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Omentum transplant for spinal cord injury

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    Omentum transplant for spinal cord injury

    The following are published abstracts of clinical studies from various countries, describing their experience with omentum transplants:

    A clinical trial that was carried out in England
    • Duffill J, Buckley J, Lang D, Neil-Dwyer G, McGinn F and Wade D (2001). Prospective study of omental transposition in patients with chronic spinal injury. J Neurol Neurosurg Psychiatry. 71 (1): 73-80. Summary: OBJECTIVES: This prospective study was designed to assess the effects of omental transposition in patients with a chronic spinal injury. METHODS: Neurological status was established to be stable and multiple baseline across patient studies were done preoperatively and repeated postoperatively. Assessments included activities of daily living (ADL), functional ability, degree of spasticity, motor power, sensation, pain perception, urodynamic studies, electromyography, sensory evoked potentials (SEPs), and infrared thermography to measure peripheral and general skin vascular responses. Each patient had MRI. Assessments were done at 3, 6, and 12 months after omental transposition in 17 patients. RESULTS: The detailed assessments failed to show significant improvement, although some patients showed minor objective and subjective change in some categories. Neurological deterioration occurred in one patient. There were 20 surgical complications including urinary tract infection, deep vein thrombosis, wound infection, and incisional hernia. CONCLUSIONS: Omental transposition has not been shown to improve neurological function in 17 patients with chronic spinal cord injury, and continued use of this operation in this situation is not supported by this study. Further advances in spinal cord repair may utilise the pedicled omental graft to provide an alternative vascular supply, but its current use should be limited to experimental models. <> Department of Neurosurgery, Wessex Neurological Centre, Southampton University Hospitals Trust, Tremona Road, Southampton SO16 6YD, UK.
    Here is another study from England that concluded that omentum transplants do not improve recovery:
    • Sgouros S and Williams B (1996). A critical appraisal of pediculated omental graft transposition in progressive spinal cord failure. Br J Neurosurg. 10 (6): 547-53. Summary: A critical review of patients who had pediculated omental grafting for progressive spinal cord failure was performed in order to assess the impact of this procedure on the natural history of the spinal cord function after spinal cord injury. Ten patients were reviewed; all had complete or partial paraplegia. Mean age at injury was 29.1 years. There was an average interval of 9.7 years between injury and onset of progressive worsening of symptoms, and 5.6 years between onset of such symptoms and diagnosis. Average follow-up was 24.5 months. Five patients underwent omental grafting as primary surgical treatment whereas the other five had earlier procedures. One patient died on the postoperative period. Significant morbidity was also observed. All the surviving patients were asked to score themselves by answering a questionnaire exploring the effect of surgery in limb function and performance on activities of daily living. Only two patients improved following the procedure. Two others remained unchanged, while the remaining six continued to deteriorate. There was no difference in clinical outcome between the primary surgery group and the ones that had had previous procedures. Delayed omental grafting done as tried in this clinic did not seem to improve the prognosis of the injured cord and was associated with significant morbidity. < st_uids=9115649> Midland Centre for Neurosurgery and Neurology, Birmingham, UK.
    Clinical experience with omentum procedures to treat neuropathic pain in Russia
    • Spaic M, Minic L, Djitic R, Lukic Z and Tadic R (2001). [Omentomyelosynangiosis--a direct intraoperative observation]. Vojnosanit Pregl. 58 (3): 249-54. Summary: The late outcome of implantation of the vascular omental pedicle on the injured spinal cord performed in 7 patients to improve functional recovery through revascularization of the injured cord tissue is reported. All the patients were reoperated at the same spinal level 2-5 years after the omental pedicle implantation for the treatment of chronic neuropathic spinal pain by employing DREZ (Dorsal Root Entry Zone lesion) surgery. From the technical standpoint it was necessary to mobilize the implanted omental pedicle from the cord surface to provide the access to dorsolateral cord sulcus for the DREZ operation. Mobilization of the omental pedicle provided unique opportunity to observe omental-cord contact surface (omentomielosinangiosis) that is believed to stimulate revascularization of the cord tissue. In our report particular attention was paid to the specificity of the omental-cord contact surface and the late tissue changes of the cord as well as omental tissue knowing the fact that the capacity of omental tissue to stimulate neoangiogenesis still represents the actual doubt in neurobiological theory and practice. Detailed analysis of the actual neurological condition of these patients compared to neurological condition assessed before the implantation of the pediculated-vascular omental graft revealed neither sensory nor motoric improvement (in the postimplantation period). The effect of DREZ surgery of the chronic neuropathic spinal pain was not a topic of this report. < st_uids=11548549>
    Here is a study of somatosensory and motor evoked potentials associated with omental transplants at the Burdenko Institute in Moscow, suggesting that there may be some changes of evoked potentials below the injury site but none of the evoked potentials were reaching the brain:

    • Sokolova AA, Iundin VI, Iarikov DE, Kolpachkov VA, Baskov AV and Shevelev IN (1999). [Changes in the somatosensory evoked potentials of patients with complicated spinal trauma after an omentomyelopexy operation]. Zh Vopr Neirokhir Im N N Burdenko. (1): 15-20. Summary: The purpose of the study was to record somatosensory evoked potentials (SSEP) to objectify the results omentomyelopexy in late spinal cord injury. SSEP were recorded in 25 patients in leads of three levels of the somatosensory tract (from the popliteal fossa, from the lumbar enlargement of the spinal cord, and from the surface of the skull in the region of projection of leg presentation in cerebral hemispherical cortex) before and after surgery. The study indicated that there were no pre- or postoperative records of cortical evoked potentials. At the same time there was improvement in the magnitude of SSEP at the level of the lumbar enlargement (36%). In 4 (16%) and 5 (20%) cases of them SSEP changes were clear and unclear, respectively. The assessment of SSEP changes requires consideration of cases with unclear SSEP. Comparison of the results with clinical findings shows a correlation mainly with urological and urodynamic evidence. Thus, there are minor positive changes in the magnitude of SSEP after omentomyelopexy in the lumbar enlargement lead with unclearly pronounced evoked potentials. < st_uids=10335571>
    Here is a report of a procedural change to avoid the complication of omental necrosis (death of the omentum graft due to pressure) in Belgrade, Yugoslavia

    • Ignjatovic M, Zivotic-Vanovic M, Cuk V, Ignjatovic D, Stankovic N, Minic L and Tadic R (1999). [Necrosis of the omental flap]. Acta Chir Iugosl. 46 (1-2): 33-7. Summary: The aim of this research is to review the frequency of the omental flap necrosis comparing the vascularized omental flaps based on the left or right gastroepiploic vessels. The first 100 patients, with injuries of spinal cord on different levels, are included in this prospective clinical study with follow-up from 12 to 24 months. The special surgical technique was used for preparation of omental pedicled graft, for its lengthening and transposition to the level of the spinal cord injury and direct and indirect signs of the omental flap necrosis were studied. In our patients there was no necrosis of the omental grafts based on the left gastroepiploic artery. The insufficiency of the left gastroepiploic artery was not present in any patient and so it was not the reason of the omental flap necrosis. Devascularisation of the great gastric curvature until to the root of the left gastroepiploic artery, administration of the prophylactic doses of the Heparin and to put gently pressure on the omental flap do not contribute to the appearance of the omental flap necrosis. Based on our experiences and on results of this research we conclude that this way of forming the omental graft can be used for the other omentopexies. < st_uids=10951796> Vojnomedicinska akademija, Klinika za opstu i vaskularnu hirurgiju, Beograd.

    • Ignjatovic M, Cuk V, Zivotic-Vanovic M and Minic L (1998). New surgical technique of omental pedicle graft preparation for omentomyelopexy. Vojnosanit Pregl. 55 (3): 247-54. Summary: Omental pedicle graft with left gastroepiploic vessels is very rarely used extraabdominally and all existing techniques of graft mobilization and lengthening are related to the graft with right gastroepiploic vessels. The aim of this research was to present the new surgical preparation technique of the omental graft based on the left gastroepiploic vessels for omentomyelopexy. First 100 patients, with injuries of spinal cord on different levels, were included in this prospective clinical study. In all these cases we performed omentomyelopexy with omental pedicle graft based on the new surgical technique of omental mobilization and lengthening. The results revealed that the way of preparation of omental pedicle graft depended on the level of the spinal cord lesion: in most cases for the lesions of cervical spinal cord the omental grafts had to be lengthened, for the midthoracic lesions omental graft was prepared without lengthening, while for the thoracolumbar lesions, only a part of omentum for graft was mostly used. The new surgical technique for preparation of omental pedicle graft for omentomyelopexy enabled the application of one of three possibilities for omentum lengthening. It depended on the type of omental vascularization, based on our own original classification and not on the level of spinal cord lesion. The preparation of omental pedicled graft with the left gastroepiploic vessels enabled the omentomyelopexy regardless of the level of spinal cord injury. < st_uids=9720439> Clinic of General and Vascular Surgery, Belgrade.
    Here is a report from Russia that concluded that the procedure is not recommended:

    • Baskov AV, Shevelev IN, Iarikov DE, Iundin VI, Kolpachkov VA and Sokolova AA (1998). [The results of omentomyelopexy in the late period of traumatic spinal cord disease]. Zh Vopr Neirokhir Im N N Burdenko. (2): 17-9. Summary: The results of omental transplantation to the site of spinal cord lesion in 40 patients in late injury are given. Neurological deficit was alleviated in 17.5% of patients. Improvement of segmentary functions was observed in most cases and was recorded within 1 week to 3 months postoperatively. There was no neurological improvement after 6 months postoperatively. Patients with mild spinal cord injuries (D10-L1) had the best outcomes. Comparative analysis of the outcomes of omentomyelopexy with those of treatment in 115 patients undergone meningomyeloradicolysis did not demonstrate any significant difference. Thus, it is not justifiable to use omental transposition in late spinal cord injury. < st_uids=9720161>
    Finally, this is a U.S. study by Clifton, et al. that also concluded that the treatment is not effective:
    • Clifton GL, Donovan WH, Dimitrijevic MM, Allen SJ, Ku A, Potts JR, 3rd, Moody FG, Boake C, Sherwood AM and Edwards JV (1996). Omental transposition in chronic spinal cord injury. Spinal Cord. 34 (4): 193-203. Summary: The results of omental transposition in chronic spinal cord injury have been reported in 160 patients operated upon in the United States, Great Britain, China, Japan, India and Mexico, with detailed outcomes reported in few studies. Recovery of function to a greater degree than expected by natural history has been reported. In this series, 15 patients with chronic traumatic spinal cord injury (> 1.5 years from injury) underwent transposition of pedicled omentum to the area of the spinal cord injury. Of the first series of four patients who were operated upon in 1988, one died, one was lost to follow-up and two were followed with sequential neurological examinations and Magnetic Resonance Imaging (MRI) scans preoperatively, at 1 year post injury and 4 1/2 years post injury. Another 11 patients were operated in 1992 and underwent detailed neurological and neurophysiological examinations and had MRI scans preoperatively and every 4 months for at least 1 year after surgery. All patients completed a detailed self-report form. Of the total of 13 operated patients in both series followed for 1-4 1/2 years, six reported some enhanced function at 1 year and five of these felt the changes justified surgery primarily because of improved truncal control and decreased spasticity. MRI scans showed enlargement of the spinal cord as compared to preoperative scans in seven patients. Increased T2 signal intensity of the spinal cord was found by 1 year after surgery in eight of 13 operated patients. Neurophysiological examinations of 11 patients in the second series agreed with self-reports of increases or decreases in spasticity (r = 0.65, P < 0.03). Somatosensory evoked potentials and motor evoked potentials at 4 month intervals up to 1 year in these patients showed no change after surgery. Neurological testing, using the American Spinal Injury Association [ASIA) and International Medical Society of Paraplegia [IMSOP) international scoring standards, failed to show any significant changes when the 1-year post operative examination was compared to the first preoperative examination except for decreased sensory function after surgery which approached statistical significance. When the 11 patients in the second series were compared to eight non-operated matched patients, followed for a similar length of time, no significant differences were found. Complications encountered in the operated patients from both series included one postoperative death from a pulmonary embolus, one postoperative pneumonia, three chronic subcutaneous cerebrospinal fluid [CSF) fistulae requiring wound revision, and one patient who developed biceps and wrist extensor weakness bilaterally requiring graft removal. We conclude that the omental graft remains viable over time and this operation can induce anatomical changes in the spinal cord as judged by MRI. Some patients reported subjective improvement but this was not supported by objective testing. We, therefore, find no justification for further clinical trials of this procedure in patients who have complete or sensory incomplete lesions. Further testing in motor incomplete patients would seem appropriate only with compelling supportive data. < st_uids=8963963> Department of Neurosurgery, University of Texas-Houston Medical School, USA.
    Here is one case of improvement associated with omentum transplant in Mexico:
    • Rafael H, Malpica A, Espinoza M and Moromizato P (1992). Omental transplantation in the management of chronic traumatic paraplegia. Case report. Acta Neurochir (Wien). 114 (3-4): 145-6. Summary: A 27 year old male patient with chronic traumatic paraplegia received an omental transplant to the spinal cord. During surgery we found 40 percent of the spinal cord hypotrophied, with vascular alterations and abundant scar tissue. Some neurological improvement already started a few days postoperatively. After 36 months of postoperative follow-up he presents with right crural monoparesis (grade 1-4), deep sensation and with sphincter control. < st_uids=1580194> Instituto Mexicano del Seguro Social (IMSS), Mexico city.
    Some experiences from Japan without much comment on recovery of function:

    • Nagashima C, Masumori Y, Hori E, Kubota S, Kawanuma S, Shimada Y, Iwasaki T, Heshiki A and Mizuno H (1991). [Omentum transplantation to the cervical cord with microangioanastomosis]. No Shinkei Geka. 19 (4): 309-18. Summary: Transplantation of omentum to the cervical cord was done in three cases with incomplete transection (Case 1) with posttraumatic progressing cervical myelopathy (Case 2) and with complete transection due to multisegmental, late cervical cord infarction (Case 3). Anastomoses were made between the occipital artery and the gastroepiploic artery of transplanting omentum and between the occipital vein and the gastroepiploic vein. In Case 2 and 3, omentum was maintained in tissue culture medium in an incubator (37 degrees C, 5% CO2) for about five hours following perfusion of the omentum with low molecular dextran containing urokinase, heparin, vitamin B12 until exploration of the dural tube and preparation of the occipital vessels were accomplished. Although complete transection with late infarct (Case 3) showed extremely slow improvement in follow-up period of 8 months, the incomplete traumatic lesions (Case 1 and 2) showed less slow but steady improvements in follow-up periods of 24 and 22 months with almost complete recovery of Case 2. Angiography showed patent anastomosis in all the cases. Dynamic CT at 4 (Case 1) and 6 (Case 2) months showed good perfusion in the compromised cord through the transplanted omentum. < st_uids=2046844> Department of Nerosurgery, Saitama Medical School.

    Here are some comments from Goldsmith
    • Goldsmith HS (1999). Acute spinal cord injuries: a search for functional improvement. Surg Neurol. 51 (2): 231-3. Summary: < st_uids=10029435>
    • Goldsmith HS (1997). Omental transposition in chronic spinal cord injury. Spinal Cord. 35 (3): 189-90. Summary: < st_uids=9076874>
    • Rafael H (1997). Omental transplantation and spinal cord injury. J Neurosurg. 87 (5): 800. Summary: < st_uids=9347994>

    Arnie Fonseca, Jr. provided some additional information.

    Neurosurgeons at Stanford University carried out omentum transplants in about 17 patients with spinal cord injury.

    Arnie writes further:

    Article 10

    Treatment Synopsis
    Myelocyst - Omental Grafting

    Scott P. Falci, M.D., Paul Zweibel, M.D.
    Craig Hospital;  Craig Center for Spinal Cord Research, Englewood, CO.

    Editor's Note:  This synopsis was received December, 1998.
    There was no reference to the date of surgery.
    This synopsis is being posted to illustrate the effectiveness
    of Omental Transposition in reducing or eliminating cysts and fluids.

    Progressive post-traumatic cystic myelopathy is treated with various shunting techniques and spinal cord untethering.  In some cases the injury is so severe that untethering cannot be performed and the cyst remains refractory to shunting procedures.  We describe the first case of spinal cord cyst obliteration in a aptient using his own omentum maintained on it's vascular pedicle.

    The patient is a 38 year-old C5 quadriplegic male with ascending cystic myelopathy into the brainstem. Multiple shunting procedures failed to stop the progression of the cyst.  After his third shunting in one years time, the patient presented with respiratory compromise and weakness of accessory muscles of respiration.  Baseline FUC was 440 cc sitting, 800 cc supine.  A myelocyst-omental graft was performed, filling the cyst cavity with the patients omentum maintained on its vascular pedicle.  At one year followup, the patient's cyst has been obliterated with omental graft, his FUC is 180% of baseline, his accessory muscles of respiration have increased in strength, he has recruited new muscle groups, and he is living independently at home.  He, in fact, progressed to a neurological state which existed two years prior to the surgery.

    It is felt that omentum incorporates into cord tissue, providing additional vascularity and cellular matrix, thereby halting cystic myelopathy and allowing for some recover.


      Here is a article from Larry Johnston on Harry Goldsmith:
      The Omentum Momentum

      by S. Laurance Johnston, Ph.D.

      Although acceptance is growing worldwide, the verdict is still out on this controversial procedure for treating spinal-cord injury.

      Editor's note: The following article is presented to inform readers of an "alternative" treatment. While the Paralyzed Veterans of America SCI Education and Training Foundation supports the author's work, PN and PVA neither endorse nor reject this technique. 

      Brian Sternberg was not just a superb athlete; he was the best. In 1963, the University of Washington junior established a world pole-vault record of 16'8" and seemed destined to be the first to break 20 feet. His gymnastics background had made him a strong, agile athlete, especially well-suited for the new, flexible, state-of-the-art fiberglass poles.

      Practicing on the trampoline as he often did, Sternberg tried a maneuver he had routinely carried out in the past. This time, something went wrong. Landing awkwardly on his neck, he sustained a C4-5 spinal injury.

      Harry Goldsmith believes the omental procedure may reduce the extensive secondary neurological damage that occurs soon after injury.

      More than three decades later, in 1996, surgeon Harry Goldsmith operated on Sternberg, who says the omental procedure greatly increased Sternberg's quality of life. For example, because the injury affected the nerves controlling respiration, Sternberg could only speak in a whisper before surgery. Since then, his voice increased by about 60%.

      "I wouldn't have been able to have this conversation with you before the operation," Sternberg told me. He says his overall health and strength have greatly improved. For example, the operation has reduced the incapacitating pain he once had.

      "Before the surgery, on a scale of 1-10 [with 10 being the most severe], my pain averaged 8-13," Sternberg says. "Now it is 1-2."

      He has more feeling in extremities and improved circulation. He can stay upright for long periods of time, a problem before the surgery. In a Sports Illustrated article (September 21, 1998), Sternberg said the operation "has made all the difference in the world."

      Omental transposition is a controversial surgery used to treat spinal-cord injury (SCI). In this procedure, the omentum, a physiologically dynamic, fatty membranous tissue surrounding the intestinal and lower abdominal region, is surgically lengthened and placed over the area of injury.

      Currently associated with the University of Nevada's School of Medicine (Reno), Goldsmith has spent much of his career investigating omentum's therapeutic potential. His work has stimulated many others who have treated thousands of patients for SCI and other neurological disorders such as stroke, cerebral palsy, and Alzheimer's and Parkinson's diseases.

      The procedure's acceptance has grown greatly in other parts of the world, such as in China where more than 3,000 people with SCI have had omental surgery. In the United States, however, the conservative SCI research community has been reluctant to evaluate omental therapy for a variety of reasons.

      First, many researchers urge caution when considering a new therapy like this that involves an inherently risky surgery that tampers with the spinal cord. Second, omental surgery's radical nature falls outside prevailing SCI research perspectives and priorities. Third, although many people have had omental surgery, the value of this clinical experience, especially when originating in other countries, does not count much in the U.S. scientific court of judgment. Fourth, the therapy's image received a blow after a mid-1990s controversy in which an unauthorized recruiting agent was accused of over-promoting omentum's therapeutic benefits.

      Nevertheless, Goldsmith continues to be a tireless omental-therapy advocate. Several benefactors recently donated $2 million to establish the Omental Research Foundation to support his efforts. He plans to use these funds to help defer the high patient cost of the

      surgery and fund basic-research pilot studies.

      There is too much supporting research and patient experience to continue ignoring omentum's therapeutic potential. The verdict is not in for this procedure as many of us falsely concluded in the past. We need to open-mindedly gather more evidence, especially well-designed, controlled clinical trials to help definitively determine the procedure's benefits relative to its risks.

      S. Laurance Johnston, Ph.D., is a biomedical and disability-research consultant. He has 18 years of experience in Washington, D.C., as a senior science administrator at private research foundations, the National Institutes of Health (NIH), and the Food and Drug Administration. He authors a column in PN/Paraplegia News called Healing Options, which focuses on alternative treatment methods. Contact: <>107656.2604@com