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Post-operative cicatrical-commissural epiduritis

Simple solution for complex problem.

More than 80% of world population suffers from pain syndrome associated with osteochondrosis. The utmost suffering in osteochondrosis patients is connected with discal hernias. Although surgical treatment is indicated in 2-4% of cases, the disease large prevalence makes the absolute value huge.
In the world more than 80 thousand operations are completed due to hernias. The vast majority of completed surgeries is microdiscectomy.

Cicatrical-commissural changes development in post-operative period

Neurosurgical interventions are always associated with development during post-operative period of cicatrical-commissural changes and cicatrical-commissural processes. This is natural biological process, which accompanies any surgery, trauma, cuts and everyday injuries. Unfortunately in some cases due to the same biological characteristics cicatrical-commissural process becomes very pronounced. In particular, in our neurosurgical practice we meet such phenomenon, as cicatrical-commissural epiduritis (it is also called epidural fibrosis, or peridural fibrosis), which causes secondary compression changes of nervous root compression, released after discal hernia extraction. The same manifestations are possible after surgeries on peripheral nerves, when after trauma surgeon releases nerve and sews nerve for the quickest restoration of hand or leg function, but cicatrical process development leads to situation, when many-hour surgeon efforts are practically annulated.

 

According to literature during the next 5 years after surgery up to 15% of patients are operated repeatedly due to primary surgery ineffectiveness. In part of such patients cause for repeated surgery is cicatrical process, in others – discal hernias relapses.

All such repeated surgeries are complicated by rough cicatrical-commissural changes in epidural cavity.
At that significantly increases damage risk of dura mater and nerve root.
Irina Avakesyan, Head of Pathomorphology Department of Kyiv City Clinical Hospital N16 explains the process from pathomorphological viewpoint in the following way: "Surgical trauma causes connective tissue proliferation in epidural cavity. Proliferative aseptic inflammation development in surgery zone is caused by accumulation in trauma focus of young monocytic phagocytes, which come both from surgery zone and from paraspinal muscles, damaged during surgical access. Cells maturation leads to mature fibroblasts formation, and to further young connective tissue forming. Intensive collagen synthesis by fibroblasts leads to shift in cells and fibrous structure ratio, and loose connective tissue turning into dense and fibrous. Such connective tissue ripening is associated with water content decrease and change of ground substance/fibers ratio –fibers increase. Simultaneously collagen changes its physical-chemical properties, decreasing its elasticity and increasing collagen strength. Regulation of growth and differentiation processes of connective tissue in epidural cavity is made, basically, through local mechanisms on the basis of connective tissue cell-to-cell interaction through intercellular contacts, mediators, such as monokines, lymphokines, fibrokines, as well as through cells degeneration products and intracellular matrix".
Therefore, post-operative cicatrical-commissural epiduritis is poorly controlled by medicines. Its development character is principally caused by organism individual characteristics, and, by certain degree, by pronouncement of intra-operational surgical trauma.
Scientific research of Ukrainian neurosurgical scientists successfully finished by development of material and method of prevention of cicatrical-commissural epiduritis. We already have quite considerable experience of implant NUBIPLANTTM use in our patients. Material, used for this problem solving is already well known and actively applied in plastic, esthetic, reconstructive-restorative surgery, urology, orthopedy, pediatric urology, and ophthalmology. We should note that this gel application results are extremely encouraging. In none of the cases of this gel administration we noted with secondary compressive changes, caused by cicatrical-commissural epiduritis. In several cases, when we completed repeated surgeries for such cicatrical-commissural changes, we dissected these scars-commissures and injected this gel. After this we never noted cicatrical-commissural process relapse. People are active, energetic, go in for sports, including competitive sport. And they do not exhibit any unpleasant symptoms".

Basic modern directions in cicatrical-commissural epiduritis surgical prevention are the following:

 

  • Decrease in tissues traumatization during surgery with maximal yellow ligaments preservation, thorough intra-operative hemostasis; coagulation and in epidural cavity is not desirable, besides, undesirable local hemostatics use in epidural cavity, such as hemostatic sponges or films, which remain in epidural cavity.
  • Barriers creation that are protecting epidural cavity from paraspinal muscles, damaged during surgical access (use of special plates-patches, fixated in intra-laminar space that defend epidural cavity from scar tissue in-growth from outside, in particular Gortex film).
  • Gel-like materials use that prevent scars and commissures development, one of which is NUBIPLANTTM implant, which long-term application experience proves its advantages before known world analogues.

Microdiscectomy procedure with NUBIPLANTTM implant use is carried out in two stages.
Microdiscectomy is minimally invasive surgery, aimed at relief of nerve root compression by discal hernia. Surgery is completed in out-patient setting with special micro-surgery instruments. At first stage nucleus pulposus fragments are extracted that form discal hernia, and nerve root is relieved from pressure. Second stage is implant injection that forms barrier, limiting epidural cavity from surrounding damaged tissues for effective prevention of post-operative cicatrical-commissural epiduritis. NUBIPLANT implant use in microdiscectomy of discal hernia minimizes fibrosis risk in epidural cavity.
Implant NUBIPLANTTM important characteristic and major distinguishing feature is that after getting into organism it is not destroyed, but remains in implantation site actually for all patient life.






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