Co-culture of Adult Mesenchymal Stem Cells and Nucleus Pulposus Cells in Bilaminar Pellets for Intervertebral Disc Regeneration

Background: Our goal is to optimize stem cell-based tissue engineering strategies in the context of the intervertebral disc environment. We explored the benefits of co-culturing nucleus pulposus cells (NPC) and adult mesenchymal stem cells (MSC) using a novel spherical bilaminar pellet culture system where one cell type is enclosed in a sphere of the other cell type. Our 3D system provides a structure that exploits embryonic processes such as tissue induction and condensation. We observed a unique phenomenon: the budding of co-culture pellets and the formation of satellite pellets that separate from the main pellet. Methods: MSC and NPC co-culture pellets were formed with three different structural organizations. The first had random organization. The other two had bilaminar organization with either MSC inside and NPC outside or NPC inside and MSC outside. Results: By 14 days, all co-culture pellets exhibited budding and spontaneously generated satellite pellets. The satellite pellets were composed of both cell types and, surprisingly, all had the same bilaminar organization with MSC on the inside and NPC on the outside. This organization was independent of the structure of the main pellet that the satellites stemmed from. Conclusion: The main pellets generated satellite pellets that spontaneously organized into a bilaminar structure. This implies that structural organization occurs naturally in this cell culture system and may be inherently favorable for cell-based tissue engineering strategies. The occurrence of budding and the organization of satellite pellets may have important implications for the use of co-culture pellets in cell-based therapies for disc regeneration. Clinical Relevance: From a therapeutic point of view, the generation of satellite pellets may be a beneficial feature that would serve to spread donor cells throughout the host matrix and restore normal matrix composition in a sustainable way, ultimately renewing tissue function. © 2009 The Spine Arthroplasy Society

Bovine explant model of degeneration of the intervertebral disc

Background: Many new treatments for degeneration of the intervertebral disc are being developed which can be delivered through a needle. These require testing in model systems before being used in human patients. Unfortunately, because of differences in anatomy, there are no ideal animal models of disc degeneration. Bovine explant model systems have many advantages but it is not possible to inject any significant volume into an intact disc. Therefore we have attempted to mimic disc degeneration in an explant bovine model via enzymatic digestion. Methods: Bovine coccygeal discs were incubated with different concentrations of the proteolytic enzymes, trypsin and papain, and maintained in culture for up to 3 weeks. A radio-opaque solution was injected to visualise cavities generated. Degenerative features were monitored histologically and biochemically (water and glycosaminoglycan content, via dimethylmethylene blue). Results and Conclusion: The central region of both papain and trypsin treated discs was macro- and microscopically fragmented, with severe loss of metachromasia. The integrity of the surrounding tissue was mostly in tact with cells in the outer annulus appearing viable. Biochemical analysis demonstrated greatly reduced glycosaminoglycan content in these compared to untreated discs. We have shown that bovine coccygeal discs, treated with proteolytic enzymes can provide a useful in vitro model system for developing and testing potential new treatments of disc degeneration, such as injectable implants or biological therapies

Urocortin protects chondrocytes from NO-induced apoptosis: a future therapy for osteoarthritis?

Osteoarthritis (OA) is characterized by a loss of joint mobility and pain resulting from progressive destruction and loss of articular cartilage secondary to chondrocyte death and/ or senescence. Certain stimuli including nitric oxide (NO) and the pro-inflammatory cytokine tumor necrosis factor α (TNF-α have been implicated in this chondrocyte death and the subsequent accelerated damage to cartilage. In this study, we demonstrate that a corticotrophin releasing factor (CRF) family peptide, urocortin (Ucn), is produced by a human chondrocyte cell line, C-20/A4, and acts both as an endogenous survival signal and as a cytoprotective agent reducing the induction of apoptosis by NO but not TNF-α when added exogenously. Furthermore, treatment with the NO donor S-nitroso-N-acetyl-D-L-penicillamine upregulates chondrocyte Ucn expression, whereas treatment with TNF-α does not. The chondroprotective effects of Ucn are abolished by both specific ligand depletion (with an anti-Ucn antibody) and by CRF receptor blockade with the pan-CRFR antagonist α-helical CRH(9-41). CRFR expression was confirmed by reverse transcription-PCR with subsequent amplicon sequence analysis and demonstrates that C-20/A4 cells express both CRFR1 and CRFR2, specifically CRFR1α and CRFR2β. Protein expression of these receptors was confirmed by western blotting. The presence of both Ucn and its receptors in these cells, coupled with the induction of Ucn by NO, suggests the existence of an endogenous autocrine/paracrine chondroprotective mechanism against stimuli inducing chondrocyte apoptosis via the intrinsic/mitochondrial pathway

The Comparison of Cost-Effectiveness Between Magnetic Resonance Spectroscopy and Provocative Discography in the Identification of Chronic Low Back Pain Surgery Candidates

Leslie Wilson,1 Douglas P Beall,2 Robert Kenneth Eastlack,3 Sigurd Berven,4 Jeffrey C Lotz4 1Department of Pharmacy, UC San Francisco, San Francisco, CA, 94143, USA; 2Comprehensive Specialty Care, Edmond, OK, 73034, USA; 3Department of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, 92037, USA; 4Department of Orthopaedic Surgery, UC San Francisco, San Francisco, CA, 94143-0728, USACorrespondence: Leslie Wilson, Department of Pharmacy, UC San Francisco, San Francisco, CA, 94143, USA, Tel +1 415-990-1012, Email [email protected]/Context: Chronic low back pain (CLBP) is a significant US healthcare burden with millions of lumbar spine procedures annually. Diagnostic tests are essential to guide treatment but provocative discography (PD), the most common diagnostic procedure, is without robust evidence of its value. A non-invasive alternative using Magnetic Resonance Spectroscopy (MRS) offers a potential solution.Context/Purpose: We assess cost-effectiveness of MRS with NOCISCAN diagnostic algorithm compared to PD for identifying lumbar discs requiring surgical intervention.Study Design/Setting: We conducted cost-effectiveness analysis using modelling.Patient Sample: We used data from a clinical study of 139 CLBP patients who met criteria for and received PD of lumbar spine and presented with an ODI score ≥ 40; comparing PD and MRS-based diagnostics.Outcome Measures: We considered diagnostic costs, adverse events, surgical costs and outcomes based on a 15-point improvement on the Oswestry Disability Index.Methods: Incremental cost-effectiveness ratios (ICERS) and probabilistic sensitivity analyses were determined. Some authors have consulted for Aclarion.Results: Mean total cost per PD patient was $59,711, and $57,998 for MRS, demonstrating $1712 cost savings per MRS diagnosed patient. Diagnostic costs ($1950 for PD; $1450 for MRS), saved $500 per MRS patient. PD incurred adverse event costs ($57,323) for 1% of patients, which MRS eliminated. MRS-based diagnosis showed 78% surgical success, whereas PD achieved 68%. MRS was the dominant diagnostic strategy, with better clinical outcomes and cost savings. Probabilistic sensitivity analysis confirmed MRS dominance and was cost-effective across a wide range of willingness-to-pay thresholds and across 2 different scenarios which vary base-case outcomes and surgical rates.Conclusion: This study demonstrates cost-effectiveness dominance of MRS with the Nociscan diagnostic algorithm over PD for identifying CLBP surgical candidates. MRS provides significant cost savings and leads to better surgical outcomes, making it a preferred choice for insurers and health systems.Plain Language Summary: Chronic low back pain (cLBP) is experienced by 20% of the US population. It is difficult to determine the best treatment, and many have unnecessary surgery. Discography is the currently available diagnostic but is invasive, of limited value and with serious adverse events. MRS+Nociscan, a new non-invasive diagnostic uses MR Spectroscopy and an algorithm to identify painful discs, is FDA registered. Our aim is to conduct a cost-effectiveness analysis (CEA) to compare the economic value of these two diagnostic procedures. Subjects were part of a multicenter study of 139 patients who received MR imaging and PD for chronic low back pain. The intervertebral disc MRS data post-processing was performed using the NOCISCAN-LS software algorithm. We developed a decision tree model comparing provocative discogram (PD) with an MRS+ Nociscan diagnostic algorithm using a health system perspective over 12-months. The primary endpoint was surgical ODI success or failure. Costs were from the Medicare Fee Schedule. We calculated in incremental cost-effectiveness ratio (ICER), in terms of the additional cost or savings per additional treatment success gained. The mean total PD group cost per patient was $59,711 and $57,998 in the MRS+Nociscan group demonstrating that MRS-based diagnosis saved $1712 per patient diagnosed. Clinical success with MRS-based diagnosis was 78%, and 68% with PD diagnosis. The cost-effectiveness demonstrated strong MRS-Nociscan dominance, meaning it was both cost saving and a better clinical success. The strong cost-effectiveness dominance for MRS+Nociscan diagnosis answers the budgetary questions for insurers and health systems considering adoption of this new diagnostic tool.Keywords: cost, cost-effectiveness, lumbar spine, diagnostics, outcomes, discograph

Pedicle Screw Surgery in the UK and Ireland: A Questionnaire Study

Pedicle screw (PS) malpositioning rates are high in spine surgery. This has resulted in the use of computed navigational aids to reduce the rate of malposition; but these are often expensive and limited in availability. A simple mechanical device to aid PS insertion might overcome some of these disadvantages. The purpose of this study was to determine the demand and design criteria for a simple device to aid PS placement, as well as to collect opinions and experiences on PS surgery in the UK and Ireland. A postal questionnaire was sent to 422 spinal surgeons in the UK and Ireland. 101 questionnaires were received; 67 of these (16% of total sent) contained useful information. 78% of surgeons experienced problems with PS placement. The need for a simple mechanical device to aid PS placement was expressed by 59% of respondent surgeons. The proportion of respondents that inserted PSs in the cervical spine was 14%; PSs are mainly inserted in the thoracic, lumbar and sacral spine, but potential exists for a PS placement aid for the cervical and thoracic spine. From the experiences of these 67 surgeons, there is evidence to suggest that surgeons would prefer a pedicle aid that is multiple use, one-piece, hand-held, radiolucent, unilateral and uses the line of sight principle in traditional open surgery. Based on the experiences of 67 surgeons, there is evidence to suggest that computed navigational aids are not readily used in PS surgery and that a simple mechanical device could be a better option. This paper provides useful data for improving the outcomes of spinal surgery

Finite element analysis of the effect of cementing concepts on implant stability and cement fatigue failure

Background and purpose Two contradictory cementing techniques (using an undersized stem versus a canal-filling stem) can both lead to excellent survival rates, a phenomenon known as the “French paradox”. Furthermore, previous studies have indicated that the type of bone supporting the cement mantle may affect implant survival. To further evaluate the mechanical consequences of variations in cementing technique, we studied the effect of implant size and type of bone supporting the cement mantle on the mechanical performance of cemented total hip arthroplasty, using finite element analysis

Simulated-Physiological Loading Conditions Preserve Biological and Mechanical Properties of Caprine Lumbar Intervertebral Discs in Ex Vivo Culture

Low-back pain (LBP) is a common medical complaint and associated with high societal costs. Degeneration of the intervertebral disc (IVD) is assumed to be an important causal factor of LBP. IVDs are continuously mechanically loaded and both positive and negative effects have been attributed to different loading conditions

Expression of matrix metalloproteinase-1 (MMP-1) in Wistar rat's intervertebral disc after experimentally induced scoliotic deformity

<p>Abstract</p> <p>Introduction</p> <p>A scoliotic deformity on intervertebral discs may accelerate degeneration at a molecular level with the production of metalloproteinases (MMPs). In the present experimental study we evaluated the presence of MMP-1 immunohistochemically after application of asymmetric forces in a rat intervertebral disc and the impact of the degree of the deformity on MMP-1 expression.</p> <p>Material-Method</p> <p>Thirty female Wistar rats (aged 2 months old, weighted 200 ± 10 grams) were used. All animals were age, weight and height matched. A mini Ilizarov external fixator was applied at the base of a rat tail under anaesthesia in order to create a scoliotic deformity of the intervertebral disc between the 9^thand 10^thvertebrae. Rats were divided into three groups according to the degree of the deformity. In group I, the deformity was 10°, in group II 30° and in group III 50°. The rats were killed 35 days after surgery. The discs were removed along with the neighbouring vertebral bodies, prepared histologically and stained immunohistochemically. Immunopositivity of disc's cells for MMP-1 was determined using a semi-quantitative scored system.</p> <p>Results</p> <p>MMP-1 immunopositivity was detected in disc cells of annulus fibrosus of all intervertebral disc specimens examined. The percentage of MMP-1 positive disc cells in annulus fibrosus in group I, II and III were 20%, 43% and 75%, respectively. MMP-1 positivity was significantly correlated with the degree of the deformity (p < 0,001). An increase of chondrocyte-like disc cells was observed in the outer annulus fibrosus and at the margin of the intervertebral disc adjacent to the vertebral end plates. The difference in the proportion of MMP-1 positive disc cells between the convex and the concave side was statistically not significant in group I (p = 0,6), in group II this difference was statistically significant (p < 0,01). In group III the concave side showed a remarkable reduction in the number of disc's cells and a severe degeneration of matrix microstructure.</p> <p>Conclusion</p> <p>The present study showed that an experimentally induced scoliotic deformity on a rat tail intervertebral disc results in over-expression of MMP-1, which is dependent on the degree of the deformity and follows a dissimilar distribution between the convex and the concave side.</p

Trauma induces apoptosis in human thoracolumbar intervertebral discs

BACKGROUND: Vertebral fractures resulting from high energy trauma often comprise the risk of posttraumatic degenerative changes in the affected intervertebral discs (IVD). Particularly in conservatively treated patients, or in cases after implant removal of an exclusively posterior stabilization, consecutive disc degeneration and the associated functional losing of the spinal segment clearly represent detrimental treatment results. In this regard, apoptosis of IVD cells has been suggested to be involved in the critical changes of the extracellular matrix. METHODS: To investigate whether fractures of the vertebrae induce apoptosis in the affected IVD, disc tissue from patients (n = 17) undergoing open reduction and internal fixation of thoracolumbar spine fractures were analysed in regards to caspase activity, apoptosis-receptor expression levels and gene expression of apoptosis-regulating proteins such as Bax and Bcl-2. Healthy IVD tissue (n = 3) obtained from patients undergoing surgical resection of adjacent vertebrae were used as control samples. RESULTS: In contrast to healthy control IVD tissues, samples from traumatic thoracolumbar IVD showed positive TUNEL staining and a significant increase of caspase-3/7 activity. Interestingly, analyses of the initiator caspase-8 and -9 revealed significantly increased activation levels compared to control values, suggesting the coexistent activation of both the extrinsic (receptor-mediated) and intrinsic (mitochondria-mediated) apoptosis pathway. Accordingly, expression levels of the Fas receptor (FasR) mRNA were significantly increased. Although the TNF receptor I (TNFR I) was only slightly upregulated, corresponding TNFα from trauma IVD presented significantly increased mRNA expression values. Furthermore, traumatic IVD cells demonstrated significantly reduced expression of the mitochondria-bound anti-apoptotic Bcl-2, thereby maintaining baseline transcriptional levels of the pro-apoptotic Bax protein when compared to control IVD cells. CONCLUSION: Our data suggest that thoracolumbar fractures induce early caspase-dependent apoptosis in IVD cells of the affected intervertebral disc, in part, by downregulation of the anti-apoptotic protein Bcl-2 (intrinsic apoptosis pathway), as well as signalling via the death receptor complex (TNFR I and FasR)