自体骨髓间质干细胞植入联合纤维环缝合修复腰椎间盘髓核摘除术后缺损

Repair of defects after lumbar discectomy with autologous bone marrow mesenchymal stem cells and annular suture

目的评估自体骨髓间质干细胞(bone marrow mesenchymal stem cells,BMSCs)植入联合纤维环缝合修复腰椎间盘髓核摘除术后缺损的有效性和安全性。方法抽取前期5例手术患者自体骨髓血,应用选择性细胞留滞技术将有核细胞富集于明胶海绵颗粒进行BMSCs富集试验。2016年10月至2019年3月收治腰椎间盘突出症患者109例,男61例,女48例,年龄(43.0±9.8)岁(范围24~59岁)。均采用可动式经皮内镜下行髓核摘除术,26例单纯行摘除髓核术(摘除组),39例摘除髓核后缝合纤维环(缝合组);44例摘除髓核后向椎间盘内植入富集自体BMSCs的明胶海绵颗粒,缝合纤维环(干细胞+缝合组)。记录围手术期情况,评价指标包括疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)、椎间盘退变Pfirrmann分级、椎间隙高度及椎间盘突出程度,并计算改善率和丢失率。结果BMSCs富集试验结果显示有核细胞粘附倍数为6.4±0.9,目的细胞粘附倍数为4.2±0.6,体外培养后BMSCs生长良好。109例患者手术时间35~55 min,缝合组7例缝合不成功转入摘除组,干细胞+缝合组10例缝合不成功转入单纯干细胞组。切口无红肿,均一期愈合。各组术中出血量、术后引流量和住院时间的差异均无统计学意义。各组术前指标的差异均无统计学意义,术后各组VAS和ODI均较术前明显降低,未发现椎体间融合、异位骨化和感染。18例随访0.5年,91例随访(25.0±5.6)个月(范围1~3年)。末次随访时干细胞+缝合组VAS改善率为81.7%±7.9%,大于摘除组的73.0%±8.9%、缝合组的74.0%±6.9%和干细胞组的75.3%±8.4%;干细胞+缝合组ODI改善率为91.9%±8.8%,大于摘除组的86.2%±8.1%和缝合组的86.4%±5.5%。术后1年时MRI显示椎间盘退变分级摘除组较术前平均增加0.7级,缝合组平均增加0.6级,干细胞+缝合组和单纯干细胞组与术前无明显差异,Pfirrmann分级进展较摘除组和缝合组轻;各组椎间隙高度均较术前降低,干细胞+缝合组椎间隙高度丢失率为17.2%±4.3%,小于摘除组的29.3%±6.3%和缝合组的20.6%±5.7%,缝合组小于摘除组;椎间盘突出程度均较术前降低50%以上,摘除组1例显示突出,但无临床症状。结论自体BMSCs和纤维环缝合修复腰椎间盘髓核摘除术后缺损具有较好的安全性,近期效果良好,可能有助于减缓椎间盘退变。

Objective To evaluate the safety and validity of enriched autologous bone marrow mesenchymal stem cells(BMSCs)and annular suture for repairing defect after lumbar discectomy.Methods Enrichment of autologous BMSCs:autologous bone marrow blood was collected from 5 patients undergoing lumbar surgery,and nucleated cells were enriched on gelatin sponge particles by selective cell retention technique.From October 2016 to March 2019,109 patients with lumbar disc herniation underwent discectomy with mobile microendoscopic discectomy technique,including 61 males and 48 females,aged 24-59 years.Discectomy group:26 cases received simple discectomy.Suture group:39 cases received annular suture after discectomy.BMSCs+suture group:44 cases received intradisc transplantation of gelatin sponge particles enriched with autologous BMSCs and annular suture after discectomy.The perioperative conditions were recorded,with visual analogue scale(VAS),Oswestry dysfunction index(ODI),Pfirrmann grade of disc degeneration,disc height and degree of herniationevaluated after operation.Results In enrichment test with flow cytometry,the enrichment multiple of nucleated cells and target cells was 6.4±0.9 and 4.2±0.6 respectively,and BMSCs grew well in vitro.The operation time was 35-55 mins.7 cases in the suture group were transferred to the discectomy group and 10 cases in the BMSCs+suture group were transferred to BMSCs group due to unsuccessful suture.There were no significant differences in VAS,ODI,Pfirrmann grade of disc degeneration,disc height and degree of herniation among the groups.There was no significant difference in intraoperative bleeding,postoperative drainage and length of hospital stay.The incision was healed without redness and swelling.18 patients were followed up for 6 months,and 91 cases were followed up for 1-3 years(25.0±5.6 months).There was no interbody fusion,heterotopic ossification or infection during follow-up.VAS and ODI decreased significantly after operation in all patients.At final follow-up,the VAS improvement rate of BMSCs+suture group(81.7%±7.9%)was higher than discectomy group(73.0%±8.9%),suture group(74.0%±6.9%)and BMSCs group(75.3%±8.4%);the ODI improvement rate of BMSCs+suture group(91.9%±8.8%)was higher than discectomy group(86.2%±8.1%)and suture group(86.4%±5.5%).According to MRI,the Pfirrmann grade of disc increased 0.7 in discectomy group,0.6 in suture group,while it did not increased significantly in BMSCs+suture group and BMSCs group,and the progress of Pfirrmann grade in BMSCs+suture group and BMSCs group were lighter than discectomy group and suture group.The disc height decreased in each group,the loss rate of disc height in BMSCs+suture group(17.2%±4.3%)was less than discectomy group(29.3%±6.3%)and suture group(20.6%±5.7%);and suture group was less than discectomy group.The degree of herniation was reduced by more than 50%in all groups,while 1 case in discectomy group had herniation without clinical symptoms.Conclusion Autologous BMSCs and annulus suture are safe and effective in repairing the defect after lumbar discectomy,which may help to slow down the degeneration of intervertebral disc.