新型人工颈椎间盘的设计研发与山羊体内实验研究
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摘要
目前,人工颈椎间盘置换术已广泛应用于颈椎病的手术治疗,其优点是不仅能获得充分的减压效果,缓解症状,又能保留颈椎的生理运动功能,从而避免了植骨融合内固定术后邻近节段由于代偿性地过度活动而造成的退变加速。对人工颈椎间盘置换的研究已经成为脊柱外科领域热点之一。
由于人工颈椎间盘研发的技术门槛很高,目前尚没有任何国产人工颈椎间盘进入市场,国内市场全部为欧美等国外品牌占据。进口间盘产品存在一些不足：首先,价格昂贵,增加患者的消费负担；其次,进口产品的尺寸、生物力学方面与亚洲人种有差异,因为进口产品的设计是以欧美人种解剖参数为依据的；另外,适应症的选择也是参考欧美,没有制定自己独立完善的标准。在这种形势下,我院与深圳清华大学研究院等机构共同研发与国人颈椎间盘的生理尺寸特征相符合的国产化人工颈椎间盘,产品采用固定髓核球-槽关节设计,上下终板材料为钛合金(Ti6A14V),髓核材料为超高分子量聚乙烯(UHMWPE).
因为山羊颈椎的解剖、生物力学特点等与人类非常相似,所以本实验通过建立国产人工颈椎间盘的山羊颈椎模型,来模拟人类的颈椎手术,以评估国产人工颈椎间盘置换的可行性及术后间盘的生存变化,为其进一步的改进和临床应用提供动物实验资料,最后过渡到临床应用。
1目的
建立新型国产人工颈椎间盘的实验山羊颈椎模型,观察其植入后的颈椎活动度、稳定性,相邻节段退变的情况,评价国产人工颈椎间盘的安全性和有效性,以期为该假体的进一步实验研究提供理论依据,为将来的临床应用提供实验依据。
2方法
2.1依据山羊颈椎解剖参数,制备新型国产颈椎间盘假体；
2.2建立新型国产人工颈椎间盘的实验山羊颈椎模型,评价其手术时间、出血量、术后动物恢复活动时间等情况；
2.3将实验山羊随机分组,均摘除颈3/4间盘,分别植入涂有羟基磷灰石涂层的间盘假体、未涂层假体以及自体髂骨块。通过影像学(颈椎正侧、屈伸位X线)观察,指标包括：(1)术后椎间隙的高度、椎间角、前凸角的变化情况；(2)术后颈椎椎间活动度的变化情况；(3)术后置换节段活动度；(4)kel lgren评分来评估邻节段退变情况；(5)椎间盘相对高度测量；(6)病理学观察。实验分1个月组和3个月组,并分别设立非手术对照组进行对比分析。将上述测量的指标采用均数±标准差表示(x±s),采用SPSS16.0统计软件包进行统计和分析。
3结果
3.1设计制备了新型国产人工颈椎间盘假体；
3.2所有动物均成活,均未发生切口感染,四肢活动良好,未出现瘫痪。平均术中出血量3.6±0.5ml,平均手术时间80±6min,术后恢复活动的平均时间4.5±1.2h；
3.3(1)经过统计学分析,涂层组、未涂层组与对照组术前的DSH、 IVA和LA无显著性差异；涂层组的术后即刻、术后1个月、3个月的DSH、 IVA和LA不具有统计学意义(p>0.05),术后即刻、术后1个月的DSH、IVA和LA三组间无显著性差异(p>0.05),1个月、3个月未涂层组与涂层组、对照组有显著性差异(p<0.05),对照组与涂层组间无显著性差异(p>0.05),说明涂层后的人工间盘较好的维持了椎间隙高度和生理曲度,优于未涂层间盘。涂层组与未涂层组术后较术前椎间隙高度整体增高,这是因为手术将假体植入时必须打磨终板,所以术后的椎间隙高度整体高于术前。(2)涂层组的术前、术后即刻、术后1个月、3个月的ROM不具有统计学意义(p>0.05),未涂层组的术前、术后即刻、术后1个月、3个月的ROM有统计学意义(p<0.05),三组的术后即刻ROM无统计学意义,未涂层组与涂层组、对照组在术后1个月及3个月比较有统计学意义(p<0.05),涂层组与对照组无显著性差异(p>0.05),说明羟基磷灰石涂层后的人工间盘较好的保持了颈椎的活动度,而未涂层组在术后1个月已经出现颈椎活动度差。(3)经过统计学分析,未涂层组与涂层组、对照组术前及术后即刻的C3/4节段活动度组间比较无显著性差异,涂层组的术前及术后不同时间点的活动度不具有统计学意义(p>0.05),未涂层组的术前、术后即刻与术后1个月、3个月的活动度比较有统计学意义(p<0.05),未涂层组与涂层组、对照组在术后1个月及3个月的比较均有统计学意义(p<0.05),涂层组与对照组比较无显著性差异(p>0.05),说明植入羟基磷灰石涂层假体后的山羊C3/4节段较好的保持了活动度,而未涂层组在术后1个月已经出现颈椎活动度降低。(4)kellgren评分结果：间盘组与对照组在术后1个月与3个月比较均无显著性差异(p>0.05)；术后1个月与术后3个月间盘组与自体骨组间比较差异有统计学意义(p<0.05)；术后1个月与术后3个月C2/3间隙与C4/5间隙相比较无显著性差异(p>0.05)。(5)间盘组、自体骨组、对照组术前的RDH无显著性差异,间盘组的术前、术后即刻、术后1个月、3个月的椎体前缘、中份、后缘RDH无显著性差异(p>0.05),自体骨组的术前、术后即刻、术后1个月、3个月的椎体前缘、中份、后缘RDH有统计学意义(p<0.05),三组的术后即刻RDH无统计学意义,自体骨组与间盘组、对照组在术后1个月及3个月的比较均有统计学意义(p<0.05),间盘组与对照组间无显著性差异(p>0.05)。(6)术后3个月对照组及间盘组髓核HE染色可见散在软骨样细胞,胶原纤维束状分布,含量少,整齐排列,可见大量基质成分；而自体骨组活性软骨细胞数量减少,坏死细胞出现,胶原纤维团簇状增多,基质数量少
4结论
新型人工颈椎间盘假体符合实验羊颈椎解剖,植入合理、方便,操作简便易行。术中出血量少,手术时间短,术后动物并发症少,恢复活动早,可以维持颈椎的活动度与稳定性,并可预防邻近节段退变加速,初步证实新型人工颈椎间盘假体植入山羊体内的早期效果满意,中远期疗效有待进一步观察。
At present, cervical artificial disc replacement has been widely used in the surgical treatment of cervical spondylosis, it can achieve complete decompression of the spinal canal and relieve symptoms, retaining the physiological cervical motor function, thus avoiding adjacent segment degeneration due to compensatory overactivity after interbody fusion. Artificial cervical disc replacement surgery has become one of the hot spots in the field of spine surgery
Because the technical threshold is high due to the research and development of artificial cervical disc, there is not yet any domestic cervical artificial disc into the market, the domestic market is occupied by foreign brands. There are some shortcomings for foreign products:first of all, foreign products are expensive, increasing the patients'economic burden; secondly, foreign products are different in sizes and biomechanics with Asian, because the foreign products are designed based on the European and American ethnic anatomical parameters; in addition, indications for surgery also refer to foreigners, we still did not have our own independent and comprehensive standards. In this situation, our hospital combined with the Shenzhen Research Institute of Tsinghua University institutions designed new home-made cervical disc prosthesis, consistent with the physiological size characteristics of Chinese. New home-made cervical disc prosthesis used the fixed nucleus pulposus ball-groove joint design, inferior endplate material titanium alloy (Ti6A14V), the nucleus pulposus material for ultra-high molecular weight polyethylene (UHMWPE).
Because goats have similar anatomical parameters and biomechanical characteristics with human, it can be served as an optimal model for cervical research. We establ ish home-made cervical artificial disc goat model to s imulate the human cervical spine surgery, in order to assess the feasibility of domestic cervical artificial disc implant surgery, so as to provide an experimental basis for further clinical applications.
1Objective
The purpose of this study was to establish an animal model for new home-made cervical disc prosthesis, observe cervical activity, stability and adjacent segment degeneration after implantation, and evaluate the safety and effectiveness of home-made cervical artificial disc, in order to provide a theoretical basis for the prosthesis further exper i mental study, so as to provide an experimental basis for further clinical applications.
2Methods
2.1In this part of study, a new type of home-made cervical disc prosthesis was designed and made, based on the goat cervical anatomical parameters.
2.2Establishing an animal model for new home-made cervical disc prosthesis, evaluating the operation time, blood loss, postoperative recovery time of act ivi ty.
2.3Experimental goats were randomly divided into3groups:CDR group coated with hydroxyapatite, CDR group uncoated with hydroxyapatite, and autologous iliac group, neck3/4plate were removed in3groups, replaced respectively by home-made cervical disc prosthesis and autologous iliac. Observed by imaging (cervical X-ray film), indicators include:(1) disc space height (DSH) intervertebral angle (IVA) and lordosis angle (LA);(2)the ROM of C2-C5;(3)the ROM of C3/4;(4)to assess the situation of adjacent segment degeneration by kellgren score;(5)measurement of relative disc height;(6)histological observation.
Experimental groups were divided into post-operation1month and post-operation3months, and respective control group is designed. The above measurement indicators were expressed as mean+standard deviation (x±s), and analyzed with SPSS16.0statistical package.
3Results
3.1A new type of home-made cervical disc prosthesis has been designed and made.
3.2All experiment goats survived after operation, without incision infection and paralys is, the average blood loss was3.6±0.5ml, the average operation time was80±6min, the average time of resuming activities after operation was4.5±1.2h.
3.3(l)Statistical comparison showed no significant difference of DSH, IVA and LA preoperatively and postoperatively immediately between the CDR group coated with hydroxyapatite, CDR group uncoated with hydroxyapatite and control group. There was no significant difference with respect to DSH, IVA and LA in coated disc group postoperatively immediately,1month postoperatively and3months postoperatively (p>0.05); While at1and3months postoperatively, significant difference existed in uncoated disc group and coated disc group, control group (p<0.05). There was no significant difference between coated disc group and control group (p>0.05).(2)There was no significant difference with respect to ROM in coated disc group postoperatively immediately,l month and3months postoperatively (p>0.05); While there was significant difference with respect to ROM in uncoated disc group postoperatively immediately,l month and3months postoperatively (p<0.05); At1and3months postoperatively, significant difference existed in uncoated disc group and coated disc group, control group (p<0.05). There was no significant difference between coated disc group and control group (p>0.05).(3)There was no significant difference with respect to the ROM of C3/4in coated disc group postoperat ively immediately,1month and3months postoperat ively (p>0.05); While there was significant difference with respect to ROM of C3/4in uncoated disc group postoperatively immediately,1month and3months postoperatively (p<0.05) At1and3months postoperatively, significant difference existed in uncoated disc group and coated disc group, control group. There was no significant difference between coated disc group and control group (p>0.05).(4)Kellgren score results:there was no significant difference between the CDR group and control group. At1and3months postoperatively, significant difference existed in CDR group and autologous iliac group (p<0.05), there was no significant difference with respect to score between C2/3gap and C3/4gap (p>0.05)(5)There was no significant difference with respect to RDH among CDR group, autologous iliac group and control group preoperatively (p>0.05); There was no significant difference with respect to RDH in CDR group postoperatively immediately,1month postoperatively and3months postoperatively (p>0.05); While there was significant difference with respect to RDH in autologous iliac group postoperatively immediately,1month postoperatively and3months postoperatively (p<0.05); At1and3months postoperatively, significant difference existed in autologous i l iac group and CDR group, control group. There was no significant difference between CDR group and control group (p>0.05)(6) At3months postoperatively, in CDR group and control group, nucleus pulposus had a large quantity of extracellular matrix, and some fine collagen fibrils sparsely arranged among the matrix. A few chondrocyte-like cells dotted in them. While in autologous iliac group, extracellular matrix decreased, but collagen fibrils began larger and thicker and more irregularly arranged among the matrix. The number of viable cells decreased, and necrotic cells increased.
4Conclusion
New home-made artificial cervical disc system is easy to operate, has less blood loss, shorter operative time, less complications and early recovery of movement, and can maintain the stability of the cervical spine and retain the activity of the cervical spine, what's more,can prevent adjacent segment degeneration accelerating. Preliminary evidence confirmed the prosthesis may yield good functional short-term results, further follow-up is necessary to evaluate mid-and long-term outcome in vivo applications.
由于人工颈椎间盘研发的技术门槛很高,目前尚没有任何国产人工颈椎间盘进入市场,国内市场全部为欧美等国外品牌占据。进口间盘产品存在一些不足：首先,价格昂贵,增加患者的消费负担；其次,进口产品的尺寸、生物力学方面与亚洲人种有差异,因为进口产品的设计是以欧美人种解剖参数为依据的；另外,适应症的选择也是参考欧美,没有制定自己独立完善的标准。在这种形势下,我院与深圳清华大学研究院等机构共同研发与国人颈椎间盘的生理尺寸特征相符合的国产化人工颈椎间盘,产品采用固定髓核球-槽关节设计,上下终板材料为钛合金(Ti6A14V),髓核材料为超高分子量聚乙烯(UHMWPE).
因为山羊颈椎的解剖、生物力学特点等与人类非常相似,所以本实验通过建立国产人工颈椎间盘的山羊颈椎模型,来模拟人类的颈椎手术,以评估国产人工颈椎间盘置换的可行性及术后间盘的生存变化,为其进一步的改进和临床应用提供动物实验资料,最后过渡到临床应用。
1目的
建立新型国产人工颈椎间盘的实验山羊颈椎模型,观察其植入后的颈椎活动度、稳定性,相邻节段退变的情况,评价国产人工颈椎间盘的安全性和有效性,以期为该假体的进一步实验研究提供理论依据,为将来的临床应用提供实验依据。
2方法
2.1依据山羊颈椎解剖参数,制备新型国产颈椎间盘假体；
2.2建立新型国产人工颈椎间盘的实验山羊颈椎模型,评价其手术时间、出血量、术后动物恢复活动时间等情况；
2.3将实验山羊随机分组,均摘除颈3/4间盘,分别植入涂有羟基磷灰石涂层的间盘假体、未涂层假体以及自体髂骨块。通过影像学(颈椎正侧、屈伸位X线)观察,指标包括：(1)术后椎间隙的高度、椎间角、前凸角的变化情况；(2)术后颈椎椎间活动度的变化情况；(3)术后置换节段活动度；(4)kel lgren评分来评估邻节段退变情况；(5)椎间盘相对高度测量；(6)病理学观察。实验分1个月组和3个月组,并分别设立非手术对照组进行对比分析。将上述测量的指标采用均数±标准差表示(x±s),采用SPSS16.0统计软件包进行统计和分析。
3结果
3.1设计制备了新型国产人工颈椎间盘假体；
3.2所有动物均成活,均未发生切口感染,四肢活动良好,未出现瘫痪。平均术中出血量3.6±0.5ml,平均手术时间80±6min,术后恢复活动的平均时间4.5±1.2h；
3.3(1)经过统计学分析,涂层组、未涂层组与对照组术前的DSH、 IVA和LA无显著性差异；涂层组的术后即刻、术后1个月、3个月的DSH、 IVA和LA不具有统计学意义(p>0.05),术后即刻、术后1个月的DSH、IVA和LA三组间无显著性差异(p>0.05),1个月、3个月未涂层组与涂层组、对照组有显著性差异(p<0.05),对照组与涂层组间无显著性差异(p>0.05),说明涂层后的人工间盘较好的维持了椎间隙高度和生理曲度,优于未涂层间盘。涂层组与未涂层组术后较术前椎间隙高度整体增高,这是因为手术将假体植入时必须打磨终板,所以术后的椎间隙高度整体高于术前。(2)涂层组的术前、术后即刻、术后1个月、3个月的ROM不具有统计学意义(p>0.05),未涂层组的术前、术后即刻、术后1个月、3个月的ROM有统计学意义(p<0.05),三组的术后即刻ROM无统计学意义,未涂层组与涂层组、对照组在术后1个月及3个月比较有统计学意义(p<0.05),涂层组与对照组无显著性差异(p>0.05),说明羟基磷灰石涂层后的人工间盘较好的保持了颈椎的活动度,而未涂层组在术后1个月已经出现颈椎活动度差。(3)经过统计学分析,未涂层组与涂层组、对照组术前及术后即刻的C3/4节段活动度组间比较无显著性差异,涂层组的术前及术后不同时间点的活动度不具有统计学意义(p>0.05),未涂层组的术前、术后即刻与术后1个月、3个月的活动度比较有统计学意义(p<0.05),未涂层组与涂层组、对照组在术后1个月及3个月的比较均有统计学意义(p<0.05),涂层组与对照组比较无显著性差异(p>0.05),说明植入羟基磷灰石涂层假体后的山羊C3/4节段较好的保持了活动度,而未涂层组在术后1个月已经出现颈椎活动度降低。(4)kellgren评分结果：间盘组与对照组在术后1个月与3个月比较均无显著性差异(p>0.05)；术后1个月与术后3个月间盘组与自体骨组间比较差异有统计学意义(p<0.05)；术后1个月与术后3个月C2/3间隙与C4/5间隙相比较无显著性差异(p>0.05)。(5)间盘组、自体骨组、对照组术前的RDH无显著性差异,间盘组的术前、术后即刻、术后1个月、3个月的椎体前缘、中份、后缘RDH无显著性差异(p>0.05),自体骨组的术前、术后即刻、术后1个月、3个月的椎体前缘、中份、后缘RDH有统计学意义(p<0.05),三组的术后即刻RDH无统计学意义,自体骨组与间盘组、对照组在术后1个月及3个月的比较均有统计学意义(p<0.05),间盘组与对照组间无显著性差异(p>0.05)。(6)术后3个月对照组及间盘组髓核HE染色可见散在软骨样细胞,胶原纤维束状分布,含量少,整齐排列,可见大量基质成分；而自体骨组活性软骨细胞数量减少,坏死细胞出现,胶原纤维团簇状增多,基质数量少
4结论
新型人工颈椎间盘假体符合实验羊颈椎解剖,植入合理、方便,操作简便易行。术中出血量少,手术时间短,术后动物并发症少,恢复活动早,可以维持颈椎的活动度与稳定性,并可预防邻近节段退变加速,初步证实新型人工颈椎间盘假体植入山羊体内的早期效果满意,中远期疗效有待进一步观察。
At present, cervical artificial disc replacement has been widely used in the surgical treatment of cervical spondylosis, it can achieve complete decompression of the spinal canal and relieve symptoms, retaining the physiological cervical motor function, thus avoiding adjacent segment degeneration due to compensatory overactivity after interbody fusion. Artificial cervical disc replacement surgery has become one of the hot spots in the field of spine surgery
Because the technical threshold is high due to the research and development of artificial cervical disc, there is not yet any domestic cervical artificial disc into the market, the domestic market is occupied by foreign brands. There are some shortcomings for foreign products:first of all, foreign products are expensive, increasing the patients'economic burden; secondly, foreign products are different in sizes and biomechanics with Asian, because the foreign products are designed based on the European and American ethnic anatomical parameters; in addition, indications for surgery also refer to foreigners, we still did not have our own independent and comprehensive standards. In this situation, our hospital combined with the Shenzhen Research Institute of Tsinghua University institutions designed new home-made cervical disc prosthesis, consistent with the physiological size characteristics of Chinese. New home-made cervical disc prosthesis used the fixed nucleus pulposus ball-groove joint design, inferior endplate material titanium alloy (Ti6A14V), the nucleus pulposus material for ultra-high molecular weight polyethylene (UHMWPE).
Because goats have similar anatomical parameters and biomechanical characteristics with human, it can be served as an optimal model for cervical research. We establ ish home-made cervical artificial disc goat model to s imulate the human cervical spine surgery, in order to assess the feasibility of domestic cervical artificial disc implant surgery, so as to provide an experimental basis for further clinical applications.
1Objective
The purpose of this study was to establish an animal model for new home-made cervical disc prosthesis, observe cervical activity, stability and adjacent segment degeneration after implantation, and evaluate the safety and effectiveness of home-made cervical artificial disc, in order to provide a theoretical basis for the prosthesis further exper i mental study, so as to provide an experimental basis for further clinical applications.
2Methods
2.1In this part of study, a new type of home-made cervical disc prosthesis was designed and made, based on the goat cervical anatomical parameters.
2.2Establishing an animal model for new home-made cervical disc prosthesis, evaluating the operation time, blood loss, postoperative recovery time of act ivi ty.
2.3Experimental goats were randomly divided into3groups:CDR group coated with hydroxyapatite, CDR group uncoated with hydroxyapatite, and autologous iliac group, neck3/4plate were removed in3groups, replaced respectively by home-made cervical disc prosthesis and autologous iliac. Observed by imaging (cervical X-ray film), indicators include:(1) disc space height (DSH) intervertebral angle (IVA) and lordosis angle (LA);(2)the ROM of C2-C5;(3)the ROM of C3/4;(4)to assess the situation of adjacent segment degeneration by kellgren score;(5)measurement of relative disc height;(6)histological observation.
Experimental groups were divided into post-operation1month and post-operation3months, and respective control group is designed. The above measurement indicators were expressed as mean+standard deviation (x±s), and analyzed with SPSS16.0statistical package.
3Results
3.1A new type of home-made cervical disc prosthesis has been designed and made.
3.2All experiment goats survived after operation, without incision infection and paralys is, the average blood loss was3.6±0.5ml, the average operation time was80±6min, the average time of resuming activities after operation was4.5±1.2h.
3.3(l)Statistical comparison showed no significant difference of DSH, IVA and LA preoperatively and postoperatively immediately between the CDR group coated with hydroxyapatite, CDR group uncoated with hydroxyapatite and control group. There was no significant difference with respect to DSH, IVA and LA in coated disc group postoperatively immediately,1month postoperatively and3months postoperatively (p>0.05); While at1and3months postoperatively, significant difference existed in uncoated disc group and coated disc group, control group (p<0.05). There was no significant difference between coated disc group and control group (p>0.05).(2)There was no significant difference with respect to ROM in coated disc group postoperatively immediately,l month and3months postoperatively (p>0.05); While there was significant difference with respect to ROM in uncoated disc group postoperatively immediately,l month and3months postoperatively (p<0.05); At1and3months postoperatively, significant difference existed in uncoated disc group and coated disc group, control group (p<0.05). There was no significant difference between coated disc group and control group (p>0.05).(3)There was no significant difference with respect to the ROM of C3/4in coated disc group postoperat ively immediately,1month and3months postoperat ively (p>0.05); While there was significant difference with respect to ROM of C3/4in uncoated disc group postoperatively immediately,1month and3months postoperatively (p<0.05) At1and3months postoperatively, significant difference existed in uncoated disc group and coated disc group, control group. There was no significant difference between coated disc group and control group (p>0.05).(4)Kellgren score results:there was no significant difference between the CDR group and control group. At1and3months postoperatively, significant difference existed in CDR group and autologous iliac group (p<0.05), there was no significant difference with respect to score between C2/3gap and C3/4gap (p>0.05)(5)There was no significant difference with respect to RDH among CDR group, autologous iliac group and control group preoperatively (p>0.05); There was no significant difference with respect to RDH in CDR group postoperatively immediately,1month postoperatively and3months postoperatively (p>0.05); While there was significant difference with respect to RDH in autologous iliac group postoperatively immediately,1month postoperatively and3months postoperatively (p<0.05); At1and3months postoperatively, significant difference existed in autologous i l iac group and CDR group, control group. There was no significant difference between CDR group and control group (p>0.05)(6) At3months postoperatively, in CDR group and control group, nucleus pulposus had a large quantity of extracellular matrix, and some fine collagen fibrils sparsely arranged among the matrix. A few chondrocyte-like cells dotted in them. While in autologous iliac group, extracellular matrix decreased, but collagen fibrils began larger and thicker and more irregularly arranged among the matrix. The number of viable cells decreased, and necrotic cells increased.
4Conclusion
New home-made artificial cervical disc system is easy to operate, has less blood loss, shorter operative time, less complications and early recovery of movement, and can maintain the stability of the cervical spine and retain the activity of the cervical spine, what's more,can prevent adjacent segment degeneration accelerating. Preliminary evidence confirmed the prosthesis may yield good functional short-term results, further follow-up is necessary to evaluate mid-and long-term outcome in vivo applications.
引文
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