自噬与椎间盘退变关系的研究进展

自噬是一种将细胞内受损、变性、衰老的细胞器或蛋白质运输到自噬溶酶体中进行降解、循环与再利用的生物学过程。近年来研究发现,细胞自噬存在于多数退行性疾病中,其中包括骨性关节炎以及椎间盘退变(intervertebral disc degeneration,IDD)。椎间盘退变是各种退行性脊柱疾病的病理基础,是导致下腰痛的主要原因。有研究发现,在退变的椎间盘细胞中存在不同水平的自噬,但是椎间盘退变中自噬的确切作用目前仍然存在争议。因此有必要深入了解髓核细胞自身的自噬作用及其对细胞生存的影响,这对退行性椎间盘疾病的预防和治疗具有重要的临床意义。该文概要地介绍了自噬作用和过程的最新研究进展,并着重总结自噬与椎间盘退变的关系。     

人退变椎间盘软骨终板干细胞多向分化的研究

目的：为了分离和鉴定人退变椎间盘软骨终板干细胞。方法：收集因腰椎间盘退变性疾病行腰椎间盘摘除术并植骨融合的标本。在解剖显微镜下清理软骨终板组织,并消化软骨终板,提取软骨终板细胞。获得的软骨终板细胞经过琼脂糖三维筛选系统培养后,选取细胞克隆团并进行体外扩增,扩增后的细胞行流式细胞术检测干细胞标志物证实退变软骨终板中存在干细胞。结果：共聚焦免疫荧光提示退变椎间盘软骨终板组织中存在干细胞标志物STR01、CDl05、CD73、CD90阳性的细胞。经琼脂糖三维培养基筛选的CESCs在免疫表型上符合干细胞标准。结论：在人退变椎间盘的软骨终板中存在具有多向分化潜能的干细胞。     

人退变椎间盘软骨终板干细胞多向分化的研究

目的:为了分离和鉴定人退变椎间盘软骨终板干细胞。方法:收集因腰椎间盘退变性疾病行腰椎间盘摘除术并植骨融合的标本。在解剖显微镜下清理软骨终板组织,并消化软骨终板,提取软骨终板细胞。获得的软骨终板细胞经过琼脂糖三维筛选系统培养后,选取细胞克隆团并进行体外扩增,扩增后的细胞行流式细胞术检测干细胞标志物证实退变软骨终板中存在干细胞。结果:共聚焦免疫荧光提示退变椎间盘软骨终板组织中存在干细胞标志物STRO1、CD105、CD73、CD90阳性的细胞。经琼脂糖三维培养基筛选的CESCs在免疫表型上符合干细胞标准。结论:在人退变椎间盘的软骨终板中存在具有多向分化潜能的干细胞。     

氧化应激介导的NF-kB 信号转导通路在椎间盘退变中的作用

椎间盘位于两个椎体之间,在脊柱中发挥着连接、减震和固定作用,其发生退变可以引起一系列椎间盘退变性疾病,是多数 脊柱疾病发病的根本原因,探索椎间盘的退变机制是寻找其治疗措施的前提。椎间盘退变机制十分复杂,其最主要的病理基础是 椎间盘活性细胞减少以及其引起的细胞外基质合成减少和成分的改变,而NF-kB 作为一种普遍存在在真核细胞中的多向性转录 因子,通过多种途径在细胞增殖、分化及凋亡方面起着关键的作用,研究表明,抑制NF-kB信号通路可以有效的缓解椎间盘退变; 而引起NF-kB信号通路的异常激活的因素很多,其中氧化应激是一个重要的因素,同时研究证实在椎间盘退变中存在着氧化损 伤。因此,当年龄、营养、外伤等因素引起的椎间盘细胞中发生氧化应激,进而导致NF-资B信号通路的激活,从而使其转录活性增 高,触发凋亡信号,引起髓核细胞的大量凋亡,使其参与到椎间盘退变中。     

氧化应激介导的NF-κB信号转导通路在椎间盘退变中的作用

椎间盘位于两个椎体之间,在脊柱中发挥着连接、减震和固定作用,其发生退变可以引起一系列椎间盘退变性疾病,是多数脊柱疾病发病的根本原因,探索椎间盘的退变机制是寻找其治疗措施的前提。椎间盘退变机制十分复杂,其最主要的病理基础是椎间盘活性细胞减少以及其引起的细胞外基质合成减少和成分的改变,而NF-κB作为一种普遍存在在真核细胞中的多向性转录因子,通过多种途径在细胞增殖、分化及凋亡方面起着关键的作用,研究表明,抑制NF-κB信号通路可以有效的缓解椎间盘退变;而引起NF-κB信号通路的异常激活的因素很多,其中氧化应激是一个重要的因素,同时研究证实在椎间盘退变中存在着氧化损伤。因此,当年龄、营养、外伤等因素引起的椎间盘细胞中发生氧化应激,进而导致NF-κB信号通路的激活,从而使其转录活性增高,触发凋亡信号,引起髓核细胞的大量凋亡,使其参与到椎间盘退变中。     

人工腰椎间盘置换研究应用进展

椎间盘病变是脊柱外科的常见疾病,是成年人疼痛和致残的常见原因,常常给人带来沉重的肉体和经济负担。经过长时间的发展与脊柱外科手术的进步,常规手术治疗在临床上虽然取得了一定的疗效,但是没有保留脊柱的生理运动功能,对临近阶段的椎间盘的退变起到促进作用,并且腰椎运动节段的融合加快了邻近节段椎间盘和小关节的退变。腰椎独特的解剖学特点和生物力学的研究及不同材质和特点的人工椎间盘材料的发展使人工椎间盘手术成为可能。与常规手术方式相比,人工椎间盘假体设计与人生理的解剖结构更加吻合。术后可以保持瞬时和长期的稳定性,从而对邻近的椎间盘的退变起到抑制作用。取得了较好的疗效。人工椎间盘置换术作为治疗腰椎间盘除腰椎融合之外的另一合理选择,目的是使退变导致的疼痛可以稳定长期缓解,并重建椎间隙高度以保护神经,从而避免晚期关节突关节及邻近节段的病变,恢复脊柱的运动学和载荷特性。目前人工腰椎间盘有了长远的发展,适应症不断扩大,但仍有较多限制。期待在将来能够找出更加符合人体生物力学特点的材料和设计,使之成为一种更为有效的治疗腰椎疾病的治疗方式。现就人工椎间盘的类型、疗效、适应证、禁忌证以及术后并发症等方面予以综述。     

椎间盘微环境对干细胞疗法修复椎间盘的影响的研究概况

椎间盘(IVD)退变是一种常见的病理状态,保守治疗往往失败,IVD变性的患者最后往往需要手术干预。已经提出的几种治疗方案中,只有椎间盘切除术和关节融合术被证明可以达到预料的效果。生物治疗的目的是预防和控制椎间盘变性,改善椎间盘的功能、髓核和纤维环细胞的合成代谢和修复能力,并抑制基质降解。目前,临床应用仍处于起步阶段。间充质干细胞和基因治疗在预防和治疗IVD变性的作用还需要进一步的研究。最近的研究向我们展示了一种新的保护椎间盘的结构和功能的治疗策略:间充质干细胞(MSCs)移植,尤其是骨髓间充质干细胞(BM-MSCs)。而了解MSCs是否可以以及如何在有排拆性的退化的椎间盘中存活并繁殖是十分重要的。因此,本文着重讨论内源性蛋白酶、细胞因子、低氧、低营养、机械负荷及渗透压的调节对移植的MSCs的影响。     

经Quadrant可扩张微创通道手术治疗下腰椎退变性疾病的护理

目的总结经Quadrant可扩张微创通道手术治疗下腰椎退变性疾病的护理。方法对40例经Quadrant可扩张微创通道手术治疗的下腰椎退变性疾病患者围手术期给予心理护理、术前训练、完善术前准备工作,术后加强病情和引流管的观察、体位护理、康复功能锻炼等护理措施。结果所有患者均顺利完成手术、痊愈出院,无感染,无下肢静脉血栓等并发症发生。结论积极有效的围手术期护理对促进患者早日康复,防止疾病复发,提高患者的生活质量具有重要意义。     

腰椎多节段退变性滑脱的手术治疗

目的:研讨腰椎多节段退变性滑脱手术减压和植骨融合方式与疗效的关系。方法:20例腰椎多节段退变性滑脱患者行后路椎弓根螺钉复位内固定后,采用椎管减压、神经根松解,行椎间植骨和后外侧植骨融合术,采用日本整形外科学会(JOA)下腰痛评分标准评价疗效。结果:获得连续随访者18例,随访时间9月～3年,平均24个月,优良率90%。结论:可靠的内固定、复位,神经根松解,椎间植骨融合治疗腰椎多节段退变性滑脱效果满意,充分的神经根松解是手术治疗的关键。     

微创经椎间孔减压腰椎融合内固定术用于腰椎退变性疾病中的效果

分析腰椎退变性疾病患者实施微创经椎间孔减压腰椎融合内固定术的临床效果。调查对象于我院2012年1月至2015年4月收治腰椎退变性疾病患者中挑选,将100例按照入院的先后顺序分组处理:50例对照组患者实施后路开放术式,50例研究组患者实施微创经椎间孔减压腰椎融合内固定术,手术后评定总体效果。研究组患者术后的疼痛度评分、并发症率和对照组相比,p0.05,有区别。临床针对腰椎退变性疾病患者实施微创经椎间孔减压腰椎融合内固定术作用突出,可减轻疼痛度,预防并发症,减少医疗费用,值得学习。     

The incidence of adjacent segment degeneration after cervical disc arthroplasty (CDA): a meta analysis of randomized controlled trials

Background

Cervical disc arthroplasty is being used as an alternative degenerative disc disease treatment with fusion of the cervical spine in order to preserve motion. However, whether replacement arthoplasty in the spine achieves its primary patient centered objective of lowering the frequency of adjacent segment degeneration is not verified yet.

Methodology

We conducted a meta-analysis according to the guidelines of the Cochrane Collaboration using databases including PubMed, Cochrane Central Register of Controlled Trials and Embase. The inclusion criteria were: 1) Randomized, controlled study of degenerative disc disease of the cervical spine involving single segment or double segments using Cervical disc arthroplasty (CDA) with anterior cervical discectomy and fusion (ACDF) as controls; 2) A minimum of two-year follow-up using imaging and clinical analyses; 3) Definite diagnostic evidences for “adjacent segment degeneration” and “adjacent segment disease”; 4) At least a minimum of 30 patients per population. Two authors independently selected trials; assessed methodological quality, extracted data and the results were pooled.

Results

No study has specifically compared the results of adjacent segment degenerative; Two papers describing 140 patients with 162 symptomatic cervical segment disorders and compared the rate of postoperative adjacent segment disease development between CDA and ACDF treatments, three publications describing the rate of adjacent-segment surgery including 1273 patients with symptomatic cervical segments. The result of the meta-analysis indicates that there were fewer the rate of adjacent segment disease and the rate for adjacent-segment surgery comparing CDA with ACDF, but the difference was not statistically significant.

Conclusions

Based on available evidence, it cannot be concluded, that CDA can significantly reduce the postoperative rate of the adjacent segment degenerative and adjacent segment disease. However, due to some limitations, the results of this meta-analysis should be cautiously accepted, and further studies are needed.     

Short-Term Effect of Unilateral Pedicle Screw Fixed Intervertebral Fusion in Treatment of Degenerative Disc Disease Via MAST QUADRANT Minimally Invasive System

To assess the short-term outcome of unilateral pedicle screw fixed intervertebral fusion surgery for degenerative disc disease via MAST QUADRANT minimally invasive system. Thirty patients with degenerative lumbar disease from September 2009 to September 2011 were enrolled and divided into two groups: (1) unilateral pedicle screw fixed intervertebral fusion via MAST QUADRANT system; and (2) conventional bilateral pedicle fixed intervertebral fusion via open surgery. The perioperative parameters (operation time, intraoperative blood loss, and length of stay) and the follow-up clinical curative effect parameters (VAS and ODI) were compared between two groups. All patients successfully completed surgery and were followed up for more than 1 year. The perioperative parameters of MAST QUADRANT system group were significantly better than the control group (P < 0.05). And the clinical curative effects were similar to conventional surgery (P > 0.05). Unilateral pedicle screw fixed intervertebral fusion via MAST QUADRANT system is a less invasive and safer surgical techniques. It offers a quick recovery and effective surgical option in the treatment of lumbar degenerative diseases.     

Good results of circumferential spine fusion in smokers, using autograft and allograft

We have examined the rates of anterior interbody fusion of lumbar spine segments following fusion with a fresh frozen femoral head allograft in 25 heavy smoking patients. They were all stabilized both anteriorly and posteriorly. The indications for surgery were: degenerative disc disease, degenerative spondylolisthesis and nonunion following previous posterolateral fusion of lumbar spine segments. Only patients who had fusion of one or two lumbar segments were included. They all were stabilized posteriorly with pedicle screws and autogenic iliac bone graft. The fusion was assessed at least one year after surgery according to plan X-rays as “Solid”, “Questionable” or “Failure”. One patient was found at follow up not fused, in another one the fusion was “questionable” and all the other 23 patients had an anterior solid fusion. Clinically, 84% of the patients had the same or improved work status as before surgery and 68% acknowledged that they were satisfied with the surgical results. No major complications were recorded and the average length of hospitalization was 10.3 days. This revised version was published online in July 2006 with corrections to the Cover Date.     

Biomechanical differences of Coflex-F and pedicle screw fixation combined with TLIF or ALIF--a finite element study

Lumbar interbody fusion is a common procedure for treating lower back pain related to degenerative disc diseases. The Coflex-F is a recently developed interspinous spacer, the makers of which claim that it can provide stabilisation similar to pedicle screw fixation. Therefore, this study compares the biomechanical behaviour of the Coflex-F device and pedicle screw fixation with transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion (ALIF) surgeries by using finite element analysis. The results show that the Coflex-F device combined with ALIF surgery can provide stability similar to the pedicle screw fixation combined with TLIF or ALIF surgery. Also, the posterior instrumentations (Coflex-F and pedicle screw fixation) combined with TLIF surgery had lower stability than when combined with ALIF surgery.     

Biomechanical differences of Coflex-F and pedicle screw fixation combined with TLIF or ALIF – a finite element study

Lumbar interbody fusion is a common procedure for treating lower back pain related to degenerative disc diseases. The Coflex-F is a recently developed interspinous spacer, the makers of which claim that it can provide stabilisation similar to pedicle screw fixation. Therefore, this study compares the biomechanical behaviour of the Coflex-F device and pedicle screw fixation with transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion (ALIF) surgeries by using finite element analysis. The results show that the Coflex-F device combined with ALIF surgery can provide stability similar to the pedicle screw fixation combined with TLIF or ALIF surgery. Also, the posterior instrumentations (Coflex-F and pedicle screw fixation) combined with TLIF surgery had lower stability than when combined with ALIF surgery.     

Hydroxyapatite ceramics in multilevel cervical interbody fusion - is there a role?

The aim of this study is to evaluate the efficacy of hydroxyapatite grafts in multilevel cervical interbody fusion during the one year follow-up. A total of 86 patients with degenerative cervical disc disease underwent all together 224 cervical interbody fusion procedures in which either Smith-Robinson or Cloward type hydroxyapatite grafts were used. The surgeries included radiculopathy in 38 cases, myelopathy in 20 cases and myeloradicuopathy in 28 patients. In 65 out of 86 patients, fusion was followed by an anterior instrumentation (plating). Postoperatively, patients were followed for a mean of 15.64 (range 11-23.3) months. All patients underwent radiography to evaluate fusion and the axis curvature. Excellent clinical results (86%), described as a complete or partial relief of symptoms with full return to preop activity, were obtained in patients with radiculopathy. There were 5 grafts mobilizations and one graft fracture. Two grafts extruded in non-instrumented patients and required repeated surgery. There were other three reoperations due to the hardware problems. One year fusion rate was obtained at 86% for two-level surgery, 80.1% for three-level surgery and 74% for four-level surgery. The mean (SD) hospital stay was 3.8 (0.7) days. A hydroxyapatite cheramic can be a very effective synthetic material for multilevel cervical interbody fusion. It is characterized by a high fusion rate and a small percentage of graft-related complications, especially when fusion procedure is followed by plating.     

An upper bound computational model for investigation of fusion effects on adjacent segment biomechanics of the lumbar spine

Abstract

Prediction of the biomechanical effects of fusion surgery on adjacent segments is a challenge in computational biomechanics of the spine. In this study, a two-segment L3-L4-L5 computational model was developed to simulate the effects of spinal fusion on adjacent segment biomechanical responses under a follower load condition. The interaction between the degenerative segment (L4-5) and the adjacent segment (L3-4) was simulated using an equivalent follower spring. The spring stiffness was calibrated using a rigid fusion of a completely degenerated disc model at the L4-5 level, resulting in an upper bound response at the adjacent (L3-4) segment. The obtained upper bound equivalent follower spring was used to simulate the upper bound biomechanical responses of fusion of the disc with different degeneration grades. It was predicted that as the disc degeneration grade at the degenerative segment decreased, the effect on the adjacent segment responses decreased accordingly after fusion. The data indicated that the upper bound computational model can be a useful computational tool for evaluation of the interaction between segments and for investigation of the biomechanical mechanisms of adjacent segment degeneration after fusion.     

Decompressive Laminectomy for Low Back and Sciatic Pain

A proportion of patients with lumbar disc syndromes have little in the way of disc protrusion, but have spinal canals, either congenitally narrow, or else narrowed by degenerative changes. These patients require myelography for their assessment and decompression by complete laminectomy for their treatment, as opposed to the more usual practice of discectomy via partial laminectomy and/or fusion. Five such cases with myelographic findings are presented.     

Short aggrecan gene repetitive alleles associated with lumbar degenerative disc disease in Turkish patients

We investigated a possible association between aggrecan gene polymorphism and lumbar degenerative disc disease in Turkish patients. One hundred 20-30-year-old patients with or without low back pain were selected for the study. Lumbar magnetic resonance imaging was performed on all patients. The patient group had low back pain clinically and degenerative disc disease radiographically. The control group included patients with and without low back pain: all were negative radiographically for degenerative disc disease. Genomic DNA was extracted from all participants. A PCR assay were used to evaluate variable number of tandem repeat polymorphism of aggrecan gene alleles to determine if there was any correlation with degenerative disc disease. Significant associations were found between short repeated alleles of the aggrecan gene and severe disc degeneration. A significant association was also found between short repeated alleles of the aggrecan gene and multilevel disc herniation as well as extrusion and sequestration types of disc herniation. In Turkish population, short repeated alleles of the aggrecan gene are associated with increased disc degeneration and disc herniation.     

Quadrant通道下MIS-TLIF与传统术式治疗单节段腰椎退变性疾病的疗效比较

目的:对比分析Quadrant通道下微创椎间孔椎间融合术(MIS-TLIF)与传统开放经椎间孔椎间融合术(TLIF)治疗单节段腰椎退变性疾病的临床疗效和安全性。方法:选取2012年3月至2015年3月120例我院收治的120例单节段腰椎退变性疾病患者,并将其随机分为对照组和微创(MIS)组,每组各60例。对照组患者给予TLIF治疗,微创组给予MIS-TLIF治疗。观察和比较两组患者的手术情况,手术前后的视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI),肌酸磷酸激酶(CPK)水平、椎间植骨融合率及并发症的发生情况。结果:微创组患者的切口长度、出血量、射线照射时间、下地活动时间以及住院时间均显著低于或短于对照组(P0.05);术后1周、6个月,微创组患者的VAS、ODI评分均显著低于对照组(P0.05);术后,两组患者的CPK水平出现剧烈上升,随后又逐渐下降,但同一时段微创组患者的CPK水平明显低于对照组(P0.05);微创组的椎骨性融合率为93.33%(56/60),显著低于对照组(85.00%,P0.05),且其神经损伤、硬膜囊破裂的发生率均显著低于对照组(P0.05),感染的发生率比较差异无统计学意义(P0.05)。结论:Quadrant通道下微创椎间孔椎间融合术治疗单节段腰椎退变性疾病的临床疗效明显优于传统开放经椎间孔椎间融合术,且创伤更小,患者康复更快,安全性更高。