Page 12 - Amniotic Portfolio - RV4 2020 w_ WP

Eur Spine J (2009) 18:1202–1212 1209

Table 4 Scar indexes among groups (n = 8, mean ± SD)
Group 1 week 6 weeks 12 weeks
Scar index (%) P a P b Scar index (%) P a P b Scar index (%) P a P b
FAM 4.05 ± 0.31 1.00 0.00* 18.03 ± 7.55 0.04* 0.46 19.35 ± 5.87 0.01* 0.22
CAM 3.90 ± 0.26 1.00 0.00* 11.23 ± 4.24 0.67 0.03* 11.45 ± 3.83 0.40 0.01*
AFF 3.25 ± 0.26 3.48 ± 0.60 3.70 ± 0.73
Non-treatment 9.37 ± 1.55 26.78 ± 9.38 28.43 ± 8.28
a
P value indicates treatment group versus AFF (positive control)
b
P value indicates treatment group versus non-treatment group (empty control); * \0.05
group. Then, the scar indexes of CAM group increased Table 5 Quantitative evaluation of newly formed bone among
with 11.23 ± 4.24 and 11.45 ± 3.83% at 6 and 12 weeks, groups (n = 8, mean ± SD)
respectively, which were significantly lower than those of Group 6 weeks 12 weeks
non-treatment group (P \ 0.05). However, CAM group
Bone area P a P b Bone area P a P b
showed no significant difference in comparison with AFF 2 2
(mm ) (mm )
group (P [ 0.05). The scar indexes of FAM group were
18.03 ± 7.55 and 19.35 ± 5.87% at 6 and 12 weeks, FAM 8.80 ± 3.58 0.04* 1.00 8.50 ± 2.73 0.04* 1.00
respectively. Although the scar indexes were mildly lower CAM 9.78 ± 2.43 0.01* 1.00 10.07 ± 2.70 0.01* 1.00
than those of non-treatment group (P [ 0.05), they were AFF 3.28 ± 0.76 3.65 ± 0.83
significantly higher than those of AFF group (P \ 0.05) Non- 8.00 ± 1.70 10.55 ± 1.46
(Table 4). treatment
a
P value indicates treatment group versus AFF (positive control)
Amount of newly formed bone b P value indicates treatment group versus non-treatment group
(empty control); * \0.05
After 6 weeks, the newly formed bone originated from the
vertebral lamina was observed in FAM, CAM, and non- contributing factor for a significant subset of patients suf-
treatment groups, which gradually decreased the size of fering from FBSS [3, 26, 27]. However, several authors
laminectomy defects. In contrast, less newly formed bone have reported that there are no important differences
was visible in AFF group. The areas of newly formed bone between symptomatic and asymptomatic patients in fibro-
were 8.80 ± 3.58, 8.50 ± 2.73 and 9.78 ± 2.43, sis demonstrated by computed tomography (CT) and
2
10.07 ± 2.70 mm in FAM and CAM groups at 6 and magnetic resonance imaging (MRI). They concluded that
12 weeks, respectively. They were both significantly the degree of fibrosis was not related to recurrent symp-
higher than that of AFF group (P \ 0.05). However, there toms following lumbar disc surgery [1, 23]. But at least
was no significant difference between theses two groups epidural scarring can make a reoperation much more dif-
(P [ 0.05) (Table 5). ficult, increasing the risks of dural tears, and nerve root
injury. There is no way to predict the patients in whom
symptomatic epidural fibrosis will develop, and once it
Discussion occurs there is no effective treatment. The main reasons for
scar formation include epidural fat destruction, hematoma,
The study demonstrates that CAM can be implanted as a and paraspinal muscular fiber invasion. Regardless of the
physical barrier to reduce epidural fibrosis and scar adhe- exact mechanisms of epidural scar adhesion, the crucial
sion without affecting wound healing. The results provide issue is to prevent the fibroblasts from migrating into the
evidence that CAM is a promising biomaterial to reduce exposed dura in the early healing phase. The interposition
epidural fibrosis for future clinical application. of a physical barrier to limit cell migration is considered an
The formation of postoperative epidural fibrosis is an effective strategy to reduce scar formation [30].
inevitable result of laminectomy. Although the relationship In this study, AM is selected as a barrier for its bio-
between epidural fibrosis and clinical symptoms of FBSS compatibility, absorbability, and easy manipulation. It is
has not been unequivocally proven, as many as 24% of all hypothesized to reduce inflammation, inhibit vasculariza-
FBSS cases may be attributed to epidural scar adhesion tion, and limit or prevent adhesion [31]. After implantation
[27].The mechanical tethering of nerve roots, or the dura, of FAM and CAM, there was no evidence of inflammatory
by the excessive formation of epidural fibrosis may be a reactions at 1, 6, and 12 weeks postoperatively. Few

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