title: Inhibition of peridural fibrosis after laminectomy using low-dose external beam radiation in a dog model.
abstract: OBJECTIVE
  Clinical studies have demonstrated a significant association between the presence of extensive postlumbar discectomy peridural scar formation and the recurrence of low back and radicular pain. Low-dose perioperative radiation therapy has previously been demonstrated to inhibit peridural fibrosis after laminectomy in a rat model. The current study was designed to measure the effect of low-dose radiation on postlaminectomy peridural fibrosis development in a larger animal model.
  
  
  METHODS
  Three dogs underwent a total of 12 lumbar hemilaminectomies. For each animal, two levels received 1) external beam radiation 24 hours before surgery, 2) surgery alone, or 3) radiation alone. Radiation was administered in a single fraction of 700 cGy using computed tomographic guidance for dosimetry planning. The isodose distribution was such that the dose conformed to the posterior epidural space with minimal exit dose to normal tissue. Port films were used to confirm the correct levels. Gadolinium-enhanced magnetic resonance imaging (MRI) of the lumbar spines was obtained before the animals were killed 12 weeks after surgery. The spines were harvested, and axial sections through the laminectomy defect were stained with hematoxylin and eosin and Masson's trichrome. All specimens were evaluated for extent of fibrosis along the dura, density of fibrosis, nerve root entrapment, and sublaminar fibrosis.
  
  
  RESULTS
  There were no complications from the surgery, and no new neurological deficits were noted. There was a statistically significant difference between the irradiated and nonirradiated groups regarding the extent of fibrosis (P = 0.001) and the density of fibroblasts (P = 0.001). There was also a marked difference in nerve root entrapment (P = 0.182) and the presence of sublaminar fibrosis (P = 0.061) between the treatment and control groups. MRI revealed less gadolinium enhancement at the irradiated levels compared with the nonirradiated levels, confirming the usefulness of MRI in predicting the degree of epidural fibrosis.
  
  
  CONCLUSIONS
  Low-dose external beam radiation therapy administered 24 hours before laminectomy in a dog model significantly decreased the extent and density of peridural fibrosis as well as nerve root entrapment and sublaminar fibrosis. This treatment strategy may be efficacious in patients with recurrent radicular pain after lumbar discectomy that is thought to be secondary to peridural fibrosis on the basis of gadolinium-enhanced MRI studies, and who might benefit from reoperation for nerve root decompression.
authors.affiliation: Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania, USA. gerszten@neuronet.pitt.edu
authors.forename: P C
authors.initials: PC
authors.lastname: Gerszten
authors.forename: J J
authors.initials: JJ
authors.lastname: Moossy
authors.forename: J C
authors.initials: JC
authors.lastname: Flickinger
authors.forename: K
authors.initials: K
authors.lastname: Gerszten
authors.forename: A
authors.initials: A
authors.lastname: Kalend
authors.forename: A J
authors.initials: AJ
authors.lastname: Martínez
mesh_terms: D000818:Animals; D002921:Cicatrix / Q000473:pathology / Q000517:prevention & control; D004285:Dogs; D004307:Dose-Response Relationship, Radiation; D004388:Dura Mater / Q000473:pathology / Q000528:radiation effects*; D005260:Female; D005355:Fibrosis; D007796:Laminectomy; D008159:Lumbar Vertebrae / Q000473:pathology / Q000601:surgery*; D009408:Nerve Compression Syndromes / Q000473:pathology / Q000517:prevention & control; D051381:Rats; D013126:Spinal Nerve Roots / Q000473:pathology / Q000528:radiation effects; D014945:Wound Healing / Q000528:radiation effects*