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Hsu WK, Goldstein CL, Shamji MF, Cho SK, Arnold PM, Fehlings MG, Mroz TE. Novel Osteobiologics and Biomaterials in the Treatment of Spinal Disorders. Neurosurgery 2017; 80:S100-S107. [PMID: 28350951 DOI: 10.1093/neuros/nyw085] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/11/2017] [Indexed: 12/12/2022] Open
Abstract
Spinal osteobiologics have evolved substantially in this century after the development of many product categories such as growth factors, allograft, and stem cells. The indications for the use of novel biologics within spine surgery are rapidly expanding as the mechanism of each is elucidated. While the knowledge base of bone morphogenetic protein increases with each subsequent year, the application of new nanotechnology and cell-based strategies are being reported. This review will discuss the most recent data in novel osteobiologics, and where we could use future study.
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Affiliation(s)
- Wellington K Hsu
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Mohammed F Shamji
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Canada
| | - Sam K Cho
- Department of Orthopaedic Surgery, Mount Sinai Hospital, New York, New York
| | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Missouri
| | - Michael G Fehlings
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Canada
| | - Tom E Mroz
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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Abstract
We need to overcome limitations of present assessment and also integrate newer research in our work about sciatica. Inflammation induces changes in the DRG and nerve root. It sensitizes the axons. Nociceptor is a unique axon. It is pseudo unipolar: both its ends, central and peripheral, behave in similar fashion. The nerve in periphery which carries these axons may selectively become sensitive to mechanical pressure--"mechanosensitized," as we coin the phrase. Many pain questionnaires are used and are effective in identifying neuropathic pain solely on basis of descriptors but they do not directly physically correlate nerve root and pain. A thorough neurological evaluation is always needed. Physical examination is not direct pain assessment but testing mobility of nerve root and its effect on pain generation. There is a dogmatic dominance of dermatomes in assessment of leg pain. They are unreliable. Images may not correlate with symptoms and pathology in about 28% of cases. Electrophysiology may be normal in purely inflamed nerve root. Palpation may help in such inflammatory setting to refine our assessment further. Confirmation of sciatica is done by selective nerve root block (SNRB) today but it is fraught with several complications and needs elaborate inpatient and operating room set up. We have used the unique property of the pseudo unipolar axon that both its ends have similar functional properties and so inject along its peripheral end sodium channel blockers to block the basic cause of the mechanosensitization namely upregulated sodium channels in the root or DRG. Thus using palpation we may be able to detect symptomatic nerve in stage of inflammation and with distal end injection, along same inflamed nerve we may be able to abolish and so confirm sciatica. Discussions of sciatica pain diagnosis tend to immediately shift and centre on the affected disc rather than the nerve. Theoretically it may be possible to detect the affected nerve by palpating the nerve and relieve pain moment we desensitize the nerve.
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Lee IS, Chung SG. Pathophysiology of degenerative spinal disease causing lumbar and cervical spinal pain. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2014. [DOI: 10.5124/jkma.2014.57.4.300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- In-Sik Lee
- Department of Rehabilitation Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sun G. Chung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea
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Manchikanti L, Singh V, Boswell MV. Lumbar Radiculopathy. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00089-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Osgood DP, Kenney EV, Harrington WF, Harrington JF. Excrescence of neurotransmitter glutamate from disc material has nociceptive qualities: evidence from a rat model. Spine J 2010; 10:999-1006. [PMID: 20863766 DOI: 10.1016/j.spinee.2010.07.390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Revised: 06/09/2010] [Accepted: 07/26/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND CONTEXT The authors have previously demonstrated that herniated human lumbar disc is rich in free glutamate from degradation of aggrecan. Prior data have suggested that free glutamate could contribute to a nociceptive state. PURPOSE Previous behavioral experiments suggested glutamate-related nociception by comparing pre- and postglutamate infusion responses only. This indirectly suggested nociceptive effects of epidural glutamate but was not a definitive evidence. Now, by using larger numbers of subjects, we have demonstrated that lumbar epidural glutamate infusion causes significant left-to-right differences in hind paw response during treatment, demonstrating more directly the focal nociceptive effects of glutamate. STUDY DESIGN Behavioral studies and immunohistochemistry were used to assess for evidence of a nociceptive state. All researchers were blinded to infusion solution. METHODS Via an implanted mini osmotic pump, the epidural space of rats was infused with 0.02 mM glutamate or normal saline for 72 hours. Signs of nociception were assessed by von Frey and plantar thermal stimulation testing and by glutamate receptor expression in the corresponding dorsal horn of the spinal cord and dorsal root ganglion. RESULTS Both von Frey mechanical and plantar thermal stimulations showed differences in hind paw reactivity depending on whether it was on the ipsilateral or contralateral side of glutamate infusion. Saline infusion had no significant behavioral effects. Dorsal horn expression of 2-amino-3-(5-methyl-3-oxo-1,2-oxazol-4-yl) propanoic acid and N-methyl-d-aspartic acid receptors was significantly increased in glutamate-infused animals, further indicative of a nociceptive state related to glutamate infusion. CONCLUSIONS Elevated epidural glutamate concentrations caused a focal hyperesthetic state. Increased epidural glutamate concentration could be a driving force or "chemical" component of disc-related radiculopathy.
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Affiliation(s)
- Doreen P Osgood
- Department of Neurosurgical Research, Roger Williams Medical Center, Providence, RI 02908, USA
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An injectable and in situ-gelling biopolymer for sustained drug release following perineural administration. Spine (Phila Pa 1976) 2008; 33:748-54. [PMID: 18379401 PMCID: PMC2736879 DOI: 10.1097/brs.0b013e3181695773] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study evaluated whether the aggregation behavior of a thermally responsive elastin-like polypeptide (ELP) prolongs protein residence time at the dorsal root ganglion (DRG). This work involves development of a sustained-release drug delivery vehicle to provide high and sustained levels of biologic therapeutics to the dorsal root ganglion while minimizing systemic exposure. OBJECTIVE To study the potential of the ELP biopolymer to sustain release and lower systemic exposure of bioactive peptides following perineural administration. SUMMARY OF BACKGROUND DATA Anticytokine treatment for lumbar radiculopathy may offer clinical improvement, but exposes patients to systemic toxicities of immunosuppression. ELPs are environmentally responsive polypeptides that undergo a phase transition on heating to form an insoluble aggregate. Drug conjugates with ELP exhibit both temperature-sensitivity and in vitro bioactivity. Monomer resolubilization yields solution-phase molecules, and this reversible aggregation behavior may create a perineural drug depot to sustain drug delivery to an inflamed nerve. METHODS This experiment involved 48 rats in which radiolabeled ELPs (aggregating or soluble) were injected overlying the L5 dorsal root ganglion. Animals were killed at 6 different time points, and radioactivity associated with the injected segment, serum, and other tissues was evaluated. RESULTS The aggregating ELP demonstrated a 7-fold longer perineural half-life compared with the soluble ELP. This supports the hypothesis that the aggregating ELP forms a depot from which slow resolubilization and clearance provides sustained, local protein release. Furthermore, serum radioactivity reached a lower peak for the aggregating group, demonstrating slower absorption of the aggregating protein into the systemic circulation. CONCLUSION These results suggest that ELP aggregation confer the benefit of perineural compartment longevity for bioactive therapeutics delivered fused with this carrier. This may sustain release of potent immunomodulator therapeutics to treat local neuroinflammation. Desirable features include delivery of high local doses and protection against systemic exposure and associated toxicity.
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Quante M, Hauck M, Gromoll M, Hille E, Lorenz J. Dermatomal laser-evoked potentials: a diagnostic approach to the dorsal root. Norm data in healthy volunteers and changes in patients with radiculopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 16:943-52. [PMID: 17103230 PMCID: PMC2219653 DOI: 10.1007/s00586-006-0253-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Revised: 09/06/2006] [Accepted: 10/21/2006] [Indexed: 10/23/2022]
Abstract
We conducted a cross-sectional study of 40 radiculopathy patients in comparison with norm data from healthy subjects using a new electrophysiological method. Early manifestations of dorsal root impairment escape objective diagnosis by conventional somatosensory-evoked potentials due to the overlapping innervation of the affected dermatome by thickly myelinated mechanoreceptive afferents projecting to adjacent intact roots. Evidence suggested less intersegmental overlap for thermonociceptive afferents rendering laser-evoked potentials (LEP) sensitive to monosegmental dorsal root damage. Therefore we used this new method to study acute manifestations of monosegmental dorsal root pathology. Dorsal root function was tested in 12 healthy subjects and 40 sciatica patients by intraindividual interside comparison. Mechanosensibility and thermosensibility were clinically investigated. LEP were induced by moderately painful laser stimuli. The LEP were evaluated by amplitude and latency of the averaged electroencephalogram. Normal interside differences of LEP for amplitude were +/-22% (lower limb) and +/-35% (upper limb) and +/-15 to +/-16% for latency. Twenty-six patients (65%) showed significant LEP changes, mainly amplitude decreases. Six of these patients exhibited latency prolongations. Clinical testing yielded more frequent pathological results for pain compared to mechanosensibility. The study confirmed our preliminary evidence of LEP sensitivity to objectively document dorsal root impairment in patients suffering from acute monosegmental radiculopathy. This result opens the perspective of electrophysiologically differentiating the presence or absence of dorsal root pathology in patients with similar clinical symptoms but possibly different prognoses, which require different therapies.
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Affiliation(s)
- Markus Quante
- Department of Orthopaedics and Rheumatology, University Hospital Giessen and Marburg, Marburg, Germany.
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Mulleman D, Mammou S, Griffoul I, Watier H, Goupille P. Pathophysiology of disk-related sciatica. I.--Evidence supporting a chemical component. Joint Bone Spine 2005; 73:151-8. [PMID: 16046173 DOI: 10.1016/j.jbspin.2005.03.003] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Accepted: 03/09/2005] [Indexed: 01/24/2023]
Abstract
Sciatica in patients with disk disease was long ascribed to pressure put on the sciatic nerve root by a herniated disk. However, a role for chemical factors acting in conjunction with this mechanical insult is suggested by a number of clinical observations: disk surgery does not consistently provide pain relief, large disk herniations are not always symptomatic, severe pain may be present in patients without imaging evidence of nerve root compression, the severity of symptoms and neurological signs is not well correlated with the size of the disk herniation, and conservative therapy is often effective. Experimental studies have provided further evidence for a chemical component: disk herniations can undergo spontaneous resorption, the intervertebral disk is immunogenic, and mediators for inflammation have been identified within intervertebral disk tissue. The current pathophysiological theory incriminates proinflammatory substances secreted by the nucleus pulposus (NP). When preexisting or concomitant mechanical injury to a nerve root occurs, these substances can cause nerve root pain. Animal experiments have established that the NP can induce functional and structural nerve root abnormalities in the absence of mechanical compression and that this effect is mediated by substances located at the surface of NP cells. Methylprednisolone, diclofenac, indomethacin, doxycycline, and cyclosporine induce variable inhibition of this effect. Available information points to tumor necrosis factor-alpha (TNF-alpha) as the main candidate among substances potentially responsible for nerve root pain. Therefore, trials of TNF-alpha antagonists in patients with disk-related sciatica are warranted.
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Affiliation(s)
- Denis Mulleman
- François Rabelais de Tours University, EA 3853 Immuno-Pharmaco-Génétique des Anticorps thérapeutiques, 37044 Tours, France
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Weiler C, Nerlich AG, Bachmeier BE, Boos N. Expression and distribution of tumor necrosis factor alpha in human lumbar intervertebral discs: a study in surgical specimen and autopsy controls. Spine (Phila Pa 1976) 2005; 30:44-53; discussion 54. [PMID: 15626980 DOI: 10.1097/01.brs.0000149186.63457.20] [Citation(s) in RCA: 239] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Immunohistochemical study of tumor necrosis factor alpha expression in autopsy and surgical specimens of human lumbar intervertebral discs. OBJECTIVES To investigate the occurrence and localization of tumor necrosis factor alpha in intervertebral disc tissue and to correlate its expression with age and the degree of disc degeneration. SUMMARY OF BACKGROUND DATA The source and origin of discogenic pain are as yet unknown. Recently identified changes of the cellular phenotype during senescence and disc pathology with partly phagocytic properties suggest an 'inflammatory' phenotype. Tumor necrosis factor alpha is one of the most potent proinflammatory cytokines possibly modulating cellular phenotypes. It may also promote pain induction. Very little is known about the occurrence and localization of tumor necrosis factor alpha in intervertebral disc tissue of defined age and degree of histologic tissue degeneration. METHODS The study population comprised 20 cross-sections of the complete motion segment of human lumbar vertebrae (age range 0-86 years) obtained at autopsy and 28 surgical disc specimens of individuals undergoing lumbar surgical interventions for various reasons. The temporospatial distribution of tumor necrosis factor alpha-positive cells using a polyclonal antibody was correlated with a histologic degeneration score. RESULTS Tumor necrosis factor alpha is expressed substantially in (nonsymptomatic) autopsy material in fetal/infantile and older adult nucleus pulposus, whereas it is sparsely expressed in adolescent and young adult nucleus pulposus. In the anulus fibrosus, tumor necrosis factor alpha is not found in young adults (<25 years), but then significantly increases in extent. In contrast, symptomatic nucleus pulposus and anulus fibrosus (surgical material) contain substantially more tumor necrosis factor alpha-positive cells. A significant positive correlation of tumor necrosis factor alpha expression and disc degeneration (histologic degeneration score) was found for the anulus fibrosus in both sample groups. In the surgical material, an additional significant positive correlation was identified for nuclear tumor necrosis factor alpha, disc degeneration, and age. CONCLUSIONS Tumor necrosis factor alpha is substantially expressed in disc material of symptomatic patients (surgical specimens) in comparison to samples taken at autopsy. The expression of tumor necrosis factor alpha in early fetal/infantile nucleus pulposus may indicate 'physiologic' tissue disarrangement with closure of the blood vessel canals. The expression of tumor necrosis factor alpha in adult discs, in contrast, is statistically associated with disc degeneration. Its occurrence in adults of more advanced age suggests that tumor necrosis factor alpha is not involved in the initiation of disc degeneration, but may be associated with further promotion of degenerative disarrangement and pain induction.
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Affiliation(s)
- Christoph Weiler
- Institute of Pathology, Ludwig-Maximilians University Munich, Germany.
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Willburger RE, Ehiosun UK, Kuhnen C, Krämer J, Schmid G. Clinical symptoms in lumbar disc herniations and their correlation to the histological composition of the extruded disc material. Spine (Phila Pa 1976) 2004; 29:1655-61. [PMID: 15284512 DOI: 10.1097/01.brs.0000133645.94159.64] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Fifty-five consecutive patients undergoing microdiskectomy due to lumbar disc herniation were included in this clinical study over 12 months. OBJECTIVES To investigate possible correlations between the histologic composition of the herniated disc fragments and pain, disability, clinical signs, and operative findings. SUMMARY OF BACKGROUND DATA Previous studies have investigated the histologic composition of herniated lumbar disc fragments. Few publications, however, examined correlations with clinical data. METHODS Before treatment, patients were examined using a standardized clinical protocol; subjective disability and pain were assessed by the Oswestry Disability Questionnaire and the McGill Pain Questionnaire. The herniated disc fragments were examined semiquantitatively for the relative percentages of nucleus pulposus, anulus fibrosus, and cartilaginous endplate. RESULTS In patients less than 30 years of age, significantly higher percentages of nucleus pulposus were found than in the older group, whereas anulus fibrosus was found in significantly higher percentages in patients > or =30 years. Both higher percentages of cartilage and nucleus pulposus correlated with increased pain intensity values from the McGill Pain Questionnaire. Impaired reflexes before treatment occurred significantly more often in patients with > or =20% of cartilage in the herniated fragments. If nucleus pulposus was <30%, sensory impairment tended to be more severe before treatment. CONCLUSION The histologic composition of the herniated disc fragments seems to affect pain and clinical symptoms.
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Chen C, Cavanaugh JM, Song Z, Takebayashi T, Kallakuri S, Wooley PH. Effects of nucleus pulposus on nerve root neural activity, mechanosensitivity, axonal morphology, and sodium channel expression. Spine (Phila Pa 1976) 2004; 29:17-25. [PMID: 14699271 DOI: 10.1097/01.brs.0000096675.01484.87] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This study analyzed the effects of autografted nucleus pulposus on nerve root axon morphology, neurophysiologic function, and sodium channel expression. OBJECTIVES To investigate the chronic effects of the epidural implantation of nucleus pulposus on nerve root morphology, neural activity, ectopic discharge, mechanosensitivity, and sodium channel expression. SUMMARY OF BACKGROUND DATA It has been reported that ectopic discharges were recorded antidromically from sural nerve on compressing nucleus pulposus exposed spinal nerves. However, it is not clear what the effects of nucleus pulposus are on ectopic discharges recorded directly from the spinal nerve roots. It is also not clear what the effects of nucleus pulposus are on the threshold pressure to provoke ectopic discharges in the spinal nerves. Sodium channel content increases in remodeling axons after nerve injury, but it is not clear what the effects of nucleus pulposus are on sodium channel expression in spinal nerve. METHODS Forty-six male Sprague-Dawley rats were used, 20 in a nucleus pulposus-implanted group, 18 in a fat-implanted group, and 8 in a normal group. Fresh autografted nucleus pulposus or fat tissue was implanted into the dorsal epidural space at the L4-L5 disc level. On the 7th, 21st, or 42nd day, neurophysiologic recordings were made to determine nerve root response to compression. Nerve roots were then harvested to determine sodium channel protein concentration and histologic changes in the nerve root. The correlations between sodium channel density and neural activity and mechanosensitivity of dorsal root were analyzed statistically. RESULTS Ectopic discharge rate was higher in nucleus pulposus 7-day group. Threshold pressure to evoke ectopic discharges was lower in the nucleus pulposus 7-day group, and higher in the nucleus pulposus 42-day group compared to the normal group. Sodium channel protein density increased in the nucleus pulposus 7-day and nucleus pulposus 21-day group compared to normal nerve. Sodium channel density changes were not correlated to threshold pressure. Ectopic discharge rate increased with increase of sodium channel density in the nerve roots. The number of axons with neuropathy increased in the nucleus pulposus 7-day and 21-day groups. CONCLUSIONS Acute exposure of nerve root to nucleus pulposus resulted in increased number of axons with neuropathy, higher intensity of ectopic discharges on compression, and nerve mechanosensitization. Chronic exposure resulted in mechanical desensitization. Changes of sodium channel density were correlated to ectopic discharge rate.
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Affiliation(s)
- Chaoyang Chen
- Spine Research Laboratory, Bioengineering Center, Wayne State University, Detroit, MI 48202, USA.
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Kawakami M, Hashizume H, Nishi H, Matsumoto T, Tamaki T, Kuribayashi K. Comparison of neuropathic pain induced by the application of normal and mechanically compressed nucleus pulposus to lumbar nerve roots in the rat. J Orthop Res 2003; 21:535-9. [PMID: 12706028 DOI: 10.1016/s0736-0266(02)00192-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We studied whether applying nucleus pulposus tissue, obtained from tail intervertebral discs that had been subjected to chronic mechanical compression, to the lumbar nerve roots produces hyperalgesia, which is thought to be a pain-related behavior in the rat. An Ilizarov-type apparatus was used for immobilization and chronically applied compression of the rat tail for eight weeks. Three weeks after application of extracted nucleus pulposus tissue on the lumbar nerve roots, motor function, sensitivity to noxious mechanical stimuli was measured. Eight weeks after application of the apparatus, the instrumented vertebrae were resected and sections were stained with hematoxylin and eosin to evaluate degeneration of the intervertebral disc. Mechanical hyperalgesia observed in rats treated with the compressed nucleus pulposus tissue was greater and of longer duration than in the rats treated with normal and non-compressed discs. The nucleus pulposus in the instrumented vertebrae showed some histological degeneration. In conclusion, chronic mechanical compression of nucleus pulposus, which resulted in degeneration to some extent, enhanced mechanical hyperalgesia, which was induced by application of nucleus pulposus on the nerve root in the rat. Degenerative intervertebral discs might induce more significant pain than normal intervertebral discs.
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Affiliation(s)
- Mamoru Kawakami
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Japan.
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Wheeler AH, Murrey DB. Chronic lumbar spine and radicular pain: pathophysiology and treatment. Curr Pain Headache Rep 2002; 6:97-105. [PMID: 11872180 DOI: 10.1007/s11916-002-0005-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The lumbar spine forms the foundation and infrastructure of an organic skyscraper equipped with the physiologic capacity to act as a crane for lifting and a crankshaft for walking. Subjected to aging like other "human machinery," the lumbar spine adapts to the wear and tear of gravity and biomechanical loading through structural and neurochemical changes. Many of the changes are maladaptive, resulting in pain, physical and functional disability, and altered neurophysiologic circuitry. Some compensatory reactions are constructive, but others cause more interference with the organism's capacity to cope. A conceptional understanding of the multifaceted structural, biomechanical, biochemical, medical, and psychosocial influences that compose this mix elucidates the complexity of applying effective treatments.
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Affiliation(s)
- Anthony H Wheeler
- Charlotte Spine Center, Pain and Orthopedic Neurology, 2001 Randolph Road, Suite 210, Charlotte, NC 28207, USA.
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