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각종화합물의 주입이 가견요추간판(家犬腰椎間板)에 미치는 영향에 관한 실험적연구

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 Experimental intervertebral-disc lesions produced by injection of various chmeical solutions 
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[영문] For centuries, the problem of low-back pain and sciatica has often been an enigma to the medical profession. although much excellent work has been done on the subject of backache, there is much left to be answered. An imposing list of possible causes for this syndrome has been compiled which implicates various structures and tissues in the pelvic and abdominal regions, however, convincing pathological and anatomical evidence to incriminate these various structures is frequently not to be found in patients who complain of low-back and sciatic pain. Since the demonstration of Mixter and Barr, rupture of an intervertebral disc or posterior protrusion of an intervertebral disc has been recognized as a clinical as well as pathological entity and there has been a growing tendency among clinicians to attribute low-back pain to derangements of the lumbar intervertebral discs in the absence of other demonstrable causes. Furthermore, there are many who believe that the lesions of an intervertebral disc are the only cause of idiopathic low-back pain with or without sciatica. However, in many instances, we are not only at a loss for an explanation of mechanism by which pain is produced but also difficult to demonstrate the exact pathogenesis how the derangements of an intervertebral disc is brought about. This particular problem received a great deal of attention by many workers who put forth many theories and arguments concerning degeneration of an intervertebral disc and its relation to backache. Among the evidences, a trauma or physical factors impinging upon an intervertebral disc has been considered to be playing a major role in producing such lesions. Quite frequently a practice of modern medicine requires a lumbar puncture for diagnostic, anesthetic or therapeutic purposes. Particularly the use of lumbar puncture in the investigation of lesions of the central nervous system has become so standarized that it is almost as much of a routine procedure as the systematic study of the reflexes. The possibilities of serious damage to an intervertebral disc by needle puncture are evident from the reports of many observers. Furthermore, over-enthusiasm is leading some surgeons to deliberate insertion of a needle through the disc for the purpose of injecting radio-opaque material for diagnostic purpose. Much concern has been expressed by some who warned the possible deleterious effects of such procedures. While this particular problem has been a concern to many clinicians and 8investigators in this field, we know of no work previously done dealing with this specific problem. Therefore a following experiment is planned to investigate the effects of injecting various chemical solutions directly into the intervertebral discs and clarify some aspects of disc degeneration. Materials and Methods: Fourty healthy mongrel dogs of various breeds were utilized. Each animals was subjected to simple X-ray visualization of spinal column and myelography to check the abnormalities of spine before experimental procedures. The chemical solutions selected were Pantopaque, Diodrast, Procaine hydrochloride and Normal Saline which are commonly used in the practice for the purposes of myelography, discography, subarachnoidal block or other diagnostic procedures. The animals were divided into five groups, namely pantopaque group, diodrast group, procaine group, saline group and multiple puncture group. Under pentothal sodim anesthesia, pararectal incision was made to visualize the lumbar intervertebral discs trans-peritoneally. Under direct observation of an individual disc, 0.2 to 0.4 c.c. of designated solutions were injected through 21 gauge needle. Each animal received injections into 4 intervertebral discs. The multiple punctures were made with 21 gauge needle for 10 to 15 times into the disc. Following injection of pantopaque and diodrast each animal was X-rayed to confirm the correct insertion of dyes into the disc. After operative procedures, the animals were sacrificed in the intervals of 24 hours, 72 hours, 1 week, 2 weeks, 3 weeks and 4 weeks respectively. Individual disc was separated from the vertebral column, the gross features carefully recorded and photographed and fixed into 10% neutral formalin. Paraffin section were stained with Hematoxylin and Eosin, Periodic Acid Schiff reaction, Toluidine blue and Mallory's Azan Stains. Results: As compared with the control discs, the experimental discs all showed one or more of pathological changes as shown in the tables and figures. The most devastating damage had occurred in the annulus fibrosus and nucleus pulposus. Macroscopically, the cartilage plates showed little or no alterations except for some fragmentation and hemorrhage in the multiple puncture group. The changes in the annulus fibrosus were more marked in the multiple puncture group and less marked in the diodrast and pantopaque groups, these changes were characterized by irregularity of running fibers of annulus resulting in disorganized pattern at the boundaries with the nucleus pulposus. The surfaces often showed irregular ups and downs. The nucleus pulposus of the multiple puncture group showed hemorrhage, fragmentation and irregular bulging of structures. In some discs, the entire nuclear material was lost at the time of examination. The nucleus pulposus of saline injected discs showed irregular shrinkage and fragmentation. The procaine injected discs showed somewhat transparant appearance of discs and discoloration of surface appearance. The diodrast injected discs showed cloudy discoloration. Brownish surface with hemorrhagic spots were often present but these changes gradually disappeared as the time lapsed. The pantopaque group showed little changes in the gross appearance of nucleus but considerably the nuclear materials were lost. Microscopically, the majority of the experimental discs showed inflammatory reactions centered around the sites of needle punctures. The inflammatory reaction occurred quite early and became fibrotic very soon but the fibroblastic reaction was mainly localized on the surface and the inner portions of annulus remained broken for a long time. Oftentimes, small blood vessels invaded into the bundles of annulus. Fragmentation and radial splitting of the annulus together with mucinous swelling and degeneration was very common, Vacuolization of annulus was also frequently observed. Oftentimes, particularly in the multiple puncture group, the nuclear materials herniated through the openings created by broken annulys. the herniated materials formed swollen pockets surrounded by fibrosis and healed inflammatory reaction. The nucleus pulposus of saline injected group showed extreme shrinkage of cytoplasm of notochordal cells with loss of much of them. The procaine injected group showed more of ground substance which were stained heavily with P.A.S. and Toluidine blue stains. The cells in this group showed shrinkage of cytoplasm but also contained scattered swollen physalipherous cells. The diodrast group showed more changes in the annulus and cartilage plates and created herniation of nuclear material. The nucleus pulposus showed loss of cells, and irregular fragmentation of reticular fibers. The pantopaque group showed similar changes with that ween in diodrast group but the cellular degeneration was quite more apparent. Hemorrhage, inflammation and fragmentation of nuclear material were the common findings in the multiple puncture group. The cartilage plates remained relatively intact in all the experimental discs however in some, cystic degeneration and calcification was noted. Comment and Conclusion: From the data obtained above, it is quite apparent that injection of various chemical solutions into an intervertebral disc causes a significant pathological alterations. The fact that simple multiple puncture and injection of normal saline has also caused serious damage to an intervertebral disc should be seriously taken as a clear warning toward the abuse of inadequate lumbar punctures. In many aspects, the morphological changes seen in the present investigation were quite similar to the changes seen in so-called degenerated discs. Although there were some minor differences between the chemicals utilized, the changes appeared to be of similar nature and severity. The multiple puncture of an intervertebral disc created, however, the most devastating damage among the groups. Intervertebral disc is not just a static anatomical structure but is a dynamic structure constantly functioning. From the earliest investigations, it has been said that the efficient functioning of the disc depends largely on the elasticity of the nucleus pulposus and that this in turn is closely related to its water-binding capacity. It is also known that in early life a water content of 80∼88% is usually quoted and in later life figures of 70% may occur. This change is usually accompanied by an alteration of morphology of the nucleus. The changes in the water-binding capacity have been thought to be related to the biochemical alterations occurring in the degenerated disc. The delicate mechanism of water balance can be upset by eve minute tears in the annulus or the plates if one assumes that the disc is an osmotic system. There are others who claim that the imbibition pressure and not the osmotic pressure is responsible for the hydration of nucleus pulposus. In any event, however, the derangement of this water-binding mechanism caused by introduction of chemical solutions might have caused such a degenerative changes observed in this investigation. It appeared that the interaction between the nucleus and the chemical substances were only related to the physical factors and not to the chemical interaction. It is convincingly proven that direct trauma to an intervertebral disc by needle puncture can cause serious damage to the disc and that injection of radio-opaque materials into the disc may also bring serious consequences.
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2. 학위논문 > 1. College of Medicine (의과대학) > 박사
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