基质金属蛋白酶和胶原在创伤关节软骨组织中的表达*☆

背景：研究发现,基质金属蛋白酶和胶原参与关节软骨组织机体生理重建及病理破坏。 目的：观察膝关节骨软骨缺损及表面软骨缺损动物模型关节软骨组织中胶原及基质金属蛋白酶的表达变化。 方法：雌性SD大鼠48只随机分为3组：骨软骨缺损组在双膝关节制作骨软骨缺损模型,表面缺损组在双膝关节制作表面软骨缺损,对照组双膝关节制作关节囊切开。分别于术后4、8、12周取股骨髁标本,行苏木精-伊红染色,免疫组化检测Ⅰ型胶原、Ⅱ型胶原、基质金属蛋白酶3的表达。 结果与结论：骨软骨缺损组术后4周缺损中有少量新生组织生成,8及12周可见到纤维组织填充,修复组织细胞外基质Ⅰ型胶原免疫组化染色阳性,Ⅱ型胶原免疫组化染色阴性,关节软骨组织中基质金属蛋白酶3表达增高。表面缺损组表面软骨缺损4及8周未见修复迹象,12周可见微量纤维组织填充,细胞外基质Ⅰ型胶原免疫组化染色阳性,Ⅱ型胶原免疫组化染色阴性,术后表面缺损组关节软骨组织基质金属蛋白酶3表达增高。对照组关节软骨组织Ⅰ型胶原免疫组化染色阴性,Ⅱ型胶原免疫组化染色阳性,基质金属蛋白酶3低表达,无形态学异常改变。说明机械性损伤可以导致关节软骨细胞外基质成分发生改变,丧失其原有的生物学特性而退变,基质金属蛋白酶3在损伤后的软骨组织中表达增高,使细胞外基质的降解增加,是导致关节软骨退变的重要因素。     

正常关节软骨和骨关节炎关节软骨细胞中血管活性肠肽表达的比较

背景：神经肽的发现给骨关节炎的治疗带来了新的希望,但神经肽的表达与骨关节炎发病以及软骨退变程度的关系尚不清楚。 目的：观察血管活性肠肽在正常关节软骨和不同退变程度骨关节炎软骨中的表达,以及血管活性肠肽表达与骨关节炎发病及软骨退变程度的关系。 方法：选取2007-03/11中南大学湘雅医院骨科进行关节置换的骨关节炎患者的关节软骨标本26个,选取因外伤行截肢的膝关节软骨或股骨颈暴力骨折的股骨头正常关节软骨标本10个为对照,根据大体观察凿取正常和骨关节炎不同退变程度软骨块50个,再根据关节软骨改良Mankin病理评分法进行分组,采用免疫组织化学染色检测软骨组织中血管活性肠肽的表达和分布。 结果与结论：各关节软骨中均可见到血管活性肠肽阳性神经纤维,正常关节软骨中血管活性肠肽的表达明显高于骨关节炎关节软骨(P < 0.05)。且血管活性肠肽表达与软骨改良Mankin病理评分呈负相关(r=-0.896,P < 0.05)。说明血管活性肠肽低表达与关节软骨退变程度、骨关节炎病程进展有关,可能是关节软骨退变、骨关节炎发病的机制之一。     

血管母细胞瘤35例临床分析

目的 通过对颅内血管母细胞瘤(HBs)的影像学、病理和治疗分析,探讨HBs的诊断、形成原因和疗效. 方法 皖南医学院弋矶山医院神经外科自2005年1月至2010年1月应用肿瘤切除术治疗35例颅内HBs患者,根据影像学表现分为大囊小结节型、小囊大结节型和完全实质型.分析患者的临床资料,对肿瘤标本行HE染色和免疫组化染色检测NSE和CD34的表达. 结果 本组肿瘤全切除34例,次全切除1例,术后无死亡.出院后28例获得随访,随访时间3个月至3年.其中1例复发(大囊小结节型)行伽玛刀治疗.HE染色显示纤细血管相互吻合成网状,分隔脂质胞浆;免疫组化染色显示不同类型肿瘤CD34阳性细胞数比较差异无统计学意义(P＞0.05).大囊小结节型肿瘤NSE阳性细胞数最多,小囊大结节型其次,实质型最少,差异均有统计学意义(P＜0.05). 结论 HBs无特殊临床表现,影像学表现是主要诊断方法.治疗首选手术切除,手术全切除是降低复发的关键.HBs囊腔的形成与肿瘤间质细胞密切相关.     

椎间盘突出临近退变节段是否导致腰痛☆

背景：椎间盘突出症患者腰痛原因很难判断,一直以来,认为突出的椎间盘是椎间盘突出症患者腰痛及腿痛重要原因,椎间盘突出临近退变节段是否导致腰痛需进一步研究证实。 目的：通过椎间盘造影判断突出临近退变节段是否是椎间盘突出症患者腰痛原因,并报告经椎间盘镜摘除椎间盘后残留腰痛在临近退变疼痛椎间盘经亚甲蓝注射治疗的效果。 方法：20例同时具有腰痛和腿痛椎间盘突出症患者行椎间盘造影检查,这些患者腰椎MRI表现为有1个突出椎间盘外至少合并1个或1个以上的临近退变的椎间盘,全部患者均经椎间盘镜摘除椎间盘切除突出的椎间盘,5例临近退变椎间盘造影阳性患者在椎间盘镜切除后经椎间盘内注射亚甲蓝治疗。腰痛、腿痛采用目测类比评分评定。 结果与结论：20例患者总共64个椎间盘行椎间盘造影,共11个椎间盘造影阳性,其中6个位于椎间盘突出临近退变节段,5个位于引起神经根性痛的椎间盘突出节段。全部病例腿痛行椎间盘镜切除突出椎间盘后明显缓解,腰痛有部分缓解,6例临近椎间盘造影阳性患者经椎间盘镜摘除椎间盘后腰痛明显,影响日常生活,其中5例行临近疼痛椎间盘亚甲蓝注射后腰痛缓解,1例患者拒绝亚甲蓝注射治疗仍有明显腰痛。结果显示椎间盘突出症患者腰痛可能来源于突出临近退变节段。     

脑动静脉畸形伽玛刀治疗后的组织病理研究(附5例报道)

目的研究脑动静脉畸形(CAVM)经伽玛刀治疗后的组织病理变化。方法对5例CAVM伽玛刀治疗后的病理标本进行HE染色,并用α-SMA、PCNA、OPN及VEGF等抗体进行免疫组化研究。结果伽玛刀治疗后CAVM血管病理变化包括内膜增厚,管壁增厚、玻璃样变,管腔狭窄至消失等。玻璃样变的管壁或闭塞的管腔可见管腔的再通。OPN、PCNA在表现为早期放射反应的动脉管壁中有强表达;1例标本见内皮细胞PCNA及VEGF阳性染色的网状毛细血管样血管。结论放射治疗后CAVM血管中层的VSMC增生,部分转变为合成表型。VSMC的迁移、增殖和变性是伽玛刀治疗后CAVM进行性血管病理变化的关键因素。     

JO-1综合征骨骼肌病理改变(附二例报告)

目的总结2例JO-1综合征患者骨骼肌病理改变特点并分析其发病机制。方法采用组织学、酶组织化学和抗CD68单克隆抗体的免疫组化染色对2例JO-1综合征患者骨骼肌活检标本进行病理观察。结果2例患者骨骼肌存在节段性肌束衣玻璃样变性伴随CD68阳性单核细胞浸润。可见散在或小组样分布的小角状萎缩肌纤维。结论JO-1综合征骨骼肌主要病理改变是节段性结缔组织断裂变性和单核细胞浸润,提示抗原靶点可能在成纤维细胞,并可伴发神经源性骨骼肌损害。     

退变性腰小关节疼痛的发病机制

腰椎小关节关节囊及关节组织中有大量神经末梢分布,这些神经纤维来自脊神经后支的内侧分支, 解剖学上每个小关节至少接受两个脊柱节段的神经支配。但是患有腰椎小关节损伤的患者有时会有下腰部、大腿前方、腹股沟等部位疼痛,说明腰小关节的神经支配分的复杂性,腰椎小关节的这种支配方式形成了十分复杂的腰腿痛发病机制。腰小关节骨性关节炎同其他关节的骨性关节炎一样,表现为软骨面的病损,软骨下骨的硬化及骨赘形成,关节腔狭窄,关节囊增厚及滑膜增生等改变。细胞因子及其受体的高表达是退行性骨关节炎形成的重要诱因,基中最重要的是白细胞介素1β和肿瘤坏死因子α。     

盐酸氨基葡萄糖联合非类固醇类抗炎药治疗小关节退变伴下腰痛☆

背景：盐酸葡萄糖胺对骨关节炎的治疗作用在膝关节已经得到证实,然而盐酸氨基葡萄糖与非类固醇类抗炎药物联用的治疗腰背痛鲜有报道。 目的：探讨盐酸氨基葡萄糖与小剂量非类固醇类抗炎药物联用治疗腰椎小关节退变伴下腰痛的临床效果。 方法：纳入35例小关节退变伴下腰痛患者,给予口服盐酸氨基葡萄糖750 mg,2次/d,外加双氯酚酸钠缓释片75 mg, 1次/d,周期8周。使用Oswestry残疾指数、目测类比疼痛评分和SF-36量表在治疗前,治疗完成时和完成治疗后8周进行评估。 结果与结论：33例完成最终的随访,男女比例为1∶2,平均(41.2±10.3)岁。经过治疗,患者的腰痛和腿痛症状,腰椎功能和生活质量均有显著改善和提高(P < 0.05)。提示,盐酸氨基葡萄糖与小剂量非类固醇类抗炎药物联用对小关节退变伴腰痛患者有一定治疗作用。     

慢性特发性轴索性多神经病的病理及免疫组化研究

目的 研究慢性特发性轴索性多神经病(chronic idiopathic axonal polyneuropathy,CIAP)病理改变特点,并探索腓肠神经炎细胞CD3、CD20、CD68抗体及其微小血管内皮细胞膜结合性血栓调节蛋白(thrombomodulin,TM)、内皮源性一氧化氮合酶(endothelial-nitricoxide synthase,e NOS)的表达规律。方法 10例经过临床、电生理、腓肠神经活检病理检查证实的CIAP患者,均进行腓肠神经活检标本的常规病理组织学染色以及以抗CD3、CD20、CD68、TM、e NOS、v WF(von Willebrand factor,v WF)抗体作为第一抗体的免疫组织化学染色。结果 10例患者腓肠神经病理检查显示有髓神经纤维轻-中度减少,伴随轴索变性和再生,部分可见轻微脱髓鞘改变,4例患者出现毛细血管基底膜肥厚。4例患者腓肠神经神经束衣间小血管周围有散在分布的CD68阳性单核细胞浸润。所有患者血管内皮细胞v WF、e NOS、TM均正常表达。结论 CIAP病理特点为轴索损害为主,发病可能和体液免疫异常有关,部分患者毛细血管基底膜肥厚提示血管内皮细胞可能受损,但内皮细胞功能相关蛋白表达初步提示正常。     

中枢神经系统海绵状血管畸形的免疫组化染色研究

目的 应用免疫组化染色观察不同类型中枢神经系统海绵状血管畸形的内皮细胞标记物、血管生成和增殖活性,探讨病变出血的分子基础. 方法 以自2004年4月至2008年8月南方医院神经外科经显微手术切除的97例中枢神经系统轴内海绵状血管畸形的病理标本为观察对象,根据患者MRI表现分类及其与术中病理形态的比较将所有患者分为出血组(47例)和非出血组50例；另设正常对照组20例,标本来自颅脑外伤患者切除的脑组织.将3组病理标本进行CD34、α-平滑肌肌动蛋白(α-SMA)及血管内皮生长因子(VEGF)免疫组化染色并比较. 结果 海绵状血管畸形内皮层中,CD34呈不同程度的表达,有明显的不连续性；管腔小的病变血管中.CD34染色层较厚；而在管腔大的病变血管中,CD34染色层却较薄,且常不连续.α-SMA表现为阴性或弱阳性(-)～(++).弥散地分布于内皮下层.VEGF有较明显的表达(-)～(++),主要弥散地位于内皮层、内皮下层以及病变血管之间的纤维结缔组织中.正常对照组、出血组与非出血组之间CD34、α-SMA及VEGF免疫组化染色经Kruskal-Wallis H检验示差异均有统计学意义(P＜0.05).所有标本Ki-67染色均呈阴性. 结论 血管结构上缺乏平滑肌可能是部分海绵状血管畸形容易出血的原因之一；VEGF弥散性的表达增多,可能与出血诱导的非特异上调有关；Ki-67染色呈阴性表明至少在标本取得时不存在增殖状态.     

Localization of substance P and neurofilament immunoreactive fibers in the lumbar facet joint capsule and supraspinous ligament of the rabbit

An indirect immunofluorescence method was utilized to identify substance P-like immunoreactive (SPLI) and neurofilament protein immunoreactive (NFIR) fibers in the lumbar facet joint capsule and supraspinous ligament of the rabbit. The results demonstrated a large population of NFIR fibers, indicating that these tissues are richly innervated, and a smaller population of SPLI fibers. In some fibers, neurofilament protein and substance P were colocalized. The data suggest that the facet joint capsule and the supraspinous ligament contain SPLI nociceptive fibers that could be a source of low back pain.     

Lumbar juxta-facet cyst after trauma.

We report a post-traumatic lumbar facet cyst in which results of magnetic resonance imaging (MRI) performed at the time of injury were available. The patient was a 59-year-old man who presented with severe low back and right leg pain immediately after injury of his sacroiliac region in a traffic accident. MRI at the time of injury revealed high intensity signal change in the right facet joint at L4/5. Re-examination 5 months after the injury with MRI revealed a cyst, which was continuous with the facet joint. Surgical resection of the cyst yielded satisfactory results. We describe detailed MRI findings for this case and review the literature on traumatic juxta-facet cyst in the lumbar spine.     

椎间融合器植入并双侧下关节突切除治疗退变性腰椎管狭窄症

背景：对退变性腰椎管狭窄治疗可行全椎板减压内固定置入、单侧或双侧开窗减压、后路全椎板减压等方法。但采取何种方式治疗中是否需行椎间融合器植入内固定目前还没有定论。 目的：评价以cage椎间植骨融合椎弓根内植入固定并腰后路全椎板及双侧下关节突切除减压、自体小关节骨质移植治疗退变性腰椎管狭窄症的效果。 方法：选择经3个月保守治疗无效的退变性腰椎管狭窄症患者41例,男23例,女18例,平均年龄60.3岁,行腰后路全椎板及双侧下关节突切除减压、自体小关节骨质及cage椎间植骨融合植入椎弓根内固定治疗,随访24个月,术前及术后随访时JOA评分评价患者疗效,放射学检查患者植骨融合情况及手术节段椎体稳定性。 结果与结论：随访时JOA评分较术前有明显提高(P < 0.01),临床优良率为90%;40例获得骨性融合,融合率98%,1例患者有腰椎不稳征象。术后均无内固定物松动、断裂等并发症发生,但有2例发生硬脊膜撕裂,1例发生椎弓根位置偏斜,1例假关节形成。结果提示腰后路全椎板及双侧下关节突切除减压、自体小关节骨质及cage椎间植骨融合植入椎弓根内固定治疗退变性腰椎管狭窄症具有良好的临床效果。     

The coexistence of serotonin- and substance P-like immunoreactivity in the spinal cord of the rat as shown by immunofluorescent double labeling

This study surveyed the coexistence of serotonin-like immunoreactivity (5-HT-IR) with substance P-like immunoreactivity (SP-IR) in fibers and terminals within various portions of the spinal cord of the rat. A previously characterized technique of immunofluorescent double labeling was used to stain 5-HT-IR red and SP-IR green, and a search was then made for single fibers that fluoresced both colors. These were found to be most common in the ventral horn, wherein 99% of 5-HT-IR fibers were also immunoreactive for SP. Coexistence of these substances was very rare in the superficial dorsal horn: fewer than 3% of 5-HT-IR fibers were immunoreactive for SP. In the region surrounding the central canal and in the intermediolateral cell column (IML), over half of all 5-HT-IR fibers and terminals were doubly labeled. In the white matter, doubly labeled fibers were most common in the ventral funiculus and somewhat less common in the lateral funiculus. They were rare in the dorsal columns. It is concluded that the coexistence of 5-HT and SP in nerve fibers and terminals is associated with somatic and sympathetic autonomic motoneurons. The role of the coexistence of 5-HT and SP in somatosensation, including pain, is unclear.     

Peptidergic innervation in the cerebral blood vessels of the guinea pig: an immunohistochemical study.

The distribution of peptidergic nerve fibers containing substance P (SP), calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP), and neuropeptide Y (NPY) in the cerebral arteries and veins of the guinea pig was studied using immunohistochemical techniques. The ultrastructure of these immunoreactive nerve terminals was also compared. The cerebral arteries were innervated by abundant peptidergic nerve fibers with characteristic running patterns, i.e., SP fibers in a meshwork, VIP and NPY fibers in a spiral fashion. Only CGRP fibers showed both meshwork and spiral patterns. In the cerebral veins, the abundant SP fibers innervated the cortical veins, deep cerebral veins, and dural sinuses. However, CGRP, VIP, and NPY fibers in extremely low density were noted merely in the cortical veins. Electron microscopic observations demonstrated that SP-immunoreactive nerve terminals existed apart from the arterial smooth muscle cells, while VIP- and NPY-immunoreactive nerve terminals adjoined them. As for CGRP nerve terminals, some existed close to the arterial smooth muscle cells, and others were found some distance from them. These morphological characteristics observed by light and electron microscopy suggest that SP fibers are not related directly to the vasomotor function, but VIP and NPY fibers are, and that CGRP fibers have a more complicated function. The distribution patterns of the peptidergic nerve fibers are consistent with the suggestion that vasomotor peptidergic fibers may function actively on cerebral arteries and passively on cerebral veins and that SP fibers regarded as sensory fibers may provide information regarding cerebral vascular conditions, innervating every part of both cerebral arteries and veins.     

Substance P and calcitonin gene-related peptide immunoreactive sensory DRG neurons innervating the lumbar facet joints in rats

The rat L5/6 facet joint is innervated from L1 to L5 dorsal root ganglions (DRGs) multisegmentally. Sensory fibers from L1 and L2 DRGs were reported to innervate nonsegmentally through the paravertebral sympathetic trunks, while those from L3 to L5 DRGs segmentally innervate the L5/6 facet joint. The presence of substance P (SP) and calcitonin gene-related peptide (CGRP) immunoreactive (ir) nerve fibers has been demonstrated in the lumber facet joints, but their ratios have not been determined. Fluoro-gold (F-G) labeled neurons innervating the L5/6 facet joint were distributed throughout the DRGs for levels L1 to L5. Of the F-G labeled neurons, the ratios of SP-ir L1, L2, L3, L4 and L5 DRG neurons were 13, 15, 29, 31 and 30%, respectively, and those of CGRP-ir neurons were 17, 24, 44, 56 and 50%, respectively. The ratios of SP and CGRP-ir neurons in L1 and L2 DRGs were significantly less than those in L3, L4 or L5 DRGs. In conclusion, the neurons of L3, L4 and L5 DRGs may have a more significant role in pain sensation of the facets than L1 and L2 DRG neurons.     

Facet Joint Pain and the Role of Neural Blockade in Its Management

Chronic spinal pain is a common medical problem with serious financial and social consequences. Among the various structures with potential for producing pain in the spine, facet joints as sources of chronic spinal pain have attracted considerable attention and controversy. Significant progress has been made in precision diagnosis of spinal pain with neural blockade, in the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies. Research into the role of facet joints in spinal pain has shown that cervical facet joints are the cause of chronic neck pain in 54% to 60% of patients, whereas lumbar facet joints cause pain in 15% to 40% of patients with chronic low back pain. Local anesthetic blocks of medial branches have proven to be a reliable diagnostic test; they are target-specific when used appropriately with control blocks, either with two local anesthetics with different durations of action or with the addition of an inactive placebo injection. The literature is replete with reports on uncontrolled studies, case reports, and documentation from a few controlled studies, all of which offer supporting information on the rationale and effectiveness of facet blocks and neurotomy. Facet joint injections and medial branch blocks are considered to be of equal value. Lumbar intra-articular steroid injections have been proven effective to a certain extent, but evidence indicates that cervical intra-articular steroids are ineffective. The role of repeat medial branch blocks is not known. Radiofrequency neurotomy remains the only practical and validated treatment for cervical facet joint pain; however, its role in management of either lumbar or thoracic facet joint pain awaits validation.     

Surgical Tips to Preserve the Facet Joint during Microdiscectomy

Lumbar microdiscectomy (MD) is the gold standard for treatment of lumbar disc herniation. Generally, the surgeon attempts to protect the facet joint in hopes of avoiding postoperative pain/instability and secondary degenerative arthropathy. We believe that preserving the facet joint is especially important in young patients, owing to their life expectancy and activity. However, preserving the facet joint is not easy during lumbar MD. We propose several technical tips (superolateral extension of conventional laminotomy, oblique drilling for laminotomy, and additional foraminotomy) for facet joint preservation during lumbar MD.     

Lumbar post-laminectomy syndrome: II. Pain management using neuro-modulation techniques

The application of neuro-modulation techniques in general is currently gaining acceptance in various aspects of medicine. Neuro-modulation is defined as: "Therapeutical interventions using implantable devices to modify the functioning of central, peripheral and autonomic nervous systems". Following lumbar disc surgery, or lumbar spine surgery in general, several chronic pain syndromes can result, either in the lumbar region and/or in the lower limbs. The current status is for the application of surgery to the degenerative spine (degenerative disc disease and lumbar stenosis) for the relief of chronic pain. A review of the methodology of evidence based medicine, show that the instrumented and fusion techniques are not the answered despite 20 years of the use of these techniques following failure of surgery for the relief of back pain syndrome. Neuro-modulation techniques represent a step in the right direction for the management of these chronic pain syndromes. Frequently they enable the resolution of chronic pain following spine surgery without having to resort to repeat surgery. We describe here the different neuro-modulation techniques (spinal cord stimulation, spinal drug infusions) which can be used in the case of back surgery failure, and we describe technical aspects and "tricks of the trade" for the correct implantation of the devices used in techniques. Neuro-modulation techniques are applied to the management of chronic pain following disc surgery and represent a valid alternative to repeat surgery and/or arthrodesis (instrumented or not). Neurosurgeons are again called to play active roles in the field of neuro-modulation for the treatment.