Low-dose radiotherapy for the inhibition of peridural fibrosis after reexploratory nerve root decompression for postlaminectomy syndrome

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> The authors of clinical studies have demonstrated a significant association between the presence of extensive post—lumbar discectomy peridural scar formation and the recurrence of low-back and radicular pain. Low-dose perioperative radiotherapy has been demonstrated to inhibit peridural fibrosis after laminectomy in animal models. The present study was designed to evaluate the clinical efficacy of preoperative irradiation in patients with failed—back surgery syndrome due to peridural fibrosis who underwent reexploration and nerve root decompression.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> Ten patients with symptomatic post—discectomy peridural fibrosis were randomized. Half of the patients underwent 700-cGy external-beam irradiation to the operative site 24 hours prior to reexploration and decompressive treatment of their symptomatic nerve root(s) (treatment group) and the other half underwent reexploration and decompressive treatment without preoperative irradiation (control group). All patients underwent simulated irradiation so neither patient nor surgeon was aware of the patient's group. In all patients the antiadhesion product ADCON-L was placed over the affected nerve root at the time of surgery. Clinical outcome was assessed using the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section Lumbar Disc Herniation Study Questionnaire at baseline, 6 weeks, 3 months, and 1 year follow up.</jats:p> <jats:p content-type="fine-print">Five men and five women (mean age 42 years) underwent randomization and surgery. Three patients underwent reexploration at L4–5, four at L5—S1, and three at both levels. No complication was associated with irradiation, and no new neurological deficits occurred. At 1-year follow-up examination, three irradiation-treated patients were pain free and two experienced improvement. In the control group, three patients experienced improved pain relief and two were unchanged. There was a trend toward better outcome at 1 year in the radiotherapy-treated group (p = 0.056).</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> Preoperative low-dose external-beam irradiation improved clinical outcomes after reexploration and decompression of nerve roots affected by postlaminectomy peridural fibrosis causing radicular pain. The addition of preoperative irradiation may improve outcome in patients who undergo reoperation for recurrent radicular pain associated with a significant amount of peridural fibrosis, particularly now that no antiadhesion product is available for clinical use.</jats:p>

The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model

“…Four RCTs 68,73,89,99 had used both adequate randomisation and allocation concealment (comparators included exercise therapy, intraoperative interventions and usual care). A further eight studies 81,[85][86][87][88]101,106,107 used adequate randomisation, but not allocation concealment (although two studies 87,106 used sealed envelopes), and one study 69 used adequate allocation concealment, but not randomisation. Two studies 91,93 used sealed envelopes, but gave no further details on method of randomisation.…”

Failed back surgery syndrome: casuistic and etiology

“…Epidural injections and injections on the nervous roots had been also very studied and they do not present good results 23,24 . A study defends the preoperative irradiation for reoperation after epidural fibrosis with favorable results 25 , as also exist experiments with synthetic materials for the prevention of fibrosis 26,27 . The surgery is more indicated for the root compression processes and for column instability, because in other diseases the answers are not so satisfactory.…”

Comparison of Oxiplex and Gore-Tex effectivity in an experimental peridural fibrosis model

“…Reoperation for failed back syndrome is usually unsuccessful and might cause surgical complications 8 . Non steroidal anti-inflammatory drugs (NSAIDs) 15 , Gelfoam 27 , Goretex 22,25 , carboxymethil cellulose 33 , Adcon-L 11,21 , autogenous adipose grefting 13 , mitomisin 10 , and radiotherapy 12 have been investigated as potential treatments for the prevention of scar formation after spine surgery in the last decades. Most studies provide only a qualitative evaluation of the scar formation after laminectomy therefore it is difficult to make comparisons among the different agents.…”

“…Several materials have been tested as barriers to reduce the extent of peridural fibrosis [10][11][12][13]15,25,27,32,33 . None of the barrier materials have been universally accepted for this use 1 .…”