保留黄韧带预防模型兔腰椎椎板切除后硬脊膜粘连
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摘要
背景:瘢痕组织的生成以及随之形成的与硬脊膜及神经根的粘连一直是影响椎板切除后疗效的重要因素之一。如何减少或预防这种粘连或瘢痕形成,是临床医生着重研究的问题。目的:探索术中保留黄韧带对预防腰椎椎板切除后硬脊膜周围粘连的作用。方法:将40只新西兰大白兔随机分为黄韧带切除组与黄韧带保留组,每组实验动物20只,均行L4-5椎板切除术,模拟髓核摘除,术中分别保留或切除黄韧带。参考Rydell-balazs评分标准和Nuss-baum组织学评分标准,评定椎板切除后硬脊膜与周围结组粘连情况。结果与结论:①所有手术均顺利完成,黄韧带保留组椎板切除区仍可见瘢痕组织,硬脊膜与周围组织粘连轻,容易钝性分离。黄韧带切除组可见手术创面肌肉明显瘢痕化,并有类骨质形成,其与脊柱背侧肌肉及软组织粘连紧密,钝性分离非常困难;②黄韧带保留组Rydell-balazs与Nuss-baum评分显著低于和黄韧带切除组(P <0.05);③结果提示,保留黄韧带可降低硬膜外瘢痕形成,减少硬脊膜与周围组织粘连。
BACKGROUND: Formation of scar tissue and the consequent formation of adhesions with dura and nerve root is an important factor for postoperative outcomes of laminectomy. How to reduce or prevent the adhesion or scar formation has been paid much attention in the clinic.OBJECTIVE: To explore the effect of preserving the ligamentum flavum on preventing dural adhesions after laminectomy in lumbar surgery. METHODS: Forty New Zealand white rabbits were randomly divided into ligamentum flavum resection group and ligamentum flavum preservation group(n=20 per group). All animals underwent L4-5 laminectomy, simulating nucleus pulpotomy. Postoperative dural adhesion was assessed according to Rydell-balazs and Nuss-baum criteria. RESULTS AND CONCLUSION: The operations were successfully completed, and there was visible scar in the operation area in the ligamentum flavum preservation group, the dura adhesion was easy to be separated bluntly from surrounding tissue. In the ligamentum flavum resection group, the scar tissue around the dura was very dense and the dural adhesions were serious, even osteoid was observed. The Rydell-balazs and Nuss-baum scores in the ligamentum flavum preservation group were significantly lower than those in the ligamentum flavum resection group(P < 0.05). To conclude, retaining the ligamentum flavum can reduce epidural scarring and adhesion of the dura to the surrounding tissue.
BACKGROUND: Formation of scar tissue and the consequent formation of adhesions with dura and nerve root is an important factor for postoperative outcomes of laminectomy. How to reduce or prevent the adhesion or scar formation has been paid much attention in the clinic.OBJECTIVE: To explore the effect of preserving the ligamentum flavum on preventing dural adhesions after laminectomy in lumbar surgery. METHODS: Forty New Zealand white rabbits were randomly divided into ligamentum flavum resection group and ligamentum flavum preservation group(n=20 per group). All animals underwent L4-5 laminectomy, simulating nucleus pulpotomy. Postoperative dural adhesion was assessed according to Rydell-balazs and Nuss-baum criteria. RESULTS AND CONCLUSION: The operations were successfully completed, and there was visible scar in the operation area in the ligamentum flavum preservation group, the dura adhesion was easy to be separated bluntly from surrounding tissue. In the ligamentum flavum resection group, the scar tissue around the dura was very dense and the dural adhesions were serious, even osteoid was observed. The Rydell-balazs and Nuss-baum scores in the ligamentum flavum preservation group were significantly lower than those in the ligamentum flavum resection group(P < 0.05). To conclude, retaining the ligamentum flavum can reduce epidural scarring and adhesion of the dura to the surrounding tissue.
引文
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[2]Fager CA, Freidberg SR. Analysis of failures and poor results of lumbar spine surgery. Spine.1980;5:87-94.
[3]LaRocca H, Macnab I. The laminectomy membrane. Studies in its evolution, characteristics, effects and prophylaxis in dogs. J Bone Joint Surg. 1974;56(3):545-550.
[4]宫良泰,许复郁,戴国锋,等.明胶海绵对硬脊膜作用的实验研究.山东医科大学学报,2001,39(4):373-374.
[5]Indorewala S, Pagare R, Aboojiwala S, et al. Dimensional stability of the free fascia grafts:a human study. Laryngoscope.2004;114(3):543-547.
[6]G?k A, Erkutlu I, Alptekin M, et al.Three-layer reconstruction with fascia lata and vascularized pericranium for anterior skull base defects. Acta Neurochir(Wien). 2004;146(1):53-56.
[7]Kim BS, Moon MS, Yoon MG, et al. Prevalence of Diffuse Idiopathic Skeletal Hyperostosis Diagnosed by Whole Spine Computed Tomography:A Preliminary Study. Clin Orthop Surg. 2018;10(1):41-46.
[8]李树文,银和平,吴一民,等.后路显微内窥镜下腰椎间盘切除术术中保留黄韧带的临床意义[J].中国骨与关节损伤杂志, 2010,25(3):196-198.
[9]Li SW, Xia H, Han CX. Retrospective analysis on correlation factors of preserving the ligamentum flavum in microendoscopic discectomy. Clin Neurol Neurosurg. 2015;139:46-50.
[10]Rydell NW, Balazs EA. Effect of infra-articular injection of hyaluronic acid on the clinical symptoms of osteoarthritis and on granulation tissue formation. Clin Orthop.1971; 80:25-32.
[11]Nussbaum CE, mcdonald JV, Baggs RB. Use of vicryl mesh to limit epidural scar formation after laminectomy. Neurosurgery.1990;26:649-670.
[12]Einhuas SL, Robertsery JT, Dohan FC. Reduction of peridural fibrosis after lumber laminectomy and discectomy in dog by a resorbablegel. Spine(Phila Pa 1976). 1997; 22(13):1440-1447.
[13]Songer MN, Carson EW, Pandit SM. Analysis of peridural scar formation and its prevention after lumbar laminotomy and discectomy in dogs. Spine(Phila Pa 1976). 1995;20(5):571-580.
[14]孙康,姜长明,吕德成.预防椎板切除后硬膜周围纤维化与粘连的实验研究[J].中华骨科杂志,1995,11:728-729.
[15]王欢,郝立波,于海义.血肿在硬膜外瘢痕粘连形成中作用的探讨[J].中华骨科杂志,1998, 18:161-163.
[16]Stephanie L, Einhaus P, James T. Reduction of peridaral fibrosis after lumbar laminotomy and discectomy in dogs by a resorbable gel(ADCON-L). Spine(Phila Pa 1976). 1997;22(13):1440-1446.
[17]Dullerud R, Graver V, Haakonika M. Influence of fibrinolytic factors on scar formation after lumbar discectomy:a magnetic resonance imaging follow-up study with clinic correla-tion performed 7 years after surgery. Spine(Phila Pa 1976). 1998;23(13):1464-1469.
[18]Dagistan Y, Cukur S, Dagistan E, et al. Role of expression of inflammatory mediators in primary and recurrent lumbar disc herniation. J Korean Neurosurg Soc. 2017;60(1):40-46.
[19]Yabe Y, Hagiwara Y, Ando A. Chondrogenic and fibrotic process in the ligamentum flavum of patients with lumbar spinal canal stenosis. Spine(Phila Pa 1976). 2015;40(7):429-435.
[20]Preul MC, Campbell PK, Garlick DS. Application of a new hydrogel dural sealant that reduces epidural adhesion for-mation:evaluation in a large animal laminectomy model. J Neurosurgery Spine. 2010;12(4):381–390.
[21]Aydin Y, Ziyal IM, Duman H. Clinical and radiological results of lumbar microdiskectomy technique with preserving of ligamentum flavum comparing to the standard microdiskectomy technique.Surg Neurol. 2002;57(1):5-13.
[22]Liu XW, Yang BY, Li QC. Treatment of lumbar intervertebral disc protrusion and remaining bulk ligamentum flava by micro-endoscope. Zhongguo Gu Shang. 2009;22(1):37-38.
[23]Guehring T, Urban JP, Cui Z, et al. Noninvasive 3D vital imaging and characterization of notochordal cells of the intervertebral disc by femtosecond near-infrared two-photon laser scanning microscopy and spatial-volume rendering. Microsc Res Tech.2008;71(4):298-304.
[24]Yamamoto M, Morita R, Mizoguchi T, et al. Mib-Jag1-Notch signalling regulates patterning and structural roles of the notochord by controlling cell-fate decisions. Development. 2010;137(15):2527-2537.
[25]Cornejo MC, Cho SK, Giannarelli C, et al. Soluble factors from the notochordal-rich intervertebral disc inhibit endothelial cell invasion and vessel formation in the presence and absence of pro-inflammatory cytokines. Osteoarthritis Cartilage. 2015;23(3):487-496.
[26]Won HY, Park JB, Park EY, et al. Effect of hyperglycemia on apoptosis of notochordal cells and intervertebral disc degeneration in diabetic rats. J Neurosurgery Spine.2009;11(6):741-748.
[27]Yurube T, Hirata H, Kakutani K, et al. Notochordal cell disappearance and modes of apoptotic cell death in a rat tail static compression-induced disc degeneration model. Arthritis Res Ther.2014;16(1):31-35.
[28]Guyer S, Semmer N, Birkhofer D. Risk factors for lumbar disc degen-eration:a 5-year prospective MRI study in asymptom-atic individuals. Spine(PhilaPa 1976). 2012;27:125-134.
[29]Jonsson B, Stromqvist B. Significance of a persistent positive straight leg raising test after lumbar disc surgery. J Neurosurg.2009;91:50-53.
[30]Lewis PJ, Weir BK, Broad RW. Long-term prospective study of lumbosacral discectomy. J Neurosurg. 2010;67:49-53.
[31]J?nsson B, Str?mqvist B. Neurologic signs in lumbar disc herniation:preoperative affliction and postoper-ative recovery in150 cases. Acta Orthop Scand.2006;67:466-469.
[32]Han C, Zhu H. Research progress of nucleus pulposus cells phenotypic markers. Review Chinese. 2011;25(7):867-870.
[33]Park JB, Kong CG, Riew KD. The increased expression of matrix metalloproteinases associated with elastin degradation and fibrosis of the ligamentum flavum in patients with lumbar spinal stenosis.Clin Orthop Surg. 2009;1(2):81-89.
[2]Fager CA, Freidberg SR. Analysis of failures and poor results of lumbar spine surgery. Spine.1980;5:87-94.
[3]LaRocca H, Macnab I. The laminectomy membrane. Studies in its evolution, characteristics, effects and prophylaxis in dogs. J Bone Joint Surg. 1974;56(3):545-550.
[4]宫良泰,许复郁,戴国锋,等.明胶海绵对硬脊膜作用的实验研究.山东医科大学学报,2001,39(4):373-374.
[5]Indorewala S, Pagare R, Aboojiwala S, et al. Dimensional stability of the free fascia grafts:a human study. Laryngoscope.2004;114(3):543-547.
[6]G?k A, Erkutlu I, Alptekin M, et al.Three-layer reconstruction with fascia lata and vascularized pericranium for anterior skull base defects. Acta Neurochir(Wien). 2004;146(1):53-56.
[7]Kim BS, Moon MS, Yoon MG, et al. Prevalence of Diffuse Idiopathic Skeletal Hyperostosis Diagnosed by Whole Spine Computed Tomography:A Preliminary Study. Clin Orthop Surg. 2018;10(1):41-46.
[8]李树文,银和平,吴一民,等.后路显微内窥镜下腰椎间盘切除术术中保留黄韧带的临床意义[J].中国骨与关节损伤杂志, 2010,25(3):196-198.
[9]Li SW, Xia H, Han CX. Retrospective analysis on correlation factors of preserving the ligamentum flavum in microendoscopic discectomy. Clin Neurol Neurosurg. 2015;139:46-50.
[10]Rydell NW, Balazs EA. Effect of infra-articular injection of hyaluronic acid on the clinical symptoms of osteoarthritis and on granulation tissue formation. Clin Orthop.1971; 80:25-32.
[11]Nussbaum CE, mcdonald JV, Baggs RB. Use of vicryl mesh to limit epidural scar formation after laminectomy. Neurosurgery.1990;26:649-670.
[12]Einhuas SL, Robertsery JT, Dohan FC. Reduction of peridural fibrosis after lumber laminectomy and discectomy in dog by a resorbablegel. Spine(Phila Pa 1976). 1997; 22(13):1440-1447.
[13]Songer MN, Carson EW, Pandit SM. Analysis of peridural scar formation and its prevention after lumbar laminotomy and discectomy in dogs. Spine(Phila Pa 1976). 1995;20(5):571-580.
[14]孙康,姜长明,吕德成.预防椎板切除后硬膜周围纤维化与粘连的实验研究[J].中华骨科杂志,1995,11:728-729.
[15]王欢,郝立波,于海义.血肿在硬膜外瘢痕粘连形成中作用的探讨[J].中华骨科杂志,1998, 18:161-163.
[16]Stephanie L, Einhaus P, James T. Reduction of peridaral fibrosis after lumbar laminotomy and discectomy in dogs by a resorbable gel(ADCON-L). Spine(Phila Pa 1976). 1997;22(13):1440-1446.
[17]Dullerud R, Graver V, Haakonika M. Influence of fibrinolytic factors on scar formation after lumbar discectomy:a magnetic resonance imaging follow-up study with clinic correla-tion performed 7 years after surgery. Spine(Phila Pa 1976). 1998;23(13):1464-1469.
[18]Dagistan Y, Cukur S, Dagistan E, et al. Role of expression of inflammatory mediators in primary and recurrent lumbar disc herniation. J Korean Neurosurg Soc. 2017;60(1):40-46.
[19]Yabe Y, Hagiwara Y, Ando A. Chondrogenic and fibrotic process in the ligamentum flavum of patients with lumbar spinal canal stenosis. Spine(Phila Pa 1976). 2015;40(7):429-435.
[20]Preul MC, Campbell PK, Garlick DS. Application of a new hydrogel dural sealant that reduces epidural adhesion for-mation:evaluation in a large animal laminectomy model. J Neurosurgery Spine. 2010;12(4):381–390.
[21]Aydin Y, Ziyal IM, Duman H. Clinical and radiological results of lumbar microdiskectomy technique with preserving of ligamentum flavum comparing to the standard microdiskectomy technique.Surg Neurol. 2002;57(1):5-13.
[22]Liu XW, Yang BY, Li QC. Treatment of lumbar intervertebral disc protrusion and remaining bulk ligamentum flava by micro-endoscope. Zhongguo Gu Shang. 2009;22(1):37-38.
[23]Guehring T, Urban JP, Cui Z, et al. Noninvasive 3D vital imaging and characterization of notochordal cells of the intervertebral disc by femtosecond near-infrared two-photon laser scanning microscopy and spatial-volume rendering. Microsc Res Tech.2008;71(4):298-304.
[24]Yamamoto M, Morita R, Mizoguchi T, et al. Mib-Jag1-Notch signalling regulates patterning and structural roles of the notochord by controlling cell-fate decisions. Development. 2010;137(15):2527-2537.
[25]Cornejo MC, Cho SK, Giannarelli C, et al. Soluble factors from the notochordal-rich intervertebral disc inhibit endothelial cell invasion and vessel formation in the presence and absence of pro-inflammatory cytokines. Osteoarthritis Cartilage. 2015;23(3):487-496.
[26]Won HY, Park JB, Park EY, et al. Effect of hyperglycemia on apoptosis of notochordal cells and intervertebral disc degeneration in diabetic rats. J Neurosurgery Spine.2009;11(6):741-748.
[27]Yurube T, Hirata H, Kakutani K, et al. Notochordal cell disappearance and modes of apoptotic cell death in a rat tail static compression-induced disc degeneration model. Arthritis Res Ther.2014;16(1):31-35.
[28]Guyer S, Semmer N, Birkhofer D. Risk factors for lumbar disc degen-eration:a 5-year prospective MRI study in asymptom-atic individuals. Spine(PhilaPa 1976). 2012;27:125-134.
[29]Jonsson B, Stromqvist B. Significance of a persistent positive straight leg raising test after lumbar disc surgery. J Neurosurg.2009;91:50-53.
[30]Lewis PJ, Weir BK, Broad RW. Long-term prospective study of lumbosacral discectomy. J Neurosurg. 2010;67:49-53.
[31]J?nsson B, Str?mqvist B. Neurologic signs in lumbar disc herniation:preoperative affliction and postoper-ative recovery in150 cases. Acta Orthop Scand.2006;67:466-469.
[32]Han C, Zhu H. Research progress of nucleus pulposus cells phenotypic markers. Review Chinese. 2011;25(7):867-870.
[33]Park JB, Kong CG, Riew KD. The increased expression of matrix metalloproteinases associated with elastin degradation and fibrosis of the ligamentum flavum in patients with lumbar spinal stenosis.Clin Orthop Surg. 2009;1(2):81-89.