidad de las personas intervenidas desarrollan clínicamente la sintomatología. La importancia del análisis de esta patología radica en que estas valoraciones son ingresadas al Departamento de Medicina Legal por asunto de reagravación de alguna secuela ocasionada por algún evento traumático. Es imprescindible conocer a profundidad los diferentes aspectos etiológicos, fisiopatológicos, clínicos, radiológicos y terapéuticos que involucran esta patología vertebral, así como, el respectivo análisis médico legal en este tipo de casos, tomando en consideración todos los elementos de juicio que permitan relacionar este hallazgo con algún hecho denunciado. En el presente artículo se realizará un análisis médico legal de un caso de reagravación por fibrosis epidural valorado en el Departamento de Medicina Legal de Costa Rica, donde el peritado interpone una denuncia contra el ente asegurador al ser rechazada la posibilidad de reapertura del riesgo laboral presentado.

Abstract The epidural fibrosis is a clinical and radiological finding that is related with the surgical procedures performed on the spine. This pathology is the most frequent cause of failed back syndrome or post laminectomy syndrome, that is clinically manifested by an acute pain comparable in severity with the surgical intervention. Epidural fibrosis is part of the usual healing process of the surrounding tissues of the spine, in other words, it's to be expected as a result of this procedures, nevertheless, only a small number of people who have been intervened, actually develop the symptoms clinically. The importance of this pathology lies in the fact that these assessments are attended in the Legal Medicine Department due to the aggravation issues of any sequel caused by a traumatic event. It is essential to know such things as the etiology, pathophysiology, clinical manifestations, radiological findings, and the therapeutic aspects that involve this vertebral disease, as well as, the respective forensic analysis, in order to use all the elements of judgment that allows to relate what is documented with the denounced findings.

Analysis of clinical effects in the treatment of single-segment lumbar degenerative disease by lamina osteotomy and former vertebral plates regraft / 中国骨伤

<p><b>OBJECTIVE</b>To compare the clinical effect between the lamina osteotomy and former vertebral plates regraft method and total laminectomy and interbody fusion method in treating single-segment lumbar degenerative disease.</p><p><b>METHODS</b>The clinical data of 167 patients with single-segment lumbar degenerative disease underwent surgical treatment from January 2010 to December 2014 were retrospectively analyzed. There were 92 males and 75 females, aged from 45 to 75 years old with an average of (59.6±12.4) years. The patients were divided into lamina osteotomy and former vertebral plates regraft group(82 cases) and total laminectomy and interbody fusion group(85 cases) according to the different surgical methods used. The general conditions and clinical effects were compared between two groups. General conditions included the operation time, intraoperative blood loss, postoperative drainage, hospitalization time and the clinical effects included the visual analogue scale (VAS), Japanese Orthopaedic Association(JOA), Oswestry Dability Index(ODI), MacNab results, epidural fibrosis (EF), the incidence of adjacent segment degeneration (ASD).</p><p><b>RESULTS</b>All the patients were followed for 18 to 36 months with an average of (24.8±5.7) months, furthermore, there was no significant difference in the follow-up time between two groups. There was no significant difference in general conditions such as operation time, intraoperative blood loss, postoperative drainage, or hospitalization time between two groups. At final follow-up, the VAS, ODI, JOA, of all patients were significantly improved (<0.05);and the three factors above in the lamina osteotomy and former vertebral plates regraft group respectively were(2.0±1.1) points, (24.0±1.8) %, (19.8±8.2) point, while the results of total laminectomy and interbody fusion group were(2.5±1.6) points, (23.3±2.0)%, and(22.5±8.5) point;there was statistical difference between two groups(<0.05). According to the standard of MacNab, 59 cases obtained excellent results, 20 good, 3 fair results in the lamina osteotomy and former vertebral plates regraft group;while 47 cases got excellent results, 26 good, and 12 fair results in the total laminectomy and interbody fusion group;there was significant difference between two groups(<0.05). Sixteen patients(19.51%) with EF and 20 patients(24.39%) with ASD were found in lamina osteotomy and former vertebral plates regraft group;and 30 patients(35.29%) with EF and 37 patients(43.53%) with ASD were found in total laminectomy and interbody fusion group; there was significant difference between two groups(<0.05).</p><p><b>CONCLUSIONS</b>Both two methods can achieve the ideal effects for the treatment of single-segment lumbar degenerative disease, but the lamina osteotomy and former vertebral plates regraft method can reserve the integrity of posterior ligamentous complex, reducing the incidence of EF and ASD, and is a better surgical method.</p>

Effects of a Temperature-Sensitive, Anti-Adhesive Agent on the Reduction of Adhesion in a Rabbit Laminectomy Model

OBJECTIVE: A common cause of failure in laminectomy surgery is when epidural, peridural, or perineural adhesion occurs postoperatively. The purpose of this study is to examine the efficacy of a temperature-sensitive, anti-adhesive agent (TSAA agent), Guardix-SG®, as a mechanical barrier for the prevention or reduction of peridural scar adhesion in a rabbit laminectomy model. METHODS: Twenty-six mature rabbits were used for this study. Each rabbit underwent two separate laminectomies at lumbar vertebrae L3 and L6, left empty (the control group) and applied 2 mL of the TSAA agent (the experimental group), respectively. Invasive scar formation or inflammation after laminectomy was quantitatively evaluated by measuring the thickness of the dura, the distance from the surface of dura to the scar tissues, the number of inflammatory cells in the scar tissues at the laminectomy site, and the concentration of collagen in histological sections. RESULTS: At 6 weeks postsurgery, the dura was significantly thinner and the distance from the surface of dura to the scar tissues was greater in the experimental group than in the control group (p=0.04 and p=0.01). The number of inflammatory cells was not significantly different in the two groups (p=0.08), although the mean number of inflammatory cells was relatively lower in the experimental group than in the control group. CONCLUSION: The current study suggests that the TSAA agent, Guardix-SG®, could be useful as an interpositional physical barrier after laminectomy for the prevention or reduction of adhesion.

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.

Investigation of Efficacy of Mitomycin-C, Sodium Hyaluronate and Human Amniotic Fluid in Preventing Epidural Fibrosis and Adhesion Using a Rat Laminectomy Model

STUDY DESIGN: A retrospective study. PURPOSE: The aim of this study was to evalute the effects of mitomycin-C, sodium hyaluronate and human amniotic fluid on preventing spinal epidural fibrosis. OVERVIEW OF LITERATURE: The role of scar tissue in pain formation is not exactly known, but it is reported that scar tissue causes adhesions between anatomic structures. Intensive fibrotic tissue compresses on anatomic structures and increases the sensitivity of the nerve root for recurrent herniation and lateral spinal stenosis via limiting movements of the root. Also, neuronal atrophy and axonal degeneration occur under scar tissue. METHODS: The study design included 4 groups of rats: group 1 was the control group, groups 2, 3, and 4 receieved antifibrotic agents, mitomycin-C (group 2), sodium hyaluronate (group 3), and human amniotic fluid (group 4). Midline incision for all animals were done on L5 for total laminectomy. Four weeks after the surgery, the rats were sacrificed and specimens were stained with hematoxylin-eosin and photos of the slides were taken for quantitive assesment of the scar tissue. RESULTS: There was no significant scar tissue in the experimental animals of groups 2, 3, and 4. It was found that there was no significant difference between drug groups, but there was a statistically significant difference between the drug groups and the control group. CONCLUSIONS: This experimental study shows that implantation of mitomycin-C, sodium hyaluronate and human amniotic fluid reduces epidural fibrosis and adhesions after spinal laminectomy in rat models. Further studies in humans are needed to determine the complications of the agents researched.

O tratamento de pacientes com fibrose epidural pela reeducação postural global - RPG / Treatment of patients with epidural fibrosis withglobal postural reeducation - GPR

Muitos pacientes têm convivido com a fibrose epidural no pós-operatório de hérnia de disco lombar, doença que pode contribuir para o afastamento destes pacientes de suas atividades da vida profissional, além de interferir em outros aspectos de suas vidas, impossibilitando-as de desenvolver suas atividades habituais, em decorrência do desconforto produzido pela dor. Este trabalho teve como objetivo esclarecer a importância da fisioterapia no tratamento desta doença e mostrar a eficácia da Reeducação Postural Global (RPG), para amenizar a dor, propiciando uma melhor qualidade de vida para estes pacientes. Este trabalho foi realizado no Instituto de Neurologia Deolindo Couto da UFRJ, no ambulatório de fisioterapia. Fizeram parte deste estudo 18 pacientes de ambos os sexos, com fibrose epidural comprovada por ressonância magnética (RM). Todos os pacientes responderam ao Questionário de Dor e Incapacidade Lombar de Roland-Morris, e foram avaliados por uma Escala Visual Analógica (EVA). Essas medidas de avaliação de dor foram utilizadas sempre no momento inicial do tratamento, durante as sessões de RPG. Foram realizadas 15 sessões de RPG. Todos os pacientes envolvidos no trabalho concordaram em participar do programa proposto mediante préinformação e livre consentimento. Após o término do tratamento os pacientes foram reavaliados em um período de três e seis meses.

Many patients have been living with epidural fibrosis during the postoperative of lumbar disc hernia, a kind of disorder that take the patients away from their professional activities, and also away from other aspects of their lives. It impairs their daily activities due to the discomfort produced by the pain. This work has an objective of clarifying the importance of the Physiotherapy for the treatment of this disorder, and to show the efficacy of the Global Postural Reeducation (GPR) to diminish the pain, giving to these patients a better quality of life. This work was performed in Deolindo Couto Neurology Institute û UFRJ, at the Physiotherapy Clinic. Eighteen patients, of both sexes, were included in this study, with epidural fibrosis seen by Magnetic Resonance. All patients answered to the Questionnaire of Pain and Lumbar Incapacity of Roland-Morris, and were also evaluated by a Visual Analog Scale (VAS). These methods of pain evaluation were always used on the time of initial treatment, during GPR sessions. All patients involved in the work agreed in participating of the program, by preinformation and free assent. After the treatment, the patients were reevaluated after a three and six month's period.

An experimental study on prevention of dura mater spinalis adhssion after laminectomy by using keratin substance (KS) artificial fasciae / 中国矫形外科杂志

Objective To study the effect on prevention of dura mater spinalis adhesion after laminectomy through an experiment by using keratin substance (KS) artificial fasciae.MethodSixty rats were randomly divided into three groups, each had 20. In all rats, total laminectomy were performed at T12 levels led to the defects of 2 mm?8 mm. The group A were sutured directly, which was regarded as control group; covered with artificial fasciae in group B; with self-faciae in group C. The animals were killed at the 2nd, 4th, 8th, 12th week after operation respectively, and macroscopy assessment was done with the help of the Rydell Criterion. The spine segment of T12 was removed en bloc including the paraspinal tissue, and all specimens were stained with hematoxylin and eosin. Improved Nussbaum Criterion was used for the following optical microscopy assessment. Transmission electron microscopy was performed on posterior epidural scar obtained from group-B at the 2nd, 4th, 8th, 12th week after operation respectively. The nonparametric Kruskal-Wallis test was used to determine the differences between the three groups, and a P value of 0.05).So compared to the control group, KS artificial fasciae and self-fasciae significantly reduced the formation of epidural fibrosis after laminectomy.ConclusionKS artificial fasciae have the best biological compatibility with the tissues with no adverse effects. The posterior hematoma and fibroblast (FB) are the main source of the epidural fibrosis.As placement of KS artificial fasciae over the laminectomy defect in rats could provide a physical barrier against invasion of fibrous tissue into the vertebral canal,and peridural fibrosis after laminectomy would be effectively prevented. KS artificial fasciae is safe and effective in limiting the direct contact by the postlaminectomy epidural fibrosis in rats.

The Effect of Polylactide Resorbable Film on the Epidural Fibrosis After Lumbar Laminotomy / 대한정형외과연구학회지

PURPOSE: The purpose of this study is to evaluate the effect of polylactide resorbable film in preventing epidural fibrosis after lumbar laminotomy. MATERIALS AND METHODS: Thirty-six New Zealand male rabbits about fifteen month old, weighing 3.5 kg in average, were used. Uniform laminotomy windows measuring 7x7 mm were made on the left side of the spine at three lumber locations (L2, L3 and L4). The laminotomy window at second lumbar spine was left untreated and used as control group (Group 1). The lanimotomy window of 3rd lumbar spine was covered with free fat tissue (Group 2), and polylactide ( Surgi-Wrap(R)) resorbable film was inserted on the laminotomy window of 4th lumbar spine (Group 3). Twelve rabbits were euthanized at 4, 8 and 12 weeks each after operation for biochemical analysis of hydroxyproline content and histologic examination. RESULTS: 1. There was considerable reduction in the total collagen, ranging from 40~48% in the Group 2 or the Group 3 compared to the Group 1. There was no statistical difference between the Group 2 and the Group 3. 2. The extent of fibrosis and fibroblast density was significantly lower in the Group 2 or the Group 3 than in the Group 1. However, the extent of fibrosis and fibroblast density did not differ statistically between the Group 2 and the Group 3. 3. No significant statistical differences of the collagen content and the histologic findings in each group was demonstrated during experimental period. CONCLUSION: These results suggest that polylactide (Surgi-Wrap(R)) resorbable film may be a useful method for reduction of epidural fibrosis after lumbar laminotomy.

Postoperative Epidural Fibrosis: An Erroneous Diagnosis as Epidural Abscess after Epidural Block: A case report / 대한마취과학회지

The epidural abscess, while rare, should be taken seriously, as it can result in permanent neurological complications. Fever, back pain, leukocytosis and elevation of Erythrocyte Sedimentation Rate (ESR) are major signs and symptoms of epidural abscesses. But clinical recognition of such abscesses may be very difficult because of nonspecific symptoms or signs as well as previous or underlying painful disorders. Few cases has been reported of epidural abscess and epidural fibrosis associated with back surgery or temporary epidural blocks. In these cases, however, fever, low back pain, sciatica and elevation of ESR were the major findings. Magnetic Resonance Imaging findings after Gadolinium- diethylenetriaminopenta-acetic acid (Gd-DTPA) enhancement show central low signal intensity and surrounding high signal intensity at the anterior epidural space between the 5th lumbar and 1st sacral vertebrae. We suspected an epidural abscess caused by epidural block, and so operated. But our operative finding was epidural fibrosis without abscess. Our final pathological diagnosis was epidural fibrosis.

Cliniclal Analysis of Microsurgical Reoperation after Lumbar Disc Surgery

Repeated surgery of the lumbar spine after lumbar discectomy was not uncommon. Total 817 cases of lumbar disorders were carried out surgical intervention in author's clinic from Jan. 1993. to May 1997. Among them, 82 cases were reoperated cases after lumbar disc surgery. The causes, methods and outcome of reoperation were reviewed. The most common causes of reoperation was epidural adhesion, and the most frequent method of reoperation was the interbody fusion with adhesiotomy. Epidural fibrosis was the major problem and must be studied forward for preventing reoperaion.

Surgical Results of Herniated Lumbar Disc

The surgical outcome for lumbar discectomy has improved with development of surgical techniques and strict selection of patients. The authors could follow up and analyse 818 cases who underwent surgery due to herniated lumbar disc from Jan. 1980 to Dec. 1991 at Chonbuk National University Hospital. The early operative complications were delayed wound healing(36 cases), extradural hermatoma(2 cases), discitis(2 cases), but there was no injury to nerve root and abdominal vessels. The specially designed paravertebral muscle retractor and nerve root retractor were useful in reducing the operative complications. Sixteen patients were reoperated due to acute recurrent symptoms(within one month). More than one-third of these(7/16) were due to missed disc material, and all of them had good results after reoperation. Twenty five patients were reoperated due to late recurrent symptoms(more than 6 months later). In almost two-third of them(14/25), rerupture of remained disc material was found. Reoperation of these cases had a good result as well. Epidural fibrosis and severe adhesion of nerve root were showed for reoperation in 9 of the 25 cases. These complications had a poor result except 1 case even after reoperation. The surgical outcome of 818 cases were classified ; Excellent 618 cases(82%), Good 110 cases(13.5%), Fair 29 cases(3.5%) and Poor 8 cases(1%). Surgical technique and proper selection of patients were considered as important facter obtaining the better result.

A Clinical Analysis of Re-operated Cases of Herniated Intervertebral Disc

The authors experienced 32 cases of reoperation due to persistent or recurred symptoms who had once low back operation due to herniated lumbar disc. The results were summarized as follows: 1) The reoperated cases were most common in 5th decade(31.3% ) and 2nd most common in 4th decade(28.1%) of age, and the male to female ratio was 2:1. 2) The lesion sites of reoperated cases were L4-5 space(68.8%), L5-S1 space(18.8%), multiple space(9.4%) and L3-4 space(3.1%) in orders. 3) The symptom-free interval between 1st and 2nd operation were 1-5 years(34.4%), 6-10 years(15.6%) and 2-6 months(12.5%) in orders. The longest interval were above the 11 years (21.9%) and the shortest interval were below the 1 month(15.6%). 4) The main pathologic findings of reoperated 32 cases were epidural fibrosis(31.2%), incomplete disc removal+epidural fibrosis(31.2%), new disc herniation(21.8%), foraminal stenosis(9.4%) and opposite site herniation(6.3%) in orders. 5) The results of 32 reoperated cases were good(43.7%), excellent(21.8%), fair(18.7%) and poor(15.6%) in orders.

Clinical Analysis of the Results of Reoperations for Recurrent Herniated lumbar Disc

Thirty-one Patients who underwent reoperation from Jan. 1983 to Dec. 1988. were analysed retrospectively. The results of reoperation showed the excellent recovery in 13 cases(42%) and good recovery in 12 cases(39%) in terms of pain relief and working capability. But 6 cases(19%) couldn't be managed successfully. The most common intraoperative findings were true recurrences(14 cases: 45%), missed disc material(7 cases: 23%), and small recurrent fragment embedded in epidural fibrosis(7 cases: 23%). The clinical result is affected predominantly by the intraoperative pathology and the time interval between the first and second operation. The excellent or good results could be achieved among patients with true recurrences occurred after more than 6 months following initial surgery and among the patients who were operated again within one month because of missed disc material, hematoma, and inadequate laminectomy and discectomy. But the patients who underwent reoperation between 1 month and 6 months because of a small recurrence and fibrosis or epidural fibrosis showed the poor results. The complete removal of disc, adequate bleeding control, adequate laminectomy were considered to be helpful to reduce the chance of reoperation. Microsurgery is advisable in reoperations because it can facilitate the dissection between fibrous scar and nerve root, making the small recurrent disc material removed completely.

Experiences of Reoperation on Failed Lumbar Disc Surgery

Nine patients, who had once low back operation due to herniated lumbar disc, underwent repeated low back surgery at the same level because of persistent or recurred symptoms. All patients were proved to have no psychological or compensative problems. Seven of them had satisfactory results but two, one who had no definite symptom free interval and had surgically proven epidural fibrosis only and another who underwent reoperation as early as 45 days after the first operation had persistent previous symptoms. After review of these cases we obtained several favorable factors which influence the post-operative results. When a patient had a definite symptoms free interval longer than 2 years or the main offending lesion was proved to be a disc herniation or spinal stenosis, satisfactory results could be anticipated.