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Leão Monteiro R. Future of low back pain: unravelling IVD components and MSCs' potential. CELL REGENERATION (LONDON, ENGLAND) 2024; 13:1. [PMID: 38227139 DOI: 10.1186/s13619-023-00184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
Low back pain (LBP) mainly emerges from intervertebral disc (IVD) degeneration. However, the failing mechanism of IVD ́s components, like the annulus fibrosus (AF) and nucleus pulposus (NP), leading to IVD degeneration/herniation is still poorly understood. Moreover, the specific role of cellular populations and molecular pathways involved in the inflammatory process associated with IVD herniation remains to be highlighted. The limited knowledge of inflammation associated with the initial steps of herniation and the lack of suitable models to mimic human IVD ́s complexity are some of the reasons for that. It has become essential to enhance the knowledge of cellular and molecular key players for AF and NP cells during inflammatory-driven degeneration. Due to unique properties of immunomodulation and pluripotency, mesenchymal stem cells (MSCs) have attained diverse recognition in this field of bone and cartilage regeneration. MSCs therapy has been particularly valuable in facilitating repair of damaged tissues and may benefit in mitigating inflammation' degenerative events. Therefore, this review article conducts comprehensive research to further understand the intertwine between the mechanisms of action of IVD components and therapeutic potential of MSCs, exploring their characteristics, how to optimize their use and establish them safely in distinct settings for LPB treatment.
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Hsu YH, Chen CN, Chang HI, Tsai HL, Chang YH, Cheng IS, Yang YS, Huang KY. Manipulation of osteogenic and adipogenic differentiation of human degenerative disc and ligamentum flavum derived progenitor cells using IL-1β, IL-19, and IL-20. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3413-3424. [PMID: 37563485 DOI: 10.1007/s00586-023-07878-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/22/2023] [Accepted: 07/28/2023] [Indexed: 08/12/2023]
Abstract
PURPOSE To elucidate whether pro-inflammatory cytokines might influence the commitment of intervertebral disc (IVD)- and ligamentum flavum (LF)-derived progenitor cells toward either osteogenesis or adipogenesis, specifically Interleukin-1β (IL-1β), IL-19, and IL-20. METHODS Sixty patients with degenerative spondylolisthesis and lumbar or lumbosacral spinal stenosis were included in the study. Injuries to the spine, infections, and benign or malignant tumors were excluded. From nine patient samples, IVD- and LF-derived cells were isolated after primary culture, and two clinical samples were excluded due to mycoplasma infection. The effects of IL-1β, IL-19, as well as IL-20 in regulating osteogenic and adipogenic differentiation in vitro were investigated. RESULTS Primary IVD- and LF-derived cells were found to have a similar cell morphology and profile of surface markers (CD44, CD90, and CD105) as placenta-derived mesenchymal stem cells (MSCs). Primary IVD/LF cells have a high capacity to differentiate into osteocytes and adipocytes. IL-19 had a tendency to promote adipogenesis. IL-20 inhibited osteogenesis and promoted adipogenesis; IL-1β promoted osteogenesis but inhibited adipogenesis. CONCLUSION IL-1β, IL-19, and IL-20 impact the adipogenic and osteogenic differentiation of IVD-derived and LF-derived cells. Modulating the expression of IL-1β, IL-19, and IL-20 provides a potential avenue for controlling cell differentiation of IVD- and LF-derived cells, which might have beneficial effect for degenerative spondylolisthesis and spinal stenosis.
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Affiliation(s)
- Yu-Hsiang Hsu
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Nan Chen
- Department of Biochemical Science and Technology, National Chiayi University, Chiayi City, Taiwan
| | - Hsin-I Chang
- Department of Biochemical Science and Technology, National Chiayi University, Chiayi City, Taiwan
| | - Hui-Ling Tsai
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 704, Taiwan
| | - Yu-Hsien Chang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-Szu Cheng
- College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Shiuan Yang
- Education Center, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Kuo-Yuan Huang
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, Tainan, 704, Taiwan.
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Miranda L, Quaranta M, Oliva F, Maffulli N. Stem cells and discogenic back pain. Br Med Bull 2023; 146:73-87. [PMID: 37164906 PMCID: PMC10788843 DOI: 10.1093/bmb/ldad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Chronic low back pain, common from the sixth decade, negatively impacts the quality of life of patients and health care systems. Recently, mesenchymal stem cells (MSCs) have been introduced in the management of degenerative discogenic pain. The present study summarizes the current knowledge on the effectiveness of MSCs in patients with discogenic back pain. SOURCES OF DATA We performed a systematic review of the literature following the PRISMA guidelines. We searched PubMed and Google Scholar database, and identified 14 articles about management of chronic low back pain with MSCs injection therapy. We recorded information on type of stem cells employed, culture medium, clinical scores and MRI outcomes. AREAS OF AGREEMENT We identified a total of 303 patients. Ten studies used bone marrow stem cells. In the other four studies, different stem cells were used (of adipose, umbilical, or chondrocytic origin and a pre-packaged product). The most commonly used scores were Visual Analogue Scale and Oswestry Disability Index. AREAS OF CONTROVERSY There are few studies with many missing data. GROWING POINTS The studies analysed demonstrate that intradiscal injections of MSCs are effective on discogenic low-back pain. This effect may result from inhibition of nociceptors, reduction of catabolism and repair of injured or degenerated tissues. AREAS TIMELY FOR DEVELOPING RESEARCH Further research should define the most effective procedure, trying to standardize a single method.
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Affiliation(s)
- Luca Miranda
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Via Salvador Allende, 43, Baronissi SA 84081, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, Via San Leonardo, Salerno 84131, Italy
| | - Marco Quaranta
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Via Salvador Allende, 43, Baronissi SA 84081, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, Via San Leonardo, Salerno 84131, Italy
| | - Francesco Oliva
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Via Salvador Allende, 43, Baronissi SA 84081, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, Via San Leonardo, Salerno 84131, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, Via Salvador Allende, 43, Baronissi SA 84081, Italy
- Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D’Aragona, Via San Leonardo, Salerno 84131, Italy
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England
- Guy Hilton Research Centre, Faculty of Medicine, School of Pharmacy and Bioengineering, Keele University, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, England
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Wang R, Zhang M, Hu Y, He J, Lin Q, Peng N. MiR-100-5p inhibits osteogenic differentiation of human bone mesenchymal stromal cells by targeting TMEM135. Hum Cell 2022; 35:1671-1683. [PMID: 35947339 DOI: 10.1007/s13577-022-00764-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/29/2022] [Indexed: 02/05/2023]
Abstract
Osteoporosis is a disorder characterized by reduced bone mass, disruption of bone microarchitecture, and a propensity to fracture. The osteogenic differentiation of human bone mesenchymal stromal cells (hBMSCs) exerts a critical effect on preventing bone loss during osteoporosis. Herein, the study recognized miR-100-5p as a deregulated miRNA during osteoporosis (upregulated) and BMSC osteogenic differentiation (downregulated). miR-100-5p was upregulated in osteoporosis patients-isolated BMSCs compared to non-osteoporosis trauma patients-isolated BMSCs. hBMSCs, overexpression inhibited hBMSC proliferation and osteogenic differentiation, whereas miR-100-5p inhibition exerted opposite effects. TMEM135 was downregulated in osteoporosis and upregulated in differentiated osteoblasts, as well as downregulated upon the overexpression of miR-100-5p. MiR-100-5p directly targeted and inhibited TMEM135. In hBMSCs, TMEM135 silencing also inhibited hBMSC osteogenic differentiation. When co-transfected to hBMSCs, antagomir-100-5p promoted, whereas TMEM135 silencing inhibited hBMSC osteogenic differentiation; TMEM135 knockdown dramatically attenuated the effects of miR-100-5p inhibition. Taken together, miR-100-5p forms a regulatory axis with TMEM135 by direct binding. The miR-100-5p/TMEM135 axis modulates hBMSC differentiation into osteoblast. Considering the critical effect of BMSC osteogenesis on osteoporosis, this axis might play a role in osteoporosis, and further in vivo and clinical investigations are required.
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Affiliation(s)
- Rui Wang
- Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Miao Zhang
- Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Ying Hu
- Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Juan He
- Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Qiao Lin
- Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Nianchun Peng
- Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China.
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Single-Cell RNA-Seq Analysis of Cells from Degenerating and Non-Degenerating Intervertebral Discs from the Same Individual Reveals New Biomarkers for Intervertebral Disc Degeneration. Int J Mol Sci 2022; 23:ijms23073993. [PMID: 35409356 PMCID: PMC8999935 DOI: 10.3390/ijms23073993] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 02/07/2023] Open
Abstract
In this study, we used single-cell transcriptomic analysis to identify new specific biomarkers for nucleus pulposus (NP) and inner annulus fibrosis (iAF) cells, and to define cell populations within non-degenerating (nD) and degenerating (D) human intervertebral discs (IVD) of the same individual. Cluster analysis based on differential gene expression delineated 14 cell clusters. Gene expression profiles at single-cell resolution revealed the potential functional differences linked to degeneration, and among NP and iAF subpopulations. GO and KEGG analyses discovered molecular functions, biological processes, and transcription factors linked to cell type and degeneration state. We propose two lists of biomarkers, one as specific cell type, including C2orf40, MGP, MSMP, CD44, EIF1, LGALS1, RGCC, EPYC, HILPDA, ACAN, MT1F, CHI3L1, ID1, ID3 and TMED2. The second list proposes predictive IVD degeneration genes, including MT1G, SPP1, HMGA1, FN1, FBXO2, SPARC, VIM, CTGF, MGST1, TAF1D, CAPS, SPTSSB, S100A1, CHI3L2, PLA2G2A, TNRSF11B, FGFBP2, MGP, SLPI, DCN, MT-ND2, MTCYB, ADIRF, FRZB, CLEC3A, UPP1, S100A2, PRG4, COL2A1, SOD2 and MT2A. Protein and mRNA expression of MGST1, vimentin, SOD2 and SYF2 (p29) genes validated our scRNA-seq findings. Our data provide new insights into disc cells phenotypes and biomarkers of IVD degeneration that could improve diagnostic and therapeutic options.
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Wang H, Wang D, Luo B, Wang D, Jia H, Peng P, Shang Q, Mao J, Gao C, Peng Y, Gan L, Du J, Luo Z, Yang L. Decoding the annulus fibrosus cell atlas by scRNA-seq to develop an inducible composite hydrogel: A novel strategy for disc reconstruction. Bioact Mater 2022; 14:350-363. [PMID: 35386822 PMCID: PMC8964821 DOI: 10.1016/j.bioactmat.2022.01.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/22/2022] [Accepted: 01/23/2022] [Indexed: 02/08/2023] Open
Abstract
Low back pain is one of the most serious public health problems worldwide and the major clinical manifestation of intervertebral disc degeneration (IVDD). The key pathological change during IVDD is dysfunction of the annulus fibrosus (AF). However, due to the lack of an in-depth understanding of AF biology, the methods to reconstruct the AF are very limited. In this study, the mice AF cell atlas were decoded by single-cell RNA sequencing to provide a guide for AF reconstruction. The results first identify a new population of AF cells, fibrochondrocyte-like AF cells, which synthesize both collagen I and collagen II and are potential functional cells for AF reconstruction. According to the dual features of the AF extracellular matrix, a composite hydrogel based on the acylation of methacrylated silk fibroin with methacrylated hyaluronic acid was produced. To obtain the ability to stimulate differentiation, the composite hydrogels were combined with a fibrochondrocyte-inducing supplement. Finally, reconstruction of the AF defects, by the novel AF stem cell-loaded composite hydrogel, could be observed, its amount of chondroid matrices recovered to 31.7% of AF aera which is significantly higher than that in other control groups. In summary, this study decodes the AF cell atlas, based on which a novel strategy for AF reconstruction is proposed. There are 10 populations of cells in the annulus fibrosus (AF), as decoded by single cell RNA sequencing. Lineage tracing shows the route of migration and differentiation of annulus fibrosus-derived stem cells (AFSCs). A new population of AF cells, fibrochondrocyte-like AF cells, was identified. Both the fibrinoid and chondroid matrices of AF are reconstructed by the novel AFSCs-loaded composite hydrogel.
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7
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Stem Cell Therapy and Exercise for Treatment of Intervertebral Disc Degeneration. Stem Cells Int 2021; 2021:7982333. [PMID: 34691192 PMCID: PMC8528633 DOI: 10.1155/2021/7982333] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/13/2021] [Indexed: 02/07/2023] Open
Abstract
As part of the motor system, intervertebral disc (IVD) is a complicated tissue with multiple components. The degeneration of IVD may result in low back pain (LBP), which strongly impairs quality of life. Various causes are related to the degeneration of IVD, including cell senescence, hydration lost, and inflammation. Stem cells founded in different tissues have attracted the interest of the researchers and clinicians to study the implication of these cells in the treatment for tissue injury and degeneration. In this report, we will review the study of stem cells in the treatment for IVD degeneration. On the other hand, the effect of exercise on IVD degeneration and the relationship between IVD degeneration and musculoskeletal disorders like sarcopenia are discussed.
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Intervertebral Disc Stem/Progenitor Cells: A Promising "Seed" for Intervertebral Disc Regeneration. Stem Cells Int 2021; 2021:2130727. [PMID: 34367292 PMCID: PMC8342144 DOI: 10.1155/2021/2130727] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/08/2021] [Indexed: 12/11/2022] Open
Abstract
Intervertebral disc (IVD) degeneration is considered to be the primary reason for low back pain (LBP), which has become more prevalent from 21 century, causing an enormous economic burden for society. However, in spite of remarkable improvements in the basic research of IVD degeneration (IVDD), the effects of clinical treatments of IVDD are still leaving much to be desired. Accumulating evidence has proposed the existence of endogenous stem/progenitor cells in the IVD that possess the ability of proliferation and differentiation. However, few studies have reported the biological properties and potential application of IVD progenitor cells in detail. Even so, these stem/progenitor cells have been consumed as a promising cell source for the regeneration of damaged IVD. In this review, we will first introduce IVD, describe its physiology and stem/progenitor cell niche, and characterize IVDSPCs between homeostasis and IVD degeneration. We will then summarize recent studies on endogenous IVDSPC-based IVD regeneration and exogenous cell-based therapy for IVDD. Finally, we will discuss the potential applications and future developments of IVDSPC-based repair of IVD degeneration.
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9
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The Cellular Composition of Bovine Coccygeal Intervertebral Discs: A Comprehensive Single-Cell RNAseq Analysis. Int J Mol Sci 2021. [DOI: 10.3390/ijms22094917
expr 996488947 + 961598850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Intervertebral disc (IVD) degeneration and its medical consequences is still one of the leading causes of morbidity worldwide. To support potential regenerative treatments for degenerated IVDs, we sought to deconvolute the cell composition of the nucleus pulposus (NP) and the annulus fibrosus (AF) of bovine intervertebral discs. Bovine calf tails have been extensively used in intervertebral disc research as a readily available source of NP and AF material from healthy and young IVDs. We used single-cell RNA sequencing (scRNAseq) coupled to bulk RNA sequencing (RNAseq) to unravel the cell populations in these two structures and analyze developmental changes across the rostrocaudal axis. By integrating the scRNAseq data with the bulk RNAseq data to stabilize the clustering results of our study, we identified 27 NP structure/tissue specific genes and 24 AF structure/tissue specific genes. From our scRNAseq results, we could deconvolute the heterogeneous cell populations in both the NP and the AF. In the NP, we detected a notochordal-like cell cluster and a progenitor stem cell cluster. In the AF, we detected a stem cell-like cluster, a cluster with a predominantly fibroblast-like phenotype and a potential endothelial progenitor cluster. Taken together, our results illustrate the cell phenotypic complexity of the AF and NP in the young bovine IVDs.
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10
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Calió M, Gantenbein B, Egli M, Poveda L, Ille F. The Cellular Composition of Bovine Coccygeal Intervertebral Discs: A Comprehensive Single-Cell RNAseq Analysis. Int J Mol Sci 2021; 22:ijms22094917. [PMID: 34066404 PMCID: PMC8124861 DOI: 10.3390/ijms22094917] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 02/07/2023] Open
Abstract
Intervertebral disc (IVD) degeneration and its medical consequences is still one of the leading causes of morbidity worldwide. To support potential regenerative treatments for degenerated IVDs, we sought to deconvolute the cell composition of the nucleus pulposus (NP) and the annulus fibrosus (AF) of bovine intervertebral discs. Bovine calf tails have been extensively used in intervertebral disc research as a readily available source of NP and AF material from healthy and young IVDs. We used single-cell RNA sequencing (scRNAseq) coupled to bulk RNA sequencing (RNAseq) to unravel the cell populations in these two structures and analyze developmental changes across the rostrocaudal axis. By integrating the scRNAseq data with the bulk RNAseq data to stabilize the clustering results of our study, we identified 27 NP structure/tissue specific genes and 24 AF structure/tissue specific genes. From our scRNAseq results, we could deconvolute the heterogeneous cell populations in both the NP and the AF. In the NP, we detected a notochordal-like cell cluster and a progenitor stem cell cluster. In the AF, we detected a stem cell-like cluster, a cluster with a predominantly fibroblast-like phenotype and a potential endothelial progenitor cluster. Taken together, our results illustrate the cell phenotypic complexity of the AF and NP in the young bovine IVDs.
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Affiliation(s)
- Martina Calió
- Tissue Engineering for Orthopaedics & Mechanobiology (TOM), Department for BioMedical Research (DBMR), University of Bern, 3008 Bern, Switzerland; (M.C.); (B.G.)
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
- Space Biology Group, Institute of Medical Engineering, School of Engineering and Architecture, Lucerne University of Applied Sciences and Arts, 6052 Hergiswil, Switzerland;
| | - Benjamin Gantenbein
- Tissue Engineering for Orthopaedics & Mechanobiology (TOM), Department for BioMedical Research (DBMR), University of Bern, 3008 Bern, Switzerland; (M.C.); (B.G.)
- Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - Marcel Egli
- Space Biology Group, Institute of Medical Engineering, School of Engineering and Architecture, Lucerne University of Applied Sciences and Arts, 6052 Hergiswil, Switzerland;
| | - Lucy Poveda
- Functional Genomics Center Zurich, Swiss Federal Institute of Technology, University of Zurich, 8057 Zurich, Switzerland;
| | - Fabian Ille
- Space Biology Group, Institute of Medical Engineering, School of Engineering and Architecture, Lucerne University of Applied Sciences and Arts, 6052 Hergiswil, Switzerland;
- Correspondence: ; Tel.: +41-41-349-36-15
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11
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Tessier S, Risbud MV. Understanding embryonic development for cell-based therapies of intervertebral disc degeneration: Toward an effort to treat disc degeneration subphenotypes. Dev Dyn 2020; 250:302-317. [PMID: 32564440 DOI: 10.1002/dvdy.217] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/09/2020] [Accepted: 06/14/2020] [Indexed: 12/19/2022] Open
Abstract
Chronic low back and neck pain are associated with intervertebral disc degeneration and are major contributors to the global burden of disability. New evidence now suggests that disc degeneration comprises a spectrum of subphenotypes influenced by genetic background, age, and environmental factors, which may be contributing to the mixed outcomes seen in clinical trials of cell-based therapies that aim to treat disc degeneration. This problem is further compounded by the fact that disc degeneration and aging coincide with an exhaustion of endogenous progenitor cells, imposing limitations on the regenerative capacity of the disc. At the bench-side, current work is focused on applying our knowledge of embryonic disc development to direct and refine differentiation of adult and human-induced pluripotent stem cells into notochord-like and nucleus pulposus-like cells for use in novel cell-based therapies. Accordingly, this review presents the salient features of intervertebral disc development, post-natal maintenance, and regeneration, with emphasis on recent advancements. We also discuss how a stratified approach can be undertaken for the development of future cell-based therapies to bring emerging subphenotypes into consideration.
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Affiliation(s)
- Steven Tessier
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA.,Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Makarand V Risbud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Graduate Program in Cell Biology and Regenerative Medicine, Jefferson College of Life Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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12
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Advanced Strategies for the Regeneration of Lumbar Disc Annulus Fibrosus. Int J Mol Sci 2020; 21:ijms21144889. [PMID: 32664453 PMCID: PMC7402314 DOI: 10.3390/ijms21144889] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 12/15/2022] Open
Abstract
Damage to the annulus fibrosus (AF), the outer region of the intervertebral disc (IVD), results in an undesirable condition that may accelerate IVD degeneration causing low back pain. Despite intense research interest, attempts to regenerate the IVD have failed so far and no effective strategy has translated into a successful clinical outcome. Of particular significance, the failure of strategies to repair the AF has been a major drawback in the regeneration of IVD and nucleus replacement. It is unlikely to secure regenerative mediators (cells, genes, and biomolecules) and artificial nucleus materials after injection with an unsealed AF, as IVD is exposed to significant load and large deformation during daily activities. The AF defects strongly change the mechanical properties of the IVD and activate catabolic routes that are responsible for accelerating IVD degeneration. Therefore, there is a strong need to develop effective therapeutic strategies to prevent or reconstruct AF damage to support operational IVD regenerative strategies and nucleus replacement. By the way of this review, repair and regenerative strategies for AF reconstruction, their current status, challenges ahead, and future outlooks were discussed.
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13
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Frapin L, Clouet J, Chédeville C, Moraru C, Samarut E, Henry N, André M, Bord E, Halgand B, Lesoeur J, Fusellier M, Guicheux J, Le Visage C. Controlled release of biological factors for endogenous progenitor cell migration and intervertebral disc extracellular matrix remodelling. Biomaterials 2020; 253:120107. [PMID: 32450408 DOI: 10.1016/j.biomaterials.2020.120107] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/20/2020] [Accepted: 05/06/2020] [Indexed: 02/06/2023]
Abstract
The recent description of resident stem/progenitor cells in degenerated intervertebral discs (IVDs) supports the notion that their regenerative capacities could be harnessed to stimulate endogenous repair of the nucleus pulposus (NP). In this study, we developed a delivery system based on pullulan microbeads (PMBs) for sequential release of the chemokine CCL-5 to recruit these disc stem/progenitor cells to the NP tissue, followed by the release of the growth factors TGF-β1 and GDF-5 to induce the synthesis of a collagen type II- and aggrecan-rich extracellular matrix (ECM). Bioactivity of released CCL5 on human adipose-derived stem cells (hASCs), selected to mimic disc stem/progenitors, was demonstrated using a Transwell® chemotaxis assay. The regenerative effects of loaded PMBs were investigated in ex vivo spontaneously degenerated ovine IVDs. Fluorescent hASCs were seeded on the top cartilaginous endplates (CEPs); the degenerated NPs were injected with PMBs loaded with CCL5, TGF-β1, and GDF-5; and the IVDs were then cultured for 3, 7, and 28 days to allow for cell migration and disc regeneration. The PMBs exhibited sustained release of biological factors for 21 days. Ex vivo migration of seeded hASCs from the CEP toward the NP was demonstrated, with the cells migrating a significantly greater distance when loaded PMBs were injected (5.8 ± 1.3 mm vs. 3.5 ± 1.8 mm with no injection of PMBs). In ovine IVDs, the overall NP cellularity, the collagen type II and the aggrecan staining intensities, and the Tie2+ progenitor cell density in the NP were increased at day 28 compared to the control groups. Considered together, PMBs loaded with CCL5/TGF-β1/GDF-5 constitute an innovative and promising strategy for controlled release of growth factors to promote cell recruitment and extracellular matrix remodelling.
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Affiliation(s)
- Leslie Frapin
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France
| | - Johann Clouet
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; CHU Nantes, Pharmacie Centrale, PHU 11, Nantes, F-44093, France; Université de Nantes, UFR Sciences Biologiques et Pharmaceutiques, Nantes, F-44035, France
| | - Claire Chédeville
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France
| | - Constantin Moraru
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; CHU Nantes, Service de Neurotraumatologie, PHU4 OTONN, Nantes, F-44093, France
| | - Edouard Samarut
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; CHU Nantes, Service de Neurotraumatologie, PHU4 OTONN, Nantes, F-44093, France
| | - Nina Henry
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France
| | - Manon André
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; SC3M -"Electron Microscopy, Microcharacterization, and Functional Morphohistology Imaging" Core Facility, Structure Fédérative de Recherche François Bonamy, INSERM - UMS016, CNRS 3556, CHU Nantes, Université de Nantes, Nantes, Nantes, F-04402, France
| | - Eric Bord
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; CHU Nantes, Service de Neurotraumatologie, PHU4 OTONN, Nantes, F-44093, France
| | - Boris Halgand
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; CHU Nantes, PHU4 OTONN, Nantes, F-44093, France
| | - Julie Lesoeur
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; SC3M -"Electron Microscopy, Microcharacterization, and Functional Morphohistology Imaging" Core Facility, Structure Fédérative de Recherche François Bonamy, INSERM - UMS016, CNRS 3556, CHU Nantes, Université de Nantes, Nantes, Nantes, F-04402, France
| | - Marion Fusellier
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; Department of Diagnostic Imaging, CRIP, National Veterinary School (ONIRIS), Nantes, F-44307, France
| | - Jérôme Guicheux
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France; SC3M -"Electron Microscopy, Microcharacterization, and Functional Morphohistology Imaging" Core Facility, Structure Fédérative de Recherche François Bonamy, INSERM - UMS016, CNRS 3556, CHU Nantes, Université de Nantes, Nantes, Nantes, F-04402, France; CHU Nantes, PHU4 OTONN, Nantes, F-44093, France.
| | - Catherine Le Visage
- Inserm, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes, F-44042, France; Université de Nantes, UFR Odontologie, Nantes, F-44042, France.
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14
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Abstract
Intervertebral disc (IVD) degeneration is associated with low back pain. In IVDs, a high mechanical load, high osmotic pressure and hypoxic conditions create a hostile microenvironment for resident cells. How IVD homeostasis and function are maintained under stress remains to be understood; however, several research groups have reported isolating native endogenous progenitor-like or otherwise proliferative cells from the IVD. The isolation of such cells implies that the IVD might contain a quiescent progenitor-like population that could be activated for IVD repair and regeneration. Increased understanding of endogenous disc progenitor cells will improve our knowledge of IVD homeostasis and, when combined with tissue engineering techniques, might hold promise for future therapeutic applications. In this Review, the characteristics of progenitor cells in different IVD compartments are discussed, as well as the potency of different cell populations within the IVD. The stem cell characteristics of these cells are also compared with those of mesenchymal stromal cells. On the basis of existing evidence, whether and how IVD degeneration and the hostile microenvironment might affect endogenous progenitor cell function are considered, and ways to channel the potential of these cells for IVD repair are suggested.
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15
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Barakat AH, Elwell VA, Lam KS. Stem cell therapy in discogenic back pain. JOURNAL OF SPINE SURGERY (HONG KONG) 2019; 5:561-583. [PMID: 32043007 PMCID: PMC6989932 DOI: 10.21037/jss.2019.09.22] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
Chronic low back pain has both substantial social and economic impacts on patients and healthcare budgets. Adding to the magnitude of the problem is the difficulty in identifying the exact causes of disc degeneration with modern day diagnostic and imaging techniques. With that said, current non-operative and surgical treatment modalities for discogenic low back pain fails to meet the expectations in many patients and hence the challenge. The objective for newly emerging stem cell regenerative therapy is to treat degenerative disc disease (DDD) by restoring the disc's cellularity and modulating the inflammatory response. Appropriate patient selection is crucial for the success of stem cell therapy. Regenerative modalities for discogenic pain currently focus on the use of either primary cells harvested from the intervertebral discs or stem cells from other sources whether autogenic or allogenic. The microenvironment in which stem cells are being cultured has been recognized to play a crucial role in directing or maintaining the production of the desired phenotypes and may enhance their regenerative potential. This has led to a more specific focus on innovating more effective culturing techniques, delivery vehicles and scaffolds for stem cell application. Although stem cell therapy might offer an attractive alternative treatment option, more clinical studies are still needed to establish on the safety and feasibility of such therapy. In this literature review, we aim to present the most recent in vivo and in vitro studies related to the use of stem cell therapy in the treatment of discogenic low back pain.
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Affiliation(s)
- Ahmed H. Barakat
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Vivian A. Elwell
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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16
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Frapin L, Clouet J, Delplace V, Fusellier M, Guicheux J, Le Visage C. Lessons learned from intervertebral disc pathophysiology to guide rational design of sequential delivery systems for therapeutic biological factors. Adv Drug Deliv Rev 2019; 149-150:49-71. [PMID: 31445063 DOI: 10.1016/j.addr.2019.08.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 08/05/2019] [Accepted: 08/18/2019] [Indexed: 12/20/2022]
Abstract
Intervertebral disc (IVD) degeneration has been associated with low back pain, which is a major musculoskeletal disorder and socio-economic problem that affects as many as 600 million patients worldwide. Here, we first review the current knowledge of IVD physiology and physiopathological processes in terms of homeostasis regulation and consecutive events that lead to tissue degeneration. Recent progress with IVD restoration by anti-catabolic or pro-anabolic approaches are then analyzed, as are the design of macro-, micro-, and nano-platforms to control the delivery of such therapeutic agents. Finally, we hypothesize that a sequential delivery strategy that i) firstly targets the inflammatory, pro-catabolic microenvironment with release of anti-inflammatory or anti-catabolic cytokines; ii) secondly increases cell density in the less hostile microenvironment by endogenous cell recruitment or exogenous cell injection, and finally iii) enhances cellular synthesis of extracellular matrix with release of pro-anabolic factors, would constitute an innovative yet challenging approach to IVD regeneration.
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17
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Clouet J, Fusellier M, Camus A, Le Visage C, Guicheux J. Intervertebral disc regeneration: From cell therapy to the development of novel bioinspired endogenous repair strategies. Adv Drug Deliv Rev 2019; 146:306-324. [PMID: 29705378 DOI: 10.1016/j.addr.2018.04.017] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 03/29/2018] [Accepted: 04/24/2018] [Indexed: 12/15/2022]
Abstract
Low back pain (LBP), frequently associated with intervertebral disc (IVD) degeneration, is a major public health concern. LBP is currently managed by pharmacological treatments and, if unsuccessful, by invasive surgical procedures, which do not counteract the degenerative process. Considering that IVD cell depletion is critical in the degenerative process, the supplementation of IVD with reparative cells, associated or not with biomaterials, has been contemplated. Recently, the discovery of reparative stem/progenitor cells in the IVD has led to increased interest in the potential of endogenous repair strategies. Recruitment of these cells by specific signals might constitute an alternative strategy to cell transplantation. Here, we review the status of cell-based therapies for treating IVD degeneration and emphasize the current concept of endogenous repair as well as future perspectives. This review also highlights the challenges of the mobilization/differentiation of reparative progenitor cells through the delivery of biologics factors to stimulate IVD regeneration.
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Affiliation(s)
- Johann Clouet
- INSERM, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France; CHU Nantes, Pharmacie Centrale, PHU 11, Nantes F-44093, France; Université de Nantes, UFR Sciences Biologiques et Pharmaceutiques, Nantes F-44035, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France
| | - Marion Fusellier
- INSERM, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France; Department of Diagnostic Imaging, CRIP, National Veterinary School (ONIRIS), Nantes F-44307, France
| | - Anne Camus
- INSERM, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France
| | - Catherine Le Visage
- INSERM, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France
| | - Jérôme Guicheux
- INSERM, UMR 1229, RMeS, Regenerative Medicine and Skeleton, Université de Nantes, ONIRIS, Nantes F-44042, France; Université de Nantes, UFR Odontologie, Nantes F-44042, France; CHU Nantes, PHU4 OTONN, Nantes, F-44093, France.
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18
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Abstract
STUDY DESIGN Systematic review. OBJECTIVE The aim of this study was to investigate, quantify, compare, and compile the various mesenchymal stem cell (MSC) tissue sources within human spinal tissues to act as a compendium for clinical and research application. SUMMARY OF BACKGROUND DATA Recent years have seen a dramatic increase in academic and clinical understanding of human MSCs. Previously limited to cells isolated from bone marrow, the past decade has illicited the characterization and isolation of human MSCs from adipose, bone marrow, synovium, muscle, periosteum, peripheral blood, umbilical cord, placenta, and numerous other tissues. As researchers explore practical applications of cells in these tissues, the absolute levels of MSCs in specific spinal tissue will be critical to guide future research. METHODS The PubMED, MEDLINE, EMBASE, and Cochrane databases were searched for articles relating to the harvest, characterization, isolation, and quantification of human MSCs from spinal tissues. Selected articles were examined for relevant data, categorized according to type of spinal tissue, and when possible, standardized to facilitate comparisons between sites. RESULTS Human MSC levels varied widely between spinal tissues. Yields for intervertebral disc demonstrated roughly 5% of viable cells to be positive for MSC surface markers. Cartilage endplate cells yielded 18,500 to 61,875 cells/0.8 mm thick sample of cartilage end plate. Ligamentum flavum yielded 250,000 to 500,000 cells/g of tissue. Annulus fibrosus fluorescence activated cell sorting treatment found 29% of cells positive for MSC marker Stro-1. Nucleus pulposus yielded mean tissue samples of 40,584 to 234,137 MSCs per gram of tissue. CONCLUSION Numerous tissues within and surrounding the spine represent a consistent and reliable source for the harvest and isolation of human MSCs. Among the tissues of the spine, the annulus fibrosus and ligamentum flavum each offer considerable levels of MSCs, and may prove comparable to that of bone marrow. LEVEL OF EVIDENCE 5.
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19
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Fernandez-Moure J, Moore CA, Kim K, Karim A, Smith K, Barbosa Z, Van Eps J, Rameshwar P, Weiner B. Novel therapeutic strategies for degenerative disc disease: Review of cell biology and intervertebral disc cell therapy. SAGE Open Med 2018; 6:2050312118761674. [PMID: 29568524 PMCID: PMC5858682 DOI: 10.1177/2050312118761674] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/05/2018] [Indexed: 12/17/2022] Open
Abstract
Intervertebral disc degeneration is a disease of the discs connecting adjoining vertebrae in which structural damage leads to loss of disc integrity. Degeneration of the disc can be a normal process of ageing, but can also be precipitated by other factors. Literature has made substantial progress in understanding the biological basis of intervertebral disc, which is reviewed here. Current medical and surgical management strategies have shortcomings that do not lend promise to be effective solutions in the coming years. With advances in understanding the cell biology and characteristics of the intervertebral disc at the molecular and cellular level that have been made, alternative strategies for addressing disc pathology can be discovered. A brief overview of the anatomic, cellular, and molecular structure of the intervertebral disc is provided as well as cellular and molecular pathophysiology surrounding intervertebral disc degeneration. Potential therapeutic strategies involving stem cell, protein, and genetic therapy for intervertebral disc degeneration are further discussed.
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Affiliation(s)
- Joseph Fernandez-Moure
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Regenerative and Biomimetic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Caitlyn A Moore
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Azim Karim
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Kevin Smith
- Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Zonia Barbosa
- Department of Regenerative and Biomimetic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Jeffrey Van Eps
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Regenerative and Biomimetic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Pranela Rameshwar
- Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bradley Weiner
- Department of Regenerative and Biomimetic Medicine, Houston Methodist Research Institute, Houston, TX, USA.,Department of Orthopedic Surgery, Houston Methodist Hospital, Houston, TX, USA
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20
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Bendtsen M, Bunger C, Colombier P, Le Visage C, Roberts S, Sakai D, Urban JPG. Biological challenges for regeneration of the degenerated disc using cellular therapies. Acta Orthop 2016; 87:39-46. [PMID: 28287303 PMCID: PMC5389430 DOI: 10.1080/17453674.2017.1297916] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 01/07/2017] [Indexed: 02/08/2023] Open
Affiliation(s)
| | - Cody Bunger
- Department of Orthopaedics, Aarhus University Hospital, Denmark
| | - Pauline Colombier
- INSERM UMR 1229, Regenerative Medecine and Skeleton, University of Nantes, France
| | - Catherine Le Visage
- INSERM UMR 1229, Regenerative Medecine and Skeleton, University of Nantes, France
| | - Sally Roberts
- Spinal Studies and ISTM (Keele University), Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, UK
| | - Daisuke Sakai
- Department of Orthopaedics, Tokai University Hospital, Japan
| | - Jill P G Urban
- Department of Physiology, Anatomy and Genetics, Oxford University, Oxford, UK
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21
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Iatridis JC, Kang J, Kandel R, Risbud MV. New Horizons in Spine Research: Disc biology, spine biomechanics and pathomechanisms of back pain. J Orthop Res 2016; 34:1287-8. [PMID: 27571441 PMCID: PMC5072778 DOI: 10.1002/jor.23375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- James C. Iatridis
- Leni & Peter W. May Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, NY 10029
| | - James Kang
- Department of Orthopedic
Surgery, Brigham and Women’s Hospital, Boston, MA 02115
| | - Rita Kandel
- Department of Pathology and Laboratory Medicine, Sinai Health System, Toronto, Ontario, Canada M5G1X5
| | - Makarand V. Risbud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107
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