Surachai Sae-Jung, Natthapoch Busarakham

The effect of adding carboxymethylcellulose and alginate to hyaluronic acid on reducing epidural fibrosis in a lumbar laminectomized rat model

Objective: This study aimed to compare the anti-epidural fibrosis and anti-inflammation effects of hyaluronic acid (HA)-carboxy- methylcellulose (CMC)-alginate hydrogel, pure HA, and normal saline using a lumbar laminectomized rat model. Methods: Thirty lumbar laminectomized adult rats were randomly assigned to three groups. The control group received normal saline, the HCA group received HA-CMC-alginate gel, and the HA group received pure HA gel soaked over the dura of the laminectomized area before closing the surgical wound. All rats were housed for eight weeks, then epidural fibrosis (EF) was histologically graded. In addition, the fibroblast and inflammatory cell density were computerized for evaluation. Results: The mean fibroblast densities were 32.03 × 10 2 ± 488, 13.22 × 10 2 ± 200, and 14.52 × 10 2 ± 368 cell/mm2 in the control, HCA, and HA groups, respectively. The mean inflammatory cell density was 30.74 × 10 2 ± 459, 5.90 × 10 2 ± 129, and 11.08 × 10 2 ± 282 cell/mm2 in the control, HCA, and HA groups, respectively. The mean fibroblast and inflammatory cell densities in the HCA and HA groups were significantly lower than in the control group (P < 0.05). The HCA group had a significantly lower inflammatory cell density than the HA group (P < 0.05). The fibrous adherence grading of HCA and HA was significantly lower than the control (P < 0.05). Conclusion: HA-CMC-alginate gel and HA hydrogels seem to have a better preventative effect on EF than no treatment (control). HA-CMC- alginate can exhibit a better anti-inflammatory effect than HA. HA-CMC-alginate can be effective in reducing EF and inflammation after lumbar laminectomy.

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1. Jönsson B, Strömqvist B. Repeat decompression of lumbar nerve roots: a prospec- tive two-year evaluation. J Bone Joint Surg Br. 1993;75(6):894-897. [CrossRef]
2. Sae-Jung S, Jirarattanaphochai K. Prevention of peridural fibrosis using a cyclooxygenase-2 inhibitor (nonsteroidal anti-inflammatory drug) soaked in absorbable gelatin sponge: an experimental comparative animal model. Spine (Phila Pa 1976). 2013;38(16):E985-E991. [CrossRef]
3. Siqueira EB, Kranzler LI, Dharkar DD. Fibrosis of the dura mater: a cause of "failed back" syndrome. Surg Neurol. 1983;19(2):168-170. [CrossRef]
4. Topsakal C, Akpolat N, Erol FS, et al. Seprafilm superior to Gore-Tex in the prevention of peridural fibrosis. J Neurosurg. 2004;101(2):295-302. [CrossRef]
5. Schimizzi AL, Massie JB, Murphy M, et al. High-molecular-weight hyaluronan inhibits macrophage proliferation and cytokine release in the early wound of a preclinical postlaminectomy rat model. Spine J. 2006;6(5):550-556. [CrossRef]
6. Liu H, Li HF, Wang JY. Prevention effect of medical self-crosslinking sodium hyaluronate gel on epidural scar adhesion after laminectomy. Asian Pac J Trop Med. 2014;7(6):501-504. [CrossRef]
7. Kasimcan MO, Bakar B, Aktaş S, Alhan A, Yilmaz M. Effectiveness of the bio- physical barriers on the peridural fibrosis of a postlaminectomy rat model: an experimental research. Injury. 2011;42(8):778-781. [CrossRef]
8. Akeson WH, Massie JB, Huang B, et al. Topical high-molecular-weight hyaluro- nan and a roofing barrier sheet equally inhibit postlaminectomy fibrosis. Spine J. 2005;5(2):180-190. [CrossRef]
9. Kato T, Haro H, Komori H, Shinomiya K. Evaluation of hyaluronic acid sheet for the prevention of postlaminectomy adhesions. Spine J. 2005;5(5):479-488. [CrossRef]
10. Park JS, Lee JH, Han CS, Chung DW, Kim GY. Effect of hyaluronic acid-carbo xymethylcellulose solution on perineural scar formation after sciatic nerve repair in rats. Clin Orthop Surg. 2011;3(4):315-324. [CrossRef]
11. Ørning P, Hoem KS, Coron AE, et al. Alginate microsphere compositions dictate different mechanisms of complement activation with consequences for cytokine release and leukocyte activation. J Control Release. 2016;229:58-69. [CrossRef]
12. Sae-Jung S, Jirarattanaphochai K, Sumananont C, Wittayapairoj K, Suk - honthamarn K. Interrater reliability of the postoperative epidural fibrosis clas- sification: a histopathologic study in the rat model. Asian Spine J. 2015;9(4):587-594. [CrossRef]
13. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175-191. [CrossRef]
14. Zhang Z, Xu H, Zhang Y, et al. Nonsteroidal anti-inflammatory drugs for postoperative pain control after lumbar spine surgery: a meta- analysis of randomized controlled trials. J Clin Anesth. 2017;43:84-89. [CrossRef]
15. Lalountas MA, Ballas KD, Skouras C, et al. Preventing intraperitoneal adhe - sions with atorvastatin and sodium hyaluronate/carboxymethylcellulose: a comparative study in rats. Am J Surg. 2010;200(1):118-123. [CrossRef]
16. Kelekci S, Yilmaz B, Oguz S, Zergeroğlu S, Inan I, Tokucoğlu S. The efficacy of a hyaluronate/carboxymethylcellulose membrane in prevention of postopera- tive adhesion in a rat uterine horn model. Tohoku J Exp Med. 2004;204(3):189- 194. [CrossRef]
17. Lee SY, Jeon CW, Lee MB, Lee KR, Koh ES, Uhm YI. A experimental study for the effect of sodium carboxymethyl cellulose on prevention of percardial adhe- sion. Korean J Thorac Cardiovasc Surg. 2000;33:541-546.
18. Kim JH, Kim KS, Yoon HC, et al. Anti-adhesive effect of GUARDIX-SL (R) after endoscopic sinus surgery. Korean J Otolaryngol Head Neck Surg. 2005;48: 1478-1483.
19. Cross SE, Naylor IL, Coleman RA, Teo TC. An experimental model to investi- gate the dynamics of wound contraction. Br J Plast Surg. 1995;48(4):189-197. [CrossRef]
20. Zucker I, Beery AK. Males still dominate animal studies. Nature. 2010;465(7299):690. [CrossRef]
21. Kemaloglu S, Ozkan U, Yilmaz F, et al. Prevention of spinal epidural fibrosis by recombinant tissue plasminogen activator in rats. Spinal Cord. 2003;41(8):427- 431. [CrossRef]