Biology of lumbar spine fusion and use of bone graft substitutes: present, future, and next generation

Biomimetic vascularized adipose-derived mesenchymal stem cells bone-periosteum graft enhances angiogenesis and osteogenesis in a male rabbit spine fusion model

Aims

Several artificial bone grafts have been developed but fail to achieve anticipated osteogenesis due to their insufficient neovascularization capacity and periosteum support. This study aimed to develop a vascularized bone-periosteum construct (VBPC) to provide better angiogenesis and osteogenesis for bone regeneration.

Methods

A total of 24 male New Zealand white rabbits were divided into four groups according to the experimental materials. Allogenic adipose-derived mesenchymal stem cells (AMSCs) were cultured and seeded evenly in the collagen/chitosan sheet to form cell sheet as periosteum. Simultaneously, allogenic AMSCs were seeded onto alginate beads and were cultured to differentiate to endothelial-like cells to form vascularized bone construct (VBC). The cell sheet was wrapped onto VBC to create a vascularized bone-periosteum construct (VBPC). Four different experimental materials - acellular construct, VBC, non-vascularized bone-periosteum construct, and VBPC - were then implanted in bilateral L4-L5 intertransverse space. At 12 weeks post-surgery, the bone-forming capacities were determined by CT, biomechanical testing, histology, and immunohistochemistry staining analyses.

Results

At 12 weeks, the VBPC group significantly increased new bone formation volume compared with the other groups. Biomechanical testing demonstrated higher torque strength in the VBPC group. Notably, the haematoxylin and eosin, Masson's trichrome, and immunohistochemistry-stained histological results revealed that VBPC promoted neovascularization and new bone formation in the spine fusion areas.

Conclusion

The tissue-engineered VBPC showed great capability in promoting angiogenesis and osteogenesis in vivo. It may provide a novel approach to create a superior blood supply and nutritional environment to overcome the deficits of current artificial bone graft substitutes.

PDZ and LIM Domain-Encoding Genes: Their Role in Cancer Development

PDZ-LIM family proteins (PDLIMs) are a kind of scaffolding proteins that contain PDZ and LIM interaction domains. As protein-protein interacting molecules, PDZ and LIM domains function as scaffolds to bind to a variety of proteins. The PDLIMs are composed of evolutionarily conserved proteins found throughout different species. They can participate in cell signal transduction by mediating the interaction of signal molecules. They are involved in many important physiological processes, such as cell differentiation, proliferation, migration, and the maintenance of cellular structural integrity. Studies have shown that dysregulation of the PDLIMs leads to tumor formation and development. In this paper, we review and integrate the current knowledge on PDLIMs. The structure and function of the PDZ and LIM structural domains and the role of the PDLIMs in tumor development are described.

Sclerostin small-molecule inhibitors promote osteogenesis by activating canonical Wnt and BMP pathways

Background

The clinical healing environment after a posterior spinal arthrodesis surgery is one of the most clinically challenging bone-healing environments across all orthopedic interventions due to the absence of a contained space and the need to form de novo bone. Our group has previously reported that sclerostin in expressed locally at high levels throughout a developing spinal fusion. However, the role of sclerostin in controlling bone fusion remains to be established.

Methods

We computationally identified two FDA-approved drugs, as well as a single novel small-molecule drug, for their ability to disrupt the interaction between sclerostin and its receptor, LRP5/6. The drugs were tested in several in vitro biochemical assays using murine MC3T3 and MSCs, assessing their ability to (1) enhance canonical Wnt signaling, (2) promote the accumulation of the active (non-phosphorylated) form of β-catenin, and (3) enhance the intensity and signaling duration of BMP signaling. These drugs were then tested subcutaneously in rats as standalone osteoinductive agents on plain collagen sponges. Finally, the top drug candidates (called VA1 and C07) were tested in a rabbit posterolateral spine fusion model for their ability to achieve a successful fusion at 6 wk.

Results

We show that by controlling GSK3b phosphorylation our three small-molecule inhibitors (SMIs) simultaneously enhance canonical Wnt signaling and potentiate canonical BMP signaling intensity and duration. We also demonstrate that the SMIs produce dose-dependent ectopic mineralization in vivo in rats as well as significantly increase posterolateral spine fusion rates in rabbits in vivo, both as standalone osteogenic drugs and in combination with autologous iliac crest bone graft.

Conclusions

Few if any osteogenic small molecules possess the osteoinductive potency of BMP itself - that is, the ability to form de novo ectopic bone as a standalone agent. Herein, we describe two such SMIs that have this unique ability and were shown to induce de novo bone in a stringent in vivo environment. These SMIs may have the potential to be used in novel, cost-effective bone graft substitutes for either achieving spinal fusion or in the healing of critical-sized fracture defects.

Funding

This work was supported by a Veteran Affairs Career Development Award (IK2-BX003845).

Preparation of chitosan-tannic acid coating and its anti-osteoclast and antibacterial activities in titanium implants

INTRODUCTION

Bacterial infection and aseptic loosening caused by bone resorption at the implant interface are major clinical complications during bone defect implantation surgery, and surface modification of the implant to address the aforementioned problems has long been a research focus.

MATERIALS AND METHODS

In this paper, a chitosan (CTS)-tannic acid (TA) colloid coating with a negative charge and excellent hydrophilicity was prepared on a Ti6Al4V (TC4) surface using a layer-by-layer assembly method. The physical properties, anti-osteoclast activity, and antimicrobial activity of the coatings were investigated.

RESULTS

The findings showed that when the pH value was 5 and the ratio of CTS:TA was 0.8, the carrying rate of TA was the best. Furthermore, the CTS-TA coating had no cytotoxicity on the morphology and proliferation of BMSCs cells and effectively inhibited the differentiation of RAW264.7 cells into osteoclasts and the proliferation of Staphylococcus aureus and Escherichia coli. With the increase in the immersion time of TC4 in CTS-TA colloid solution, the inhibitory effects will also enhance.

CONCLUSION

Therefore, the preparation of the CTS-TA coating provides a revolutionary technique for implant surface modification to avoid postoperative bacterial infection and aseptic loosening.

Synthesis of Human Bone Morphogenetic Protein-2 (hBMP-2) in E. coli Periplasmic Space: Its Characterization and Preclinical Testing

Human BMP-2, a homodimeric protein that belongs to the TGF- β family, is a recognized osteoinductor due to its capacity of inducing bone regeneration and ectopic bone formation. The administration of its recombinant form is an alternative to autologous bone grafting. A variety of E. coli-derived hBMP-2 has been synthesized through refolding of cytoplasmic inclusion bodies. The present work reports the synthesis, purification, and characterization of periplasmic hBMP-2, obtained directly in its correctly folded and authentic form, i.e., without the initial methionine typical of the cytoplasmic product that can induce undesired immunoreactivity. A bacterial expression vector was constructed including the DsbA signal peptide and the cDNA of hBMP-2. The periplasmic fluid was extracted by osmotic shock and analyzed via SDS-PAGE, Western blotting, and reversed-phase high-performance liquid chromatography (RP-HPLC). The purification was carried out by heparin affinity chromatography, followed by high-performance size-exclusion chromatography (HPSEC). HPSEC was used for qualitative and quantitative analysis of the final product, which showed >95% purity. The classical in vitro bioassay based on the induction of alkaline phosphatase activity in myoblastic murine C2C12 cells and the in vivo bioassay consisting of treating calvarial critical-size defects in rats confirmed its bioactivity, which matched the analogous literature data for hBMP-2.

The temporal and spatial expression of sclerostin and Wnt signaling factors during the maturation of posterolateral lumbar spine fusions

The bone healing environment in the posterolateral spine following arthrodesis surgery is one of the most challenging in all of orthopedics and our understanding of the molecular signaling pathways mediating osteogenesis during spinal fusion is limited. In this study, the spatial and temporal expression pattern of Wnt signaling factors and inhibitors during spinal fusion was assessed for the first time. Bilateral posterolateral spine arthrodesis with autologous iliac crest bone graft was performed on 21 New Zealand White rabbits. At 1-, 2-, 3-, 4-, and 6-weeks, the expression of sclerostin and a variety of canonical and noncanonical Wnts signaling factors was measured by qRT-PCR from tissue separately collected from the transverse processes, the Outer and Inner Zones of the fusion mass, and the adjancent paraspinal muscle. Immunohistochemistry for sclerostin protein was also performed. Sclerostin and many Wnt factors, especially Wnt3a and Wnt5a, were found to have distinct spatial and temporal expression patterns. For example, harvesting ICBG caused a significant increase in sclerostin expression. Furthermore, the paraspinal muscle immediately adjacent to the transplanted ICBG also had significant increases in sclerostin expression at 3 weeks, suggesting new potential mechanisms for pseudarthroses following spinal arthrodesis. The presented work is the first description of the spatial and temporal expression of sclerostin and Wnt signaling factors in the developing spine fusion, filling an important knowledge gap in the basic biology of spinal fusion and potentially aiding in the development of novel biologics to increase spinal fusion rates.

Biomaterials Regulating Bone Hematoma for Osteogenesis

Blood coagulation in tissue healing not only prevents blood loss, but also forms a natural scaffold for tissue repair and regeneration. As blood clot formation is the initial and foremost phase upon bone injury, and the quality of blood clot (hematoma) orchestrates the following inflammatory and cellular processes as well as the subsequent callus formation and bone remodeling process. Inspired by the natural healing hematoma, tissue-engineered biomimic scaffold/hydrogels and blood prefabrication strategies attract significant interests in developing functional bone substitutes. The alteration of the fracture hematoma ca significantly accelerate or impair the overall bone healing process. This review summarizes the impact of biomaterials on blood coagulation and provides evidence on fibrin network structure, growth factors, and biomolecules that contribute to bone healing within the hematoma. The aim is to provide insights into the development of novel implant and bone biomaterials for enhanced osteogenesis. Advances in the understanding of biomaterial characteristics (e.g., morphology, chemistry, wettability, and protein adsorption) and their effect on hematoma properties are highlighted. Emphasizing the importance of the initial healing phase of the hematoma endows the design of advanced biomaterials with the desired regulatory properties for optimal coagulation and hematoma properties, thereby facilitating enhanced osteogenesis and ideal therapeutic effects.

Polymeric nanofibrous scaffolds laden with cell-derived extracellular matrix for bone regeneration

Bone tissue engineering aims to alleviate the shortage of available autograft material and the biological/mechanical incompatibility of allografts through fabrication of bioactive synthetic bone graft substitutes. However, these substitute grafting materials have insufficient biological potency that limits their clinical efficacy in regenerating large defects. Extracellular matrix, a natural tissue scaffold laden with biochemical and structural cues regulating cell adhesion and tissue morphogenesis, may be a versatile supplement that can extend its biological functionality to synthetic grafts. Embedding decellularized extracellular matrix (dECM) into synthetic polymers offers a promising strategy to enhance cellular response to synthetic materials, mitigate physical and mechanical limitations of dECMs, and improve clinical utility of synthetic bone grafts. Enriched with dECM biochemical cues, synthetic polymers can be readily fabricated into complex biocomposite grafts that mimic bone structure and stimulate endogenous cells to regenerate bone. In this study, cell-derived dECMs from osteoblast and endothelial cells were incorporated into polycaprolactone (PCL) solutions for electrospinning dual-layer nanofibrous scaffolds with osteogenic and vascular cues. The study examined the bioactivity of dECM scaffolds in osteoblast cultures for cell number, mineral deposits, and osteogenic markers, as well as regeneration of cortical bone defect in a rat femur. Scaffolds with osteoblast dECM had a significantly robust osteoblast proliferation, Alizarin Red staining/concentration, and osteopontin-positive extracellular deposits. Implanted scaffolds increased bone growth in femoral defects, and constructs with both osteogenic and vascular cues significantly improved cortical width. These findings demonstrate the potential to fabricate tailored biomimetic grafts with dECM cues and fibrous architecture for bone applications.

The effect of insulin dependent diabetes on bone metabolism and growth after spinal fusion

STUDY DESIGN

Experimental animal model.

OBJECTIVE

The purpose of this study was to evaluate the hypothesis that insulin dependent diabetes mellitus (IDDM) will inhibit the formation of a solid bony union after spinal fusion surgery via an alteration of the microenvironment at the fusion site in a rat model.

SUMMARY OF BACKGROUND DATA

Previous studies report diabetes mellitus (DM) and specifically IDDM as a risk factor for complications and poor surgical outcomes following spinal fusion.

METHODS

Twenty control and 22 diabetic rats were obtained at 5 weeks of age. At 20 weeks of age, all animals underwent posterolateral lumbar fusion surgery using a tailbone autograft with diabetic rats receiving an implantable time release insulin pellet. A subset of rats was sacrificed 1-week postsurgery for growth factor (PDGF, IGF-I, TGF-β, and VEGF) and proinflammatory cytokine ELISA analysis. All other rats were sacrificed 3-months postsurgery for fusion evaluation via manual palpation and micro CT. Glycated hemoglobin (HbA1c) was measured at surgery and sacrifice on all animals.

RESULTS

Compared with healthy rats undergoing spinal fusion, rats with IDDM demonstrated a significant reduction in manual palpation fusion rates (16.7% vs. 43%, p<.05). Average bone mineral density, bone volume, and bone volume fraction were also significantly reduced and negatively correlated to blood glucose levels. IL-1B, IL-5, IL-10, TNF-α, and KC/GRO were significantly elevated in fusion beds of IDDM rats.

CONCLUSIONS

This study demonstrates that rats with IDDM demonstrate a reduced rate and quality of spinal fusion with increased local levels of inflammatory cytokines. Targeted modalities are required to improve bone healing in this growing, high-risk population.

CLINICAL SIGNIFICANCE

This is the first translational animal model of IDDM to evaluate the rate and quality of spinal fusion while controlling for other surgical and patient-related risk factors. Our findings demonstrate the complex nature by which IDDM impairs bone healing and highlight the need for additional basic science research to further elucidate this mechanism in order to develop more effective therapeutic interventions.

Human bone morphogenetic protein-2 (hBMP-2) characterization by physical-chemical, immunological and biological assays

Commercially available preparations of methionyl-human BMP-2 and CHO-derived hBMP-2, which belongs to the transforming growth factor β (TGF-β) superfamily, were used for a complete characterization. This protein is an extremely efficient osteoinductor that plays an important role during bone regeneration and embryonic development. Characterization was carried out via SDS-PAGE and Western blotting, followed by reversed-phase HPLC, size-exclusion HPLC and MALDI-TOF-MS. The classical in vitro bioassay, based on the induction of alkaline phosphatase activity in C2C12 cells, confirmed that hBMP-2 biological activity is mostly related to the dimeric form, being ~ 4-fold higher for the CHO-derived glycosylated form when compared with the E. coli counterpart. The E. coli-derived met-hBMP-2 has shown, by MALDI-TOF-MS, a large presence of the bioactive dimer. A more complex molecular mass (MM) distribution was found for the CHO-derived product, whose exact MM has never been reported because of its variable glycosylation. A method based on RP-HPLC was set up, allowing a quantitative and qualitative hBMP-2 determination even directly on ongoing culture media. Considering that hBMP-2 is highly unstable, presenting moreover an extremely high aggregate value, we believe that these data pave the way to a necessary characterization of this important factor when synthesized by DNA recombinant techniques in different types of hosts.

Vertebral body defects treated with umbilical-cord mesenchymal stem cells combined with hydroxyapatite scaffolds: The first case report

INTRODUCTION

Vertebral body defects (VBDs) are one of the most frequent orthopaedic disorders. Such defects often require bone grafts or fusion procedures; however, both procedures often fail due to various factors. Mesenchymal stem cells (MSCs) have been used as a potential therapy to fill bone voids in bone defects, and they may be a potential treatment for VBDs. We reported VBDs treated with MSCs combined with hydroxyapatite scaffolds.

PRESENTATION OF CASE

A 27-year-old female presented with recurrent back pain. She had a history of decompression and stabilization procedure one year ago after diagnosed with spinal tuberculosis. Initially, she felt back pain that intensifies with activity and relieved with rest. She noticed that the pain begun when once she heard a crack sound on her back while trying to get up from sitting position. There was no history of numbness or tingling sensation. There were no walking problems. Other functions, including micturition and defecation, were within normal limits. The patient firstly underwent lumbotomy procedure, and the images were all confirmed with fluoroscopy X-ray. The vertebrae went debridement, and finally, the bone defect was filled with 20 millions of umbilical cord-mesenchymal stem cells (UC-MSCs) combined with hydroxyapatite in 2 cc of saline.

DISCUSSION

At three months postoperative, the patient could walk and had no pain. At six months of follow-up, no complications occurred. We also did not see any signs of neoplasm formation, which is consistent with previous studies that used MSCs for orthopaedic treatment. Moreover, no significant bone deformation or spinal cord compression was observed, which suggested the safety of the transplantation procedure.

CONCLUSIONS

We found that MSCs combined with hydroxyapatite represents a potential therapy for bone regeneration in VBD. Further clinical studies are required to investigate the safety and efficacy of this combination of therapy in VBDs.

An evaluation of biomaterials and osteobiologics for arthrodesis achievement in spine surgery

An increasing variety of orthobiologic materials, including autologous and allogeneic bone graft, bone marrow aspirate, demineralized bone matrix, ceramics, and growth factors are available to the spine surgeon. Although autologous bone graft remains the gold standard material, concerns for failure in achieving fusion have prompted evaluation of current and new biologic materials. As such, this review attempts to summarize the available biologic materials with their pertinent characteristics, advantages, disadvantages, and primary uses.

Enhancement of MicroRNA-200c on Osteogenic Differentiation and Bone Regeneration by Targeting Sox2-Mediated Wnt Signaling and Klf4

MicroRNA (miR)-200c functions in antitumorigenesis and mediates inflammation and osteogenic differentiation. In this study, we discovered that miR-200c was upregulated in human bone marrow mesenchymal stromal cells (hBMSCs) during osteogenic differentiation. Inhibition of endogenous miR-200c resulted in downregulated osteogenic differentiation of hBMSCs and reduced bone volume in the maxilla and mandible of a transgenic mouse model. Overexpression of miR-200c by transfection of naked plasmid DNA (pDNA) encoding miR-200c significantly promoted the biomarkers of osteogenic differentiation in hBMSCs, including alkaline phosphatase, Runt-related transcription factor 2, osteocalcin, and mineral deposition. The pDNA encoding miR-200c also significantly enhanced bone formation and regeneration in calvarial defects of rat models. In addition, miR-200c overexpression was shown to downregulate SRY (sex determining region Y)-box 2 (Sox2) and Kruppel-like factor 4 by directly targeting 3'-untranslated regions and upregulate the activity of Wnt signaling inhibited by Sox2. These results strongly indicated that miR-200c may serve as a unique osteoinductive agent applied for bone healing and regeneration.

Effect of the type of electrical stimulation on spinal fusion in a rat posterolateral spinal fusion model

BACKGROUND CONTEXT

Posterolateral fusion (PLF) with autogenous iliac bone graft is one of the most common surgical procedures for lumbar spinal disease. However, its limited success demands new biologically competent graft enhancers or substitutes. Although the use of direct current (DC) electrical stimulation has been shown to increase rate of successful spinal fusions, little is known about the effect of the type of current in DC stimulation.

PURPOSE

To evaluate the effects of various DC stimulators on the strength and success rate of posterolateral fusion facilitated by using a nitinol mesh container, in rats.

STUDY DESIGN

This was an experimental animal study.

METHODS

A conductive, tubular nitinol mesh container was used to carry small pieces of bone grafts. The nitinol mesh container received electrical stimulation via a lead that connected the container to different types of DC stimulators. Sixty male Sprague-Dawley rats were divided into three groups (N=20 in each): a control group that underwent PLF with a nitinol container filled with autograft, a constant DC group that received a nitinol container and constant DC (100 μA), and a pulsed DC group that received a nitinol container and pulsed DC (100 μA, 100 Hz, 200 μs). The rats underwent PLF between L4 and L5, and transverse processes were grafted with bilateral iliac grafts. A stimulator was implanted subcutaneously. The rats were sacrificed 8 weeks postsurgery, and lumbar spines were removed. Spinal fusion was evaluated by microcomputed tomography, manual testing, biomechanical testing, histologic examination, and molecular analysis.

RESULTS

All animals in the DC stimulation groups displayed solid fusion, whereas only 70% of control animals showed solid fusion. Radiographic images, biomechanical testing, histologic examination, and molecular analysis revealed improved fusion in the order control group<constant DC group<pulsed DC group. The volume of new bone mass was significantly higher in the pulsed DC group (p<.05). Fusion was more solid in the pulsed DC group than in control group (p<.05). The pulsed DC group displayed the lowest inflammatory responses.

CONCLUSIONS

Pulsed DC electrical stimulation is efficacious in improving both strength and fusion rate in a rat spinal fusion model. In addition, tubular nitinol mesh, made of conductive suture, appears useful for holding small pieces of bone grafts and maintaining a good environment for bone fusion.

CLINICAL RELEVANCE

Pulsed DC electrical stimulation may be potentially useful to increase the fusion rate after spinal fusion in humans. Future research is required to evaluate the safety and efficacy of tubular nitinol mesh and pulsed DC electrical stimulation in humans.

Poly(Thioketal Urethane) Autograft Extenders in an Intertransverse Process Model of Bone Formation

IMPACT STATEMENT

The development of autograft extenders is a significant clinical need in bone tissue engineering. We report new settable poly(thioketal urethane)-based autograft extenders that have bone-like mechanical properties and handling properties comparable to calcium phosphate bone cements. These settable autograft extenders remodeled to form new bone in a biologically stringent intertransverse process model of bone formation that does not heal when treated with calcium phosphate bone void fillers or cements alone. This is the first study to report settable autograft extenders with bone-like strength and handling properties comparable to ceramic bone cements, which have the potential to improve treatment of bone fractures and other orthopedic conditions.

IGFBP3 deposited in the human umbilical cord mesenchymal stem cell-secreted extracellular matrix promotes bone formation

The extracellular matrix (ECM) contains rich biological cues for cell recruitment, proliferationm, and even differentiation. The osteoinductive potential of scaffolds could be enhanced through human bone marrow mesenchymal stem cell (hBMSC) directly depositing ECM on surface of scaffolds. However, the role and mechanism of human umbilical cord mesenchymal stem cells (hUCMSC)-secreted ECM in bone formation remain unknown. We tested the osteoinductive properties of a hUCMSC-secreted ECM construct (hUCMSC-ECM) in a large femur defect of a severe combined immunodeficiency (SCID) mouse model. The hUCMSC-ECM improved the colonization of endogenous MSCs and bone regeneration, similar to the hUCMSC-seeded scaffold and superior to the scaffold substrate. Besides, the hUCMSC-ECM enhanced the promigratory molecular expressions of the homing cells, including CCR2 and TβRI. Furthermore, the hUCMSC-ECM increased the number of migrated MSCs by nearly 3.3 ± 0.1-fold, relative to the scaffold substrate. As the most abundant cytokine deposited in the hUCMSC-ECM, insulin-like growth factor binding protein 3 (IGFBP3) promoted hBMSC migration in the TβRI/II- and CCR2-dependent mechanisms. The hUCMSC-ECM integrating shRNA-mediated silencing of Igfbp3 that down-regulated IGFBP3 expression by approximately 60%, reduced the number of migrated hBMSCs by 47%. In vivo, the hUCMSC-ECM recruited 10-fold more endogenous MSCs to initiate bone formation compared to the scaffold substrate. The knock-down of Igfbp3 in the hUCMSC-ECM inhibited nearly 60% of MSC homing and bone regeneration capacity. This research demonstrates that IGFBP3 is an important MSC homing molecule and the therapeutic potential of hUCMSC-ECM in bone regeneration is enhanced by improving MSC homing in an IGFBP3-dependent mechanism.

Rapid Osteogenic Enhancement of Stem Cells in Human Bone Marrow Using a Glycogen-Synthease-Kinase-3-Beta Inhibitor Improves Osteogenic Efficacy In Vitro and In Vivo

Non‐union defects of bone are a major problem in orthopedics, especially for patients with a low healing capacity. Fixation devices and osteoconductive materials are used to provide a stable environment for osteogenesis and an osteogenic component such as autologous human bone marrow (hBM) is then used, but robust bone formation is contingent on the healing capacity of the patients. A safe and rapid procedure for improvement of the osteoanabolic properties of hBM is, therefore, sought after in the field of orthopedics, especially if it can be performed within the temporal limitations of the surgical procedure, with minimal manipulation, and at point‐of‐care. One way to achieve this goal is to stimulate canonical Wingless (cWnt) signaling in bone marrow‐resident human mesenchymal stem cells (hMSCs), the presumptive precursors of osteoblasts in bone marrow. Herein, we report that the effects of cWnt stimulation can be achieved by transient (1–2 hours) exposure of osteoprogenitors to the GSK3β‐inhibitor (2′Z,3′E)‐6‐bromoindirubin‐3′‐oxime (BIO) at a concentration of 800 nM. Very‐rapid‐exposure‐to‐BIO (VRE‐BIO) on either hMSCs or whole hBM resulted in the long‐term establishment of an osteogenic phenotype associated with accelerated alkaline phosphatase activity and enhanced transcription of the master regulator of osteogenesis, Runx2. When VRE‐BIO treated hBM was tested in a rat spinal fusion model, VRE‐BIO caused the formation of a denser, stiffer, fusion mass as compared with vehicle treated hBM. Collectively, these data indicate that the VRE‐BIO procedure may represent a rapid, safe, and point‐of‐care strategy for the osteogenic enhancement of autologous hBM for use in clinical orthopedic procedures. stemcellstranslationalmedicine2018;7:342–353

BMP and Beyond: A 25-Year Historical Review of Translational Spine Research at Emory University

A high rate of symptomatic spinal pseudoarthrosis and a wide range of complications associated with the use of iliac crest bone graft (the gold standard) have prompted the spine surgery community to seek alternative options to promote spinal fusion. Emory University has been one of the global leaders in this endeavor. This invited review covers the last 25 years of Emory's contributions to translational spine research, focusing specifically on our work with bone morphogenetic proteins (BMP) and the BMP signaling pathway. As a result of this work, recombinant human BMP-2 is the only Food and Drug Administration approved biologic bone graft substitute. It has been shown to significantly increase spinal fusion rates across the spinal column because of its potent ability to stimulate local bone formation through the recruitment of mesenchymal stem cells. This review covers our development of animal models of spinal fusion, our body of work regarding the translation of BMP from the benchtop to the clinic, the discovery of LMP-1 and strategies to enhance cellular responsiveness to BMPs, and the design of various small molecule drugs that can enhance local bone formation.

Preparing Platelet-Rich Plasma with Whole Blood Harvested Intraoperatively During Spinal Fusion

BACKGROUND Platelet-rich plasma (PRP) has gained growing popularity in use in spinal fusion procedures in the last decade. Substantial intraoperative blood loss is frequently accompanied with spinal fusion, and it is unknown whether blood harvested intraoperatively qualifies for PRP preparation. MATERIAL AND METHODS Whole blood was harvested intraoperatively and venous blood was collected by venipuncture. Then, we investigated the platelet concentrations in whole blood and PRP, the concentration of growth factors in PRP, and the effects of PRP on the proliferation and viability of human bone marrow-derived mesenchymal stem cells (HBMSCs). RESULTS Our results revealed that intraoperatively harvested whole blood and whole blood collected by venipuncture were similar in platelet concentration. In addition, PRP formulations prepared from both kinds of whole blood were similar in concentration of platelet and growth factors. Additional analysis showed that the similar concentrations of growth factors resulted from the similar platelet concentrations of whole blood and PRP between the two groups. Moreover, these two kinds of PRP formulations had similar effects on promoting cell proliferation and enhancing cell viability. CONCLUSIONS Therefore, intraoperatively harvested whole blood may be a potential option for preparing PRP spinal fusion.

Difference in Spinal Fusion Process in Osteopenic and Nonosteopenic Living Rat Models Using Serial Microcomputed Tomography

Objective

To identify and investigate differences in spinal fusion between the normal and osteopenic spine in a rat model.

Methods

Female Sprague Dawley rats underwent either an ovariectomy (OVX) or sham operation and were randomized into two groups: non-OVX group and OVX group. Eight weeks after OVX, unilateral lumbar spinal fusion was performed using autologous iliac bone. Bone density (BD) was measured 2 days and 8 weeks after fusion surgery. Microcomputed tomography was used to evaluate the process of bone fusion every two weeks for 8 weeks after fusion surgery. The fusion rate, fusion process, and bone volume parameters of fusion bed were compared between the two groups.

Results

BD was significantly higher in the non-OVX group than in the OVX group 2 days and 8 weeks after fusion surgery. The fusion rate in the non-OVX group was higher than that in the OVX group 8 weeks after surgery (p=0.044). The bony connection of bone fragments with transverse processes and bone formation between transverse processes in non-OVX group were significantly superior to those of OVX group from 6 weeks after fusion surgery. The compactness and bone maturation of fusion bed in non-OVX were prominent compared with the non-OVX group.

Conclusion

The fusion rate in OVX group was inferior to non-OVX group at late stage after fusion surgery. Bone maturation of fusion bed in the OVX group was inferior compared with the non-OVX group. Fusion enhancement strategies at early stage may be needed to patients with osteoporosis who need spine fusion surgery.

An allograft generated from adult stem cells and their secreted products efficiently fuses vertebrae in immunocompromised athymic rats and inhibits local immune responses

BACKGROUND CONTEXT

Spine pain and the disability associated with it are epidemic in the United States. According to the National Center for Health Statistics, more than 650,000 spinal fusion surgeries are performed annually in the United States, and yet there is a failure rate of 15%-40% when standard methods employing current commercial bone substitutes are used. Autologous bone graft is the gold standard in terms of fusion success, but the morbidity associated with the procedure and the limitations in the availability of sufficient material have limited its use in the majority of cases. A freely available and immunologically compatible bone mimetic with the properties of live tissue is likely to substantially improve the outcome of spine fusion procedures without the disadvantages of autologous bone graft.

PURPOSE

This study aimed to compare a live human bone tissue analog with autologous bone grafting in an immunocompromised rat model of posterolateral fusion.

DESIGN/SETTING

This is an in vitro and in vivo preclinical study of a novel human stem cell-derived construct for efficacy in posterolateral lumbar spine fusion.

METHODS

Osteogenically enhanced human mesenchymal stem cells (OEhMSCs) were generated by exposure to conditions that activate the early stages of osteogenesis. Immunologic characteristics of OEhMSCs were evaluated in vitro. The secreted extracellular matrix from OEhMSCs was deposited on a clinical-grade gelatin sponge, resulting in bioconditioned gelatin sponge (BGS). Bioconditioned gelatin sponge was used alone, with live OEhMSCs (BGS+OEhMSCs), or with whole human bone marrow (BGS+hBM). Efficacy for spine fusion was determined by an institutionally approved animal model using 53 nude rats.

RESULTS

Bioconditioned gelatin sponge with live OEhMSCs did not cause cytotoxicity when incubated with immunologically mismatched lymphocytes, and OEhMSCs inhibited lymphocyte expansion in mixed lymphocyte assays. Bioconditioned gelatin sponge with live OEhMSC and BGS+hBM constructs induced profound bone growth at fusion sites in vivo, with a comparable rate of fusion with syngeneic bone graft (negative [0 of 10], BGS alone [0 of 10], bone graft [7 of 10], BGS+OEhMSC [10 of 15], and BGS+hBM [8 of 8]).

CONCLUSIONS

Collectively, these studies demonstrate that BGS+OEhMSC constructs possess low immunogenicity and drive vertebral fusion with efficiency matching syngeneic bone graft in rodents. We also demonstrate that BGS serves as a promising scaffold for spine fusion when combined with hBM.

LOSS OF CORRECTION AFTER VERTEBRECTOMY FOR TREATMENT OF SPINAL DEFORMITIES

ABSTRACT Objective: To evaluate the loss of correction after treatment of spine deformities with the technique of isolated posterior vertebrectomy. Methods: Twenty-one patients were followed-up for three years after surgery with panoramic X-rays, CT scans, SF-36 and Oswestry questionnaires. We evaluated the loss of correction, CAGE subsidence and the evolution of the pelvis-T1 angle during follow-up. The correlation among the radiographic changes and functional and quality of life scores was also assessed. Results: All patients had some degree of loss of correction and subsidence of CAGE, especially in the first year of follow-up. Such losses exerted negative impact on the function, pain and self-image of the patients. Factors such as the stiffness of the fusion mass and size of implant used appear to have contributed to the occurrence of subsidence, regardless of age and bone mineral density. Conclusions: The use of spacers with larger cross-sectional diameter and more rigid rods can reduce the overloading on the anterior column of Denis, reducing the subsidence and loss of correction. Additional stabilization strategies such as the use of orthoses postoperatively can also be useful, and should be evaluated in subsequent studies.

Bone marrow-derived mesenchymal stem cells assembled with low-dose BMP-2 in a three-dimensional hybrid construct enhances posterolateral spinal fusion in syngeneic rats

BACKGROUND CONTEXT

The combination of potent osteoinductive growth factor, functional osteoblastic cells, and osteoconductive materials to induce bone formation is a well-established concept in bone tissue engineering. However, supraphysiological dose of growth factor, such as recombinant human bone morphogenetic protein 2 (rhBMP-2), which is necessary in contemporary clinical application, have been reported to result in severe side effects.

PURPOSE

We hypothesize that the synergistic osteoinductive capacity of low-dose bone morphogenetic protein 2 (BMP-2) combined with undifferentiated bone marrow-derived stromal cells (BMSCs) is comparable to that of osteogenically differentiated BMSCs when used in a rodent model of posterolateral spinal fusion.

STUDY DESIGN/SETTING

A prospective study using a rodent model of posterolateral spinal fusion was carried out.

PATIENT SAMPLE

Thirty-six syngeneic Fischer rats comprised the patient sample.

METHODS

Six groups of implants were evaluated as follows (n=6): (1) 10 µg BMP-2 with undifferentiated BMSCs; (2) 10 µg BMP-2 with osteogenic-differentiated BMSCs; (3) 2.5 µg BMP-2 with undifferentiated BMSCs; (4) 2.5 µg BMP-2 with osteogenic-differentiated BMSCs; (5) 0.5 µg BMP-2 with undifferentiated BMSCs; and (6) 0.5 µg BMP-2 with osteogenic-differentiated BMSCs. Optimal in vitro osteogenic differentiation of BMSCs was determined by quantitative real-time polymerase chain reaction (qRT-PCR) gene analysis whereas in vivo bone formation capacity was evaluated by manual palpation, micro-computed tomography, and histology.

RESULTS

Rat BMSCs cultured in fibrin matrix that was loaded into the pores of medical-grade poly epsilon caprolactone tricalcium phosphate scaffolds differentiated toward osteogenic lineage by expressing osterix, runt-related transcription factor 2, and osteocalcium mRNA when supplemented with dexamethasone, ascorbic acid, and β-glycerophosphate. Whereas qRT-PCR revealed optimal increase in osteogenic genes expression after 7 days of in vitro culture, in vivo transplantation study showed that pre-differentiation of BMSCs before transplantation failed to promote posterolateral spinal fusion when co-delivered with low-dose BMP-2 (1/6 or 17% fusion rate). In contrast, combined delivery of undifferentiated BMSCs with low-dose BMP-2 (2.5 µg) demonstrated significantly higher fusion rate (4/6 or 67%) as well as significantly increased volume of new bone formation (p<.05).

CONCLUSION

In summary, this study supports the combination of undifferentiated BMSCs and low-dose rhBMP-2 for bone tissue engineering construct.

Gene therapy for spinal fusion using an insect vector

Fu T-S, Chang Y-H, Wong C-B, Wang I-C, Tsai T-T, Lai P-L, et al. Mesenchymal stem cells expressingbaculovirus-engineered BMP-2 and VEGF enhance posterolateral spine fusion in a rabbit model. Spine J 2015;15(9):2036-44.

Fast degradable citrate-based bone scaffold promotes spinal fusion

It is well known that high rates of fusion failure and pseudoarthrosis development (5~35%) are concomitant in spinal fusion surgery, which was ascribed to the shortage of suitable materials for bone regeneration. Citrate was recently recognized to play an indispensable role in enhancing osteconductivity and osteoinductivity, and promoting bone formation. To address the material challenges in spinal fusion surgery, we have synthesized mechanically robust and fast degrading citrate-based polymers by incorporating N-methyldiethanolamine (MDEA) into clickable poly(1, 8-octanediol citrates) (POC-click), referred to as POC-M-click. The obtained POC-M-click were fabricated into POC-M-click-HA matchstick scaffolds by compositing with hydroxyapatite (HA) for interbody spinal fusion in a rabbit model. Spinal fusion was analyzed by radiography, manual palpation, biomechanical testing, and histological evaluation. At 4 and 8 weeks post surgery, POC-M-click-HA scaffolds presented optimal degradation rates that facilitated faster new bone formation and higher spinal fusion rates (11.2±3.7, 80±4.5 at week 4 and 8, respectively) than the poly(L-lactic acid)-HA (PLLA-HA) control group (9.3±2.4 and 71.1±4.4) (p<0.05). The POC-M-click-HA scaffold-fused vertebrates possessed a maximum load and stiffness of 880.8±14.5 N and 843.2±22.4 N/mm, respectively, which were also much higher than those of the PLLA-HA group (maximum: 712.0±37.5 N, stiffness: 622.5±28.4 N/mm, p<0.05). Overall, the results suggest that POC-M-click-HA scaffolds could potentially serve as promising bone grafts for spinal fusion applications.

Engineered decellularized matrices to instruct bone regeneration processes

Despite the significant progress in the field of bone tissue engineering, cell-based products have not yet reached the stage of clinical adoption. This is due to the uncertain advantages from the standard-of-care, combined with challenging cost-and regulatory-related issues. Novel therapeutic approaches could be based on exploitation of the intrinsic regenerative capacity of bone tissue, provided the development of a deeper understanding of its healing mechanisms. While it is well-established that endogenous progenitors can be activated toward bone formation by overdoses of single morphogens, the challenge to stimulate the healing processes by coordinated and controlled stimulation of specific cell populations remains open. Here, we review the recent approaches to generate osteoinductive materials based on the use of decellularized extracellular matrices (ECM) as reservoirs of multiple factors presented at physiological doses and through the appropriate ligands. We then propose the generation of customized engineered and decellularized ECM (i) as a tool to better understand the processes of bone regeneration and (ii) as safe and effective "off-the-shelf" bone grafts for clinical use. This article is part of a Special Issue entitled Stem Cells and Bone.

Bone regeneration with osteogenically enhanced mesenchymal stem cells and their extracellular matrix proteins

Although bone has remarkable regenerative capacity, about 10% of long bone fractures and 25% to 40% of vertebral fusion procedures fail to heal. In such instances, a scaffold is employed to bridge the lesion and accommodate osteoprogenitors. Although synthetic bone scaffolds mimic some of the characteristics of bone matrix, their effectiveness can vary because of biological incompatibility. Herein, we demonstrate that a composite prepared with osteogenically enhanced mesenchymal stem cells (OEhMSCs) and their extracellular matrix (ECM) has an unprecedented capacity for the repair of critical-sized defects of murine femora. Furthermore, OEhMSCs do not cause lymphocyte activation, and ECM/OEhMSC composites retain their in vivo efficacy after cryopreservation. Finally, we show that attachment to the ECM by OEhMSCs stimulates the production of osteogenic and angiogenic factors. These data demonstrate that composites of OEhMSCs and their ECM could be utilized in the place of autologous bone graft for complex orthopedic reconstructions.

Osteoinductivity of engineered cartilaginous templates devitalized by inducible apoptosis

The role of cell-free extracellular matrix (ECM) in triggering tissue and organ regeneration has gained increased recognition, yet current approaches are predominantly based on the use of ECM from fully developed native tissues at nonhomologous sites. We describe a strategy to generate customized ECM, designed to activate endogenous regenerative programs by recapitulating tissue-specific developmental processes. The paradigm was exemplified in the context of the skeletal system by testing the osteoinductive capacity of engineered and devitalized hypertrophic cartilage, which is the primordial template for the development of most bones. ECM was engineered by inducing chondrogenesis of human mesenchymal stromal cells and devitalized by the implementation of a death-inducible genetic device, leading to cell apoptosis on activation and matrix protein preservation. The resulting hypertrophic cartilage ECM, tested in a stringent ectopic implantation model, efficiently remodeled to form de novo bone tissue of host origin, including mature vasculature and a hematopoietic compartment. Importantly, cartilage ECM could not generate frank bone tissue if devitalized by standard "freeze & thaw" (F&T) cycles, associated with a significant loss of glycosaminoglycans, mineral content, and ECM-bound cytokines critically involved in inflammatory, vascularization, and remodeling processes. These results support the utility of engineered ECM-based devices as off-the-shelf regenerative niches capable of recruiting and instructing resident cells toward the formation of a specific tissue.

Intradiscal injection of simvastatin results in radiologic, histologic, and genetic evidence of disc regeneration in a rat model of degenerative disc disease

BACKGROUND CONTEXT

A large percentage of back pain can be attributed to degeneration of the intervertebral disc (IVD). Bone morphogenetic protein 2 (BMP-2) is known to play an important role in chondrogenesis of the IVD. Simvastatin is known to upregulate expression of BMP-2. Thus, we hypothesized that intradiscal injection of simvastatin in a rat model of degenerative disc disease (DDD) would result in retardation of DDD.

PURPOSE

The purpose of the present study was to develop a novel conservative treatment for DDD and related discogenic back pain.

STUDY DESIGN/SETTING

The setting of this study is the laboratory investigation.

METHODS

Disc injury was induced in 272 rats via 21-ga needle puncture. After 6 weeks, injured discs were treated with simvastatin in a saline or hydrogel carrier. Rats were sacrificed at predetermined time points. Outcome measures assessed were radiologic, histologic, and genetic. Radiologically, the magnetic resonance imaging (MRI) index (number of pixels multiplied by the corresponding image densities) was determined. Histologically, disc spaces were read by three blinded scorers using a previously described histologic grading scale. Genetically, nuclei pulposi were harvested, and polymerase chain reaction was run to determine relative levels of aggrecan, collagen type II, and BMP-2 gene expression.

RESULTS

Radiologically, discs treated with 5 mg/mL of simvastatin in hydrogel or saline demonstrated MRI indices that were normal through 8 weeks after treatment, although this was more sustained when delivered in hydrogel. Histologically, discs treated with 5 mg/mL of simvastatin in hydrogel demonstrated improved grades compared with discs treated at higher doses. Genetically, discs treated with 5 mg/mL of simvastatin in hydrogel demonstrated higher gene expression of aggrecan and collagen type II than control.

CONCLUSIONS

Degenerate discs treated with 5 mg/mL of simvastatin in a hydrogel carrier demonstrated radiographic and histologic features resembling normal noninjured IVDs. In addition, the gene expression of aggrecan and collagen type II (important constituents of the IVD extracellular matrix) was upregulated in treated discs. Injection of simvastatin into degenerate IVDs may result in retardation of disc degeneration and represents a promising investigational therapy for conservative treatment of DDD.

Enhanced spinal fusion using a biodegradable porous mesh container in a rat posterolateral spinal fusion model

BACKGROUND CONTEXT

Posterolateral fusion (PLF) with an autogenous iliac bone graft is the most common procedure for treating various lumbar spinal diseases. However, the limited success and associated morbidity from an iliac crest graft demands new biologically competent graft enhancers or substitutes.

PURPOSE

To investigate the feasibility of tubular mesh container made of bioabsorbable sutures (poly-1,4-dioxane-2-one, PDO) for spinal fusion.

STUDY DESIGN

Experimental animal study.

METHODS

A biodegradable PDO tubular mesh container was used to contain small pieces of bone grafts. Twenty Sprague-Dawley male rats underwent PLF between L4 and L5 transverse processes with bilateral iliac grafts. Experimental animals were assigned into two different groups: autograft-only group (N=10) that underwent PLF with autograft-only or mesh container group (N=10) that underwent PLF with tubular mesh container filled with autogenous bone grafts. The rats were sacrificed at 8 weeks postoperatively, and the lumbar spines were removed. Spinal fusion was evaluated by manual palpation, microcomputed tomography, three-point bending test, and histological examination.

RESULTS

Solid fusion was achieved in all cases of the mesh container group, whereas the autograft-only group showed 60% of solid fusion. New bone mass was higher and more solidly fused in the mesh container group than the autograft-only group (p<.01). Volume of fusion mass and density of bone were significantly higher in the mesh container group (p<.05). In all cases, inflammatory response was minimal.

CONCLUSIONS

This study demonstrated that a tubular mesh container made of bioabsorbable suture is useful to hold small pieces of bone grafts and to enhance spinal fusion.

Short Term Culture of Human Mesenchymal Stem Cells with Commercial Osteoconductive Carriers Provides Unique Insights into Biocompatibility

For spinal fusions and the treatment of non-union fractures, biological substrates, scaffolds, or carriers often are applied as a graft to support regeneration of bone. The selection of an appropriate material critically influences cellular function and, ultimately, patient outcomes. Human bone marrow mesenchymal stem cells (BMSCs) are regarded as a critical component of bone healing. However, the interactions of BMSCs and commercial bone matrices are poorly reported. BMSCs were cultured with several commercially available bone substrates (allograft, demineralized bone matrix (DBM), collagen, and various forms of calcium phosphates) for 48 h to understand their response to graft materials during surgical preparation and the first days following implantation (cell retention, gene expression, pH). At 30 and 60 min, bone chips and inorganic substrates supported significantly more cell retention than other materials, while collagen-containing materials became soluble and lost their structure. At 48 h, cells bound to β-tricalcium phosphate-hydroxyapatite (βTCP-HA) and porous hydroxyapatite (HA) granules exhibited osteogenic gene expression statistically similar to bone chips. Through 24 h, the DBM strip and βTCP-collagen became mildly acidic (pH 7.1–7.3), while the DBM poloxamer-putties demonstrated acidity (pH < 5) and the bioglass-containing carrier became basic (pH > 10). The dissolution of DBM and collagen led to a loss of cells, while excessive pH changes potentially diminish cell viability and metabolism. Extracts from DBM-poloxamers induced osteogenic gene expression at 48 h. This study highlights the role that biochemical and structural properties of biomaterials play in cellular function, potentially enhancing or diminishing the efficacy of the overall therapy.

Evaluation of injectable constructs for bone repair with a subperiosteal cranial model in the rat

While testing regenerative medicine strategies, the use of animal models that match the research questions and that are related to clinical translation is crucial. During the initial stage of evaluating new strategies for bone repair, the main goal is to state whether the strategies efficiently induce the formation of new bone tissue at an orthotopic site. Here, we present a subperiosteal model in rat calvaria that allow the evaluation of a broad range of approaches including bone augmentation, replacement and regeneration. The model is a fast to perform, minimally invasive, and has clearly defined control groups. The procedure enables to evaluate the outcomes quantitatively using micro-computed tomography and qualitatively by histology and immunohistochemistry. We established this new model, using bone morphogenetic protein-2 as an osteoinductive factor and hyaluronic acid hydrogel as injectable biomaterial. We showed that this subperiosteal cranial model offers a minimally invasive and promising solution for a rapid initial evaluation of injectables for bone repair. We believe that this approach could be a powerful platform for orthopedic research and regenerative medicine.

Establishment and characterization of an open mini-thoracotomy surgical approach to an ovine thoracic spine fusion model

A large animal model is required for the assessment of minimally invasive, tissue-engineering-based approaches to thoracic spine fusion, with relevance to deformity correction surgery for human adolescent idiopathic scoliosis. Here, we develop a novel open mini-thoracotomy approach in an ovine model of thoracic interbody fusion that allows the assessment of various fusion constructs, with a focus on novel, tissue-engineering-based interventions. The open mini-thoracotomy surgical approach was developed through a series of mock surgeries, and then applied in a live sheep study. Customized scaffolds were manufactured to conform with intervertebral disc space clearances that were required of the study. Six male Merino sheep aged 4-6 years and weighing 35-45 kg underwent the procedure mentioned earlier and were alloted a survival timeline of 6 months. Each sheep underwent a three-level discectomy (T6/7, T8/9, and T10/11) with a randomly allocated implantation of a different graft substitute at each of the following three levels: (1) polycaprolactone (PCL)-based scaffold plus 0.54 μg recombinant human bone morphogenetic protein-2 (rhBMP-2); (2) PCL-based scaffold alone; or (3) autograft. The sheep were closely monitored postoperatively for signs of pain (i.e., gait abnormalities/teeth gnawing/social isolation). Fusion assessments were conducted postsacrifice using computed tomography and hard-tissue histology. All scientific work was undertaken in accordance with the study protocol that was approved by the Institute's committee on animal research. All six sheep were successfully operated on and reached the allotted survival timeline, thereby demonstrating the feasibility of the surgical procedure and postoperative care. There were no significant complications and during the postoperative period, the animals did not exhibit marked signs of distress according to the previously described assessment criteria. Computed tomographic scanning demonstrated higher fusion grades in the rhBMP-2 plus PCL-based scaffold group in comparison to either PCL-based scaffold alone or autograft. These results were supported by a histological evaluation of the respective groups. This novel open mini-thoracotomy surgical approach to the ovine thoracic spine represents a safe surgical method that can reproducibly form the platform for research into various spine-tissue-engineered constructs and their fusion-promoting properties.

The future of spine surgery: New horizons in the treatment of spinal disorders

Background and Methods:

As with any evolving surgical discipline, it is difficult to predict the future of the practice and science of spine surgery. In the last decade, there have been dramatic developments in both the techniques as well as the tools employed in the delivery of better outcomes to patients undergoing such surgery. In this article, we explore four specific areas in spine surgery: namely the role of minimally invasive spine surgery; motion preservation; robotic-aided surgery and neuro-navigation; and the use of biological substances to reduce the number of traditional and revision spine surgeries.

Results:

Minimally invasive spine surgery has flourished in the last decade with an increasing amount of surgeries being performed for a wide variety of degenerative, traumatic, and neoplastic processes. Particular progress in the development of a direct lateral approach as well as improvement of tubular retractors has been achieved. Improvements in motion preservation techniques have led to a significant number of patients achieving arthroplasty where fusion was the only option previously. Important caveats to the indications for arthroplasty are discussed. Both robotics and neuro-navigation have become further refined as tools to assist in spine surgery and have been demonstrated to increase accuracy in spinal instrumentation placement. There has much debate and refinement in the use of biologically active agents to aid and augment function in spine surgery. Biological agents targeted to the intervertebral disc space could increase function and halt degeneration in this anatomical region.

Conclusions:

Great improvements have been achieved in developing better techniques and tools in spine surgery. It is envisaged that progress in the four focus areas discussed will lead to better outcomes and reduced burdens on the future of both our patients and the health care system.

A novel low-molecular-weight compound enhances ectopic bone formation and fracture repair

BACKGROUND

Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) is expensive and may cause local side effects. A small synthetic molecule, SVAK-12, has recently been shown in vitro to potentiate rhBMP-2-induced transdifferentiation of myoblasts into the osteoblastic phenotype. The aims of this study were to test the ability of SVAK-12 to enhance bone formation in a rodent ectopic model and to test whether a single percutaneous injection of SVAK-12 can accelerate callus formation in a rodent femoral fracture model.

METHODS

Collagen disks with rhBMP-2 alone or with rhBMP-2 and SVAK-12 were implanted in a standard athymic rat chest ectopic model, and radiographic analysis was performed at four weeks. In a second set of rats (Sprague-Dawley), SVAK-12 was percutaneously injected into the site of a closed femoral fracture. The fractures were analyzed radiographically and biomechanically (with torsional testing) five weeks after surgery.

RESULTS

In the ectopic model, there was dose-dependent enhancement of rhBMP-2 activity with use of SVAK-12 at doses of 100 to 500 μg. In the fracture model, the SVAK-12-treated group had significantly higher radiographic healing scores than the untreated group (p = 0.028). Biomechanical testing revealed that the fractured femora in the 200 to 250-μg SVAK-12 group were 43% stronger (p = 0.008) and 93% stiffer (p = 0.014) than those in the control group. In summary, at five weeks the femoral fracture group injected with SVAK-12 showed significantly improved radiographic and biomechanical evidence of healing compared with the controls.

CONCLUSIONS

A single local dose of a low-molecular-weight compound, SVAK-12, enhanced bone-healing in the presence of low-dose exogenous rhBMP-2 (in the ectopic model) and endogenous rhBMPs (in the femoral fracture model).

CLINICAL RELEVANCE

This study demonstrates that rhBMP-2 responsiveness can be enhanced by a novel small molecule, SVAK-12. Local application of anabolic small molecules has the potential for potentiating and accelerating fracture-healing. Use of this small molecule to lower required doses of rhBMPs might both decrease their cost and improve their safety profile.

Basic research: Issues with animal experimentations

In vivo studies using the animals are helpful in developing the treatment strategies as they are important link between the successful in vitro testing and safe human use. Various research projects in the field of fixation of fractures, development of newer biomaterials, chemotherapeutic drugs, use of stem cells in nonunion of fractures and cartilage defects etc., have hugely depended on animal experimentation. The employment of animals in experiments is both scientific and ethical issue. There must be reasonable reasons to show that it will significantly advance the present knowledge and lead to improvement in care. The regulatory bodies exist for humane use and care of animals used for experiments e.g., International Council for Laboratory Animal Science, Council for International Organizations of Medical Sciences, International Union of Biological Sciences, International Committee on Laboratory Animals. In India, Indian National Science Academy, Indian Council of Medical Research, National Centre for Laboratory Animal Sciences promote high standards of laboratory animal quality, care and health. The Committee for the Purpose of Control and Supervision on Experiments on Animals guidelines are well defined and is a must read document for any one interested to carry out research with animal facilities.

Bone morphogenetic proteins and degenerative disk disease

Bone morphogenetic proteins (BMPs) are involved not only in osteogenesis but also in chondrogenesis. They play an important role in the development and maintenance of the intervertebral disk (IVD). For this reason, an increasing amount of research has been performed to examine the relationship between BMPs and degenerative disk disease (DDD). Moreover, researchers are examining the safe use of BMPs as a potential treatment for diskogenic back pain. We performed a literature search using databases from the US National Library of Medicine and the National Institutes of Health to identify studies relating BMPs to DDD. According to in vitro and in vivo studies in different animal and human IVDs, BMP-2 and BMP-7 are upregulated with aging and with induced disk injury; this represents an anabolic response. Direct administration of BMP-2 to IVD cells results in increased production of components of the extracellular matrix. Upregulation of the BMP pathway via other agents, namely simvastatin and LIM mineralization protein-1, has resulted in similar outcomes. Adenoviruses loaded with BMPs, transfected either directly to IVD cells or via articular chondrocytic vectors, also resulted in reversal of the typical findings in DDD. We conclude that the use of BMPs to treat DDD has a promising future. Further studies are indicated to determine optimal delivery and efficacy in humans.

Perspective on the evolution of cell-based bone tissue engineering strategies

Despite the compelling clinical needs in enhancing bone regeneration and the potential offered by the field of tissue engineering, the adoption of cell-based bone graft substitutes in clinical practice is limited to date. In fact, no study has yet convincingly demonstrated reproducible clinical performance of tissue-engineered implants and at least equivalent cost-effectiveness compared to the current treatment standards. Here, we propose and discuss how tissue engineering strategies could be evolved towards more efficient solutions, depicting three different experimental paradigms: (i) bioreactor-based production; (ii) intraoperative manufacturing, and (iii) developmental engineering. The described approaches reflect the need to streamline graft manufacturing processes while maintaining the potency of osteoprogenitors and recapitulating the sequence of biological steps occurring during bone development, including vascularization. The need to combine the assessment of efficacy of the different strategies with the understanding of their mechanisms of action in the target regenerative processes is highlighted. This will be crucial to identify the necessary and sufficient set of signals that need to be delivered at the injury or defect site and should thus form the basis to define release criteria for reproducibly effective engineered bone graft substitutes.

Should symptomatic iliac screws be electively removed in adult spinal deformity patients fused to the sacrum?

STUDY DESIGN

Retrospective, single-institution review of adult deformity patients who underwent iliac screw (IS) removal placed during fusion to the sacrum.

OBJECTIVE

To demonstrate whether IS removal offered benefit in terms of hip/buttock pain overlying the IS and whether IS could be removed without significant complications.

SUMMARY OF BACKGROUND DATA

ISs are effective at countering cantilever forces imparted on sacral pedicle screws. Despite the efficacy of IS fixation, pain or implant prominence can lead to elective IS removal. There has been no study about IS removal in adult spinal deformity patients.

METHODS

A total of 395 consecutive walking adult spinal deformity patients fused to the sacrum with IS fixation and minimum 2-year follow-up met study inclusion criteria. Clinical/radiographical data were analyzed. Because there is no validated pain outcomes instrument specific to this situation, an 8-question IS removal questionnaire was designed and used for the sole purpose of this inquiry, within which a universally accepted numeric rating scale for pain was included. RESULTS.: Twenty-four of 395 (6.1%) patients (2 men and 22 women) with mean age of 50.5 ± 10.8 years underwent elective IS removal at mean 2.6 ± 1.3 years from index surgery. Mean follow-up from initial surgery was 6.3 ± 4.0 years. Symptoms included hip/buttock pain in all 24 patients and IS prominence in 5 patients (20.8%). Screw removal was bilateral in 18 (75%) patients and unilateral in 6 (25%) patients. Using a numeric rating pain scale (0-10), hip/buttock pain improved after IS removal: preoperative 6.9 ± 1.8, postoperative 2.0 ± 2.7 (P < 0.05). Patients reported hip/buttock symptoms post-IS removal as "much improved" (78.3%), "somewhat improved" (8.7%), and "unchanged" (13.0%). Two of 24 (8.3%) patients sustained complications from IS removal (wound infection, n = 1; coronal/sagittal imbalance, n = 1). Presented with the same set of circumstances, 22 of 24 (91.7%) patients would have their IS removed again, including one of the patients who had a complication.

CONCLUSION

Of 395 consecutive walking patients who had ISs placed during fusion to the sacrum for adult spinal deformity, 24 (6.1%) underwent elective removal. Patients had a statistically significant improvement in hip/buttock pain after IS removal, and a low prevalence of complications after the procedure was observed.

Positive effect on bone fusion by the combination of platelet-rich plasma and a gelatin β-tricalcium phosphate sponge: a study using a posterolateral fusion model of lumbar vertebrae in rats

We developed a novel method for bone fusion by combining platelet-rich plasma (PRP) and a gelatin β-tricalcium phosphate (β-TCP) sponge. The PRP is an autologous concentration of platelets that includes several growth factors. The gelatin β-TCP sponge comprises gelatin and β-TCP, thus enabling the sustained release of growth factors and osteoconduction. To evaluate this method, we generated a posterolateral fusion model of lumbar vertebrae in rats and divided it into five groups by implanting the following materials between transverse processes of vertebrae, (1) the gelatin β-TCP sponge with PRP (PRP sponge), (2) the gelatin β-TCP sponge with platelet-poor plasma, (3) gelatin hydrogel with PRP, (4) autologous iliac bone (autograft), and (5) no material was implanted as a control. The assessment of bone fusion by a radiographic assessment, a biomechanical test, microcomputed tomography, and histological evaluations demonstrated that there were no significant differences between the PRP sponge and the autograft groups regarding the osteogenic effect. Subsequent examinations revealed that no significant differences existed between the PRP sponge and the autograft groups in either biomechanical stiffness or the bone volume over time; whereas the radiographic and histological composition underwent similar changes in the fusion process. These results indicate that the PRP sponge could, therefore, be potentially useful as an attractive and less invasive method for bone fusion.

Acceleration of spinal fusion using COMP-angiopoietin 1 with allografting in a rat model

INTRODUCTION

Allografting has become widely available for the elimination of morbidity due to autogenous bone grafting procedures for spinal fusion. Enhancement of stable bone formation could facilitate this procedure. COMP-Ang1 is a recombinant chimeric protein of angiopoietin-1 that induces angiogenesis and vascular enlargement. We investigated the osteogenic potential of COMP-Ang1 for spinal fusion with allograft based on the enhancement of angiogenesis.

METHODS

Sixty Sprague-Dawley rats underwent bilateral posterior and posterolateral arthrodesis with allograft at L3-4 and L4-5. The animals were divided into three groups (n=20 each): (1) no treatment (sham group); (2) the bovine serum albumin-impregnated collagen sponge group (BSA group); 3) the COMP-Ang1-impregnated collagen sponge group (COMP-Ang1 group). Animals were sacrificed at six weeks for evaluation of spinal fusion using manual palpation, radiographs, and biomechanical and histomorphometric assessments. Total RNA was prepared from the fusion site and analyzed for osteogenic marker protein expression using RT-PCR analysis.

RESULTS

The fusion rates determined by manual palpation were 38.9% in the sham group, 42.1% in the BSA group, and 89.5% in the COMP-Ang1 group. Optical density of fusion masses in the COMP-Ang1 group was significantly higher than those in the sham and BSA groups (p<0.001). Total bone volume was significantly higher in the COMP-Ang1 group than in the sham and BSA groups (p<0.001). The mechanical strength was significantly greater in the COMP-Ang1 group than in the sham and BSA groups (p<0.01). Histologically, the fusion site of the COMP-Ang1 group showed a larger number of reactive bones compared with those in the BSA and sham groups. Immunostaining of endothelial cells for factor VIII revealed that COMP-Ang1 group showed higher levels of vascularity in the fusion site. Runt-related transcription factor 2 and its target genes were significantly up-regulated in the COMP-Ang1 group.

CONCLUSIONS

COMP-Ang1 induced radiologically and histologically demonstrable active osteogenesis by promoting angiogenesis in spinal fusions. It was concluded that COMP-Ang1 enhances spinal fusion and hence the strength of the fusion.

Ex vivo gene therapy using autologous dermal fibroblasts expressing hLMP3 for rat mandibular bone regeneration

BACKGROUND

Implantation of autologous skin fibroblasts transduced ex vivo with a replication-defective adenoviral vector, carrying the LIM mineralization protein-3 (Ad-LMP-3), and adsorbed on a hydroxyapatite/collagen (HA/COL) scaffold.

METHODS

Twenty-seven Wistar rats were used. A 5- x 5-mm full-thickness defect was created in the exposed mandible. All animals were randomized into 3 experimental groups: (1) autologous dermal fibroblasts transduced with Ad-LMP-3 and adsorbed on the HA/COL; (2) nontransduced dermal fibroblasts adsorbed on the HA/COL scaffold; and (3) HA/COL scaffold without cells. Three-dimensional micro-CT (3DmicroCT or 3DmuCT) and histological analysis were performed.

RESULTS

Efficient neoosteogenesis was observed in animals treated with LMP-3-expressing cells (group 1) as soon as 4 weeks after surgery. Conversely, nonsignificant bone formation was detected in control animals (groups 2 and 3) at all time points tested.

CONCLUSION

These results suggest that the experimental approach based on transplantation of genetically modified autologous cells could provide an alternative treatment for cranio-maxillo-facial defects. Nonetheless, additional data from the study on larger bone defects must follow to foresee a clinical application in the near future.

Two-year fusion and clinical outcomes in 224 patients treated with a single-level instrumented posterolateral fusion with iliac crest bone graft

BACKGROUND CONTEXT

Reported fusion rates for spine fusions using iliac crest bone graft (ICBG) vary between 40% and 100% because of different fusion techniques, patient comorbidity, diagnosis and assessment criteria.

PURPOSE

We report two-year results of single-level instrumented posterolateral fusions evaluated with radiographs, fine-cut computed tomography (CT) scans with reconstructions and outcome measures. STUDY DESIGN/ SETTING: Retrospective analysis of data from a prospective multicenter randomized clinical controlled trial.

PATIENT SAMPLE

Patients with various degenerative diagnoses enrolled in the control arm of a Food and Drug Administration (FDA)-regulated, multicenter trial of single-level decompression and posterolateral fusion for degenerative lumbar disease.

OUTCOME MEASURES

Short Form-36 (SF-36), Oswestry Disability Index (ODI), Numeric Rating Scales (0-20) for back, leg, and graft site pain, CT scans, anteroposterior and lateral flexion/extension radiographs.

METHODS

Patients enrolled in an FDA-regulated, multicenter trial at 29 sites with degenerative lumbar disease treated with single-level instrumented posterolateral fusion with ICBG were included in the analysis. Demographic and surgical data were collected. Clinical outcomes were followed using standard metrics. Fusion was assessed by independent radiologists at 6, 12, and 24 months postoperatively. Two fusion criteria were compared: anteroposterior and flexion/extension radiographs to assess motion and bridging bone, with CT scans as needed to confirm bridging bone; and CT scan assessment for bridging bone only.

RESULTS

One hundred ninety-four of 224 subjects (86.6%) completed the study. The mean operative time was 2.9 hours with a blood loss of 448.6 mL. The average graft volume was 36.3 mL. There were 21 (9.4%) wound infections, 18 (8.0%) incidental durotomies, 3 (1.3%) implant displacements, 2 (0.9%) malpositioned implants, and 17 (7.6%) graft-related complications. Twenty-seven patients (13.9%) required reoperation, the majority for nonunions. Fusion rates based on radiographs with selective CTs at 6, 12, and 24 months were 65.3%, 82.5%, and 89.3%, respectively. Fusion rates based on bridging bone on CT scans were 56.1%, 71.5%, 83.9%, respectively. Two-year improvement for all outcome measures was significant (p<.001)-ODI 25.3, SF-36 Physical Component Score (PCS) 12.2, back pain 7.9, and leg pain 7.1. Two years postoperatively, 60% of patients complained of graft site pain (mean pain score=8.5).

CONCLUSION

In a large series of patients who had primary single-level instrumented posterolateral fusion with ICBG, evidence of bridging bone on fine-cut CT scans improved with time to 83.9% at 24 months. Significant improvement from baseline was noted in all clinical outcome measures at all time intervals with 75% achieving minimum clinically important difference (MCID) for ODI and 66% achieving MCID for SF-36 PCS.

The safety and efficacy of OP-1 (rhBMP-7) as a replacement for iliac crest autograft in posterolateral lumbar arthrodesis: a long-term (>4 years) pivotal study

STUDY DESIGN

Randomized controlled trial comparing OP-1 (rhBMP-7) with iliac crest autograft in patients with symptomatic degenerative spondylolisthesis and spinal stenosis treated with decompression and uninstrumented posterolateral arthrodesis.

OBJECTIVE

To determine the safety and the clinical and radiographic efficacy of OP-1 (rhBMP-7) Putty as compared with an iliac crest bone autograft control in uninstrumented, single-level posterolateral spinal arthrodesis.

SUMMARY OF BACKGROUND DATA

Preclinical and preliminary clinical data have demonstrated successful fusion and clinical outcomes with the use of OP-1 Putty in posterolateral spinal arthrodesis. No prior randomized controlled trial with adequate study power has been performed.

METHODS

A total of 335 patients were randomized in 2:1 fashion to receive either OP-1 Putty or autograft in the setting of an uninstrumented posterolateral arthrodesis performed for degenerative spondylolisthesis and symptomatic spinal stenosis. Patients were observed serially with radiographs, clinical examinations, and appropriate clinical indicators, including ODI, Short-Form 36, and visual analog scale scores. Serum samples were examined at regular intervals to assess the presence of antibodies to OP-1. The primary end point, Overall Success, was analyzed at 24 months. The study was extended to include additional imaging data and long-term clinical follow-up at 36+ months. At the 36+ month time point, CT scans were obtained in addition to plain radiographs to evaluate the presence and location of new bone formation. Modified Overall Success, including improvements in ODI, absence of retreatment, neurologic success, absence of device-related serious adverse events, angulation and translation success, and new bone formation by CT scan (at 36+ months), was then calculated using the 24-month primary clinical endpoints, updated retreatment data, and CT imaging and radiographic end points.

RESULTS

OP-1 Putty was demonstrated to be statistically equivalent to autograft with respect to the primary end point of modified overall success. The use of OP-1 Putty when compared to autograft was associated with statistically lower intraoperative blood loss and shorter operative times. Although patients in the OP-1 Putty group demonstrated an early propensity for formation of anti-OP-1 antibodies, this resolved completely in all patients with no clinical sequelae.

CONCLUSION

OP-1 Putty is a safe and effective alternative to autograft in the setting of uninstrumented posterolateral spinal arthrodesis performed for degenerative spondylolisthesis and symptomatic spinal stenosis.