105SProceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S

PURPOSE: To evaluate relationships among ROM and self-reported clin-

ical outcomes in single or multilevel ProDisc-L patients.

STUDY DESIGN/SETTING: USA-FDA IDE trial, one site.

PATIENT SAMPLE: Randomized (RCT, n559), Pilot (P, n56), Contin-

ued Access (CA, n5147) and Compassionate Use (CU, n5 37).

OUTCOME MEASURES: Oswestry Disability Index (ODI), Visual An-

alogue Scale for pain (VAS).

METHODS: An analysis between ROM and clinical outcomes of single

& multilevel ProDisc-L treated patients. Patients were followed at 6

weeks, 3, 6, 12, 24 months. Self-assessments included Oswestry Disability

Index (ODI), Visual Analogue Scale for pain (VAS). Physical exams were

completed; radiographs were analyzed. Degree of ROM was determined

from disc angle on extension - flexion. ROM average was calculated over

lumbar levels. Relationships between ROM and self-assessments were

evaluated.

RESULTS: Results: There were a total of 219 ProDisc-L treated patients

(89%) with 24-month data. The average ROM was 8.5� 6 2.8 preopera-

tively and slightly lower at 6.6� 6 2.4 at 6 weeks, while steadily recover-

ing with 7.1� 6 2.4 at 3 months, 7.8� 6 2.7 at 6 months, 8.4� 6 2.6 at 12

months, and 8.7� 6 2.6 at 24 months postoperatively. There was 29% to

52% range of average improvement in ODI and 44% to 56% improvement

in VAS pain from 6 weeks to 24 months. There was a significant negative

correlation between ODI and ROM (r5�0.41, p! 0.0001) with 18% com-

mon variability, indicating that the greater the average lumbar ROM, the

less the reported functional disability (ODI); associations were similar

for ROM and ODI at 3 months (r5�0.27, p! 0.0002), 6 months

(r5�0.19, p! 0.006), 12 months (r5�0.26, p! 0.0003), and 24 months

(r5�0.31, p! 0.0001). Greater average ROM was significantly correlated

with less VAS pain at 6 weeks (r5�0.29, p!0.0001), 3 months (r5�0.12,

p50.09), 12 months (r5�0.15, p! 0.04), and 24 months (r5�0.22, p!0.002). Greater body mass index (BMI) was related to less ROM preoper-

atively (r5�0.16, p! 01), and postoperatively at 12 months (r5 �0.16,

p! 02) and 24 months (r5 �0.18, p! 01). BMI was marginally related

to VAS pain preoperatively (r50.12, p506) yet not postoperatively, while

BMI was not related to ODI (all NS). Multiple regressions yielded power-

ful associations of greater ODI with lower ROM at 12 months (r5�1.07,

p! 0.0003) and 24 months (r5�1.41, p! 0.0001), and similarly, the asso-

ciations held when controlling for BMI and age. A relationship was found

for higher VAS pain and lower ROM at 12 months (p! 0.04) and 24

months (p!0.002). Further, higher satisfaction was associated with greater

ROM at 12 months (r50.14, p! 0.04) and 24 months (r50.40, p! 0.002).

CONCLUSIONS: ROM was maintained throughout follow-up in Pro-

Disc-L patients. Importantly, greater ROM was strongly associated with

greater functional ability, less pain, and greater satisfaction. This is the first

report of these associations.

FDA DEVICE/DRUG STATUS: ProDisc-L (1-Level): Approved for this

indication; ProDisc-L (multi-level): Investigational/Not approved.

doi: 10.1016/j.spinee.2009.08.240

199. Fibrin Injection Stimulates Early Disc Healing in the Porcine

Model

Zorica Buser, MD1, Fabrice Kuelling, MD1, Liu Jane1, Ellen Liebenberg1,

Jessica Tang2, Kevin Thorne, PhD3, Dezba Coughlin, MD1, Jeffrey Lotz,

PhD1; 1University of California, San Francisco, CA, USA; 2University of

California, Berkeley, CA, USA; 3Spinal Restoration, Austin, TX, USA

BACKGROUND CONTEXT: Pathologic disc degeneration includes in-

effective healing of tissue damage that accumulates over time. Regions

of inflammation, neoinnervation, and nociceptor sensitization can lead to

chronic discogenic pain. An important component of normal wound heal-

ing occurs when fibrin interacts with matrix and cellular structures. The

biostimulatory effects of fibrin include fibroblast recruitment, matrix syn-

thesis, and granulation tissue formation. The Biostat Disc Augmentation

System has been developed as a fibrin-based treatment for discogenic pain.

PURPOSE: To test the hypothesis that interdiscal application of fibrin

stimulates healing by reducing cytokine levels and stimulating matrix

synthesis.

STUDY DESIGN/SETTING: Full thickness annular injury and nucleot-

omy was performed in three lumbar levels in Yucatan mini-pigs using

the DeKompressor (Stryker). These discs were randomized to no-treatment

or fibrin injection. Animals were recovered up to 12 weeks.

PATIENT SAMPLE: None.

OUTCOME MEASURES: Discs were assessed by histology, biochemi-

cal composition (GAG, fibrin, and cell content), cytokine concentration

(TGF-, IL-1, -4, -6, -8, and TNF-), and quantitative discomanometry.

METHODS: Pig lumbar spines were accessed using an open, retroperito-

neal approach. The DeKompressor was introduced in to the disc nucleus

using a 19 G needle to remove approximately 1 ml of tissue. For the fi-

brin-treated discs, approximately 1 ml of Biostat sealant was injected using

a specially-designed injection gun that limited the pressure to 100 psi. His-

tology: The discs and adjacent vertebra were fixed and decalcified, embed-

ded in paraffin, and stained with Safranin-O. Biochemical assessment: The

discs were enzymatically digested using collagenase. Proteoglycan content

was quantified by DMMB while cellularity was assessed using PicoGreen.

Cytokines were quantified by ELISA. Mechanical assessment: A custom

discomanometry device was used to quantify disc pressure/volume rela-

tionships and maximum pressure/volume retention. Saline mixed with vi-

sual and x-ray contrast was injected at a rate of 1 ml/min using a 22 G

needle placed into the disc nucleus.

RESULTS: Nucleotomy produced transient increases in IL-6 and TNF- at

3 weeks that were prevented by fibrin injection. For the no-treatment and

fibrin-treated discs, stiffness and leakage pressure were less than control at

3 weeks. Stiffness returned to normal at 6 weeks for the fibrin-treated

levels and at 12 weeks for the no-treatment levels. Disc proteoglycan con-

tent was less than controls at 3 and 6 weeks for the no-treatment and fibrin-

treated levels. GAG content returned to normal at 12 weeks for the fibrin-

treated levels, but not for degenerate discs. No adverse cellular reaction to

fibrin injection was noted by histology.

CONCLUSIONS: In the porcine nucleotomy model, fibrin injection

blunts acute increases in inflammatory cytokine production, promotes

a more rapid recovery of mechanical properties, and enhanced proteogly-

can matrix synthesis. These data are consistent with prior reports of the

beneficial effects of fibrin on wound healing, and suggest that continued

investigations are warranted to assess the clinical efficacy of fibrin as

a treatment option for discogenic pain.

FDA DEVICE/DRUG STATUS: Biostat Disc Augmentation System: In-

vestigational/Not approved.

doi: 10.1016/j.spinee.2009.08.241

Saturday, November 14, 200910:30–11:30 AM

Concurrent Session 1: Biologics/Basic Science

200. The New Concept of Nerve Root Damage under Stretch and

Compression Force

Kei Tateno, MD, PhD1, Koji Kanzaki, MD1, Hajime Saito, MD1,

Keizo Sugisaki, MD1, Kyosuke Shiohara, MD1, Junichi Ochiai, MD1,

Yohei Ishihara, MD1, Yusuke Oshita, MD, PhD1; 1Showa University

Fujigaoka Hospital Orthopedics, Yokohama, Kanagawa, Japan

BACKGROUND CONTEXT: The most often considered causes of nerve

root damage are stretch and compression force. Many researchers have re-

ported experimental studies of compression force, but it is difficult to find

reports describing stretch force to nerve roots. The nerve root paralysis was

immediately recovered after releasing the stretch force.The different phys-

iological reactions may occurre between stretch force and compression

106S Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S

force are hard to explain by circulation insufficiency,hypoxemia and hypo-

alimentation.

PURPOSE: The purpose of this study is to evaluate the physiological re-

action of nerve roots of rats under stretch force and compression.

STUDY DESIGN/SETTING: Experimental animal study.

PATIENT SAMPLE: Non-human primate.

OUTCOME MEASURES: Experimental study: All research protocols

have been approved by both a Scientific Board and the Animal Ethics

Committee of the Showa University.

METHODS: Eight Wister rats (weight: 300~400 g) were used in this

study. Nerve tissue from the cauda equina was taken out from Wister rats

under anesthesia of Nembutal (from 30 to 50 mg/kg). The nerve tissue was

placed in plastic chambers for experimental studies. Four nerve roots were

prepared for the compression test, and also 4 nerve roots for the stretch

test. We investigated the changes in threshold and action potential of the

nerve roots under stretch force and compression force. Several weights

(0.5, 1.0, 2.0, and 5.0 g) were used to apply stretch force to the nerve roots.

We investigated threshold and action potential of the nerve roots in each

condition, as well as 10 minutes after releasing the stretch force. The com-

pression test was performed as in the stretch test. The compression force

was added to the nerve roots in the central portion of the chamber utilizing

weights (1.0, 2.0, 3.0, and 5.0 g).

RESULTS: The threshold of the nerve roots increased and action potential

decreased in parallel with stretch force. Also, the threshold and action po-

tential recovered after release from stretch without any damage of nerve.

On the other hand, under compression force, the threshold and action po-

tential did not significantly change until a certain level; both suddenly

changed over that level and never recovered after release from compres-

sion force. The results of the other 3 tests in both . All data were reversible.

CONCLUSIONS: The data strongly suggest that the nerve root paralysis

was reversible after releasing the stretch force without any damage. The

structural change of nerve cells might influence the opening and closing

of the ionic channel. We considered that the opposite reaction must occur

when the stretch force elongates the nerve, closes the ionic channel and the

structural change of the nerve cell framework caused by stretch force

changed the activity of the ion-channel of the nerve cells, resulting in

the change of the threshold and action potential. The physiological reac-

tion of the nerve root under stretch force differed from that under compres-

sion force and recovered from the damage after release from stretch force.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

doi: 10.1016/j.spinee.2009.08.243

201. Fibronectin Alternative Splice Variants in the Human

Intervertebral Disc

D. Greg Anderson, MD1, Dessislava Markova, PhD2, Sherrill Adams,

PhD2, Maurizio Pacifici1, Howard An, MD3, Yejia Zhang, MD4; 1Thomas

Jefferson University, Philadelphia, PA, USA; 2Philadelphia, PA, USA;3Chicago, IL, USA; 4Rush University Medical Center, Chicago, IL, USA

BACKGROUND CONTEXT: Fibronectin (Fn) is a multifunctional gly-

coprotein found in the extracellular matrix (ECM). Fn splice variants

may play an important role in regulating cell-matrix and matrix-matrix in-

teractions in human disc tissues. In this study, we have characterized the Fn

alternative splice variants in normal and degenerative human IVD tissues.

PURPOSE: To facilitate the development of rational biological treatments

as alternatives to the surgical removal of degenerative intervertebral discs

(IVD), our aim is to better understand the pathophysiology of disc

degeneration.

STUDY DESIGN/SETTING: Surgically-collected human IVD tissues

were examined using molecular biology techniques and FN splice variants

were identified.

PATIENT SAMPLE: Fresh human IVDs with different degrees of degen-

eration were collected during spine surgery (IRB# 05U.237). The severity

of degeneration was graded using MRIs according to Pfirrmann et al.[1]

Normal human discs were acquired through the Cooperative Human Tissue

Network.

OUTCOME MEASURES: N/A.

METHODS: Frozen IVD tissues were crushed and soluble protein and to-

tal cellular RNA were extracted. The proteins were analyzed by western

blot. The RNA was analyzed by reverse transcriptase-polymerase chain re-

action (RT-PCR) using primers flanking the alternatively spliced regions:

extra domain A (EDA), EDB and variable (V). The V region was

sequenced.

RESULTS: Our data indicate that infant disc tissues express more EDB

than those of normal adults. The EDB inclusion is increased in moderately

degenerative tissue (grades II and III), suggesting that EDB inclusion may

correlate with a reparative process in early disc degeneration. EDA is

found in infant IVD tissues, but not in adult tissues, suggesting that this

domain may play a role in IVD development. All five variants of the V re-

gion are present in IVD tissues.

CONCLUSIONS: Our study is the first to describe the splice variants of

FN using well characterized human IVD tissues. This information should

prove useful to researchers studying FN forms and functions in disc tis-

sues. Furthering the understanding of the pathophysiology of disc degen-

eration should promote the design of successful treatment strategies.

FDA DEVICE/DRUG STATUS: This abstract does not discuss or include

any applicable devices or drugs.

doi: 10.1016/j.spinee.2009.08.244

202. P38 MAPK Inhibition Selectively Mitigates Pain-Related

Inflammatory Mediator Production in AF and Activated

Macrophage-like THP-1 Cell Co-Culture

Joo Han Kim, MD, PhD1, Rebecca Studer, PhD2, Gwendolyn Sowa, MD,

PhD2, Nam Vo, PhD2, Youn-Kwan Park, MD3, James Kang, MD2; 1Seoul,

South Korea; 2University of Pittsburgh, Pittsburgh, PA, USA; 3Korea

University School of Medicine, Seoul, South Korea

BACKGROUND CONTEXT: Recent data suggest that macrophages are

involved in the pathogenesis of discogenic low back pain and we have

shown that macrophages enhance secretion of inflammatory mediators in

co-culture with annulus fibrosus (AF) cells or AF cells previously cultured

with macrophages.

PURPOSE: The purpose of these studies is to determine the role of p38

Mitogen Activated Protein Kinase (p38MAPK) signaling in (1) the inter-

actions between macrophage and AF cells, and (2) naı̈ve and macrophage

exposed AF cell’s response to TNF-a activation.

STUDY DESIGN/SETTING: Human AF cells were co-cultured with

phorbol myristate acetate stimulated macrophage-like THP-1 cells.

PATIENT SAMPLE: Human AF cells were isolated from tissue of six pa-

tients (M: F 5 2: 4) removed during elective surgical procedures per-

formed for degenerative spinal disease (disc grade: II-III) by one

surgeon (J.D.K).

OUTCOME MEASURES: The conditioned medium from cells cultured

alone or in co-culture, with or without the selective p38 MAPK inhibitor

Sb 202190 (0.1 M, 1 M, or 10 M), was assayed for IL-6, IL-8, PGE2,

and PGF2 by ELISA. Using the same outcome measures, comparisons

of response to TNF-a in the presence of 0.1 M and 1 M sb 202190 were

made among macrophage-like cells, naı̈ve AF cells, and macrophage ex-

posed AF cells.

METHODS: Human AF cells were co-cultured with phorbol myristate ac-

etate stimulated macrophage-like THP-1 cells. The conditioned medium

from cells cultured alone or in co-culture, with or without the selective

p38 MAPK inhibitor Sb 202190 (0.1 M, 1 M, or 10 M), was assayed for

IL-6, IL-8, PGE2, and PGF2 by ELISA. Using the same outcome mea-

sures, comparisons of response to TNF-a in the presence of 0.1 M and

1 M sb 202190 were made among macrophage-like cells, naı̈ve AF cells,

and macrophage exposed AF cells.