Ligament flavum koruyucu cerrahinin güncel yaklaşımları, önemi ve prognoza etkisi

Öz

Amaç: Bu çalışmanın amacı, lomber disk hernisi cerrahisinde flavum koruyucu cerrahilerin kullanımını değerlendirmek, klinik sonuçlarını standart mikrodiskektomi teknikleri ile karşılaştırmak ve transflaval mikrodiskektomi tekniğini göstermektir. Gereç ve yöntem: 2020-2023 yılları arasında tek bir merkezde transflaval mikrodiskektomi uygulanan toplam 48 hasta ve standart mikrodiskektomi uygulanan 48 hasta çalışmaya dahil edildi. Grupların yaş ve cinsiyet özellikleri tanımlandı ve bacak ağrısı (LPVAS) ve sırt ağrısı (BPVAS) için ameliyat öncesi ve sonrasındaki 12 ay boyunca izlenerek VAS skorları retrospektif olarak analiz edildi. Bulgular: Ameliyat öncesi ortalama LPVAS skorlarında gruplar arasında ve ameliyat sonrası ortalama LPVAS skorlarında anlamlı fark bulunamadı (Sırasıyla p=0,474 ve p=0,598). Ameliyat öncesi ortalama BPVAS skorlarında gruplar arasında da anlamlı bir fark gözlenmedi (p=0,608). Ancak ameliyat sonrası ortalama BPVAS skorlarında gruplar arasında anlamlı bir fark saptandı (p<0,001) Bu sonuç, transflaval mikrodiskektomi ameliyatının standart mikrodiskektomi ameliyatına kıyasla bel ağrısı açısından takipte daha iyi klinik sonuçlar gösterdiğini ortaya koymaktadır. Grup 1’de (transflaval cerrahi grubu) 3 hastada nüks görülürken, Grup 2’de (mikrodiskektomi grubu) 4 hastada nüks görüldü. Nüks görülen hastaların yeniden ameliyatı sırasında, Grup 1'deki hiçbir hastada epidural fibrozis görülmezken, Grup 2'deki tüm hastalarda epidural fibrozis belirtileri görüldü. Ayrıca, yeniden ameliyat sırasında Grup 1'deki hiçbir hastada dural yaralanma görülmezken, Grup 2'deki 2 hastada dural yaralanma meydana gelmişti. Sonuç: Lomber mikrodiskektomi ameliyatı sırasında ligamentum flavum yapısının korunması ve hasarının en aza indirilmesi, takiplerde daha az aksiyel ağrı ve daha iyi klinik sonuçlarla sonuçlanır.

Anahtar Kelimeler

• Ligamentum flavum
• ligamentum flavum koruyucu cerrahi
• transflaval microdiskektomi

Current approaches, significance and prognostic impact of lumbar ligament flavum preserving surgeries

Öz

Purpose: The aim of this study is to evaluate the use of flavum-preserving surgeries in lumbar disc herniation surgery, compare their clinical outcomes with standard microdiscectomy techniques, and demonstrate the transflaval microdiscectomy technique. Material and methods: Between 2020 and 2023, a total of 48 patients who underwent transflaval microdiscectomy and 48 patients who underwent standard microdiscectomy at a single center were included in the study. Epidemiologic characteristics of the groups were described, and from the preoperative and postoperative 12 months visual analog scale scores for leg pain (LPVAS) and back pain (BPVAS) were retrospectively analyzed. Results: There is no significant difference between the groups in preoperative mean LPVAS scores (p=0.474) and there is no significant difference between the groups in postoperative mean LPVAS scores (p=0.598). There is no significant difference between the groups in preoperative mean BPVAS scores (p=0.608). However, there is a significant difference between the groups in postoperative mean BPVAS scores (p<0.001). This result indicates transflaval microdiscectomy surgery shows better clinical outcomes in follow-up in terms of back pain compared to standard microdiscectomy surgery. In Group 1 (transflaval group), recurrence occurred in 3 patients, while in Group 2 (microdiscectomy), 4 patients experienced recurrence. During the reoperation of patients with recurrence, none of the patients in Group 1 exhibited epidural fibrosis, whereas all patients in Group 2 showed signs of epidural fibrosis. Additionally, during reoperation, no patient in Group 1 experienced dural injury, while dural injury occurred in 2 patients in Group 2. Conclusion: Preserving the ligamentum flavum structure and minimizing its damage during lumbar microdiscectomy surgery results in less axial pain and improved clinical outcomes during follow-ups.

Anahtar Kelimeler

• Ligamentum flavum
• ligamentum flavum preserving surgery
• transflaval microdiscectomy.

Kaynakça

1. 1. Dowdell J, Erwin M, Choma T, Vaccaro A, Latridis J, Cho SK. Intervertebral disk degeneration and repair. Neurosurgery 2017;80:46-54. https://doi.org/10.1093/neuros/nyw078
2. 2. Blamoutier A. Nerve root compression by lumbar disc herniation: a french discovery? Orthop Traumatol Surg Res 2019;105:335-338. https://doi.org/10.1016/j.otsr.2018.10.025
3. 3. Feng F, Xu Q, Yan F, et al. Comparison of 7 surgical interventions for lumbar disc herniation: a network meta-analysis. Pain Physician 2017;20:863-871.
4. 4. Jiang HW, Chen CD, Zhan BS, Wang YL, Tang P, Jiang XS. Unilateral biportal endoscopic discectomy versus percutaneous endoscopic lumbar discectomy in the treatment of lumbar disc herniation: a retrospective study. J Orthop Surg Res 2022;17:30. https://doi.org/10.1186/s13018-022-02929-5
5. 5. Zuo R, Jiang Y, Ma M, et al. The clinical efficacy of biportal endoscopy is comparable to that of uniportal endoscopy via the interlaminar approach for the treatment of L5/S1 lumbar disc herniation. Front Surg 2022;9:1014033(e1-11). https://doi.org/10.3389/fsurg.2022.1014033
6. 6. Askar Z, Wardlaw D, Choudhary S, Rege A. A ligamentum flavum-preserving approach to the lumbar spinal canal. Spine (Phila Pa 1976). 2003;28:385-390. https://doi.org/10.1097/01.BRS.0000085100.10349.15
7. 7. Salimi H, Suzuki A, Habibi H, et al. Biglycan expression and its function in human ligamentum flavum. Sci Rep 2021;11:4867(e1-13). https://doi.org/10.1038/s41598-021-84363-x
8. 8. Hirabayashi S. Ossification of the ligamentum flavum. Spine Surg Relat Res 2017;1:158-163. https://doi.org/10.22603/ssrr.1.2016-0031

9. 9. Lee U, Kim CH, Kuo CC, et al. Does preservation of ligamentum flavum in percutaneous endoscopic lumbar ınterlaminar discectomy ımprove clinical outcomes? Neurospine 2019;16:113-119. https://doi.org/10.14245/ns.1938008.004
10. 10. Aydin Y, Ziyal IM, Duman H, Türkmen CS, Başak M, Sahin Y. Clinical and radiological results of lumbar microdiskectomy technique with preserving of ligamentum flavum comparing to the standard microdiskectomy technique. Surg Neurol 2002;57:5-13(discussion13-14). https://doi.org/10.1016/s0090-3019(01)00677-2
11. 11. Ozer AF, Oktenoglu T, Sasani M, Bozkus H, Canbulat N, Karaarslan E, Sungurlu SF, Sarioglu AC. Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery. Neurosurgery 2006;59:126-133. https://doi.org/10.1227/01.NEU.0000220078.90175.E6
12. 12. Özay R, Ogur T, Durmaz HA, Turkoglu E, Caglar YS, Sekerci Z, Sorar M, Hanalioglu S. Revisiting ligament-sparing lumbar microdiscectomy: when to preserve ligamentum flavum and how to evaluate radiological results for epidural fibrosis. World Neurosurg 2018;114:378-387. https://doi.org/10.1016/j.wneu.2018.02.186
13. 13. Truumees E. A history of lumbar disc herniation from Hippocrates to the 1990s. Clin Orthop Relat Res 2015;473:1885-1895. https://doi.org/10.1007/s11999-014-3633-7
14. 14. Butler AJ, Munakomi S, Donnally III CJ. Discectomy. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544281. Accessed Aug 13, 2023
15. 15. Kwon WK, Kelly KA, McAvoy M, et al. Full endoscopic ligamentum flavum sparing unilateral laminotomy for bilateral recess decompression: surgical technique and clinical results. Neurospine 2022;19:1028-1038. https://doi.org/10.14245/ns.2244344.172
16. 16. Cruccu G, Aziz TZ, Garcia Larrea L, et al. EFNS guidelines on neurostimulation therapy for neuropathic pain. Eur J Neurol 2007;14:952-970. https://doi.org/10.1111/j.1468-1331.2007.01916.x
17. 17. Cemil B, Tun K, Kaptanoglu E, et al. Use of pimecrolimus to prevent epidural fibrosis in a postlaminectomy rat model. J Neurosurg Spine 2009;11:758-763. https://doi.org/10.3171/2009.6.SPINE08580
18. 18. Li J, Ma Q, Wu J, Zhao P, Li T, Li J. Dose preservation of ligament flavum really help prevent postoperative epidural fibrosis and improve outcome in microdiscectomy? J Clin Neurosci 2020;80:331-335. https://doi.org/10.1016/j.jocn.2020.06.013
19. 19. Li S, Xia H, Han C. Retrospective analysis on correlation factors of preserving the ligamentum flavum in microendoscopic discectomy. Clin Neurol Neurosurg 2015;139:46-50. https://doi.org/10.1016/j.clineuro.2015.08.018
20. 20. Song J, Park Y. Ligament-sparing lumbar microdiscectomy: technical note. Surg Neurol 2000;53:592-596(discussion596-597). https://doi.org/10.1016/s0090-3019(00)00231-7
21. 21. Keskin E, Tönge Ç, Kaya M, Işık E. Evaluation of the effects of berberine in the prevention of epidural fibrosis in rats: An experimental research. Saudi Med J 2022;43:370-377. https://doi.org/10.15537/smj.2022.43.4.20210918
22. 22. Dayanır H, Dayanır D, Emmez G, et al. Medical ozone treatment on prevention of epidural fibrosis in the rat model. Niger J Clin Pract 2023;26:1197-1203. https://doi.org/10.4103/njcp.njcp_161_23
23. 23. Keskin E, Can EY, Aydın HA, et al. The preventative effect of of Ro5-4864 (peripheral benzodiazepine receptor agonist) on spinal epidural fibrosis after laminectomy in a rat model. Neurol Res 2021;43:1107-1115. https://doi.org/10.1080/01616412.2021.1949689
24. 24. Yue Z, Hu B, Chen Z, et al. Continuous release of mefloquine featured in electrospun fiber membranes alleviates epidural fibrosis and aids in sensory neurological function after lumbar laminectomy. Mater Today Bio 2022;17:100469(e1-13). https://doi.org/10.1016/j.mtbio.2022.100469