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Couasnay G, Garcia H, Elefteriou F. A comparative analysis of TonEBP conditional knockout mouse models reveals inter-dependency between compartments of the intervertebral disc. Development 2024; 151:dev202354. [PMID: 38421307 PMCID: PMC11006390 DOI: 10.1242/dev.202354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
Interactions between notochord and sclerotome are required for normal embryonic spine patterning, but whether the postnatal derivatives of these tissues also require interactions for postnatal intervertebral disc (IVD) growth and maintenance is less established. We report here the comparative analysis of four conditional knockout mice deficient for TonEBP, a transcription factor known to allow cells to adapt to changes in extracellular osmotic pressure, in specific compartments of the IVD. We show that TonEBP deletion in nucleus pulposus (NP) cells does not affect their survival or aggrecan expression, but promoted cell proliferation in the NP and in adjacent vertebral growth plates (GPs). In cartilage end plates/GPs, TonEBP deletion induced cell death, but also structural alterations in the adjacent NP cells and vertebral bodies. Embryonic or postnatal TonEBP loss generated similar IVD changes. In addition to demonstrating the requirement of TonEBP in the different compartments of the IVD, this comparative analysis uncovers the in vivo interdependency of the different IVD compartments during the growth of the postnatal IVD-vertebral units.
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Affiliation(s)
- Greig Couasnay
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Haley Garcia
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Florent Elefteriou
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, USA
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2
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Abel F, Altorfer FCS, Rohatgi V, Gibbs W, Chazen JL. Imaging of Discogenic and Vertebrogenic Pain. Radiol Clin North Am 2024; 62:217-228. [PMID: 38272616 DOI: 10.1016/j.rcl.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Chronic low back pain is a major source of pain and disability globally involving multifactorial causes. Historically, intervertebral disc degeneration and disruption have been associated as primary back pain triggers of the anterior column, termed "discogenic pain." Recently, the vertebral endplates have been identified as another possible pain trigger of the anterior column. This "endplate-driven" model, defined "vertebrogenic pain," is often interconnected with disc degeneration. Diagnosis of vertebrogenic and discogenic pain relies on imaging techniques that isolate pain generators and exclude comorbid conditions. Traditional methods, like radiographs and discography, are augmented by more sensitive methods, including SPECT, CT, and MRI. Morphologic MRI is pivotal in revealing indicators of vertebrogenic (eg, Modic endplate changes) and discogenic pain (eg, disc degeneration and annular fissures). More advanced methods, like ultra-short-echo time imaging, and quantitative MRI further amplify MRI's accuracy in the detection of painful endplate and disc pathology. This review explores the pathophysiology of vertebrogenic and discogenic pain as well as the impact of different imaging modalities in the diagnosis of low back pain. We hope this information can help identify patients who may benefit from personalized clinical treatment and image-guided therapies.
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Affiliation(s)
- Frederik Abel
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA
| | - Franziska C S Altorfer
- Department of Spine Surgery, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA; Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, Zurich 8008, Switzerland
| | - Varun Rohatgi
- Department of Radiology, Weill Cornell Medicine, 525 East 68th Street, NY 10065, USA
| | - Wende Gibbs
- Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, AZ 85013, USA
| | - Joseph Levi Chazen
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 East 70th Street, NY 10021, USA.
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Jung J, Habib M, Morrissette LJ, Timmons SC, Maerz T, Fields AJ. Non-enzymatic glycation reduces glucose transport in the human cartilage endplate independently of matrix porosity or proteoglycan content. JOR Spine 2024; 7:e1297. [PMID: 38222801 PMCID: PMC10782066 DOI: 10.1002/jsp2.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 01/16/2024] Open
Abstract
Background Intervertebral disc degeneration is associated with low back pain, which is a leading cause of disability. While the precise causes of disc degeneration are unknown, inadequate nutrient and metabolite transport through the cartilage endplate (CEP) may be one important factor. Prior work shows that CEP transport properties depend on the porosity of the CEP matrix, but little is known about the role of CEP characteristics that could influence transport properties independently from porosity. Here, we show that CEP transport properties depend on the extent of non-enzymatic glycation of the CEP matrix. Methods and Results Using in vitro ribosylation to induce non-enzymatic glycation and promote the formation of advanced glycation end products, we found that ribosylation reduced glucose partition coefficients in human cadaveric lumbar CEP tissues by 10.7%, on average, compared with donor- and site-matched CEP tissues that did not undergo ribosylation (p = 0.04). These reductions in glucose uptake were observed in the absence of differences in CEP porosity (p = 0.89) or in the amounts of sulfated glycosaminoglycans (sGAGs, p = 0.47) or collagen (p = 0.61). To investigate whether ribosylation altered electrostatic interactions between fixed charges on the sGAG molecules and the mobile free ions, we measured the charge density in the CEP matrix using equilibrium partitioning of a cationic contrast agent using micro-computed tomography. After contrast enhancement, mean X-ray attenuation was 11.9% lower in the CEP tissues that had undergone ribosylation (p = 0.02), implying the CEP matrix was less negatively charged. Conclusions Taken together, these findings indicate that non-enzymatic glycation negatively impacts glucose transport in the CEP independent of matrix porosity or sGAG content and that the effects may be mediated by alterations to matrix charge density.
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Affiliation(s)
- Jae‐Young Jung
- Department of Orthopaedic SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Mohamed Habib
- Department of Orthopaedic SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Luke J. Morrissette
- Department of Natural SciencesLawrence Technological UniversitySouthfieldMichiganUSA
| | - Shannon C. Timmons
- Department of Natural SciencesLawrence Technological UniversitySouthfieldMichiganUSA
| | - Tristan Maerz
- Departments of Orthopaedic Surgery and Biomedical EngineeringUniversity of MichiganAnn ArborMichiganUSA
| | - Aaron J. Fields
- Department of Orthopaedic SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUSA
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Kuchynsky K, Stevens P, Hite A, Xie W, Diop K, Tang S, Pietrzak M, Khan S, Walter B, Purmessur D. Transcriptional profiling of human cartilage endplate cells identifies novel genes and cell clusters underlying degenerated and non-degenerated phenotypes. Arthritis Res Ther 2024; 26:12. [PMID: 38173036 PMCID: PMC10763221 DOI: 10.1186/s13075-023-03220-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/22/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Low back pain is a leading cause of disability worldwide and is frequently attributed to intervertebral disc (IVD) degeneration. Though the contributions of the adjacent cartilage endplates (CEP) to IVD degeneration are well documented, the phenotype and functions of the resident CEP cells are critically understudied. To better characterize CEP cell phenotype and possible mechanisms of CEP degeneration, bulk and single-cell RNA sequencing of non-degenerated and degenerated CEP cells were performed. METHODS Human lumbar CEP cells from degenerated (Thompson grade ≥ 4) and non-degenerated (Thompson grade ≤ 2) discs were expanded for bulk (N=4 non-degenerated, N=4 degenerated) and single-cell (N=1 non-degenerated, N=1 degenerated) RNA sequencing. Genes identified from bulk RNA sequencing were categorized by function and their expression in non-degenerated and degenerated CEP cells were compared. A PubMed literature review was also performed to determine which genes were previously identified and studied in the CEP, IVD, and other cartilaginous tissues. For single-cell RNA sequencing, different cell clusters were resolved using unsupervised clustering and functional annotation. Differential gene expression analysis and Gene Ontology, respectively, were used to compare gene expression and functional enrichment between cell clusters, as well as between non-degenerated and degenerated CEP samples. RESULTS Bulk RNA sequencing revealed 38 genes were significantly upregulated and 15 genes were significantly downregulated in degenerated CEP cells relative to non-degenerated cells (|fold change| ≥ 1.5). Of these, only 2 genes were previously studied in CEP cells, and 31 were previously studied in the IVD and other cartilaginous tissues. Single-cell RNA sequencing revealed 11 unique cell clusters, including multiple chondrocyte and progenitor subpopulations with distinct gene expression and functional profiles. Analysis of genes in the bulk RNA sequencing dataset showed that progenitor cell clusters from both samples were enriched in "non-degenerated" genes but not "degenerated" genes. For both bulk- and single-cell analyses, gene expression and pathway enrichment analyses highlighted several pathways that may regulate CEP degeneration, including transcriptional regulation, translational regulation, intracellular transport, and mitochondrial dysfunction. CONCLUSIONS This thorough analysis using RNA sequencing methods highlighted numerous differences between non-degenerated and degenerated CEP cells, the phenotypic heterogeneity of CEP cells, and several pathways of interest that may be relevant in CEP degeneration.
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Affiliation(s)
- Kyle Kuchynsky
- Department of Biomedical Engineering, The Ohio State University, 3016 Fontana Laboratories, 140 W. 19th Ave, Columbus, OH, 43210, USA
| | - Patrick Stevens
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - Amy Hite
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
| | - William Xie
- Department of Chemistry and Biochemistry, The Ohio State University, Columbus, OH, USA
| | - Khady Diop
- Department of Biomedical Engineering, The Ohio State University, 3016 Fontana Laboratories, 140 W. 19th Ave, Columbus, OH, 43210, USA
| | - Shirley Tang
- Department of Biomedical Engineering, The Ohio State University, 3016 Fontana Laboratories, 140 W. 19th Ave, Columbus, OH, 43210, USA
| | - Maciej Pietrzak
- Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USA
- The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Safdar Khan
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Benjamin Walter
- Department of Biomedical Engineering, The Ohio State University, 3016 Fontana Laboratories, 140 W. 19th Ave, Columbus, OH, 43210, USA
| | - Devina Purmessur
- Department of Biomedical Engineering, The Ohio State University, 3016 Fontana Laboratories, 140 W. 19th Ave, Columbus, OH, 43210, USA.
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Jarraya M, Guermazi A, Roemer FW. Osteoarthritis year in review 2023: Imaging. Osteoarthritis Cartilage 2024; 32:18-27. [PMID: 37879600 DOI: 10.1016/j.joca.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/24/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE This narrative review summarizes the original research in the field of in vivo osteoarthritis (OA) imaging between 1 January 2022 and 1 April 2023. METHODS A PubMed search was conducted using the following several terms pertaining to OA imaging, including but not limited to "Osteoarthritis / OA", "Magnetic resonance imaging / MRI", "X-ray" "Computed tomography / CT", "artificial intelligence /AI", "deep learning", "machine learning". This review is organized by topics including the anatomical structure of interest and modality, AI, challenges of OA imaging in the context of clinical trials, and imaging biomarkers in clinical trials and interventional studies. Ex vivo and animal studies were excluded from this review. RESULTS Two hundred and forty-nine publications were relevant to in vivo human OA imaging. Among the articles included, the knee joint (61%) and MRI (42%) were the predominant anatomical area and imaging modalities studied. Marked heterogeneity of structural tissue damage in OA knees was reported, a finding of potential relevance to clinical trial inclusion. The use of AI continues to rise rapidly to be applied in various aspect of OA imaging research but a lack of generalizability beyond highly standardized datasets limit interpretation and wide-spread application. No pharmacologic clinical trials using imaging data as outcome measures have been published in the period of interest. CONCLUSIONS Recent advances in OA imaging continue to heavily weigh on the use of AI. MRI remains the most important modality with a growing role in outcome prediction and classification.
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Affiliation(s)
- Mohamed Jarraya
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Ali Guermazi
- Department of Radiology, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, USA.
| | - Frank W Roemer
- Department of Radiology, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, USA; Department of Radiology, Universitätsklinikum Erlangen & Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.
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Crump KB, Alminnawi A, Bermudez‐Lekerika P, Compte R, Gualdi F, McSweeney T, Muñoz‐Moya E, Nüesch A, Geris L, Dudli S, Karppinen J, Noailly J, Le Maitre C, Gantenbein B. Cartilaginous endplates: A comprehensive review on a neglected structure in intervertebral disc research. JOR Spine 2023; 6:e1294. [PMID: 38156054 PMCID: PMC10751983 DOI: 10.1002/jsp2.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 12/30/2023] Open
Abstract
The cartilaginous endplates (CEP) are key components of the intervertebral disc (IVD) necessary for sustaining the nutrition of the disc while distributing mechanical loads and preventing the disc from bulging into the adjacent vertebral body. The size, shape, and composition of the CEP are essential in maintaining its function, and degeneration of the CEP is considered a contributor to early IVD degeneration. In addition, the CEP is implicated in Modic changes, which are often associated with low back pain. This review aims to tackle the current knowledge of the CEP regarding its structure, composition, permeability, and mechanical role in a healthy disc, how they change with degeneration, and how they connect to IVD degeneration and low back pain. Additionally, the authors suggest a standardized naming convention regarding the CEP and bony endplate and suggest avoiding the term vertebral endplate. Currently, there is limited data on the CEP itself as reported data is often a combination of CEP and bony endplate, or the CEP is considered as articular cartilage. However, it is clear the CEP is a unique tissue type that differs from articular cartilage, bony endplate, and other IVD tissues. Thus, future research should investigate the CEP separately to fully understand its role in healthy and degenerated IVDs. Further, most IVD regeneration therapies in development failed to address, or even considered the CEP, despite its key role in nutrition and mechanical stability within the IVD. Thus, the CEP should be considered and potentially targeted for future sustainable treatments.
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Affiliation(s)
- Katherine B. Crump
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Ahmad Alminnawi
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Paola Bermudez‐Lekerika
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
- Graduate School for Cellular and Biomedical Sciences (GCB)University of BernBernSwitzerland
| | - Roger Compte
- Twin Research & Genetic EpidemiologySt. Thomas' Hospital, King's College LondonLondonUK
| | - Francesco Gualdi
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM)BarcelonaSpain
| | - Terence McSweeney
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
| | - Estefano Muñoz‐Moya
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Andrea Nüesch
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Liesbet Geris
- GIGA In Silico MedicineUniversity of LiègeLiègeBelgium
- Skeletal Biology and Engineering Research Center, KU LeuvenLeuvenBelgium
- Biomechanics Research Unit, KU LeuvenLeuvenBelgium
| | - Stefan Dudli
- Center of Experimental RheumatologyDepartment of Rheumatology, University Hospital Zurich, University of ZurichZurichSwitzerland
- Department of Physical Medicine and RheumatologyBalgrist University Hospital, Balgrist Campus, University of ZurichZurichSwitzerland
| | - Jaro Karppinen
- Research Unit of Health Sciences and TechnologyUniversity of OuluOuluFinland
- Finnish Institute of Occupational HealthOuluFinland
- Rehabilitation Services of South Karelia Social and Health Care DistrictLappeenrantaFinland
| | - Jérôme Noailly
- BCN MedTech, Department of Information and Communication TechnologiesUniversitat Pompeu FabraBarcelonaSpain
| | - Christine Le Maitre
- Division of Clinical Medicine, School of Medicine and Population HealthUniversity of SheffieldSheffieldUK
| | - Benjamin Gantenbein
- Tissue Engineering for Orthopaedics & Mechanobiology, Bone & Joint Program, Department for BioMedical Research (DBMR), Medical FacultyUniversity of BernBernSwitzerland
- Department of Orthopaedic Surgery and Traumatology, InselspitalBern University Hospital, Medical Faculty, University of BernBernSwitzerland
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Wang H, Liu X, Yang H, Jing X, Wang W, Liu X, Zhang B, Liu X, Shao Y, Cui X. Activation of the Nrf-2 pathway by pinocembrin safeguards vertebral endplate chondrocytes against apoptosis and degeneration caused by oxidative stress. Life Sci 2023; 333:122162. [PMID: 37820754 DOI: 10.1016/j.lfs.2023.122162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/28/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
AIM The occurrence and progression of intervertebral disc degeneration (IDD) are significantly influenced by the cartilaginous endplate (CEP). Pinocembrin (PIN), a type of flavonoid present in propolis and botanicals, demonstrates both antioxidant and anti-inflammatory characteristics, which could potentially be utilized in management. Therefore, it is crucial to investigate how PIN protects against CEP degeneration and its mechanisms, offering valuable insights for IDD therapy. MATERIALS AND METHODS To investigate the protective impact of PIN in vivo, we created the IDD mouse model through bilateral facet joint transection. In vitro, an IDD pathological environment was mimicked by applying TBHP to treat endplate chondrocytes. KEY FINDINGS In vivo, compared with the IDD group, the mouse in the PIN group effectively mitigates IDD progression and CEP calcification. In vitro, the activation of the Nrf-2 pathway improves the process of Parkin-mediated autophagy in mitochondria and decreases ferroptosis in chondrocytes. This enhancement promotes cell survival by addressing the imbalance of redox during pathological conditions related to IDD. Knocking down Nrf-2 with siRNA fails to provide protection to endplate chondrocytes against apoptosis and degeneration. SIGNIFICANCE The Nrf-2-mediated activation of mitochondrial autophagy and suppression of ferroptosis play a crucial role in safeguarding against oxidative stress-induced degeneration and calcification of CEP through the protective function of PIN. To sum up, this research offers detailed explanations about how PIN can protect against apoptosis and calcification in CEP, providing valuable information about the development of IDD and suggesting possible treatment approaches.
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Affiliation(s)
- Heran Wang
- Department of Spine Surgery, Shandong Provincial Hospital, Shandong University, Jinan 250000, China.
| | - Xiaoyang Liu
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, China.
| | - Heng Yang
- Department of Spine Surgery, Shandong Provincial Hospital, Shandong University, Jinan 250000, China.
| | - Xingzhi Jing
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, China.
| | - Wenchao Wang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, China.
| | - Xiaodong Liu
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250000, China.
| | - Bofei Zhang
- Key Laboratory of Endocrine Glucose & Lipids Metabolism and Brain Aging, Ministry of Education, Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong 250021, China.
| | - Xin Liu
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China.
| | - Yuandong Shao
- Department of Spine Surgery, Shandong Provincial Hospital, Shandong University, Jinan 250000, China; Department of Spine Surgery, Binzhou People's Hospital, Binzhou 256600, China.
| | - Xingang Cui
- Department of Spine Surgery, Shandong Provincial Hospital, Shandong University, Jinan 250000, China.
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Russo F, Ambrosio L, Giannarelli E, Vorini F, Mallio CA, Quattrocchi CC, Vadalà G, Papalia R, Denaro V. Innovative quantitative magnetic resonance tools to detect early intervertebral disc degeneration changes: a systematic review. Spine J 2023; 23:1435-1450. [PMID: 37247638 DOI: 10.1016/j.spinee.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/25/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND CONTEXT Low back pain (LBP) is the leading cause of disability worldwide, with a tremendous socioeconomic burden. It is mainly caused by intervertebral disc degeneration (IDD), a progressive and age-related process. Due to its ability to accurately characterize intervertebral disc morphology, magnetic resonance imaging (MRI) has been established as one of the most valuable tools in diagnosing IDD. Innovative quantitative MRI (qMRI) techniques able to detect the earliest signs of IDD have been increasingly reported. PURPOSE To systematically review available reports on the application of novel qMRI techniques to detect early IDD changes. STUDY DESIGN Systematic literature review. METHODS A systematic search of PubMed/MEDLINE, Scopus, CINAHL, EMBASE, CENTRAL and Cochrane databases was performed through January 21, 2023. Randomized and nonrandomized studies on innovative qMRI tools able to diagnose early biochemical and architectural IDD changes in patients with or without discogenic LBP were searched. Data on study population, follow-up time (when applicable) and MRI sequence used were recorded. The QUADAS-2 tool was utilized to assess the risk of bias of included studies. RESULTS A total of 39 articles published between 2005 and 2022 resulted from the search. All novel qMRI techniques showed an increased capacity to detect early IDD changes thanks to the ability to assess subtle alterations of water content, proteoglycan and glycosaminoglycan concentration, and increased levels of catabolic biomarkers compared to conventional MRI. CONCLUSIONS Innovative qMRI techniques have proven effective in identifying premature IDD changes. Further studies are needed to validate their application in wider populations and confirm their applicability in the clinical setting.
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Affiliation(s)
- Fabrizio Russo
- Department of Orthopaedic and Trauma Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Luca Ambrosio
- Department of Orthopaedic and Trauma Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy.
| | - Eugenio Giannarelli
- Department of Orthopaedic and Trauma Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Ferruccio Vorini
- Department of Orthopaedic and Trauma Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carlo A Mallio
- Department of Diagnostic Imaging and Interventional Radiology, Research Unit of Diagnostic Imaging and Interventional Radiology, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Diagnostic Imaging and Interventional Radiology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carlo C Quattrocchi
- Department of Diagnostic Imaging and Interventional Radiology, Research Unit of Diagnostic Imaging and Interventional Radiology, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Diagnostic Imaging and Interventional Radiology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Gianluca Vadalà
- Department of Orthopaedic and Trauma Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Research Unit of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Rome, Italy; Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Vincenzo Denaro
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Samanta A, Lufkin T, Kraus P. Intervertebral disc degeneration-Current therapeutic options and challenges. Front Public Health 2023; 11:1156749. [PMID: 37483952 PMCID: PMC10359191 DOI: 10.3389/fpubh.2023.1156749] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Degeneration of the intervertebral disc (IVD) is a normal part of aging. Due to the spine's declining function and the development of pain, it may affect one's physical health, mental health, and socioeconomic status. Most of the intervertebral disc degeneration (IVDD) therapies today focus on the symptoms of low back pain rather than the underlying etiology or mechanical function of the disc. The deteriorated disc is typically not restored by conservative or surgical therapies that largely focus on correcting symptoms and structural abnormalities. To enhance the clinical outcome and the quality of life of a patient, several therapeutic modalities have been created. In this review, we discuss genetic and environmental causes of IVDD and describe promising modern endogenous and exogenous therapeutic approaches including their applicability and relevance to the degeneration process.
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10
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Yuan L, Huang Z, Han W, Chang R, Sun B, Zhu M, Li C, Yan J, Liu B, Yin H, Ye W. The impact of dyslipidemia on lumbar intervertebral disc degeneration and vertebral endplate modic changes: a cross-sectional study of 1035 citizens in China. BMC Public Health 2023; 23:1302. [PMID: 37415123 PMCID: PMC10326938 DOI: 10.1186/s12889-023-16224-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Intervertebral disc degeneration (IDD) and vertebral endplate Modic changes (MCs) are common lumbar degenerative phenotypes related to low back pain (LBP). Dyslipidemia has been linked to LBP but its associations with IDD and MCs have not been fully elucidated. The present study aimed to address the possible link between dyslipidemia, IDD and MCs in the Chinese population. METHODS 1035 citizens were enrolled in the study. The levels of serum total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were collected. IDD was evaluated based on the Pfirrmann grading system and subjects with an average grade ≥ 3 were defined as having degeneration. MCs were classified into typical types 1, 2 and 3. Covariables, including age, sex, BMI and fasting plasma glucose, were included for the adjustment of the logistic analyses. RESULTS The degeneration group included 446 subjects while the nondegeneration group included 589 subjects. The degeneration group had significant higher levels of TC and LDL-C (p < 0.001) whereas TG and HDL-C were not significantly different between the two groups. TC and LDL-C concentrations were significantly positively correlated with average IDD grades (p < 0.001). Multivariate logistic regression revealed that high TC (≥ 6.2 mmol/L, adjusted OR = 1.775, 95% CI = 1.209-2.606) and high LDL-C (≥ 4.1 mmol/L, adjusted OR = 1.818, 95% CI = 1.123-2.943) were independent risk factors for IDD. Type 1 MC presented in 84 (8.12%) subjects, type 2 MC presented in 244 (23.57%) subjects, type 3 MC presented in 27 (2.61%) subjects and no MC was observed in the remaining 680 (65.70%) subjects. The type 2 MC group demonstrated a higher level of TC, but the association between serum lipids and MCs could not be confirmed in further multivariate logistic regression. CONCLUSIONS High TC (≥ 6.2 mmol/L) and LDL-C (≥ 4.1 mmol/L) concentrations were independent risk factors for IDD for citizens in China. However, the association between dyslipidemia and MCs could not be determined. The effect of excess serum cholesterol may be critical for IDD and cholesterol lowering treatment may provide new opportunities in the management of lumbar disc degeneration.
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Affiliation(s)
- Liang Yuan
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhengqi Huang
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weitao Han
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruiming Chang
- Department of Health Examination Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bo Sun
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mingxi Zhu
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
- Department of Spine Surgery, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Chenjing Li
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jiansen Yan
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bin Liu
- Department of Spine Surgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Haidong Yin
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
- Department of Minimally Invasive Spine Surgery, Panyu Hospital of Chinese Medicine, Guangzhou, China.
| | - Wei Ye
- Department of Spine Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China.
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11
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Bonnheim NB, Lazar AA, Kumar A, Akkaya Z, Zhou J, Guo X, O'Neill C, Link TM, Lotz JC, Krug R, Fields AJ. ISSLS Prize in Bioengineering Science 2023: Age- and sex-related differences in lumbar intervertebral disc degeneration between patients with chronic low back pain and asymptomatic controls. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:1517-1524. [PMID: 36805320 PMCID: PMC10205694 DOI: 10.1007/s00586-023-07542-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Revised: 10/18/2022] [Accepted: 01/13/2023] [Indexed: 02/20/2023]
Abstract
PURPOSE Clinical management of disc degeneration in patients with chronic low back pain (cLBP) is hampered by the challenge of distinguishing pathologic changes relating to pain from physiologic changes related to aging. The goal of this study was to use imaging biomarkers of disc biochemical composition to distinguish degenerative changes associated with cLBP from normal aging. METHODS T1ρ MRI data were acquired from 133 prospectively enrolled subjects for this observational study (80 cLBP, 53 controls; mean ± SD age = 43.9 ± 13.4 years; 61 females, 72 males). The mean T1ρ relaxation time in the nucleus pulposus (NP-T1ρ; n = 650 discs) was used as a quantitative biomarker of disc biochemical composition. Linear regression was used to assess associations between NP-T1ρ and age, sex, spinal level, and study group, and their interactions. RESULTS NP-T1ρ values were lower in cLBP patients than controls (70.8 ± 22.8 vs. 76.4 ± 22.2 ms, p = 0.009). Group differences were largest at L5-S1 (ΔT1ρcLBP-control = -11.3 ms, p < 0.0001), representing biochemical deterioration typically observed over a 9-12 year period (NP-T1ρ declined by 0.8-1.1 ms per year [95% CI]). Group differences were large in younger patients and diminished with age. Finally, the age-dependence of disc degeneration was stronger in controls than cLBP patients. CONCLUSION Aging effects on the biochemical composition of the L5-S1 disc may involve a relatively uniform set of factors from which many cLBP patients deviate. NP-T1ρ values at L5-S1 may be highly relevant to clinical phenotyping, particularly in younger individuals.
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Affiliation(s)
- Noah B Bonnheim
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Ann A Lazar
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Anika Kumar
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Zehra Akkaya
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Jiamin Zhou
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Xiaojie Guo
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Conor O'Neill
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Thomas M Link
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Jeffrey C Lotz
- Department of Orthopaedic Surgery, University of California, San Francisco, USA
| | - Roland Krug
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Aaron J Fields
- Department of Orthopaedic Surgery, University of California, San Francisco, USA.
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12
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Liang T, Gao B, Zhou J, Qiu X, Qiu J, Chen T, Liang Y, Gao W, Qiu X, Lin Y. Constructing intervertebral disc degeneration animal model: A review of current models. Front Surg 2023; 9:1089244. [PMID: 36969323 PMCID: PMC10036602 DOI: 10.3389/fsurg.2022.1089244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/08/2022] [Indexed: 03/12/2023] Open
Abstract
Low back pain is one of the top disorders that leads to disability and affects disability-adjusted life years (DALY) globally. Intervertebral disc degeneration (IDD) and subsequent discogenic pain composed major causes of low back pain. Recent studies have identified several important risk factors contributing to IDD's development, such as inflammation, mechanical imbalance, and aging. Based on these etiology findings, three categories of animal models for inducing IDD are developed: the damage-induced model, the mechanical model, and the spontaneous model. These models are essential measures in studying the natural history of IDD and finding the possible therapeutic target against IDD. In this review, we will discuss the technical details of these models, the duration between model establishment, the occurrence of observable degeneration, and the potential in different study ranges. In promoting future research for IDD, each animal model should examine its concordance with natural IDD pathogenesis in humans. We hope this review can enhance the understanding and proper use of multiple animal models, which may attract more attention to this disease and contribute to translation research.
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Affiliation(s)
- Tongzhou Liang
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bo Gao
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jinlang Zhou
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xianjian Qiu
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jincheng Qiu
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Taiqiu Chen
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yanfang Liang
- Department of Operating Theater, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Wenjie Gao
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xuemei Qiu
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
- Correspondence: Xuemei Qiu Youxi Lin
| | - Youxi Lin
- Department of Orthopedic Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, Guangzhou, China
- Correspondence: Xuemei Qiu Youxi Lin
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13
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Velnar T, Gradisnik L. Endplate role in the degenerative disc disease: A brief review. World J Clin Cases 2023; 11:17-29. [PMID: 36687189 PMCID: PMC9846967 DOI: 10.12998/wjcc.v11.i1.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/19/2022] [Accepted: 12/16/2022] [Indexed: 01/04/2023] Open
Abstract
The degenerative disease of the intervertebral disc is nowadays an important health problem, which has still not been understood and solved adequately. The vertebral endplate is regarded as one of the vital elements in the structure of the intervertebral disc. Its constituent cells, the chondrocytes in the endplate, may also be involved in the process of the intervertebral disc degeneration and their role is central both under physiological and pathological conditions. They main functions include a role in homeostasis of the extracellular environment of the intervertebral disc, metabolic support and nutrition of the discal nucleus and annulus beneath and the preservation of the extracellular matrix. Therefore, it is understandable that the cells in the endplate have been in the centre of research from several viewpoints, such as development, degeneration and growth, reparation and remodelling, as well as treatment strategies. In this article, we briefly review the importance of vertebral endplate, which are often overlooked, in the intervertebral disc degeneration.
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Affiliation(s)
- Tomaz Velnar
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana 1000, Slovenia
- Alma Mater Europaea Maribor, Maribor 2000, Slovenia
| | - Lidija Gradisnik
- Alma Mater Europaea Maribor, Maribor 2000, Slovenia
- Institute of Biomedical Sciences, University of Maribor, University of Maribor, Maribor 2000, Slovenia
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14
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Habib M, Hussien S, Jeon O, Lotz JC, Wu PIK, Alsberg E, Fields AJ. Intradiscal treatment of the cartilage endplate for improving solute transport and disc nutrition. Front Bioeng Biotechnol 2023; 11:1111356. [PMID: 36923455 PMCID: PMC10008947 DOI: 10.3389/fbioe.2023.1111356] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/09/2023] [Indexed: 03/03/2023] Open
Abstract
Poor nutrient transport through the cartilage endplate (CEP) is a key factor in the etiology of intervertebral disc degeneration and may hinder the efficacy of biologic strategies for disc regeneration. Yet, there are currently no treatments for improving nutrient transport through the CEP. In this study we tested whether intradiscal delivery of a matrix-modifying enzyme to the CEP improves solute transport into whole human and bovine discs. Ten human lumbar motion segments harvested from five fresh cadaveric spines (38-66 years old) and nine bovine coccygeal motion segments harvested from three adult steers were treated intradiscally either with collagenase enzyme or control buffer that was loaded in alginate carrier. Motion segments were then incubated for 18 h at 37 °C, the bony endplates removed, and the isolated discs were compressed under static (0.2 MPa) and cyclic (0.4-0.8 MPa, 0.2 Hz) loads while submerged in fluorescein tracer solution (376 Da; 0.1 mg/ml). Fluorescein concentrations from site-matched nucleus pulposus (NP) samples were compared between discs. CEP samples from each disc were digested and assayed for sulfated glycosaminoglycan (sGAG) and collagen contents. Results showed that enzymatic treatment of the CEP dramatically enhanced small solute transport into the disc. Discs with enzyme-treated CEPs had up to 10.8-fold (human) and 14.0-fold (bovine) higher fluorescein concentration in the NP compared to site-matched locations in discs with buffer-treated CEPs (p < 0.0001). Increases in solute transport were consistent with the effects of enzymatic treatment on CEP composition, which included reductions in sGAG content of 33.5% (human) and 40% (bovine). Whole disc biomechanical behavior-namely, creep strain and disc modulus-was similar between discs with enzyme- and buffer-treated CEPs. Taken together, these findings demonstrate the potential for matrix modification of the CEP to improve the transport of small solutes into whole intact discs.
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Affiliation(s)
- Mohamed Habib
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, United States.,Department of Mechanical Engineering, Al Azhar University, Cairo, Egypt
| | - Shayan Hussien
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Oju Jeon
- Department of Biomedical Engineering, University of Illinois, Chicago, IL, United States
| | - Jeffrey C Lotz
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Peter I-Kung Wu
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Eben Alsberg
- Department of Biomedical Engineering, University of Illinois, Chicago, IL, United States
| | - Aaron J Fields
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, United States
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15
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Zhao X, Xu B, Duan W, Chang L, Tan R, Sun Z, Ye Z. Insights into Exosome in the Intervertebral Disc: Emerging Role for Disc Homeostasis and Normal Function. Int J Med Sci 2022; 19:1695-1705. [PMID: 36237988 PMCID: PMC9553858 DOI: 10.7150/ijms.75285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
Abstract
Low back pain (LBP) is a chronic condition that causes great individual suffering and economic burden. The major contributor of LBP is intervertebral disc degeneration (IDD), which is caused by a spectrum of homeostasis alteration, including the apoptosis of nucleus pulposus (NP) and annulus fibrosus (AF) cells, degradation of extracellular matrix (ECM), calcification of cartilaginous endplates (CEP) and so on. Currently, the therapeutic strategy for IDD includes conservative and surgery treatment. Nevertheless, none of them could reverse the progressive destruction of the intervertebral disc. Hence, it is pivotal to pursue a new therapeutic approach. Exosomes, nano-sized substances with diameters of 30-150 nm, can be synthesized and secreted by various types of cells. They play an important role in intercellular communication. Increasing evidence implicates that exosomes could impact the intracellular transcription activities, thereby inhibiting or accelerating the proliferation and apoptosis of cells. Thus, it is a new therapeutic source for IDD. This review chiefly focuses on generalizing and clarifying the roles of exosomes in the onset and deterioration of IDD, and their therapeutic potential.
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Affiliation(s)
- Xin Zhao
- Department of Orthopedic, Xijing Hospital, Fourth Military Medical University. Western Changle Road, Xi'an, 710032, Shannxi Provence, P. R. China
| | - Benchi Xu
- Department of Orthopedic, Xijing Hospital, Fourth Military Medical University. Western Changle Road, Xi'an, 710032, Shannxi Provence, P. R. China
| | - Wei Duan
- Department of Orthopedic, Xijing Hospital, Fourth Military Medical University. Western Changle Road, Xi'an, 710032, Shannxi Provence, P. R. China
| | - Le Chang
- Department of Orthopedic, Xijing Hospital, Fourth Military Medical University. Western Changle Road, Xi'an, 710032, Shannxi Provence, P. R. China
| | - Rui Tan
- Department of Orthopedic, Xijing Hospital, Fourth Military Medical University. Western Changle Road, Xi'an, 710032, Shannxi Provence, P. R. China
| | - Zhen Sun
- Department of Orthopedic, Xijing Hospital, Fourth Military Medical University. Western Changle Road, Xi'an, 710032, Shannxi Provence, P. R. China
| | - Zhengxu Ye
- Department of Orthopedic, Xijing Hospital, Fourth Military Medical University. Western Changle Road, Xi'an, 710032, Shannxi Provence, P. R. China
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