title: Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery.
abstract: OBJECTIVE
  Postoperative fibrosis is one of the most important causes of failed back surgery syndrome after lumbar disc surgery. Numerous natural and synthetic materials have been investigated as means to prevent or reduce postoperative scarring after these operations. Preservation of the ligamentum flavum for this purpose has not been studied in depth. A prospective, randomized, controlled clinical study was conducted. The aim was to present a new technique for preserving the ligamentum flavum during lumbar discectomy, and to evaluate whether this helps prevent or diminish postoperative fibrosis.
  
  
  METHODS
  Twenty patients with unilateral L5-S1 disc herniation were randomly divided into two equal groups. Group A patients underwent classic microlumbar discectomy, and Group B patients underwent the same procedure but with preservation of the ligamentum flavum. Visual analog pain scale (VAPS) scores, Oswestry scale scores, and straight-leg raising angles were recorded preoperatively and at 6 months postoperatively. Differences between the pre-operative and postoperative findings for each group were statistically compared using the Wilcoxon test. Magnetic resonance imaging was also done at 6 months to assess the extent of postoperative fibrosis, and a "scarring grade" was recorded for each patient. The group findings for this were analyzed with Levene's test.
  
  
  RESULTS
  Both groups' clinical parameters were significantly improved at 6 months postsurgery. In Group A, the mean pre- and postoperative VAPS scores were 9.2 and 3.2, respectively (P < 0.05); the corresponding mean Oswestry scale scores were 88 and 28.2, respectively (P < 0.05); and the corresponding mean straight-leg raising angles were 290 and 630, respectively (P < 0.05). In Group B, the mean pre- and postoperative VAPS scores were 9.2 and 2.6, respectively (P < 0.05); the corresponding mean Oswestry scores were 85.2 and 22.2, respectively (P < 0.05); and the corresponding mean straight-leg raising scores were 260 and 710, respectively (P < 0.05). The mean scarring grades in Groups A and B were 1.8 and 1.0, respectively (P < 0.05).
  
  
  CONCLUSIONS
  The groups both showed satisfactory clinical outcomes and the improvements were comparable; however, the group with preserved ligamentum flavum showed significantly less local fibrosis at 6 months postoperatively. The authors speculate that this surgical technique provides a physical protective barrier that can reduce or even eliminate fibrosis-related complications after lumbar disc surgery.
authors.affiliation: Neurosurgery Department, Vehbi Koc Foundation, American Hospital, Istanbul, Turkey.
authors.forename: Ali F
authors.initials: AF
authors.lastname: Ozer
authors.forename: Tunc
authors.initials: T
authors.lastname: Oktenoglu
authors.forename: Mehdi
authors.initials: M
authors.lastname: Sasani
authors.forename: Hakan
authors.initials: H
authors.lastname: Bozkus
authors.forename: Nazan
authors.initials: N
authors.lastname: Canbulat
authors.forename: Ercan
authors.initials: E
authors.lastname: Karaarslan
authors.forename: Suleyman F
authors.initials: SF
authors.lastname: Sungurlu
authors.forename: Ali C
authors.initials: AC
authors.lastname: Sarioglu
mesh_terms: D000273:Adipose Tissue / Q000033:anatomy & histology / Q000502:physiology; D000328:Adult; D002921:Cicatrix / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D017586:Diskectomy / Q000009:adverse effects / Q000379:methods*; D004824:Epidural Space / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D005260:Female; D005355:Fibrosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000601:surgery; D007796:Laminectomy / Q000009:adverse effects / Q000379:methods*; D017843:Ligamentum Flavum / Q000033:anatomy & histology / Q000601:surgery*; D008159:Lumbar Vertebrae / Q000033:anatomy & histology / Q000601:surgery*; D008297:Male; D010149:Postoperative Pain / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D011183:Postoperative Complications / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D011446:Prospective Studies; D013115:Spinal Canal / Q000473:pathology / Q000503:physiopathology / Q000601:surgery; D013126:Spinal Nerve Roots / Q000293:injuries / Q000503:physiopathology; D000267:Tissue Adhesions / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology