CHALLENGES and STRATEGIES in the REPAIR of RUPTURED ANNULUS FIBROSUS Clare C
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EuropeanCC Guterl Cells et al and. Materials Vol. 25 2013 (pages 1-21) DOI: 10.22203/eCM.v025a01 Challenges and strategies for annulus ISSN fibr osus1473-2262 repair CHALLENGES AND STRATEGIES IN THE REPAIR OF RUPTURED ANNULUS FIBROSUS Clare C. Guterl1,9, Eugene Y. See2,9, Sebastien B.G. Blanquer3,9, Abhay Pandit2,9, Stephen J. Ferguson4,9, Lorin M. Benneker5,9, Dirk W. Grijpma3,7,9, Daisuke Sakai6,9, David Eglin8,9, Mauro Alini8,9, James C. Iatridis1,9 and Sibylle Grad8,9* 1Department of Orthopaedics, Mount Sinai Medical Centre, New York, NY, USA 2Network of Excellence for Functional Biomaterials, National University of Ireland, Galway, Ireland 3Department of Biomaterials Science and Technology, University of Twente, Enschede, The Netherlands 4Institute for Biomechanics, ETH Zurich, Zurich, Switzerland 5Department of Orthopaedic Surgery, University of Bern, Bern, Switzerland 6Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan 7Department of Biomedical Engineering, University Medical Centre Groningen and University of Groningen, Groningen, The Netherlands 8AO Research Institute Davos, Davos, Switzerland 9Collaborative Research Partner Annulus Fibrosus Rupture Program of AO Foundation, Davos, Switzerland Abstract Telephone Number: +41 81 414 2480 FAX Number: +41 81 414 2288 Lumbar discectomy is the surgical procedure most frequently E-mail: [email protected] performed for patients suffering from low back pain and sciatica. Disc herniation as a consequence of degenerative Introduction or traumatic processes is commonly encountered as the underlying cause for the painful condition. While Intervertebral disc (IVD) herniation is a common discectomy provides favourable outcome in a majority of condition that frequently affects the spine of young and cases, there are conditions where unmet requirements exist middle-aged patients. The IVD is a complex structure in terms of treatment, such as large disc protrusions with composed of different but interrelated tissues: the central minimal disc degeneration; in these cases, the high rate of gelatinous highly hydrated nucleus pulposus (NP), the recurrent disc herniation after discectomy is a prevalent surrounding fibres of the annulus fibrosus (AF), and the problem. An effective biological annular repair could cartilaginous endplates that connect these tissues to the improve the surgical outcome in patients with contained vertebral bodies. The extracellular network of collagens disc herniations but otherwise minor degenerative changes. and proteoglycans is maintained by sparse populations An attractive approach is a tissue-engineered implant that of cells with generally fibro-chondrocytic phenotypes will enable/stimulate the repair of the ruptured annulus. and serves to transmit loads exerted on the spine. As a The strategy is to develop three-dimensional scaffolds and result of aging or degeneration, the normal extracellular activate them by seeding cells or by incorporating molecular matrix (ECM) turnover may be disturbed; if proteoglycan signals that enable new matrix synthesis at the defect site, concentration decreases, disc hydration and disc height are while the biomaterial provides immediate closure of the diminished, increasing the strain on the fibres in the AF. defect and maintains the mechanical properties of the This can lead to tears and fissures in the AF and ultimately disc. This review is structured into (1) introduction, (2) to protrusion of the NP. On the other hand, injurious clinical problems, current treatment options and needs, mechanical forces in combination with traumatic or (3) biomechanical demands, (4) cellular and extracellular degenerative failure of the AF may provoke herniation of components, (5) biomaterials for delivery, scaffolding and disc tissue. Irrespective of aetiology, back pain may occur support, (6) pre-clinical models for evaluation of newly due to disc protrusions, whether they do or do not enter developed cell- and material-based therapies, and (7) the spinal canal and exert pressure on the lumbar nerve conclusions. This article highlights that an interdisciplinary roots. It is believed that the pain associated with lumbar approach is necessary for successful development of new disc herniation results from a combination of nerve root clinical methods for annulus fibrosus repair. This will ischemia and inflammatory processes occurring at the site benefit from a close collaboration between research groups of extrusion (Takahashi et al., 2008). with expertise in all areas addressed in this review. Surgical intervention has widely shown positive outcome in cases where conservative treatment including Keywords: Annulus fibrosus rupture; disc herniation; physical therapy, pain medication and epidural steroid disc biomechanics; biomaterial scaffold; pre-clinical injections are not successful. The majority of studies model; interdisciplinary approach; annulus fibrosus tissue support earlier relief of pain-related symptoms and engineering; annulus fibrosus regeneration. conceivably superior restoration of function in patients who undergo surgery (Guilfoyle et al., 2007; Spengler *Address for correspondence: et al., 1990; Weber, 1983; Weinstein et al., 2006b; Sibylle Grad, PhD Weinstein et al., 2008). In fact, lumbar disc herniation AO Research Institute Davos is the pathological condition for which spinal surgery Clavadelerstrasse 8 is most often performed. The incidence of disc surgery 7270 Davos, Switzerland is 160/100,000 inhabitants in the USA and 62/100,000 www.ecmjournal.org 1 CC Guterl et al. Challenges and strategies for annulus fibrosus repair in Switzerland, indicating large geographic variations condition of the degenerating spine. There are two specific (Andersson and Deyo, 1996; Berney et al., 1990; Weinstein clinical situations for which the impaired function of the AF et al., 2006a). plays a crucial role: as the source of discogenic low back Lumbar discectomy is the most common surgical pain (LBP) and, in the case of insufficiency, as the origin of procedure performed for patients suffering from back pain disc herniation. Both conditions are very common and have and sciatica, with over 300,000 operations done yearly in an enormous socio-economic impact with no established the USA (Atlas et al., 1996; Deyo and Weinstein, 2001). satisfactory treatment options to date (Gore et al., 2012; While standard discectomy provides favourable results in Mehra et al., 2012; Parker et al., 2010; Weinstein et al., the majority of the cases, conditions with unmet needs in 2006a; Weber, 1994). terms of treatment include large disc protrusion with only Discogenic low back pain is believed to arise from minimal disc degeneration and adolescent disc protrusion. acute tears or fissures of the AF and from focal defects of In both conditions, the partial removal of the protruding the outer AF. These defects result in a repair process where herniation tissue is indicated, and the breach in the annulus granulation tissue is formed along with neovascularisation removes the safe constraints encasing and maintaining and concomitant ingrowth of nerve fibres (Melroseet al., pressurisation of the gel-like nucleus pulposus. In these 2002; Freemont et al., 1997; Aoki et al., 2006). Although cases, recurrent herniations are quite frequent, necessitating the AF has not fully lost its main function to withstand the revision surgery (McGirt et al., 2009; Lebow et al., 2011). hydrostatic pressure from the NP and to stabilise the FSU, Furthermore, an average disc height loss of 25 % has been discogenic low back pain has a high likelihood to develop reported after discectomy, which has been associated with chronicity and often needs medical treatment. increased back pain and disability (Barth et al., 2008; Acute and chronic disc herniations not only generate Yorimitsu et al., 2001; Loupasis et al., 1999). local pain from the disc but can also create pain and loss Another problem after discectomy is the so-called of function of the segmental nerves by direct compression ‘post-discectomy syndrome’ involving recurrent herniation and irritation from local inflammatory processes. As this with return of symptoms, motivating surgeons to remove a condition has a lifetime prevalence of 1-3 % and often greater portion of disc tissues during the original herniation affects active, working persons of 30-50 years of age, the procedure. A recent investigation suggests that the main socioeconomic impact due to medical treatment and long- source for chronic low back pain after surgical discectomy term absence from work are enormous (Weinstein et al., is discogenic and that annular fissures may be the primary 2006a; Weber, 1994). cause for the painful symptoms (DePalma et al., 2012). This finding indicates the need for repairing annular Diagnostics and classification fissures after discectomy. In the case of disc herniation, a correct diagnosis is usually To prevent recurrent symptoms, novel strategies made due to the irritation of the segmental nerves, which towards annular repair are compulsory. Efficient AF repair is frequently accompanied by low back pain observed could significantly improve the presently limited surgical during a clinical examination. The clinical symptoms of outcome, with the largest improvement likely to occur in discogenic low back pain on the other hand are less specific, cases of contained disc herniations but otherwise minor which requires a diagnosis that is mostly based on imaging degenerative changes,