Effects of exogenous crosslinking on in vitro tensile and compressive moduli of lumbar intervertebral discs

A Self-Polymerizing Mesh of Nano-Tethers for the Mechanical Constraint of Degraded Intervertebral Discs-A Review of 25 Years of Pre-Clinical and Early Clinical Research

Genipin polymers are self-forming tensile-load-carrying oligomers, derived from the gardenia fruit, that covalently bond to amines on collagen. The potential therapeutic mechanical benefits of a non-discrete in situ forming mesh of genipin oligomers for degraded spinal discs were first conceived in 1998. Over more than two decades, numerous studies have demonstrated the immediate mechanical effects of this injectable, intra-annular polymeric mesh including an early demonstration of an effect on clinical outcomes for chronic or recurrent discogenic low back pain. This literature review focused on articles investigating mechanical effects in cadaveric animal and human spinal discs, biochemical mechanism of action studies, articles describing the role of mechanical degradation in the pathogenesis of degenerative disc disease, initial clinical outcomes and articles describing current discogenic low back pain treatment algorithms. On the basis of these results, clinical indications that align with the capabilities of this novel injectable polymer-based treatment strategy are discussed. It is intended that this review of a novel nano-scale material-based solution for mechanical deficiencies in biologically limited tissues may provide a helpful example for other innovations in spinal diseases and similarly challenging musculoskeletal disorders.

Understanding the etiopathogenesis of lumbar intervertebral disc herniation: From clinical evidence to basic scientific research

Lumbar intervertebral disc herniation, as a leading cause of low back pain, productivity loss, and disability, is a common musculoskeletal disorder that results in significant socioeconomic burdens. Despite extensive clinical and basic scientific research efforts, herniation etiopathogenesis, particularly its initiation and progression, is not well understood. Understanding herniation etiopathogenesis is essential for developing effective preventive measures and therapeutic interventions. Thus, this review seeks to provide a thorough overview of the advances in herniation-oriented research, with a discussion on ongoing challenges and potential future directions for clinical, translational, and basic scientific investigations to facilitate innovative interdisciplinary research aimed at understanding herniation etiopathogenesis. Specifically, risk factors for herniation are identified and summarized, including familial predisposition, obesity, diabetes mellitus, smoking tobacco, selected cardiovascular diseases, disc degeneration, and occupational risks. Basic scientific experimental and computational research that aims to understand the link between excessive mechanical load, catabolic tissue remodeling due to inflammation or insufficient nutrient supply, and herniation, are also reviewed. Potential future directions to address the current challenges in herniation-oriented research are explored by combining known progressive development in existing research techniques with ongoing technological advances. More research on the relationship between occupational risk factors and herniation, as well as the relationship between degeneration and herniation, is needed to develop preventive measures for working-age individuals. Notably, researchers should explore using or modifying existing degeneration animal models to study herniation etiopathogenesis, as such models may allow for a better understanding of how to prevent mild-to-moderately degenerated discs from herniating.

Design principles in mechanically adaptable biomaterials for repairing annulus fibrosus rupture: A review

Annulus fibrosus (AF) plays a crucial role in the biomechanical loading of intervertebral disc (IVD). AF is difficult to self-heal when the annulus tears develop, because AF has a unique intricate structure and biologic milieu in vivo. Tissue engineering is promising for repairing AF rupture, but construction of suitable mechanical matching devices or scaffolds is still a grand challenge. To deeply know the varied forces involved in the movement of the native annulus is highly beneficial for designing biomimetic scaffolds to recreate the AF function. In this review, we overview six freedom degrees of forces and adhesion strength on AF tissue. Then, we summarize the mechanical modalities to simulate related forces on AF and to assess the characteristics of biomaterials. We finally outline some current advanced techniques to develop mechanically adaptable biomaterials for AF rupture repair.

Non-enzymatic glycation increases the failure risk of annulus fibrosus by predisposing the extrafibrillar matrix to greater stresses

Growing clinical evidence suggests a correlation between diabetes and more frequent and severe intervertebral disc failure, partially attributed to accelerated advanced glycation end-products (AGE) accumulation in the annulus fibrosus (AF) through non-enzymatic glycation. However, in vitro glycation (i.e., crosslinking) reportedly improved AF uniaxial tensile mechanical properties, contradicting clinical observations. Thus, this study used a combined experimental-computational approach to evaluate the effect of AGEs on anisotropic AF tensile mechanics, applying finite element models (FEMs) to complement experimental testing and examine difficult-to-measure subtissue-level mechanics. Methylglyoxal-based treatments were applied to induce three physiologically relevant AGE levels in vitro. Models incorporated crosslinks by adapting our previously validated structure-based FEM framework. Experimental results showed that a threefold increase in AGE content resulted in a ∼55% increase in AF circumferential-radial tensile modulus and failure stress and a 40% increase in radial failure stress. Failure strain was unaffected by non-enzymatic glycation. Adapted FEMs accurately predicted experimental AF mechanics with glycation. Model predictions showed that glycation increased stresses in the extrafibrillar matrix under physiologic deformations, which may increase tissue mechanical failure or trigger catabolic remodeling, providing insight into the relationship between AGE accumulation and increased tissue failure. Our findings also added to the existing literature regarding crosslinking structures, indicating that AGEs had a greater effect along the fiber direction, while interlamellar radial crosslinks were improbable in the AF. In summary, the combined approach presented a powerful tool for examining multiscale structure-function relationships with disease progression in fiber-reinforced soft tissues, which is essential for developing effective therapeutic measures. STATEMENT OF SIGNIFICANCE: Increasing clinical evidence correlates diabetes with premature intervertebral disc failure, likely due to advanced glycation end-products (AGE) accumulation in the annulus fibrosus (AF). However, in vitro glycation reportedly increases AF tensile stiffness and toughness, contradicting clinical observations. Using a combined experimental-computational approach, our work shows that increases in AF bulk tensile mechanical properties with glycation are achieved at the risk of exposing the extrafibrillar matrix to increased stresses under physiologic deformations, which may increase tissue mechanical failure or trigger catabolic remodeling. Computational results indicate that crosslinks along the fiber direction account for 90% of the increased tissue stiffness with glycation, adding to the existing literature. These findings provide insight into the multiscale structure-function relationship between AGE accumulation and tissue failure.

Early Clinical Results of Intervertebral Joint Stabilization by Injectable Load-Sharing Polymers

Background

Genipin is a polymer-forming collagen bonding substance that can be dissolved in a buffered carrier and injected into disc annulus tissues. Therapeutic benefit is derived from the mechanical support provided by a large number of genipin polymers attached to collagen fibers in a degraded disc.

Study Design/Setting

IRB-approved prospective, multi-site, single-arm, 12-month feasibility studies were undertaken in two countries to evaluate the safety and efficacy of the genipin-based implant for treating discogenic chronic low back pain (CLBP).

Patient Sample

Twenty CLBP patients with symptomatic discs at one or two levels were enrolled in the study.

Outcome Measures

The primary safety endpoint was serious adverse events at 1 month, and the primary efficacy endpoint was reduction of pain and disability at 3 months. Secondary efficacy endpoints included reduction of pain and disability at 2 weeks, 1 month, 6 months, and 12 months; reduction of flexion-extension instability; increase in segmental lordosis and rotation; and patient satisfaction.

Methods

Fluoroscopic image-guidance was used to deliver two posterolateral injections of buffered genipin to each symptomatic disc. Flexion-extension radiographs were used to quantify joint kinematics at three time-points.

Results

Clinically meaningful improvements in pain and disability scores were reported in 80% or more of patients from 2 weeks to 1 year post-treatment. For the more severely unstable joints, treatment significantly reduced the instability score from a pre-treatment level of 2.4 standard deviations above the mean for an asymptomatic population to the asymptomatic mean at the 3-month follow-up.

Conclusion

These initial clinical data demonstrate the safety and efficacy of a genipin-based collagen tethering device capable of improving spinal joint stability while successfully addressing CLBP. This work merits additional randomized clinical studies.

A Novel Testing Method to Quantify Mechanical Properties of the Intact Annulus Fibrosus Ring From Rat-Tail Intervertebral Discs

The annulus fibrosus is the ring-like exterior of the intervertebral disc which is composed of concentrically organized layers of collagen fibre bundles. The mechanical properties of the annulus have been studied extensively; however, tests are typically performed on extracted fragments or multilayered samples of the annulus and not on the annulus as a whole. The purpose of this study was two-fold: 1) to develop a novel testing technique to measure the mechanical properties of the intact, isolated annulus; and 2) to perform a preliminary analysis of the rate-dependency of these mechanical properties. Twenty-nine whole annulus ring samples were dissected from 11 skeletally mature Sprague Dawley rat tails and underwent a tensile failure test at either 2%/s (n=16) or 20%/s (n=13). Force and displacement were sampled at 100Hz and were subsequently normalized to stress and strain. Various mechanical properties were derived from the stress-strain curves and statistically compared between the rates. All mechanical variables, with the exception of initial failure stress, were found to be unaffected by rate. Interestingly, initial failure stress was higher for samples tested at the slower rate compared to the higher rate which is atypical for viscoelastic tissues. Although in general rate did not appear to impact the annulus ring response to tensile loading, this novel, intact annular ring testing technique provides an alternative way to quantify mechanical properties of the annulus.

Can UVA-light-activated riboflavin-induced collagen crosslinking be transferred from ophthalmology to spine surgery? A feasibility study on bovine intervertebral disc

Background

Collagen cross-links contribute to the mechanical resilience of the intervertebral disc (IVD). UVA-light-activated riboflavin-induced collagen crosslinking (UVA-CXL) is a well-established and effective ophthalmological intervention that increases the mechanical rigidity of the collagen-rich corneal matrix in Keratoconus. This study explores the feasibility, safety and efficacy of translating this intervention in reinforcing the IVD.

Methods

Annulus fibrosus (AF) cells were isolated from bovine IVDs and treated with different combinations of riboflavin (RF) concentrations (0.05–8 mM) and UVA light intensities (0.3–4 mW/cm²). Metabolic activity (resazurin assay), cell viability (TUNEL assay), and gene expression of apoptosis regulators C-FOS and PT5 were assessed immediately and 24 hours after treatment. Biomechanical effects of UVA-CXL on IVDs were measured by indentation analysis of changes in the instantaneous modulus and by peel-force delamination strength analysis of the AF prior and after treatment.

Results

Different intensities of UVA did not impair the metabolic activity of AF cells. However, RF affected metabolic activity (p < 0.001). PT53 expression was similar in all RF conditions tested while C-FOS expression decreased 24 hours after treatment. Twenty-four hours after treatment, no apoptotic cells were observed in any condition tested. Biomechanical characterizations showed a significant increase in the annular peel strength of the UVA-CXL group, when compared to controls of UVA and RF alone (p < 0.05). UVA-CXL treated IVDs showed up to 152% higher (p < 0.001) instantaneous modulus values compared to the untreated control.

Conclusion

This is the first study on UVA-CXL treatment of IVD. It induced significantly increased delamination strength and instantaneous modulus indentation values in intact IVD samples in a structure–function relationship. RF concentrations and UVA intensities utilized in ophthalmological clinical protocols were well tolerated by the AF cells. Our findings suggest that UVA-CXL may be a promising tool to reinforce the IVD matrix.

Multifaceted Design and Emerging Applications of Tissue Adhesives

Tissue adhesives can form appreciable adhesion with tissues and have found clinical use in a variety of medical settings such as wound closure, surgical sealants, regenerative medicine, and device attachment. The advantages of tissue adhesives include ease of implementation, rapid application, mitigation of tissue damage, and compatibility with minimally invasive procedures. The field of tissue adhesives is rapidly evolving, leading to tissue adhesives with superior mechanical properties and advanced functionality. Such adhesives enable new applications ranging from mobile health to cancer treatment. To provide guidelines for the rational design of tissue adhesives, here, existing strategies for tissue adhesives are synthesized into a multifaceted design, which comprises three design elements: the tissue, the adhesive surface, and the adhesive matrix. The mechanical, chemical, and biological considerations associated with each design element are reviewed. Throughout the report, the limitations of existing tissue adhesives and immediate opportunities for improvement are discussed. The recent progress of tissue adhesives in topical and implantable applications is highlighted, and then future directions toward next-generation tissue adhesives are outlined. The development of tissue adhesives will fuse disciplines and make broad impacts in engineering and medicine.

Soft Palate Modification Using a Collagen Crosslinking Reagent for Equine Dorsal Displacement of the Soft Palate and Other Upper Airway Breathing Disorders

The mechanical properties of the soft palate can be associated with breathing abnormalities. Dorsal displacement of the soft palate (DDSP) is a naturally occurring equine soft palate disorder caused by displacement of the caudal edge of the soft palate. Snoring and a more serious, sometimes life-threatening, condition called obstructive sleep apnea (OSA) are forms of sleep-related breathing disorders in humans which may involve the soft palate. The goal of this study was to investigate the effect of injecting the protein crosslinker genipin into the soft palate to modify its mechanical properties for the treatment of equine DDSP with potential implications for the treatment of snoring and OSA in humans. Ex vivo experiments consisted of mechanical testing and a wind tunnel study to examine the effect of genipin on the mechanical properties, displacement, and vibration of equine soft palates. A pilot in vivo study was completed using DDSP and control horses to test the safety and effectiveness of injecting a genipin reagent into the soft palate. The wind tunnel testing demonstrated a greater than 50% decrease in transient deformation and a greater than 33% decrease in steady-state vibrations for all doses of genipin tested. Ultimate tensile stress, yield stress, and Young's modulus were higher in the genipin-treated distal soft palate specimens by 52%, 53%, and 63%, respectively. The pilot in vivo study showed a reduction of snoring loudness in all DDSP horses and elimination of DDSP in at least one of three horses. The difficulty of using a 1-meter-long endoscopic injection needle contributed to a consistent overinjection of the equine soft palates, causing excessive stretching (pillowing) and related degradation of the tissue. These ex vivo and in vivo results demonstrated reduced vibration amplitude and flaccidity and increased strength of genipin-treated soft palates, suggesting that genipin crosslinking could become an effective and safe treatment for soft palate related breathing abnormalities.

Dietary advanced glycation end-product consumption leads to mechanical stiffening of murine intervertebral discs

Back pain is a leading cause of disability and is strongly associated with intervertebral disc (IVD) degeneration. Reducing structural disruption and catabolism in IVD degeneration remains an important clinical challenge. Pro-oxidant and structure-modifying advanced glycation end-products (AGEs) contribute to obesity and diabetes, which are associated with increased back pain, and accumulate in tissues due to hyperglycemia or ingestion of foods processed at high heat. Collagen-rich IVDs are particularly susceptible to AGE accumulation due to their slow metabolic rates, yet it is unclear whether dietary AGEs can cross the endplates to accumulate in IVDs. A dietary mouse model was used to test the hypothesis that chronic consumption of high AGE diets results in sex-specific IVD structural disruption and functional changes. High AGE diet resulted in AGE accumulation in IVDs and increased IVD compressive stiffness, torque range and failure torque, particularly for females. These biomechanical changes were likely caused by significantly increased AGE crosslinking in the annulus fibrosus, measured by multiphoton imaging. Increased collagen damage measured with collagen hybridizing peptide did not appear to influence biomechanical properties and may be a risk factor as these animals age. The greater influence of high AGE diet on females is an important area of future investigation that may involve AGE receptors known to interact with estrogen. We conclude that high AGE diets can be a source for IVD crosslinking and collagen damage known to be important in IVD degeneration. Dietary modifications and interventions that reduce AGEs warrant further investigation and may be particularly important for diabetics, in whom AGEs accumulate more rapidly.

Summary: Dietary AGEs lead to sex-specific intervertebral disc structural and functional changes and may be targeted for promoting spinal health, especially in diabetes, in which AGEs form rapidly.

Examination of toxicity and collagen linearity after the administration of the protein cross-linker genipin in equine tendon and dermis: a pilot study

OBJECTIVE

Collagen cross-linking is an attractive therapeutic route aimed at supplementing natural collagen stabilisation. In this study the toxicity of the cross-linker genipin (GP) was examined in avascular (tendon) and vascular (dermis) tissue.

METHODS

High doses of GP were injected intratendinously into three yearling horses and evaluated at various time points up to 30 days. A second group of three yearlings were injected into the dermis and evaluated at various time points up to 1 year. Metrics used included lameness, circumferential swelling, ultrasound evaluation, microscopic morphology, collagen production and systemic effect on blood parameters.

RESULTS

The tendon injection sites exhibited mild lameness and swelling with no apparent systemic toxicity or stabilisation defects. Treated tendons exhibited increased linear collagen microscopically. Dermal injections showed similar results, with mild swelling at the injection site. Microscopic morphology resulted in a decrease in dermal collagen at 30 days post-injection. Dermis injected at the high dose of 355 mmol/L examined 1 year post-treatment appeared similar to the untreated biopsies; however, there was an increase in mature collagen.

CONCLUSION

GP injection appeared to be well tolerated, with transient lameness and mild circumferential swelling when injected into the tendon and local tissue swelling when injected into the dermis. No systemic hypersensitivities or toxicities were observed. Microscopically, GP resulted in increased linear collagen in tendons at 30 days post-injection and overall increased collagen in dermal tissue when evaluated 1 year post-injection.

Effects of Collagen Crosslink Augmentation on Mechanism of Compressive Load Sharing in Intervertebral Discs

Exogenous crosslinking has been shown to have potential for treating disc degeneration and back pain due to its ability to increase the strength and toughness of the annulus fibrosus, increase intervertebral joint stability, decrease intradiscal pressure, and increase fluid flow through the disc. Some results imply that crosslink augmentation may also lead to changes in the compressive load sharing properties of the disc. The objective of the present study was to evaluate directional stress distribution changes of the disc following genipin crosslinking treatment. Bovine lumbar motion segments were randomly divided into control and crosslinked groups. Annular strains were determined from simultaneous deformation measurements at various time points during compressive creep testing. Four stress components of the annulus were then calculated according to the previously measured modulus data. Immediately after the application of a 750-N compressive load, mean axial and radial compressive stresses in the crosslinked group were twofold higher than control means. Conversely, mean lamellae-aligned and circumferential tensile stresses of the crosslinked discs were 8- and threefold lower, respectively, compared to control means. After 1-h creep loading, the two compressive mean stresses in both the control and genipin-crosslinked specimens increased approximately threefold from their initial 750-N-loaded values. The two tensile mean stresses in the crosslinked group remained lower than the respective levels of the control means after creep loading. A greater proportion of annular compressive load support under compressive creep loading, with a commensurate decrease in both tensile stresses and strains, was seen in the discs following exogenous crosslink augmentation.

A regenerative approach towards recovering the mechanical properties of degenerated intervertebral discs: Genipin and platelet-rich plasma therapies

Degenerative disc disease, associated with discrete structural changes in the peripheral annulus and vertebral endplate, is one of the most common pathological triggers of acute and chronic low back pain, significantly depreciating an individual's quality of life and instigating huge socioeconomic costs. Novel emerging therapeutic techniques are hence of great interest to both research and clinical communities alike. Exogenous crosslinking, such as Genipin, and platelet-rich plasma therapies have been recently demonstrated encouraging results for the repair and regeneration of degenerated discs, but there remains a knowledge gap regarding the quantitative degree of effectiveness and particular influence on the mechanical properties of the disc. This study aimed to investigate and quantify the material properties of intact (N = 8), trypsin-denatured (N = 8), Genipin-treated (N = 8), and platelet-rich plasma-treated (N = 8) discs in 32 porcine thoracic motion segments. A poroelastic finite element model was used to describe the mechanical properties during different treatments, while a meta-model analytical approach was used in combination with ex vivo experiments to extract the poroelastic material properties. The results revealed that both Genipin and platelet-rich plasma are able to recover the mechanical properties of denatured discs, thereby affording promising therapeutic modalities. However, platelet-rich plasma-treated discs fared slightly, but not significantly, better than Genipin in terms of recovering the glycosaminoglycans content, an essential building block for healthy discs. In addition to investigating these particular degenerative disc disease therapies, this study provides a systematic methodology for quantifying the detailed poroelastic mechanical properties of intervertebral disc.

Exogenous Crosslinking Restores Intradiscal Pressure of Injured Porcine Intervertebral Discs: An In Vivo Examination Using Quantitative Discomanometry

STUDY DESIGN

In vivo examination of intradiscal pressure by quantitative discomanometry (QD).

OBJECTIVE

To determine whether an injectable, exogenous crosslinking could acutely restore intradiscal pressure of stab-injured discs in vivo by short-term treatment.

SUMMARY OF BACKGROUND DATA

Disc biomechanical performance depends on its integrity associated with the intradiscal pressure and mechanical properties. Genipin crosslink augmentation has demonstrated the in vitro biomechanical capability to improve intervertebral joint stability and increase mechanical properties of the annulus fibrosus.

METHODS

4 lumbar discs on each of 8 swine were randomly assigned to 4 groups: intact, injured, untreated, and crosslinked. A 16G needle was stabbed into the annulus fibrosus to create the disc injury model. An injection of 0.33% genipin solution was delivered into the annulus to treat the injury. QD technique was performed to examine the intradiscal pressure for the intact and injured discs at the time of surgery, while untreated and crosslinked discs were measured 1-week postsurgery. 4 QD parameters were analyzed and compared across the 4 groups: leakage pressure and volume, and saturation pressure and volume.

RESULTS

The leakage and saturation pressures of the injured group were significantly lower than those of the intact group (P = 0.004 and P = 0.01, respectively). The leakage and saturation pressures of untreated discs were statistically equivalent to the injured levels, but with a 2-times higher saturation volume. Relative to the untreated group, the leakage pressure and saturation pressure of genipin-crosslinked discs had a 617% (P = 0.008) and a 473% increase (P = 0.007), respectively.

CONCLUSION

A large disc injury produced by annular puncture immediately lowered intradiscal pressure when left untreated. Genipin crosslinking can restore intradiscal pressure acutely in vivo without any obvious morbidity associated with the injection.

Nucleus Implantation: The Biomechanics of Augmentation Versus Replacement With Varying Degrees of Nucleotomy

Nucleus pulposus replacement and augmentation has been proposed to restore disk mechanics in early stages of degeneration with the option of providing a minimally invasive procedure for pain relief to patients with an earlier stage of degeneration. The goal of this paper is to examine compressive stability of the intervertebral disk after either partial nucleus replacement or nuclear augmentation in the absence of denucleation. Thirteen human cadaver lumbar anterior column units were used to study the effects of denucleation and augmentation on the compressive mechanical behavior of the human intervertebral disk. Testing was performed in axial compression after incremental steps of partial denucleation and subsequent implantation of a synthetic hydrogel nucleus replacement. In a separate set of experiments, the disks were not denucleated but augmented with the same synthetic hydrogel nucleus replacement. Neutral zone, range of motion, and stiffness were measured. The results showed that compressive stabilization of the disk can be re-established with nucleus replacement even for partial denucleation. Augmentation of the disk resulted in an increase in disk height and intradiskal pressure that were linearly related to the volume of polymer implanted. Intervertebral disk instability, evidenced by increased neutral zone and ranges of motion, associated with degeneration can be restored by volume filling of the nucleus pulposus using the hydrogel device presented here.

Specimen specific parameter identification of ovine lumbar intervertebral discs: On the influence of fibre-matrix and fibre-fibre shear interactions

Numerical models of the intervertebral disc, which address mechanical questions commonly make use of the difference in water content between annulus and nucleus, and thus fluid and solid parts are separated. Despite this simplification, models remain complex due to the anisotropy and nonlinearity of the annulus and regional variations of the collagen fibre density. Additionally, it has been shown that cross-links make a large contribution to the stiffness of the annulus. Because of this complex composite structure, it is difficult to reproduce several sets of experimental data with one single set of material parameters. This study addresses the question to which extent the ultrastructure of the intervertebral disc should be modelled so that its moment-angle behaviour can be adequately described. Therefore, a hyperelastic constitutive law, based on continuum mechanical principles was derived, which does not only consider the anisotropy from the collagen fibres, but also interactions among the fibres and between the fibres and the ground substance. Eight ovine lumbar intervertebral discs were tested on a custom made spinal loading simulator in flexion/extension, lateral bending and axial rotation. Specimen-specific geometrical models were generated using CT images and T2 maps to distinguish between annulus fibrosus and nucleus pulposus. For the identification of the material parameters the annulus fibrosus was described with two scenarios: with and without fibre-matrix and fibre-fibre interactions. Both scenarios showed a similar behaviour on a load displacement level. Comparing model predictions to the experimental data, the mean RMS of all specimens and all load cases was 0.54±0.15° without the interaction and 0.54±0.19° when the fibre-matrix and fibre-fibre interactions were included. However, due to the increased stiffness when cross-links effects were included, this scenario showed more physiological stress-strain relations in uniaxial and biaxial stress states. Thus, the present study suggests that fibre-matrix and fibre-fibre interactions should be considered in the constitutive law when the model addresses questions concerning the stress field of the annulus fibrosus.

Rheological and dynamic integrity of simulated degenerated disc and consequences after cross-linker augmentation

STUDY DESIGN

An in situ study using whole-organ culture system.

OBJECTIVE

To study the effect of disc degeneration at different stages on its rheological and dynamic properties and to investigate the efficacy of exogenous cross-linking therapy.

SUMMARY OF BACKGROUND DATA

Disc degeneration can involve protein denaturation or microdefects to the disc's collagen fiber network. A disc degeneration model using whole-organ culture technique can be effectively used for the screening of treatments of degenerated discs. Exogenous cross-linking therapy has been shown to enhance the mechanical properties of the disc by cross-linking collagen. However, the efficacy of this therapy on the degenerated disc is unclear.

METHODS

A total of 40 porcine thoracic discs were assigned to 5 groups: intact discs, moderately degenerated discs, moderately degenerated discs with cross-linker augmentation, severely degenerated discs, and severely degenerated discs with cross-linker augmentation. The disc degeneration was simulated by trypsin digestion and mechanical fatigue loading. Rheological properties, dynamic properties, water content, and histological analysis were conducted after a 7-day incubation.

RESULTS

The mechanical properties of moderate degenerated discs significantly decrease both in rheological and dynamic properties, and laminate structure disorganization was observed. Mechanical defects of severely degenerated discs resulted in disc height loss, an increase in the aggregate modulus and stiffness modulus, and a decrease in the damping coefficient, hydraulic permeability, and water content. Cross-linker augmentation significantly recovered mechanical properties of moderately degenerated discs and restored the water content compared with the intact disc. However, the augmentation did not fully repair the severely degenerated discs.

CONCLUSION

Trypsin-induced extracellular matrix damage resulted in a change of the disc's biomechanics. Cross-linker augmentation recovers the rheological and dynamic properties of moderately degenerated discs but not of the severely degenerated discs. The genipin cross-linker may be able to improve the proteoglycan depletion effect in the nucleus pulposus but may not be effective to restore the structural damage in the collagen molecule of the anulus fibrosus.

Changes in the interfacial shear resistance of disc annulus fibrosus from genipin crosslinking

Crosslinking soft tissue has become more common in tissue engineering applications, and recent studies have demonstrated that soft tissue mechanical behavior can be directly altered through crosslinking. Using a recently reported test method that shears adjacent disc lamella, the effect of genipin crosslinking on interlamellar shear resistance was studied using in vitro bovine disc annulus. Specimens of adjacent lamella were dissected from four discs taken from three fresh frozen bovine tails. These specimens were paired and soaked in either 50 mM EPPS Phosphate (ph9) with 20 mM genipin at 37 °C for 4 h or in 50 mM EPPS Phosphate (ph9) of which twelve specimens (6 per treatment) were successfully tested and analyzed. Crosslinked specimens were noted to have significantly higher yield force per width (59%), peak force per width (70%), and resilience (69%) compared to sham treated controls, supporting the hypothesis that genipin crosslinking increases the resistance to interlamellar shear of the annulus interface. Additionally, a possible dependency may exist between the interlamellar shear strength and neighboring lamella because of the bridging fiber network previously described by other investigators.

BENEFICIAL EFFECTS OF EXOGENOUS CROSSLINKING AGENTS ON SELF-ASSEMBLED TISSUE ENGINEERED CARTILAGE CONSTRUCT BIOMECHANICAL PROPERTIES

BACKGROUND

As articular cartilage is unable to repair itself, there is a tremendous clinical need for a tissue engineered replacement tissue. Current tissue engineering efforts using the self-assembly process have demonstrated promising results, but the biomechanical properties remain at roughly 50% of native tissue.

METHODOLOGY/PRINCIPAL FINDINGS

The objective of this study was to determine the feasibility of using exogenous crosslinking agents to enhance the biomechanical properties of a scaffoldless cartilage tissue engineering approach. Four crosslinking agents (glutaraldehyde, ribose, genipin, and methylglyoxal) were applied each at a single concentration and single application time. It was determined that ribose application resulted in a significant 69% increase in Young's modulus, a significant 47% increase in ultimate tensile strength, as well as a trend toward a significant increase in aggregate modulus. Additionally, methylglyoxal application resulted in a significant 58% increase in Young's modulus. No treatments altered the biochemical content of the tissue.

CONCLUSIONS/SIGNIFICANCE

To our knowledge, this is the first study to examine the use of exogenous crosslinking agents on any tissue formed using a scaffoldless tissue engineering approach. In particular, this study demonstrates that a one-time treatment with crosslinking agents can be employed effectively to enhance the biomechanical properties of tissue engineered articular cartilage. The results are exciting, as they demonstrate the feasibility of using exogenous crosslinking agents to enhance the biomechanical properties without the need for increased glycosaminoglycan (GAG) and collagen content.

Exogenous collagen crosslinking of the intervertebral disc restores joint stability after lumbar posterior decompression surgery

STUDY DESIGN

In vitro evaluation of a chemical, injectable intervention for discectomy induced destabilization.

OBJECTIVE

To investigate the ability of two collagen crosslinking agents to restore mechanical properties to lumbar joints destabilized by surgical decompression procedures.

SUMMARY OF BACKGROUND DATA

Posterior decompression surgery is a common procedure indicated for tissue pathology that interferes with surrounding neural structures. Previous in vitro, analytical, and clinical studies have shown that removal of load-supporting tissue can compromise joint stability mandating some form of postsurgical stabilization. Currently, no nonsurgical treatments are capable of restoring stability and preventing subsequent degeneration. Exogenous crosslinking of intact discs has shown a fourfold increase in joint stability.

METHODS

Fifteen bovine lumbar intervertebral joints were randomly separated into methylglyoxal or genipin treatment groups. Flexion-extension flexibility was quantified in three conditions: intact, postdecompression surgery, and after crosslinking reagent injections. Instability was quantified by calculating neutral zone (NZ), percentage of hysteresis, range of motion, and percentage of strain energy.

RESULTS

Simulated surgical decompression increased NZ 111% (P = 0.009), 28% (P = 0.004), range of motion 57% (P = 0.003), and decreased strain energy 37% (P = 0.004). For those discs undergoing methylglyoxal treatment NZ was subsequently reduced 68% (P = 0.012), hysteresis 28% (P = 0.018), range of motion 29% (P = 0.012), and strain energy was increased 71% (P = 0.018). For discs subjected to genipin treatment, NZ was reduced 52% (P = 0.018), hysteresis 23% (P = 0.012), range of motion 44% (P = 0.017), and strain energy was increased 66% (P = 0.012). Mean NZ was lower than intact mean after both methylglyoxal and genipin treatments, 10% and 17% less, respectively, but these differences were not significant. Mean values for all other parameters posttreatment were within 6% of the corresponding intact mean values.

CONCLUSION

Injections of crosslinking reagents into lumbar intervertebral discs after simulated decompression surgery restored joint stability according to all parameters. Similar results were found for genipin and methylglyoxal reagents. Implementing exogenous collagen crosslinking as an adjunct to current surgical decompression procedures may be beneficial in preventing or delaying subsequent spinal instability and degeneration.

Thermal analysis reveals differential effects of various crosslinkers on bovine annulus fibrosis

Treatment of a pathological spinal disc in vivo by injection of protein crosslinking reagents to restore the disc's mechanical properties is a new approach to the treatment of degenerative disc disease. In this study, the thermal stability of the collagen in disc annulus was measured by differential scanning calorimetry following treatment with six different crosslinking agents. The crosslinkers used were; L-threose (LT), genipin (GP), methylglyoxal (MG), 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDC), glutaraldehyde (GA), and proanthrocyanidin (PA). Untreated tissue displayed a prominent peak at about 66-68°C. Comparison of endothermal patterns of untreated and crosslinker-treated disc annulus tissue samples showed that a new peak appeared at a higher temperature following treatment. The temperature of the new peak qualitatively depended on the crosslinker in the following order GA > MG > GP > PA = EDC > LT, suggesting that the enhanced thermal stability of collagen in the annulus tissue was related to the nature of the crosslinker. Also, the enthalpic ratios of the lower temperature (noncrosslinked) peaks in the treated and untreated tissue, and of the higher and lower temperature peaks in the treated tissue, both indicated that the various agents crosslinked the tissue with different efficiencies. Our data suggest that the ability of GP to penetrate into the disc and form long- and short-range crosslinks may make it the most suitable candidate for clinical development. In addition, binary combinations of long- and short-range crosslinkers, such as PA with LT, may also provide synergistic effects due to their substantially different physicochemical properties.

Optimization of protein crosslinking formulations for the treatment of degenerative disc disease

STUDY DESIGN

Biochemical studies aimed at optimization of protein crosslinking formulations for the treatment of degenerative disc disease and subsequent biomechanical testing of tissues treated with these formulations.

OBJECTIVE

To optimize protein crosslinking formulations for treatment of degenerating spinal discs.

SUMMARY OF BACKGROUND DATA

Nonsurgical exogenous crosslinking therapy is a potential new, noninvasive technology for the treatment of degenerative disc disease. The technology is based on the injection of protein crosslinking reagents into the pathologic disc to restore its mechanical properties and also to potentially increase the permeability of the tissue and so facilitate the exchange of waste products and nutrients.

METHODS

Diffusion of genipin (GP) was monitored following injection into spinal discs and the effects of surfactants on diffusion studied. Formulations for GP and methylglyoxal (MG) were biochemically optimized and used to treat bovine spinal discs. Their effects on bovine anulus tissue were evaluated using a circumferential tensile test, while the GP formulation was also tested with respect to its ability to reduce disc bulge under load.

RESULTS

GP exhibited a distinct time-dependent diffusion and sodium-dodecyl-sulfate, but not Tween-20, enhanced diffusion by 30%. Two crosslinkers, GP and MG, were inhibited by amines but enhanced by phosphate ions. Both formulations could enhance a number of physical parameters of bovine anulus tissue, while the GP formulation could reduce disc bulge following injections into spinal discs.

CONCLUSION

Formulations lacking amines and containing phosphate ions appear to be promising candidates for clinical use of the crosslinkers GP and MG.

The effects of needle puncture injury on microscale shear strain in the intervertebral disc annulus fibrosus

BACKGROUND CONTEXT

Needle puncture of the intervertebral disc (IVD) is required for delivery of therapeutic agents to the nucleus pulposus and for some diagnostic procedures. Needle puncture has also been implicated as an initiator of disc degeneration. It is hypothesized that needle puncture may initiate IVD degeneration by altering microscale mechanical behavior in the annulus fibrosus (AF).

PURPOSE

Quantify the changes in AF microscale strain behavior resulting from puncture with a hypodermic needle.

STUDY DESIGN

Cadaveric IVD tissue explant study.

METHODS

Annulus fibrosus explants from bovine caudal IVDs that had been punctured radially with hypodermic needles were loaded in dynamic sinusoidal shear while being imaged with a confocal microscope. Digital image analysis was used to quantify local tissue strain and damage propagation with repeated shearing.

RESULTS

Needle puncture changed the distribution of microscale shear strains in the AF under load from homogenous (equal to far field) to a distinct pattern of high (4× far field) and low (0.25× far field) strain areas. Repeated loading did not cause further growth of the disruption beyond the second cycle.

CONCLUSIONS

Needle puncture results in a drastic alteration of microscale strain behavior in the AF under load. This alteration may directly initiate disc degeneration by being detrimental to tissue-cell mechanotransduction.

The effects of exogenous crosslinking on hydration and fluid flow in the intervertebral disc subjected to compressive creep loading and unloading

STUDY DESIGN

In vitro study of genipin crosslinking effect on disc water content changes under compressive loading and unloading.

OBJECTIVE

To investigate the influence of collagen crosslinking on hydration and fluid flow in different regions of intact discs, and to evaluate the nutritional implications.

SUMMARY OF BACKGROUND DATA

Age-related reductions of nutrient supply and waste product removal are critically important factors in disc pathogenesis. Diffusion and fluid flow are blocked by subchondral bone thickening, cartilaginous endplate calcification, loss of hydrophilic proteoglycans, and clogging of anular pores by degraded matrix molecules. Previous studies demonstrated increased hydraulic permeability and macromolecular transport through crosslinked collagenous matrices. Genipin has also demonstrated the capability to increase retention of proteoglycans.

METHODS

A total of 57 bovine lumbar motion segments were divided randomly into phosphate buffered saline and 0.33% genipin-soaked treatment groups. Water content changes were measured using a mass-loss technique in 3 intervertebral disc regions following successive stages of compressive loading and unloading (post-treatment, after 1 hour 750 N compression, and after a subsequent 24-hour period of nominal loading). Net flow of fluid into or out of a region was determined from the percentage change in mean water content from successive groups.

RESULTS

Fluid flow to and from the nucleus doubled with genipin crosslinking. Relative to the buffer-only controls, overall net fluid flow increased 103% in the nucleus pulposus, 36% in the inner anulus, and was 31% less in the outer anulus of genipin treated discs.

CONCLUSION

The effects of genipin crosslinking on matrix permeability and proteoglycan retention can alter hydration levels and fluid flow in the intervertebral disc. Resulting increases in fluid flow, including a doubling of flow to and from the nucleus, could lead to enhanced nutritional inflow and waste product outflow for the disc, and may have implications for emerging cell-based therapies.

Kinetic characterization and comparison of various protein crosslinking reagents for matrix modification

We have characterized the relative efficacies of a number of protein crosslinking agents that have the potential for use in the crosslinking of proteinaceous matrices both in vitro and in vivo. The crosslinkers tested were; L: -threose (LT), Genipin (GP), Methylglyoxal (MG), 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide hydrochloride (EDC), proanthrocyanidin (PA) and glutaraldehyde (GA). The relative effectiveness of the crosslinkers with regard to their saturating concentrations was: GA > PA > EDC > MG = GP >> LT. Most of the crosslinkers displayed a pH dependence and were more effective at more alkaline pH. At optimal pH and saturating conditions, the relative reaction rates of the crosslinkers were: PA = GA > EDC > GP > MG >> LT.

Exogenous crosslinking recovers the functional integrity of intervertebral disc secondary to a stab injury

Exogenous crosslinking was proved to improve the fatigue resistance of anulus fibrosus and the stability of motion segment. The effect of crosslinking on the recovery of stab-injured discs, however, was less studied. The purpose of this study is to find if the exogenous crosslinking can increase the mechanical function of injured discs. Fresh healthy porcine discs (T2/T9) from 6-month-old swine were obtained immediately following death. Anular puncture using 16 and 18 G spinal needle were used to create medium and large disc stab injury models. Three treatments were designed for each injury model. The first one is the injured discs without treatment. The second one is the injured discs soaked with phosphate buffered solution for 2 days. The third one is the injured discs soaked with 0.33% genipin solution for 2 days. The disc integrity was evaluated using quantitative discomanometry (QD) apparatus. Four QD parameters, that is, the leakage pressure and volume, and the saturate pressure and volume, were analyzed to find the efficacy of treatment. We found that soaking of genipin solution recovered the disc leakage pressure from 1.3 to 1.8 MPa in 16 G-injury-model and from 2.3 to 3.2 MPa in 18 G-injury-model, and recovered the saturate pressure from 1.6 to 2.0 MPa in 16 G-injury-model and from 2.7 to 3.7 MPa in 18 G-injury-model. The improvement of disc integrity by soaking with genipin solution indicate that the exogenous crosslinking may help the biomechanical performance of an injured disc.

The influence of exogenous cross-linking and compressive creep loading on intradiscal pressure

This study involves a biomechanical evaluation of a prospective injectable treatment for degenerative discs. The high osmolarity of the non-degenerated nucleus pulposus attracts water contributing to the hydrostatic behavior of the tissue. This intradiscal pressure is known to drop as fluid is exuded from the matrix due to compressive loading. The objective of this study was to compare the changes in intradiscal pressure in control and genipin cross-linked intervertebral discs. Thirty bovine lumbar motion segments were randomly divided into a phosphate-buffered saline control group and a 0.33% genipin group and soaked at room temperature for 2 days. A needle pressure sensor was held in the center of the disc while short-term and static creep compressive loads were applied. The control group demonstrated a 25% higher average intradiscal pressure compared to genipin-treated discs under 750 N compressive load (p=0.029). Depressurization during static compressive creep was 56% higher in the control than in the genipin group (p=0.014). These results suggest cross-linking induced changes in the poroelastic properties of the involved tissues affected the mechanics of compressive load support in the disc with lower levels of nucleus pressure, a corresponding decrease in the elastic expansion of the annulus, and an increased axial compressive loading of the inner and outer annulus tissues. It is possible that concurrent changes in hydraulic permeability and proteoglycan retention known to be associated with genipin cross-linking were also contributors to poroelastic changes. Reduction of peak pressures and moderation of pressure fluctuations could be beneficial relative to discogenic pain.

Effects of enzymatic digestion on compressive properties of rat intervertebral discs

Enzymatic treatments were applied to rat motion segments to establish structure-function relationships and determine mechanical parameters most sensitive to simulated remodeling and degeneration. Rat caudal and lumbar disc biomechanical behaviors were evaluated to improve knowledge of their similarities and differences due to their frequent use during in vivo models. Caudal motion segments were assigned to four groups: soaked (control), genipin treated, elastase treated, and collagenase treated. Fresh lumbar and caudal discs were also compared. The mechanical protocol involved five force-controlled loading stages: equilibration, cyclic compression-tension, quasi-static compression, frequency sweep, and creep. Crosslinking was found to have the greatest effect on IVD properties at resting stress. Elastin's role was greatest in tension and at higher force conditions, where GAG content was also a contributing factor. Collagenase treatment caused tissue compaction, which impacted mechanical properties at both high and low force conditions. Equilibration creep and cyclic compression-tension tests were the mechanical tests most sensitive to alterations in specific matrix constituents. Caudal and lumbar motion segments had many similarities but biomechanical differences suggested some distinctions in collagenous structure and water transport characteristics in addition to the geometric differences. Results provide a basis for interpreting biomechanical changes observed in animal model studies of degeneration and remodeling, and underscore the need to maintain and/or repair collagen integrity in IVD health and disease.

Biomechanical and biologic effects of meniscus stabilization using triglycidyl amine

The susceptibility of meniscus allografts to enzymatic degradation may be reduced through tissue stabilization. We have previously reported on an epoxide-based crosslinker, triglycidyl amine (TGA), which can be used alone or with a bisphosphonate (MABP) to stabilize heterograft heart valves and reduce their pathologic calcification. Our objective was to evaluate the effects of TGA and TGA-MABP pretreatment on an orthopedic allograft involving meniscus crosslinking, degradation, calcification, and compressive properties. Ovine menisci treated with TGA or TGA-MABP for up to seven days and glutaraldehyde crosslinked controls were examined in vitro for degree of crosslinking, resistance to degradation by collagenase, and material property changes. Likewise treated menisci were implanted in rats for eight weeks and examined for calcium content and biomechanical changes. TGA treatment for three days significantly reduced collagen loss by 88% and increased thermal denaturation temperatures (Ts) above 80 degrees C versus Ts of 70 degrees C or less for non-crosslinked meniscus. In vitro, TGA and TGA-MABP significantly increased aggregate modulus by 19% and 32% compared to native controls, respectively. TGA decreased permeability by 53% while TGA-MABP increased it by 303%. In vivo, TGA significantly reduced explant calcification by 42% compared to glutaraldehyde, and including MABP reduced it by 90%. Analyses revealed that TGA and TGA-MABP stabilized menisci had significantly lower modulus and permeability values than glutaraldehyde controls by at least 28% and 86%, respectively. It is concluded that TGA crosslinking of meniscus increases resistance to both collagenase degradation and pathologic calcification, while demonstrating comparable or improved biomechanical properties versus glutaraldehyde controls.

Glutaraldehyde cross-linking of tendon--mechanical effects at the level of the tendon fascicle and fibril

Conclusive insight into the microscopic principles that govern the strength of tendon and related connective tissues is lacking and the importance of collagen cross-linking has not been firmly established. The combined application of whole-tissue mechanical testing and atomic force spectroscopy allowed for a detailed characterization of the effect of cross-linking in rat-tail tendon. The cross-link inducing agent glutaraldehyde augmented the tensile strength of tendon fascicles. Stress at failure increased from approximately 8 MPa to approximately 39 MPa. The mechanical effects of glutaraldehyde at the tendon fibril level were examined by atomic force microscopy. Peak forces increased from approximately 1379 to approximately 2622 pN while an extended Hertz fit of force-indentation data showed a approximately 24 fold increase in Young's modulus on indentation. The effect of glutaraldehyde cross-linking on the tensile properties of a single collagen fibril was investigated by a novel methodology based on atomic force spectroscopy. The Young's modulus of a secluded fibril increased from approximately 407 MPa to approximately 1.1 GPa with glutaraldehyde treatment. Collectively, the findings indicate that cross-linking at the level of the collagen fibril is of key importance for the mechanical strength of tendon tissue. However, when comparing the effects at the level of the tendon fascicle and fibril, respectively, further questions are prompted regarding the pathways of force through the tendon microstructure as fibril strength seems to surpass that of the tendon fascicle.

Effects of laser irradiation on collagen organization in chemically induced degenerative annulus fibrosus of lumbar intervertebral disc

BACKGROUND AND OBJECTIVE

The number of in vitro experimental studies was carried out with the use of intact tissues to establish a mechanism of laser-tissue interaction. However, in the process of degeneration, both biochemical composition and behavior of the disc were altered drastically. The objective of this study was to evaluate the role of the main matrix components in laser modification of annulus fibrosus (AF) under IR laser irradiation.

STUDY DESIGNS/MATERIALS AND METHODS

The samples of AF in a motion segment after hyaluronidase treatment, trypsin digestion and glycation by glyceraldehyde were heated in hydrothermal bath (95 degrees C, 2 min) or irradiated by laser at 1.56 microm. Specimens were imaged by cross-polarization optical coherence tomography (CP-OCT), and then analyzed by differential scanning calorimery (DSC).

RESULTS AND DISCUSSION

According to CP-OCT and DSC data non-significant alteration was revealed in AF after hyaluronidase treatment, glycation led to stabilization of annulus collagen and trypsin digestion resulted in a noticeable impairment of collagen fibrils. Laser treatment induced subsequent damages of AF matrix but these damages cannot be explained by laser heating only. The specificity of chemical modification of AF matrix has an influence on a character of collagen network alteration due to IR laser effect. Minimal and maximal alterations are observed for hyaluronidase and trypsin treated samples respectively. Glyceraldehyde fixed samples showed failure of the collagen structure after moderate laser treatment; at the same time thermal denaturation of collagen macromolecules was negligible. We assume that a mechanical effect of laser irradiation plays an important role in laser-induced annulus collagen modification and propose the scheme of physico-chemical process occurring under non-uniform IR laser treatment in AF tissue.

CONCLUSION

CP-OCT and DSC techniques allow us to record the alteration of collagen network organization as a result of chemical modification. There were detected significant and specific effects of the biochemical composition and material properties on the response of AF collagen network on laser irradiation. The results go in accordance with our hypothesis that the primary effect of laser influence on collagen network under tension is the mechanical damage of collagen fiber.