Potential applications of gene therapy to the treatment of intervertebral disc disorders

Assessment of a computed tomography guided injection technique of the lumbo-sacral disc in sheep

OBJECTIVES

Recent data indicate that degeneration of intervertebral discs occurs naturally in sheep, with a higher prevalence at the level of the lumbo-sacral disc. The objective of this ex vivo study was to evaluate a computed tomography (CT) guided method of injection into the ovine lumbo-sacral disc.

METHODS

Six euthanatized sheep were used for identification of the approach plane, the optimal direction of the needle and the mean distance from skin to disc. Dissection after injection of coloured ink was used to determine the anatomical structures that were penetrated. In seven other animals, all spines were assessed beforehand by CT and magnetic resonance imaging to determine whether disc pathology was present. The final position of the needle was assessed by CT to determine the accuracy of the technique. Contrast agent was injected to identify any problems associated with administration of liquid into the disc.

RESULTS

The CT guided injection technique was easy to perform and enabled adequate positioning of the needle into all (n = 7) lumbo-sacral discs. Distance between the skin and the disc ranged between 12 and 17 cm. No organ, vascular or nervous structure was penetrated and the needle path remained intramuscular without penetration of the peritoneal cavity. Contrast medium leaked out through three degenerate discs.

CLINICAL SIGNIFICANCE

The current study described a consistently safe and accurate CT guided injection technique to the lumbo-sacral disc for future in vivo experimental studies that will use sheep as animal model for human intervertebral disc disease disease.

Biological approaches to treating intervertebral disk degeneration: devising stem cell therapies

Intervertebral disk (IVD) degeneration is a common, chronic, and complex degeneration process that frequently leads to back pain and disability, resulting in a major public health issue. In this review we describe biological therapies under preclinical or clinical development with an emphasis on stem cell-based multimodal approaches that target prevention and treatment of IVD degeneration. Systematical review of the basic science and clinical literature was performed to summarize the current status of devising biological approaches to treating IVD degeneration. Since the exact mechanisms underlying IVD degeneration have not yet been fully elucidated and conservative managements appear to be mostly ineffective, current surgical treatment focuses on removal of the pathological disk tissues combined with spinal fusion. The treatment options, however, often produce insufficient efficacy and even serious complications. Therefore, there have been growing demands and endeavors for developing novel regenerative biology-guided strategies for repairing the IVD via delivery of exogenous growth factors, introduction of therapeutic genes, and transplantation of stem cells, or combinatorial therapies. Overall, the data suggest that when applied under a recovery neurobiology principle, multimodal regimens comprising ex vivo engineered stem cell-based disks hold a high potential promise for efficacious clinical translations.

Gene therapy approaches to regenerating the musculoskeletal system

Injuries to the musculoskeletal system are common, debilitating and expensive. In many cases, healing is imperfect, which leads to chronic impairment. Gene transfer might improve repair and regeneration at sites of injury by enabling the local, sustained and potentially regulated expression of therapeutic gene products; such products include morphogens, growth factors and anti-inflammatory agents. Proteins produced endogenously as a result of gene transfer are nascent molecules that have undergone post-translational modification. In addition, gene transfer offers particular advantages for the delivery of products with an intracellular site of action, such as transcription factors and noncoding RNAs, and proteins that need to be inserted into a cell compartment, such as a membrane. Transgenes can be delivered by viral or nonviral vectors via in vivo or ex vivo protocols using progenitor or differentiated cells. The first gene transfer clinical trials for osteoarthritis and cartilage repair have already been completed. Various bone-healing protocols are at an advanced stage of development, including studies with large animals that could lead to human trials. Other applications in the repair and regeneration of skeletal muscle, intervertebral disc, meniscus, ligament and tendon are in preclinical development. In addition to scientific, medical and safety considerations, clinical translation is constrained by social, financial and logistical issues.

Transgenic Expression of Human IGF1 in Intervertebral Degenerative Discs

This study investigated the role of human insulin-like growth factor-1 (hIGF-1; encoded by the hIGF1 gene) on intervertebral disc degeneration. A total of 24 male New Zealand rabbits of an intervertebral disc degeneration (IVDD) model were randomly divided into three groups where the following were injected into the lumbar 4 – 5 and 5 – 6 discs: second generation adenovirus containing cytomegalovirus hIGF1 (Ad/CMV- hIGF1); 100 μg/l hIGF-1 protein; or phosphate-buffered saline. At 1, 2, 4 and 8 weeks post-injection, intervertebral disc samples were harvested. Human IGF-1 protein was detected using Western blot analysis, and aggrecan and collagen type II gene fragments were quantified using reverse transcription—polymerase chain reaction. At week 1 post-injection, hIGF-1 protein levels were similar in the Ad/CMV- hIGF1 and hIGF-1 groups. By week 2 the level had decreased substantially in the hIGF-1 group. At week 4 it was still present in the Ad/CMV- hIGF1 group and, by week 8, no protein was detected in any of the three groups. Aggrecan and collagen type II mRNA levels increased in the Ad/CMV- hIGF1 group 1 – 4 weeks post-injection, but declined by week 8, while both decreased steadily over 8 weeks in the other two groups. In conclusion, hIGF1 gene expression lasted for 4 weeks and stimulated the synthesis of aggrecan and collagen type II in the Ad/CMV- hIGF1 group.

Cell-based regeneration of intervertebral disc defects: review and concepts

During the last century low back pain has emerged as a widespread disease often caused by intervertebral disc degeneration (IDD). IDD is a complex problem in which a variety of causes play a role. As IDD causes high costs, corporate interest has led to a number of therapies being developed. Today, these therapies focus not only on minimizing the pain caused by this disease but also on restoring intervertebral disc function. These approaches are often biological and aim to stimulate the regeneration of the intervertebral disc by injection of activator proteins, biomaterials, different cell types or complex cell matrix composites. Genetic engineering of disc cells and in vitro tissue engineering also offer a possibility for curing IDD. This article gives an overview of these concepts.

Mouse growth and differentiation factor-5 protein and DNA therapy potentiates intervertebral disc cell aggregation and chondrogenic gene expression

BACKGROUND CONTEXT

Growth and differentiation factor-5 (GDF-5)-deficient mice showed abnormalities in intervertebral disc (IVD) structure and extracellular matrix. Adenovirus-mediated GDF-5 delivery can promote the growth of rabbit disc cells.

PURPOSE

The aim of the present study was to investigate the effect of recombinant GDF-5 protein and GDF-5 complementary DNA (cDNA) on the metabolism of IVD cells.

STUDY DESIGN

The effects of recombinant GDF-5 protein and GDF-5 cDNA on mouse IVD cells will be evaluated in vitro.

METHODS

Mouse disc cells in vitro were treated with recombinant GDF-5 protein. Mouse GDF-5 cDNA was cloned into an expression vector and was used to transfect mouse disc cells in vitro. Therapy with GDF-5 protein and cDNA was assessed by measuring cell proliferation, proteoglycan production, and extracellular matrix gene expression.

RESULTS

Biochemical assays revealed an elevated sulfated glycosaminoglycan (GAG)/DNA ratio in mouse IVD cells that were cultured in the presence of various concentrations of mouse GDF-5(mGDF-5) protein. Real-time reverse transcription-polymerase chain reaction (RT-PCR) demonstrated that treating the cells with GDF-5 protein increased the expression of the collagen Type II and aggrecan genes in a dose-dependent manner but decreased matrix metalloproteinase (MMP)-3 gene expression. Immunohistochemistry showed an increase in the aggregation of mouse IVD cells that were treated with mGDF-5 in culture compared with the control group. The mouse GDF-5 gene was successfully cloned into an expression plasmid vector, and GDF-5 protein production was confirmed by Western blot analysis. Type II collagen and aggrecan gene expression by the cells increased significantly in the cells that were transfected by nucleofection with the GDF-5 plasmid compared with cells that were transfected with a control plasmid.

CONCLUSIONS

This is the first report of the cloning of the mouse GDF-5 gene and use of the nucleofection method to transfer DNA into IVD cells. The data suggest that both recombinant protein and the cDNA forms of GDF-5 can increase the expression of genes for extracellular matrix proteins in mouse IVD cells. Future attempts at gene therapy to treat degenerative disc disease with a novel ex vivo gene transfer technique are needed to develop a therapy that would alleviate the condition of patients with clinically relevant axial spine pain.

Needle puncture injury affects intervertebral disc mechanics and biology in an organ culture model

STUDY DESIGN

A bovine intervertebral disc organ culture model was used to study the effect of needle puncture injury on short-term disc mechanics and biology.

OBJECTIVE

To test the hypothesis that significant changes in intervertebral disc structure, mechanics, and cellular response would be present within 1 week of needle puncture injury with a large-gauge needle but not with a small-gauge needle.

SUMMARY OF BACKGROUND DATA

Defects in anulus fibrosus induced by needle puncture injury can compromise mechanical integrity of the disc and lead to degeneration in animal models. The immediate and short-term mechanical and biologic response to anulus injury through needle puncture in a large animal model is not known.

METHODS

Bovine caudal intervertebral discs were harvested, punctured posterolaterally using 25G and 14G needles, and placed in organ culture for 6 days. Discs underwent a daily dynamic compression loading protocol for 5 days from 0.2 to 1 MPa at 1 Hz for 1 hour. Disc structure and function were assessed with measurements of dynamic modulus, creep, height loss, water content, proteoglycan loss to the culture medium, cell viability, and histology.

RESULTS

Needle puncture injury caused a rapid decrease in dynamic modulus and increase in creep during 1-hour loading, although no changes were detected in water content, disc height, or proteoglycan lost to the media. Cell viability was maintained except for localized cell death at the needle insertion site. An increase in cell number and possible remodeling response was seen in the insertion site in the nucleus pulposus.

CONCLUSION

Relatively minor disruption in the disc from needle puncture injury had immediate and progressive mechanical and biologic consequences with important implications for the use of discography, and repair-regeneration techniques. Results also suggest diagnostic techniques sensitive to mechanical changes in the disc may be important for early detection of degenerative changes in response to anulus injury.

Gene therapy used for tissue engineering applications

This review highlights the advances at the interface between tissue engineering and gene therapy. There are a large number of reports on gene therapy in tissue engineering, and these cover a huge range of different engineered tissues, different vectors, scaffolds and methodology. The review considers separately in-vitro and in-vivo gene transfer methods. The in-vivo gene transfer method is described first, using either viral or non-viral vectors to repair various tissues with and without the use of scaffolds. The use of a scaffold can overcome some of the challenges associated with delivery by direct injection. The ex-vivo method is described in the second half of the review. Attempts have been made to use this therapy for bone, cartilage, wound, urothelial, nerve tissue regeneration and for treating diabetes using viral or non-viral vectors. Again porous polymers can be used as scaffolds for cell transplantation. There are as yet few comparisons between these many different variables to show which is the best for any particular application. With few exceptions, all of the results were positive in showing some gene expression and some consequent effect on tissue growth and remodelling. Some of the principal advantages and disadvantages of various methods are discussed.

Biological treatment strategies for disc degeneration: potentials and shortcomings

Recent advances in molecular biology, cell biology and material sciences have opened a new emerging field of techniques for the treatment of musculoskeletal disorders. These new treatment modalities aim for biological repair of the affected tissues by introducing cell-based tissue replacements, genetic modifications of resident cells or a combination thereof. So far, these techniques have been successfully applied to various tissues such as bone and cartilage. However, application of these treatment modalities to cure intervertebral disc degeneration is in its very early stages and mostly limited to experimental studies in vitro or in animal studies. We will discuss the potential and possible shortcomings of current approaches to biologically cure disc degeneration by gene therapy or tissue engineering. Despite the increasing number of studies examining the therapeutic potential of biological treatment strategies, a practicable solution to routinely cure disc degeneration might not be available in the near future. However, knowledge gained from these attempts might be applied in a foreseeable future to cure the low back pain that often accompanies disc degeneration and therefore be beneficial for the patient.

Demographic factors that influence human disc cell proliferation in vitro

BACKGROUND CONTEXT

Although previous work has shown that greater age, greater disc degeneration, female gender, and surgical derivation of disc tissue had deleterious effects on cell proliferative potential, relatively little is known about the association between disc cell proliferation in vitro and clinical donor characteristics.

PURPOSE

To identify the relationships between donor characteristic and the in vitro proliferative potential of human disc cells from the annulus.

STUDY DESIGN/SETTING

Studies were approved by the human subjects Institutional Review Board. Donor data included donor source, ethnicity, age, gender, smoking history, height, weight, number of years of back pain, and Thompson score. Cells cultured from the annulus were tested for proliferation.

PATIENT SAMPLE

There were two study populations: 1) Comparison Group (32 control donors and 33 control surgical subjects; 60 Caucasians, 5 African-Americans). Cell proliferation, age, Thompson score, height, weight, and smoking history were statistically analyzed for control donors versus control surgical group. No significant differences were present, and these two groups were pooled to form the Comparison Group. 2) Nineteen subjects from the United Arab Emirates who underwent disc surgery.

OUTCOME MEASURES

Linear models were fit to the data to determine the best prediction of cell proliferation as the outcome variable; multiple R-squared was used to determine model goodness of fit.

METHODS

Control donor specimens were obtained from the National Cancer Institute Cooperative Human Tissue Network, and control donor surgical specimens from disc surgeries. A standardized cell proliferation assay was used to evaluate monolayer and three-dimensional agarose cell proliferation. Data were expressed as mean cpm[(3)H]-thymidine per microgram deoxyribonucleic acid+/-SEM. Standard statistical methods used the SAS system for data analysis.

RESULTS

No differences were present in the Comparison Group versus the Middle Eastern group for mean Thompson score (both averaged grade III), mean age (44.3 vs. 43.0 years, respectively), gender, height, weight, length of time with back pain (1.9 years vs. 2.1 years respectively), or smoking history. Three-dimensional proliferation in agarose was not significantly different for the two groups. Monolayer proliferation, however, was significantly different (17,434+/-2,929 vs. 6,693+/-2,103, respectively), p=.019. Linear regression models were fit to the data to determine the best prediction using proliferation as the outcome variable. In the Middle Eastern group, monolayer cell proliferation bore a significant negative correlation to age (p=.02, r=-.32), whereas the Comparison Group showed no such relationship. The following equation was derived to fit these data: Log(10) of proliferation (cpm/mug deoxyribonucleic acid)=10.915-0.7919 (Middle Eastern ethnicity)-0.0296 (Age). The r(2) for this equation is 0.203 (ie, 20.3% of the change in proliferation is explained by age and Middle Eastern ethnicity). Middle Eastern ethnicity and age were significant in this equation (p=.04 and .0003, respectively).

CONCLUSIONS

Studies have shown that familial history, age, and smoking are important risk factors for disc degeneration in Arabic pedigrees. It is interesting that our present findings also point to age and familial history as important significant factors influencing monolayer proliferation. Further research is needed to identify the cellular basis for this influence on cellular proliferative capacity.

Disc Regeneration: Why, When, and How

There is increasing acknowledgment that patients with back pain who are candidates for surgery, will benefit over the long term from less invasive procedures that facilitate dynamic stabilization, rather than fusion. Dynamic stabilization can be addressed by providing assistance using mechanical devices, or relying on biologic processes such as tissue regeneration and repair. The concept of biologic disc repair has grown in recent years because of improved understanding of the cellular and molecular events of disc aging and degeneration. This article describes approaches to cell therapy, reviews relevant studies, and discusses ways to maximize clinical efficacy. Tissue engineering approaches for disc regeneration and healing have significant clinical potential.

The potential role of mesenchymal stem cell therapy for intervertebral disc degeneration: a critical overview

Low-back pain is the most common health problem for men and women between 20 and 50 years of age, resulting in 13 million doctor visits in the US annually, with significant costs to society in terms of lost time from work and direct and indirect medical expenses. Although the exact origin of most cases of low-back pain remains unknown, it is understood that degenerative damage to the intervertebral disc (IVD) plays a central role in the pathogenic mechanism leading to this disorder. Current treatment modalities for disc-related back pain (selective nerve root blocks, surgical discectomy and fusion) are costly procedures aimed only at alleviating symptoms. Consequently, there is growing interest in the development of novel technologies to repair or regenerate the degenerated IVD. Recently, mesenchymal stem cells (MSCs) have been found to possess the capacity to differentiate into nucleus pulposus–like cells capable of synthesizing a physiological, proteoglycan-rich extracellular matrix characteristic of healthy IVDs. In this article, the authors review the use of MSCs for repopulation of the degenerating IVD. Although important obstacles to the survival and proliferation of stem cells within the degenerating disc need to be overcome, the potential for MSC therapy to slow or reverse the degenerative process remains substantial.

The adeno associated viral vector as a strategy for intradiscal gene transfer in immune competent and pre-exposed rabbits

STUDY DESIGN

Experimental animal study.

OBJECTIVES

This study evaluates the in vitro and in vivo transduction efficacy and transgene expression in immune competent and pre-exposed rabbits.

SUMMARY OF BACKGROUND DATA

Degenerative disc disease (DDD) continues to pose a substantial clinical problem. Therapeutic options such as an interbody fusion are highly invasive and result in the loss of the intervertebral disc. In addition, interbody fusion puts the adjacent discs at an even higher risk for disc degeneration. A novel approach to slow DDD is to introduce high levels of growth factors into the degenerating disc by delivering the gene coding for the appropriate growth factor. The most efficient technique to do so to date uses viral vectors. However, viral vectors may be problematic because of their immunogenicity. The adeno-associated virus (AAV) viral vector is known to be less immunogenic than commonly used adenoviral vectors.

METHODS

Human nucleus pulposus cells were transduced in vitro. Twenty-four Rabbits were injected with AAV viral vectors carrying different marker genes. Transgene expression and the humoral/cellular immune response to the vector was evaluated.

RESULTS

We could show that the AAV viral vector transduces human as well as rabbit nucleus pulposus cells in vitro and in vivo. There is a significant humoral immune response against the AAV vector that decreases transgene expression over 10-fold in preimmunized animals.

CONCLUSIONS

AAV is a valuable new vector to achieve transgene expression in the intervertebral disc. In preimmunized animals, its use needs to be further evaluated because of the significant reduction in transgene expression.

Bone mesenchymal stem cells transplanted into rabbit intervertebral discs can increase proteoglycans

We sought to determine whether transplanted allogeneic bone mesenchymal stem cells can survive and increase the amount of proteoglycans in intervertebral discs. We used the rabbit intervertebral disc as a model, creating three groups: an uninjected control group, a group injected with saline, and a group injected with 1 x 10(5) of bone mesenchymal stem cells containing trace marker gene LacZ from young rabbits. At 1, 3, and 6 months, X-gal staining and DNA-polymerase chain reaction of the neomycin-resistant gene were used to ascertain cell location. Reverse transcription-polymerase chain reaction and enzyme-linked immunosorbant assay analysis were done to evaluate the effect on the disc matrix. Transplanted mesenchymal stem cells were located and identified in the group injected with mesenchymal stem cells, whereas we detected none in the saline and control groups. The amount of mRNA and protein of proteoglycan and collagen Type II in the mesenchymal stem cells group was increased, whereas the amount of collagen Type I did not change. We found no changes in the saline group. Our data suggest transplanted allogenic bone mesenchymal stem cells can survive and increase proteoglycan amount, supporting its potential use as a treatment of intervertebral disc degeneration.

Biology of intervertebral disc aging and degeneration: involvement of the extracellular matrix

STUDY DESIGN

A review of current knowledge and opinions concerning the biologic changes that take place during development, maturation and degeneration of the intervertebral disc.

OBJECTIVE

To provide an overview of the changes that occur in structure and composition of the extracellular matrix of the intervertebral disc and to explain the origin of such changes and their functional consequences.

SUMMARY OF BACKGROUND DATA

The structure of the intervertebral disc, and, in particular, the composition of its extracellular matrix, changes throughout life, ultimately resulting in tissue degeneration in the adult.

METHODS

A review of the published scientific literature.

RESULTS

In the young disc, the outer anulus fibrosus and inner nucleus pulposus have clear physical and molecular properties, although these differences become less distinct in the adult. The age changes are due to variations in both the abundance and structure of the macromolecules, particularly aggrecan, and the structural variations may be due to changes in both synthesis and degradation. It is not clear how many of the changes are by design to adapt to the altered environment of the growing spine. However, it is commonly thought that the degradative changes are detrimental to disc function, a property that is exacerbated by the inability of the mature avascular disc to remove and replace accumulated degradation products. The rate at which these detrimental changes occur may vary between individuals because of genetic, biomechanical, and nutritional differences. Such changes are thought to form the basis of tissue loss associated with disc degeneration.

CONCLUSION

Changes in intervertebral disc structure throughout life ultimately result in tissue degeneration and the need for medical intervention. Current research is aimed at trying to restore the integrity of the degenerate disc matrix by biologic means, although at present it is not clear what the structure of the most appropriate repair tissue should be or how it can be achieved.

The 2003 Nicolas Andry Award. Orthopaedic gene therapy

We review progress in the field of orthopaedic gene therapy since the concept of using gene transfer to address orthopaedic problems was initiated approximately 15 years ago. The original target, arthritis, has been the subject of two successful Phase I clinical trials, and additional human studies are pending in rheumatoid arthritis and osteoarthritis. The repair of damaged musculoskeletal tissues also has proved to be a fruitful area of research, and impressive enhancement of bone healing has been achieved in preclinical models. Rapid progress also is being made in the use of gene transfer to improve cartilage repair, ligament healing, and restoration of various additional tissues, including tendon and meniscus. Other applications include intervertebral disc degeneration, aseptic loosening, osteoporosis, genetic diseases, and orthopaedic tumors. Of these various orthopaedic targets of gene therapy, tissue repair is likely to make the earliest clinical impact because it can be achieved with existing technology. Tissue repair may become one of the earliest clinical successes for gene therapy as a whole. Orthopaedics promises to be a leading discipline for the use of human gene therapy.

Low back pain: pathophysiology and management

Basic research is advancing the understanding of the pathogenesis and management of low back pain at the molecular and genetic levels. Frequently, low back pain is caused by disorders of the intervertebral disk. Cytokines such as matrix metalloproteinases, phospholipase A2, nitric oxide, and tumor necrosis factor-alpha are thought to contribute to the development of low back pain. Drugs are being developed to modulate these chemical mediators. Recent research using growth factors to promote chondrocyte regeneration appears to be promising. Advances in gene therapy to both prevent disk degeneration and regenerate the disk eventually may have clinical application.

Osteoarthritis gene therapy

Osteoarthritis (OA) is the Western world's leading cause of disability. It is incurable, costly and responds poorly to treatment. This review discusses strategies for treating OA by gene therapy. As OA affects a limited number of weight-bearing joints and has no major extra-articular manifestations, it is well suited to local, intra-articular gene therapy. Possible intra-articular sites of gene transfer include the synovium and the cartilage. Most experimental progress has been made with gene transfer to synovium, a tissue amenable to genetic modification by a variety of vectors, using both in vivo and ex vivo protocols. The focus so far has been upon the transfer of genes whose products enhance synthesis of the cartilaginous matrix, or inhibit its breakdown, although there is certainly room for alternative targets. It is possible to build a convincing case implicating interleukin-1 (IL-1) as a key mediator of cartilage loss in OA, and the therapeutic effects of IL-1 receptor anatagonist (IL-1Ra) gene transfer have been confirmed in three different experimental models of OA. As transfer of IL-1Ra cDNA to human arthritic joints has already been accomplished safely, we argue that clinical studies of intra-articular IL-1Ra gene transfer in OA are indicated and should be funded. Of the available vector systems, recombinant adeno-associated virus may provide the best combination of safety with in vivo delivery using current technology.

Cell-based tissue engineering for the intervertebral disc: in vitro studies of human disc cell gene expression and matrix production within selected cell carriers

BACKGROUND CONTEXT

Little is known about how disc cells attach, proliferate and form extracellular matrix (ECM) within carrier materials. Such information is needed to help formulate criteria for successful cell-carrier interactions in tissue engineering.

PURPOSE

To compare proliferation, ECM production and gene expression in annulus cells cultured in a variety of cell carrier materials with potential application in tissue engineering of the disc.

STUDY DESIGN

Human intervertebral disc cells from the annulus were used in a prospective study of proliferation, ECM production and gene expression within selected cell carriers.

METHODS

Annulus cells from discs of 29 individuals were tested in collagen sponge, collagen gel, agarose, alginate or fibrin gel formulations. In situ hybridization assessed ECM gene expression of Types I and II collagen, aggrecan and chondroitin-6 sulfotransferase. Cell proliferation, cell shape, attachment and ECM production were evaluated.

RESULTS

Collagen sponges provided the best microenvironment for disc cell ECM production and gene expression. Although collagen gels often could support good cell growth, such constructs did not result in either abundant ECM production or ECM gene expression, as shown by in situ hybridization. Growth and ECM production and gene expression in alginate, agarose and fibrin microenvironments were inferior.

CONCLUSIONS

Tissue engineering techniques open new therapeutic possibilities for use of autologous disc cells, but fundamental questions on how these cells interact with cell carriers are unexplored. Results provide novel data on disc cell gene expression within diverse microenvironments. The collagen sponge proved to be a superior microenvironment.

Ad/CMV- hTGF-beta1 treats rabbit intervertebral discs degeneration in vivo

To investigate therapeutic efficiency of Ad/CMV- hTGF-beta1 gene for rabbit intervertebral disc degeneration model. 60 Japanese white rabbits were selected to form the 1.5-L6 Anterior-Lateral-Anulus-Fibrosus-Incision-Induced model in order to simulate human intervertebral disc degeneration. 36 rabbits, whose corresponding intervertebral discs were injected with 20 microl (10 x 10(6) pfu) of Ad/CMV- hTGF-beta1 gene, constituted the therapy group, 12 were injected with 20 microl (10 x 10(6) pfu)of Ad/CMV-LacZ gene as comparison group, while 12 were only injected with equivalent capacity of saline for empty comparison group, 3 weeks after injection, examples were taken for investigation of HE staining, MRI, Western Blotting and immunohistochemical research TGF-beta1. Wide distribution of TGF-beta1 was detected by immunohistochemical research in the degenerated annulus fibrosus after injection. Western Blotting research showed significant increase of TGF-beta1 content in intervertebral discs treated with TGF-beta1 gene than comparison groups. MRI signal transformed from low to comparatively high and that intervertebral disc pathological degree improved. Ad/CMV- hTGF-beta1 gene transfection is a potential method to increase TGF-beta1 content and reverse intervertebral disc degeneration.

Transplantation of mesenchymal stem cells embedded in Atelocollagen gel to the intervertebral disc: a potential therapeutic model for disc degeneration

Intervertebral disc degeneration is considered to be one of the major causes of low back pain. Despite this irreversible phenomenon, attempts to decelerate disc degeneration using various techniques have been reported. However, to date there has been no proven technique effective for broad clinical application. Based on previous studies, we hypothesize that maintenance of proteoglycan content in the disc is achieved by avoiding the depletion of nucleus pulposus and preserving the structure of the annulus is a primary factor in decelerating disc degeneration. One novel approach to solve the dilemma of intervertebral disc degeneration is found at the stem cell level. Mesenchymal stem cells (MSCs) are known to possess the ability to differentiate into various kinds of cells from mesenchymal origin. Although the majority of cells that contribute to disc formation are known to obtain chondrocyte-like phenotypes, no reported study has emphasized the correlation with mesenchymal stem cells. To evaluate the possible potential of MSCs in disc cell research and treatment of degenerative disc disease, autologous MSCs embedded in Atelocollagen gel were transplanted into the discs of rabbits which had undergone a procedure proven to induce degeneration. The results suggest that MSC transplantation is effective in decelerating disc degeneration in experimental models and provided new hopes for treatment of degenerative disc disease in humans. Atelocollagen gel served as an important carrier of MSCs in transplantation, permitting proliferation, matrix synthesis and differentiation of MSCs. This study strengthens the viable efficacy of practical application of MSCs in treatment of intervertebral disc disease.

An experimental study of the regeneration of the intervertebral disc with an allograft of cultured annulus fibrosus cells using a tissue-engineering method

STUDY DESIGN

Cultured annulus fibrosus cells within an atelocollagen honeycomb-shaped scaffold with a membrane seal were allografted into the lacunas of intervertebral discs of which the nucleus pulposus had been vaporized using an indocyanine green dye-enhanced laser. Regeneration of the intervertebral disc was assessed based on the viability and histologic status of the allografted annulus fibrosus cells, as well as the prevention of narrowing disc space.

OBJECTIVES

To study the regeneration of intervertebral disc after laser discectomy using tissue-engineering methods.

SUMMARY OF BACKGROUND DATA

Intervertebral disc is the most avascular tissue in the human body, and its ability to regenerate is as low as that of articular cartilage. When nucleotomy is carried out, little regeneration of the annulus fibrosus is observed; consequently, intervertebral disc degeneration is inevitable.

METHODS

Annulus fibrosus cells isolated from 20 Japanese white rabbits were labeled with a PKH-26 fluorescent dye and seeded within an atelocollagen honeycomb-shaped scaffold with a membrane seal. Annulus fibrosus cells cultured in atelocollagen honeycomb-shaped scaffold with a membrane seal for 1 week were allografted into the lacunas of intervertebral discs of recipient rabbit of which the nucleus pulposus had been vaporized using an ICG dye-enhanced laser. Soft radiograph photographs of the lumbar spine of these anesthetized rabbits were taken, the disc space measured, and the lumbar spine extracted 2, 4, 8, and 12 weeks after the operation. The proliferation of allografted annulus fibrosus cells with 5-bromo-2'-deoxyuridine/PKH-26 fluorescent labels was assessed using consecutive frozen sections, and safranin-O staining carried out for histologic evaluation.

RESULTS

The allografted annulus fibrosus cells were viable and showed proliferation activity with a hyaline-like cartilage being produced. The narrowing of the intervertebral disc space of the cell translation group was significantly prevented, as shown, up to 12 postoperative weeks.

CONCLUSION

The annulus fibrosus cells cultured in an ACHMS-scaffold were allografted into the lacunae of nucleus pulposus (obtained using laser vaporization), as well as the hole of annulus fibrosus (obtained by laser fiber insertion) of rabbit intervertebral discs. These cells were viable and showed cell proliferation in the disc tissues of recipients.

Gene therapy and tissue engineering in repair of the musculoskeletal system

Historically, surgeons have sought and used different procedures in order to augment the repair of various skeletal tissues. Now, with the completion of the Human Genome Project, many researchers have turned to gene therapy as a means to aid various ailments. In the orthopedic field, many strides have been made toward using gene therapy and tissue engineering in a clinical setting. In this review, several studies are outlined in different areas that gene therapy has or will influence orthopedic surgery. Gene therapy and tissue engineering can aid in fracture healing and spinal fusions by inducing bone formation, ligamentous repairs by increasing the production of connective tissue fibers, intervertebral disc disease by creating potential replacements, and articular cartilage repairs by providing means to improve cartilage. As we continue to see great contributions, such as the few mentioned here, this field will continue to mature and develop.

Recent advances in disc cell biology

STUDY DESIGN

There have been many advances over the past decade in understanding and experimentally modulating biologic aspects of intervertebral disc cell function. An overview of the current state of this biologic research is presented.

OBJECTIVES

To provide clinicians with a review of important recent advances in biologic studies of the disc and their implications for potential disc therapies.

SUMMARY OF BACKGROUND DATA

Historically, anatomic, biochemical, radiologic, and biomechanical studies of the intervertebral disc formed the foundation on which our understanding of disc function was built. Magnetic resonance imaging techniques that allowed viewing of soft tissue components of the disc further advanced imaging capabilities.

METHODS

Recent publications are reviewed.

RESULTS

Experimental approaches over the past decade have enabled researchers to look more critically at disc cell function. This is important because disc cell function produces the extracellular matrix components of the disc, which, in turn, shape the disc's subsequent physiologic and biomechanical functions. New approaches to the study of disc cell function, methods to manipulate disc cells, studies of intact discs and disc nutrition, vertebral endplate structure and function, tissue engineering, gene therapy, and the potential of stem cells in disc therapy are reviewed and discussed.

CONCLUSIONS

Many believe that disc degeneration has a cellular basis. New research is helping us better understand healthy, aging, and degenerating discs. Modern methods to manipulate and modulate disc cell function open exciting and challenging new therapeutic possibilities for future biologic treatments of disc degeneration.

Synthesis of a Kunitz-type serine proteinase inhibitory protein that shares homology with bovine pancreatic trypsin inhibitor by ovine intervertebral disc cells in serum-free alginate bead culture

The objective of this study was to determine whether disc cells could be cultured under serum-free conditions and whether they synthesized bovine pancreatic trypsin inhibitor (BPTI)-like serine proteinase inhibitory proteins (SPIs) previously demonstrated for ovine chondrocytes. Intervertebral discs from 1- to 2-year-old merino wether sheep were dissected into the annulus fibrosus and nucleus pulposus, and the cells isolated by sequential enzymatic digestion. The cells were grown encapsulated in calcium alginate microspheres under serum-free conditions for 10 days. They remained more than 92% viable as assessed using the vital fluorescent dyes chloromethyl fluorescein diacetate and ethidium homodimer-1 to delineate live/dead cells, respectively. Western and affinity blotting identified a 12-16-kDa media SPI and an additional 34-36-kDa BPTI-like species in solubilized bead samples. This study has demonstrated ovine disc cells synthesized BPTI-like SPIs in serum-free alginate bead culture similar to chondrocyte SPIs; however, the 58-kDa precursor SPI form was not detected suggesting differences in the endogenous processing of these SPIs.

Gene therapy for spinal applications

Gene therapy is a promising drug delivery mechanism for the treatment of spinal disorders. Currently, the technique has been most useful in enhancing growth factor therapy for spinal fusion, intervertebral disc regeneration, and spinal cord injury healing. Gene therapy allows for the high-level local production of growth factors, obviating the need for slow release carriers or continuous infusion pumps that are otherwise necessary because of the short half-lives of most peptide growth factors. Although continuous expression is desirable, growth factor therapy is usually intended to be transient. The typical expression profile of Ad vectors--at a high level over 2 weeks or so--has been ideal, leading to its widespread use in these applications. Despite the ability of Ad to deliver genes directly in vivo, however, the cell-based ex vivo approach has been used widely in spinal applications. In spinal cord injury, cells such as peripheral nerve or Schwann cells may provide a permissive substrate for axonal growth [51]. For spinal fusion and IVD regeneration, ex vivo manipulation of cells facilitates gene transfer, because bone and IVD tissue are too dense to be penetrated by injection of Ad or other vectors. The use of cells may be advantageous in these applications in which new tissue formation is the goal. Finally, the use of genetically modified cells may decrease the inflammatory reaction induced by Ad vectors. Although gene therapy for spinal disorders has been centered around Ad-mediated transfer of single growth factor genes, the options for candidate genes and vectors are growing rapidly. Ad vectors are being improved by decreasing their immunogenicity and altering their tropism [2]. Vectors based on other viruses (such as herpes, adeno-associated virus, and lentivirus) are being developed, also with lower immunogenicity and with longer durations of expression [26,67]. Regulated expression, such as with the tetracycline regulated promoter, is being developed so that genes can be turned on or off as needed. Such regulation may be sensitive even to physiologic cues in the future [68,69]. Finally, the high throughput technologies, such as the gene chip, are elucidating thousands of genes that may be good candidates for the enhancement of bone healing and IVD and spinal cord regeneration. Genes whose products not only support bone, fibrocartilage, or axon growth but also neutralize natural inhibitors or promote tissue remodeling and maturation may be good future candidates. In the future, a series of vectors with multiple genes that are regulated by physiologic cues might be used to enhance spinal fusion, restore IVD tissue, or support spinal cord healing.