Experimental chemonucleolysis with recombinant human matrix metalloproteinase 7 in human herniated discs and dogs.

BACKGROUND CONTEXT: Chemonucleolysis has been proposed as a less invasive technique than surgery for patients with lumbar disc herniation. Once chymopapain had been approved as a chemonucleolysis drug, it was withdrawn because of serious complications. A novel agent with fewer complications would be desirable. PURPOSE: The purpose of this study was to investigate the effects of recombinant human matrix metalloproteinase 7 (rhMMP-7) in experimental chemonucleolysis in vitro and in vivo and examine its effects on tissue damage. STUDY DESIGN: The study design is the experimental study using human herniated discs and enzyme substrates in vitro and dogs in vivo. METHODS: The effects of rhMMP-7 on the degradation of human herniated discs were examined by measuring the wet weight in vitro. The correlations between the decrease in wet weight by rhMMP-7 and the conditions associated with herniated discs were also analyzed. The effects of rhMMP-7 on the proteoglycan and water contents were respectively examined with alcian blue staining and T2-weighted magnetic resonance imaging at 7 days after intradiscal injection in dogs. The distribution of [125I]-labeled rhMMP-7 was investigated by autoradioluminography at 7 days after intradiscal injection in dogs. An epidural injection study with rhMMP-7 was performed to evaluate the effects on the tissue damage around the discs at 1 and 13 weeks after the treatment in dogs. The Type 1 and 2 collagen cleavage rates were measured and compared with those of aggrecan in vitro. RESULTS: Recombinant human matrix metalloproteinase 7 concentration dependently decreased the wet weight of herniated discs in vitro. The decrease in wet weight of the discs by rhMMP-7 did not significantly correlate with the conditions associated with herniated discs. Intradiscal injection of rhMMP-7 reduced the proteoglycan and water contents, with an increase in the serum keratan sulfate levels. Radioactivity of [125I]-labeled rhMMP-7 was detected in the nucleus pulposus and annulus fibrosus but not in the muscle. Epidural injection of rhMMP-7 had no effect on the injection site or the nerve tissues. The Type 1 and 2 collagen cleavage rates of rhMMP-7 were 1,000-fold weaker than those of aggrecan. CONCLUSIONS: This study demonstrated experimental chemonucleolysis with rhMMP-7 in vitro and in vivo. The effects of rhMMP-7 were not affected by the conditions associated with herniated discs. The epidural injection study together with the autoradioluminography and in vitro enzyme assay suggests that intradiscal injection of rhMMP-7 may not induce tissue damage around the discs because of its distribution and substrate selectivity. Recombinant human matrix metalloproteinase 7 may be a novel and promising chemonucleolysis agent.

Evaluation of hyaluronic acid sheet for the prevention of postlaminectomy adhesions.

BACKGROUND CONTEXT: Various materials have been tested for their ability to maintain a barrier between muscles and epidural space in order to physically or chemically inhibit scar ingrowths. Hyaluronic acid (HA) solution and gel have been reported to be effective in preventing adhesions postlaminectomy; however, neither has been used clinically after spinal surgery. PURPOSE: To determine the efficacy of HA sheet for the prevention of postlaminectomy adhesions compared with that of HA gel or another sheet. STUDY DESIGN/SETTING: An animal model of lumbar laminectomy in rabbits was used to study postoperative scar tissue formation around the spinal cord. The histologic effects of HA sheet were compared with those of Gelfoam (GF) and further evaluated by an inflammation model using rhTNF-alpha. PATIENT SAMPLE: Rabbit. OUTCOME MEASURES: Histologic examination. METHODS: Five rabbits were killed at 2, 4, 8, and 24 weeks after laminectomy, respectively. Another 18 rabbits were examined in an environment of active inflammation experimentally induced by rhTNF-alpha to compare the effects of HA sheet with those of GF or HA gel. Histologic examination was performed to quantitatively assess invasive scar formation or inflammation postlaminectomy, and then, the histologic effects of HA sheet were compared with those of GF or HA gel. RESULTS: In the HA group, significantly, the area of subarachnoid space was larger, distance from the surface of dura to scar tissues was greater, the number of inflammatory cells in the scar tissues at the site of laminectomy was less, and enlargement of dura was suppressed. Using an inflammation model, we also demonstrated the efficacy of HA sheet treatment. CONCLUSIONS: In an experimental laminectomy model, HA sheet formed a solid interpositional membrane barrier and exhibited anti-inflammatory activity. Further investigations will be needed for HA sheet to be used clinically.

Visualization of incomplete conduction block by neuromagnetic recording.

OBJECTIVE: We previously reported on evoked compound action magnetic fields (CAFs) in isolated sciatic nerves with complete conduction block. In this study, we examined evoked CAFs of the nerve with incomplete conduction block, which is clinically common. METHODS: Rabbits' isolated nerves were electrically stimulated in a chamber containing Ringer's solution. Compound action potentials (CAPs) and CAFs were recorded before and after the incomplete conduction block induced by a vascular clip. The positions of the lesion were estimated by dipole localization. RESULTS: Before the nerve clipping, magnetic contour maps showed CAFs with a characteristic quadrupolar pattern. After the clipping, CAFs attenuated in the amplitude and decelerated through the lesion. Estimated position of the lesion was 0.12+/-3.23 mm (mean+/-SD, n=10) assuming that the real position of the clip was 0 mm. CONCLUSIONS: The time-course of changes of CAFs in the incomplete conduction block was visualized by magnetic contour maps, and the lesions were closely localized focusing on the velocity change of the leading dipole. SIGNIFICANCE: The neural conduction with incomplete conduction block was visualized and the lesion was closely localized by neuromagnetic recordings.

Sequential dynamics of inflammatory cytokine, angiogenesis inducing factor and matrix degrading enzymes during spontaneous resorption of the herniated disc.

Intervertebral disc herniation (HD) is one of the most common orthopaedic conditions. MRI analysis of HD has revealed a spontaneous resorption mechanism related with neo-vascularization. It appears that the interaction of activated macrophages with disc tissues leads to the generation of inflammatory cytokines. Moreover, inflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) is required for the induction of angiogenesis inducing factors such as vascular endothelial growth factor (VEGF) or matrix degrading enzymes such as MMP-3, MMP-7 and plasmin. We hypothesized that these molecules play a crucial role during spontaneous HD resorption. In this study, we have examined the sequential expression of these molecules using a co-culture system which is composed of the interaction of activated macrophages and disc tissues as a model of the acute response of inflammation occurred in HD. We have also considered the mechanism of activating latent MMPs during HD resorption process. Current our results indicate that upregulation of both TNF-alpha mRNA and protein expressions occur first in the inflammation induced by HD. VEGF upregulation follows the increased level of TNF-alpha expression. Both plasmin and MMP-3 are upregulated at later time points. We also demonstrate that both TNF-alpha and VEGF induce upregulated expression of urokinase-type plasminogen activator (u-PA). Our previous work has demonstrated that TNF-alpha could upregulate the expression of VEGF, MMP-3 and MMP-7 in the co-culture system. It has been reported that plasmin could affect to activate latent MMPs. Based on these findings, we suggest that TNF-alpha acts as the initiator of inflammation following contact between macrophages and disc chondrocytes and that plasmin and u-PA play a crucial role in activation of MMPs. We propose a spontaneous HD resorption cascade. Further understanding of the resorption process may provide future novel therapies for HD.

Long-term outcomes of surgical treatment for tethered cord syndrome.

SUMMARY: Surgical outcomes for tethered spinal cord syndrome (TCS) associated with low-lying conus medullaris were evaluated. We investigated the long-term results of untethering the spinal cord and dural plasty in surgical patients with a wide age range. Improvement of bladder dysfunction and suppression of leg deformity progression were noted in two pediatric patients. However, severe urinary dysfunction generally remained postoperatively. Adult patients commonly showed low back or leg pain as clinical manifestations. In seven adult patients, urinary dysfunction also improved. Neurologic findings and urinary deficits showed a favorable improvement mostly in adult TCS in comparison with natal or juvenile onset of TCS. A short duration from onset to surgery and cranial movement of the conus medullaris as assessed by postoperative magnetic resonance imaging were factors indicating a favorable prognosis.

New interdisciplinary approach for removing large clivus and upper cervical spine tumors.

We have developed a new interdisciplinary approach for removing large clivus and upper cervical spine tumors. This approach is a combination of the Le Fort I osteotomy, midfacial degloving, and median labiomandibular glossotomy. Our approach gives an excellent, wide surgical field from the nasopharynx, including the base of the skull, to the base of the tongue and permits sufficiently safe extirpation of clivus and upper cervical spine tumors that may not be removed by transoral or transcervical approaches. Our approach not only incorporates the merits of each approach but also creates a larger surgical field that may be modified or expanded to accommodate the removal of more bulky tumors in this region. This novel approach will facilitate more successful resection of tumors arising between the nasopharynx, including the skull base, and the retropharyngeal area.

Imaging of neural conduction block by neuromagnetic recording.

OBJECTIVE: For the clinical application of neuromagnetic recordings in neural conduction block, the patterns of magnetic fields in the region should be clarified. Using an experimental in vitro model, the spatiotemporal course of the neuromagnetic fields at the site of complete conduction block was examined. Additionally, the magnetic compound action fields (CAFs) and electric compound action potentials (CAPs) were compared and correlated. METHODS: In a chamber containing Ringer's solution, 10 isolated sciatic nerves of rabbits were electrically stimulated. Both evoked CAPs and CAFs were measured before and after the ligation of the nerve. The sequential positions of the current dipoles and the location of the conduction block were estimated by the least-squares search. RESULTS: The magnetic contour maps of the CAFs showed a characteristic quadrupolar pattern propagating along the nerve. The peak of the leading magnetic field ceased and disappeared at the position of the nerve ligation, while the trailing magnetic field became attenuated before reaching that position. The positions of the conduction blocks were localized by magnetic recordings within a difference of 2mm. CONCLUSIONS: The neuromagnetic recordings could visualize the change of the magnetic fields at the site of the complete conduction block and closely localize that position. SIGNIFICANCE: The neural conduction block was visualized and localized by neuromagnetic recordings.

Surgical treatment of cervical spondylotic myelopathy associated with athetoid cerebral palsy.

After a mean follow-up period of 7 years (range 4-17 years), we reviewed the cases of 14 patients who underwent surgical treatment for cervical spondylotic myelopathy associated with athetoid cerebral palsy. All of the patients who underwent anterior decompression and arthrodesis showed degeneration and increased range of motion of the adjacent disc despite halo-vest immobilization postoperatively. Laminoplasty is useful in cases in which physiological lordosis is present preoperatively, whereas a case with preoperative kyphotic deformity showed increased neurological symptoms and deterioration of activities of daily living postoperatively due to increased kyphotic deformity and canal stenosis. Anterior decompression and arthrodesis following posterior fusion with lateral mass plating and posterior wiring is a favorable option for patients with highly kyphotic deformity and canal stenosis, as it preserves neurological status and cervical alignment postoperatively.

Vascular endothelial growth factor (VEGF)-induced angiogenesis in herniated disc resorption.

Intervertebral disc herniation is a major cause of low back pain and sciatica. Spontaneous resorption of herniated disc (HD) is frrequently detected by magnetic resonance imaging (MRI). Marked infiltration by macrophages and neo-vascularization are observed upon histogical examination of HD. In addition, enhanced MRI studies suggest that HD resorption occurs more frequently in those completely exposed to the epidural space and that this correlates with their degree of vascularization. We have postulated that the angiogenic factor, vascular endothelial growth factor (VEGF), may be implicated in the neo-vascularization of HD tissues. Here we demonstrate that VEGF and its receptors VEGFR-1 and VEGFR-2 are expressed in human surgical samples of HD. Using a co-culture system comprised of murine peritoneal macrophages and intervertebral disc tissue as a model of the acute phase of HD developed previously, an increase in macrophage VEGF protein and mRNA expression was observed upon exposure to disc tissue. Tumor necrosis factor alpha (TNF-alpha) was required for this induction of VEGF. Use of a novel angiogenesis assay revealed that addition of the conditioned media from the co-culture system resulted in an increase of vascular tubule formation. This effect was strongly inhibited by anti-VEGF antibody, but augmented by recombinant VEGF. We conclude that VEGF induction, under the co-culture conditions tested can result in neo-vascularization of intervertebral disc tissue and may thus play a role in the resorption of HD.