| Low back pain was defined as a pain syndrome mainly located at lumbosacral area and buttocks, with or without weakness and radiating pain on the legs. The result of America and Europe researchers'studies show that about 60% to 80% of adult patients would be suffered form low back pain for at least one time during their whole life-time. In fact, low back pain was considered as the common cause of disability among patient under 45 years old. In addition, .its incidence is still rising year on year complied with the population aging process. In China, about 1 / 3 outpatients come for their low back pain generally. Low back pain is the most common disorder of orthopedic, sports medicine and pain rehabilitation and the second common cause for visit, which is only second to upper respiratory tract infection. Currently, low back pain is not only a pure medical problem, but also a complex problem which may lead to a series of psychological and socio-economic burdens. Waddell says that "the development of modern medicine did not solve the problem of low back pain and even made it worse than before. Low back pain is a disaster and unsolved mystery in twentieth century health care.The generation of low back pain is influenced by a variety of factors. Previous studies about low back pain are mainly focused on the discogenic pain. However, lumbar facet joint was proven to be a important pain generator. Recently, the low back pain derived from lumbar facet joint gradually arouses our attention. In the present study, we'd like to established two facet joint pain animal models though intra-articular injection of complete freund's adjuvant or monosodium iodoacetate, and study about the pathological and functional characteristics of this two new models. Based on the animal model, we make a preliminary study on the mechanisms of lumbar facet joint pain. The new animal models would be used as a helpful tool for the further studies. In addition, we also make some retrospective studies on the diagnosis and outcome of two low back pain-relative lumbar facet joint diseases in order to make sure the clinical feature of lumbar facet joint pain and its treatment.Part?. Establishment of the rat model of lumbar facet joint pain and relative study1. The distribution of substance P positive nerve fiber in the SD rat lumbar facet joint Objective: Study about the distribution of substance P positive nerve fiber in the SD rat lumbar facet joint. Method: Immunohistochemical staining on the pathological section of SD rat lumbat facet joint was used to the distribution of substance P positive nerve fiber in articular cartilage, plica synovialis and subchondral bone. Results: Substance P positive nerve fibers were found in articular cartilage, plica synovialis and subchondral bone. The nerve fibers were tortuous cord-like non-myelinated fibers with a diameter range from 1 to 5?m. Compared to the two other structures, the density of nerve fibers was relative high in the joint capsule. Conclusion: Substance P positive nerve fibers can be found in articular cartilage, plica synovialis and subchondral bone. It may be the anatomical basis of lumbar facet joint pain.2. The study on the segment distribution pattern of lumbar facet joint innervated nerve fibers and the morphological feature of primary afferent sensory neuronsObjective: Study about the segment distribution pattern of lumbar facet joint innervated nerve fibers and the morphological feature of primary afferent sensory neurons in the dorsal root ganglion. Methods: The retrograde transport of fast blue was used to study the segment distribution pattern of lumbar facet joint innervated nerve fibers. Double mark of fast blue and nuclear yellow, or fast blue and substance P (immunofluorescence staining) was used to analysis the morphological and functional feature of primary afferent sensory neurons in the dorsal root ganglion. Results: The SD rat left L5/6 facet joint is innervated by unilateral multi-segment DRGs, including L1 DRG to L5 DRG. The afferent nerve fibers are mainly derived from two or three segments above. Most of the primary afferent sensory neurons are small or medium sized neurons. FB/SP double-labled neurons can be found in each DRG range from L1 to L5. A small amount of lumbar facet joint primary sensory afferent neurons have branches to dominate the ipsilateral lower extremity plantar skin. Conclusion: The fact that the innervation of lumbar facet joint is multi-segmental in SD rat and some primary afferent sensory neurons are FB/NY or FB/SP double-labled, may be the anatomical basis of lumbar facet joint pain and its referred pain.3. Establishment of the rat facet joint inflammation pain model by intra-articular injection of complete Freund's adjuvantObjective: To establish a rat facet joint pain model induce by inflammation and make a preliminary study on the pain mechanisms in this model. Methods: A monoarthritis of lumbar facet joint was induced by intra-articular injection of complete Freund's adjuvant. The change of paw withdrawal threshold for thermal hyperalgesia and mechanical hyperalgesia was measured directly on the different postoperative time points. The degeneration of articular cartilage and the extent of synovitis were evaluated by toluidine blue and HE staining, respectively. In addition, the change of substance p mRNA level in L5 DRG and spinal cord and the number of GFAP positive neurons were also recorded. Finally, the pharmacologic of celecoxib on mechanical hyperalgesia were tested on three different postoperative time points. Results: After the injection of CFA, a constant synovitis and mild or moderate degeneration of articular cartilage were found during the whole observation period. Significant decrease of paw withdrawal threshold was directly found after injection while the mRNA level of substance p L5 DRG and spinal cord and number of GFAP positive neurons were increased simultaneously. Celecoxib can effectively inhibit the decrease of PWT on both early and late period. Conclusion: A new rat facet joint inflammation pain model could be successfully established by intra-articluar injection of CFA. We presume the inflammation of synovium may play a role in the generation of pain in this animal model.4. Establishment of the rat facet joint osteoarthritis pain model by intra-articular injection of monosodium iodoacetateObjective: To establish a rat facet joint osteoarthritis pain model and make a preliminary study on the mechanisms of facet joint osteoarthritis pain in this model. Methods: Lumbar facet joint osteoarthritis was induced by intra-articular injection with different concentrations of monosodium iodoacetate. The change of paw withdrawal threshold for thermal hyperalgesia and mechanical hyperalgesia was measured directly on the different postoperative time points. The optimal dosage used for establish osteoarthritis model was selected based on the result of postoperative cartilage degeneration and the change of paw withdrawal threshold. The extent of synovium inflammation was evaluated by HE staining and the contents of three main inflammatory cytokines. The substance P and ATF-3 positive neurons were recorded on different postoperative time point. Finally, the pharmacologic of celecoxib and gabapentin on mechanical hyperalgesia were tested on different postoperative time points.Results: After the injection of MIA, OA-like cartilage degeneration was found in a time–dependent pattern. The optimal concentration MIA used for establish osteoarthritis model is 0.01mg/5?L. A transient synovium inflammation was noted within one week after injection. The change of synovium inflammation and the change of SP positive neurons number were closely track the first phase of pain- related behaviour changes (1-7days). During the late observation period, obvious structure destruction like expose of subchondral bone, bone marrow fibrosis and marginal osteophyte formation were found in consistent with the second decrease of PWT. Significant increase of ATF-3 positive neurons was only found 14 days after injection. Celecoxib was effective only at day 3 and ineffective at day 21 and 56 while gabapentin kept its inhibitory effect at all three time points. Conclusion: A new rat facet joint osteoarthritis pain model could be successfully established by intra-articluar injection of MIA. This model might provide a useful tool for further study to ascertain the complex mechanism of facet joint pain.Part?. A retrospective study of the contrast on the diagnosis, clinical present and treatment outcome of lumbar facet joint hemorrhagic and non- hemorrhagic synovial cyst Objective: To study about the difference on the epidemiology data, clinical present and treatment outcome between the lumbar facet joint hemorrhagic and non- hemorrhagic synovial cyst. Methods: A retrospective review and contrast analysis of clinical relative data on 18 patients with lumbar facet joint synovial cysts and 5 patients with lumbar facet joint hemorrhagic synovial cysts. Results: Compared to non- hemorrhagic synovial cyst, lumbar facet joint hemorrhagic synovial cyst has its own characteristics, including younger age, short course of disease, causative factor, severe radicular pain and resistance to the conservative treatment. However, there is still some come point between both cysts, like sex ratio, predilection site and concomitant local diseases. Hemilaminectomy or laminectomy with medial facetectomy without fusion was carried out on all patients in both groups. The clinical outcome was good and the complications or re-operation rate was low. Conclusion:Lumbar facet joint hemorrhagic synovial cyst has its own characteristics in clinical epidemiology data and clinical presentation. Surgical treatment for both cysts was safe and effective.Part?. Reduction, transforaminal lumbar interbody fusion (TLIF) with posterior fixation Versus Transsacral cage fusion in situ with posterior fixation in treatment of Grade?adult isthmic spondylolisthesis in lumboscacral spineObjective :To study about the outcome of transsacral cage fusion in situ with in the management of adult lumboscacral Grade?isthmic spondylolisthesis, and compare it to the TLIF and reduction procedure. Methods: 21 patients in group A were treated by reduction and TLIF, and 13 in group B was treated by transacral cage fusion. ODI score, VAS score of back pain and leg pain were used to evaluate the clinical outcomes. The radiological parameters for assessment included percentage of slippage, whole lumbar lordosis (WL) and lumbosacral angle (LSA). Operative data, fusion rate and perioperative complications were recorded.. Results: The mean operation time and blood loss of group B was less than that of group A. Both two groups obtained good recovery of previous symptoms. The decrease of back pain and leg pain after surgery were significant within each group, but without much difference between the two groups. No significant differences on LSA,WL,VAS and ODI scores were found between the two groups after surgery. Solid fusion was 95.2% in group A and in 92.3% in group B. In group A, two suffered graft site pain, one had superficial infection, and one had screw loosening , while in group B, dural tears were found in two patients, transient S1 paraesthesia in two, and extensor hallucis longus weakness in one. Conclusion: For patients with a collapsed disc space and poor bone quality, posterior in situ transsacral cage fusion might be used as an alternative to TLIF procedure. The short term clinical and radiological outcomes of transsacral cage group were comparable to those of TLIF group, though with a relatively higher neurological complication rate. |
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