CN101896140A - 用于治疗脊髓组织的装置和方法 - Google Patents

用于治疗脊髓组织的装置和方法 Download PDF

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CN101896140A
CN101896140A CN2008801210758A CN200880121075A CN101896140A CN 101896140 A CN101896140 A CN 101896140A CN 2008801210758 A CN2008801210758 A CN 2008801210758A CN 200880121075 A CN200880121075 A CN 200880121075A CN 101896140 A CN101896140 A CN 101896140A
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spinal cord
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L·C·阿金塔
D·L·凯罗
N·H·利瓦伊
刘杰
M·J·莫里夸斯
S·塔特
W·D·沃纳
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    • A61M1/90—Negative pressure wound therapy devices, i.e. devices for applying suction to a wound to promote healing, e.g. including a vacuum dressing
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Abstract

本发明提供了治疗损伤的脊髓组织，例如由疾病、感染或创伤损害的脊髓组织的装置和方法，其可导致继发于间质性水肿的肿胀、压缩和损害血流的存在。

Description

用于治疗脊髓组织的装置和方法
发明领域
本发明通常涉及采用负压治疗损伤或损害的脊髓组织的装置和方法，并且更具体地讲，但不是排他性地，涉及用于治疗已经历可恢复或不可恢复性损伤的脊髓组织的装置和方法。
发明背景
涉及脊髓姿态的解剖学、生理学和病理学过程特别关注损伤或损害的脊髓组织的治疗。保护神经元(其功能取决于与其它神经元和其它支持细胞的特殊空间关系)的三维结构解剖学与微观解剖学关系两者以及维持适当的富氧血流和其中神经元存活的均相基质是脊髓组织存活与功能所必需的。另外，脊髓细胞不能再生突出了对于使每一个可能的神经元的存活达到最大限度的需求。由于例如这些原因，治疗脊髓姿态开放与封闭的空间病理学是特别关注的问题。
在有威胁到脊髓组织存活的临床问题中，控制脊髓水肿、感染和血液供给是主要的。脊髓通过收集显著量的间质水肿应答于创伤和损伤。因为脊髓在封闭的空间(硬膜和脊管)被封闭，水肿导致脊髓的血流与营养效能的压缩和减弱，这大大地损害脊髓的生理恢复并通常因此导致脊髓损害的发展与死亡。对于减少水肿目前可得到的治疗包括药物，例如糖皮质激素(地塞米松、泼尼松、甲泼尼龙)、利尿药和广泛的手术减压。然而，对于这些治疗的不利条件包括不规则和不可预知的结果、药物并发症、感染及手术并发症。
由于脊髓感染与水肿的快速传播的灾害性后果和高可能性，对快速和有效治疗的需求也是极其重要的。目前存在几种可利用的治疗侵袭脊柱内腔、脊髓实质与周围结构的病变的成功方法。当身体别处的组织可用换药处理时，脊髓由于其不稳定的结构、感染倾向和损伤发展的潜力而不适合于该类型治疗。有证据说明对脊髓损伤及其它病变的炎症和免疫应答具有与初始损伤或伤害相同或者比初始损伤或伤害更长期的后果。脊髓对继发于水肿的血流减少的应答导致低氧和局部缺血/再灌注介导的损伤。这些损伤造成神经病理学后遗症，后者又在很大程度上造成脊髓损伤的不利结果。
另外，脊髓需要连续不断地供给富氧血流以发挥功能和存活。在完全中断至脊髓的血流几分钟内，造成不可逆的脊髓损伤。然而，脊髓可继续生存并自减少的血流中恢复更加延长的时期。有证据说明脊髓的病灶区域(focal areas)可保持局部缺血和相对无功能数天并且仍然可以恢复。该发现已经导致局部缺血区域的概念，称为半影或晕区(halo zone)，其围绕不可逆损伤的区域。局部缺血区域的次生现象(secondary phenomena)是释放由损伤的神经元局部释放的兴奋性神经毒素、病灶区血流的变化和水肿。
脊柱的血管病理学可为以下的结果：由于灌流压降低，导致对局部脊髓区域直接损伤的血管破裂，或者通过压迫邻近组织使流至脊髓细胞的血液不足；脊髓血管的固有疾病例如动脉粥样硬化、动脉瘤、炎症等；来自别处例如心脏的沉积于脊髓血管中的稀疏血栓。
在脊柱内出血的情况下，出血通常作为以压力剖析(pressure dissection)的体积生长的小块物质开始并且导致置换和压迫邻近的脊髓组织。在出血周围的邻近被压迫组织中的水肿可通过损害更大面积的脊髓组织导致质量效应和临床状况的恶化。在邻近脊髓中的水肿可引起通常经12-72小时可见的进行性恶化。在脊柱内出血后一周内发生水肿通常使预后变得更糟，尤其是在上了年纪的人中。血肿周围的组织被置换和压迫，但不一定是致命的损害。改善可由于血肿被再吸收、邻近水肿减少和受累组织恢复功能而获得。
治疗这些病症已经使人失望。脊髓的手术减压在一些预防不可逆的压迫的病例中可能是有益的。试剂例如甘露糖醇及一些其它的渗透剂可减少由水肿引起的脊柱内压力。类固醇在这些病例中具有不确定的价值并且目前已建议采用高压氧。
因此，尽管对受伤的皮肤和皮下组织施加负压力(或负压)疗法证实与传统方法比较愈合速率增加(如在US专利第5645081、5636643、7198046和7216651号以及US公开的申请第2003/0225347、2004/0039391和2004/0122434号中阐述的，其内容通过参照结合到本文中)，仍然需要特别适用于特殊的脊髓组织的装置和方法。
发明概述
本发明提供了采用负压(或负压力)治疗损伤的脊髓组织，例如由疾病、感染或创伤损害的脊髓组织的装置和方法，所述疾病、感染或创伤可导致继发于间质水肿的肿胀、压迫和减少的血流的存在。例如，脊髓可由导致可恢复或不可恢复的损伤的钝器伤损伤。
在一个方面，本发明提供采用负压治疗损伤的脊髓组织的方法。该方法包括将多孔材料安置于接近损伤的脊髓组织以在多孔材料的一个或多个孔隙与损伤的脊髓组织之间提供气体连通(gaseouscommunication)。多孔材料可被就地密封在接近损伤的脊髓组织，以在损伤的脊髓组织的周围提供维持损伤的脊髓组织保持负压的区域。多孔材料可被可操作地与用于在损伤的脊髓组织产生负压的真空系统连接，而启动的真空系统在损伤的脊髓组织提供负压。可在损伤的脊髓组织保持负压足以在脊髓减少水肿的时间。例如，负压可保持在低于大气压约25mm Hg。该方法也可包括在损伤的脊髓组织上安置保护层并密封保护层于接近损伤的脊髓组织的组织，用于在损伤的脊髓组织保持负压。保护层可以可被安置于损伤的脊髓组织上的自粘合片(self-adhesive sheet)的形式提供。在这样的情况中，密封保护层的步骤可包括胶着地密封和使自粘合片粘附于环绕损伤脊髓组织的组织，以在所述片与环绕损伤的脊髓组织的组织之间形成密封。
在另一个方面，本发明提供用于治疗损伤脊髓组织的装置。该装置可包含多孔的生物可结合材料例如开室(open-cell)胶原蛋白，其具有被成形以允许在多孔材料的一个或多个孔隙与所治疗的脊髓组织之间进行气体连通的孔隙结构。多孔材料的生物可结合性质可避免需要第二种方法以除去多孔材料。(如在此使用的术语“生物可结合的”被定义为描述可被长期放置于患者体内并且能够被重新塑造、重新吸收、溶解和/或以别的方式被同化或修饰的材料)。装置也包含用于产生负压的真空源；真空源可以与多孔材料的气体连通的方式配置用于向脊髓组织分布负压。多孔材料至少可在多孔材料的选择的表面具有足够小的孔隙以防止组织在其中生长。另外，多孔材料至少可在多孔材料的选择的表面具有小于成纤维细胞和脊髓细胞大小的孔径大小，并且可在除所选择的表面以外的位置具有大于成纤维细胞和脊髓细胞大小的孔径大小。多孔材料的孔径大小可大到足以允许白蛋白大小通过的蛋白质运动。而且，多孔的生物可结合材料可包含至少一个被密封以防止负压从中传输的表面。装置也可包含被成形以覆盖在损伤的脊髓组织上的保护层，以在损伤脊髓组织的保护层下保持负压。
因此，本发明提供用于使病理学过程的进展减至最小，使生理脊髓完整性的破坏减至最小和使对脊髓血流与营养的干扰减至最小的装置与方法。通过减少脊髓水肿和脊柱内压力，脊髓形成疝和损害的风险可被减至最小。另外，本发明便于除去介质、降解产物和增强脊髓中炎症与组织的神经病理学应答的毒素。
附图简述
当结合附图阅读时，本发明的优选实施方案的上述概述和以下详细描述将得到最好的理解，其中：
图1图解说明了在就地施加负压之前本发明装置的示例性结构的局部剖视图；
图2图解说明了当施加负压时图1的局部剖视图；
图3图解说明了显示在脊髓周围组织施加负压的效果的图1和2的局部剖视图；
图4图解说明了就地包含皮下配置在脊髓上的刚性或半刚性保护层的本发明第二个示例性结构的局部剖视图；
图5图解说明了就地包含皮下配置在脊髓上的柔性保护层的本发明第三个示例性结构的局部剖视图；
图6举例说明了BBB评分作为暴露于可恢复的脊髓钝器创伤的对照动物的时间函数；
图7举例说明了BBB评分作为暴露于可恢复的脊髓钝器创伤和用负压处理的动物的时间函数；
图8举例说明了作为暴露于不可恢复的脊髓钝器创伤的对照动物的时间函数的脊髓截面积；
图9举例说明了作为暴露于不可恢复的脊髓钝器创伤和用负压处理的动物的时间函数的脊髓截面积；和
图10图解说明了具有用于本发明负压装置的多层结构的多孔材料。
发明详述
现在提及附图时，其中同样部件在全文中采用相同的编号，本发明涉及采用负压(或负压力)治疗损伤的脊髓组织的装置和方法，其中“损伤的”组织被定义为包括被损伤、损害或者以任何其它方式削弱例如由于创伤、疾病、感染、手术并发症或者例如其它病理过程引起的损伤的组织。更具体地讲，本发明的装置和方法可实现任何原因例如以上提及原因的继发性脊髓实质水肿的治疗；脊髓周围任何间隙包括硬膜下隙/硬膜外隙的治疗；和由于任何原因例如以上提及的原因引起的脊柱内压力升高的治疗。
本发明的负压脊髓治疗装置100的示例性结构可包含用于通过管路20向布置于邻近脊髓7的多孔材料10提供负压的真空源30，图1-3。在这方面，可构造多孔材料10以向脊髓7传输和分布负压。脊髓治疗装置100可通过将多孔材料10安置于邻近损伤的脊髓组织7应用于患者，以在多孔材料10的一个或多个孔隙与损伤的脊髓组织7之间提供气体连通。管路20可在管路20的远端22连接于多孔材料10，并且多孔材料10可通过皮肤与皮下组织2中的缝合线8就地密封，以在损伤的脊髓组织7周围提供一个区域用于保持负压。管路20的近端24可被连接于真空源30以可操作地连接多孔材料10与真空源30，用于在启动真空系统30时于损伤的脊髓组织7产生负压。
转到更详细的图1，本发明的负压脊髓治疗装置100的示例性结构在局部剖视图显示的患者周围组织被就地举例说明。示例说明的组织包含皮肤和皮下组织2、肌肉组织例如斜方肌3和竖脊肌4、椎骨5、横突6和脊髓7。为了提供通向脊髓7，可缺少一部分椎骨5。例如，棘突可由于手术解剖、疾病或者损伤而缺少。多孔材料10例如开室胶原蛋白材料可被置于例如邻近用负压治疗的脊髓组织7的皮下空隙，以降低实质组织的水肿和改善生理功能。除了开室胶原蛋白材料以外，多孔材料10也可包括聚乙醇酸和/或聚乳酸材料、合成的聚合物、柔性片样筛孔、开室聚合物泡沫、泡沫部分、多孔片、聚乙烯醇泡沫、聚乙烯和/或聚酯材料、弹性蛋白、透明质酸、藻酸盐、聚二醇枸橼酸酯、聚羟基丁酸酯、聚羟基富马酸酯、聚三亚甲基碳酸酯、聚甘油癸二酸酯(sebecate)、脂肪族/芳族聚酸酐或其它合适的材料，以及例如可通过电纺(electropinning)、铸塑或印刷制备的任何上述材料的组合。这样的材料包括壳聚糖溶液(1.33％重量/体积在2％乙酸中，20ml总体积)，其可被倾入到适当大小的模具中。然后使溶液在-70℃下冷冻2小时，然后转移至冻干器中施加真空24小时。所述材料可通过2.5％-5％戊二醛蒸气交联12-24小时(或者通过紫外辐射8小时)，提供铸塑多孔材料10。
另外，多孔材料10可通过铸塑聚己内酯(PCL)制备。聚己内酯可与氯化钠混合(1份己内酯对10份氯化钠)并且置于足够体积的氯仿中以溶解组分。例如，可将8ml的溶液倾入到适当大小和形状的容器中并使之干燥12小时。然后可使氯化钠在水中浸出24小时。
也可使用电纺材料用于多孔材料10。用于制备电纺多孔材料10的制剂和方法的一个例证是采用以76％∶4％∶20％(重量)的比例存在的胶原I型：软骨素-6-硫酸酯(CS)：聚1，8-辛二醇枸橼酸酯(POC)的组合。两种溶剂用于胶原/CS/POC。使CS溶于水中并使胶原和POC溶于2，2，2-三氟乙醇(TFE)中。然后使用20％水/80％TFE溶液(体积/体积)的溶液。为了电纺，将含有胶原∶CS∶POC混合物的溶液置于配备有18Ga针的3ml注射器中。注射泵(New Era Pump Systems，Wantaugh，NY)用于将溶液以2.0ml/hr的速率输送至针末端。经高压电源(HV PowerSupply，Gamma High Voltage Research，Ormond Beach.FL)提供10-20kV电压并施加在距离为15-25cm的针(阳极)与接地收集器(阴极)之间。然后使该材料与戊二醛(II级，25％溶液)交联并热聚合(80℃)48小时。也可以在1，1，1，3，3，3-六氟-2-丙醇(HFP)中的初始浓度为80mg/ml的胶原开始电纺胶原I型多孔材料10，然后采用与胶原∶CS∶POC组合相同的电纺条件。
一种另外的用于产生多孔材料10的方法是采用热喷墨打印技术。生物可结合材料例如胶原、弹性体、透明质酸、藻酸盐和聚乳酸/聚乙醇酸共聚物可被打印。例如，溶解于0.05％乙酸中，然后用水稀释至1mg/ml的I型胶原(Elastin Products Co.，Owensville，MO)可被打印，如同藻酸钠(Dharma Trading Co.，San Raphael，CA)1mg/ml在水中可打印一样。I型胶原(2.86mg/ml在0.05％乙酸中)和聚乳酸／聚乙醇酸(PURAC America，Blair，NE)(14.29mg/ml在四甘醇中(SigmaAldrich，St.Louis MO))也可被打印。来自Hewlett Packard 660c打印机的硬件包括步进电机和用于墨粉筒(cartridges)的卷轴版台(carriage)可被安装于平台上。然后可调整硬件在平台以上的高度用于分层打印。
多孔材料10可在多孔材料10与脊髓7之间的界面包含足够小的孔隙，以防止组织在其中生长，例如孔径大小小于成纤维细胞和脊髓细胞的大小；否则多孔材料10可粘附于脊髓7并在除去多孔材料10时引起出血或创伤。另外，在多孔材料10与脊髓7之间界面上的孔径大小可足够小，以便避免在脊髓7上过度产生肉芽或瘢痕组织，肉芽或瘢痕组织可干扰脊髓7的生理功能。同时，多孔材料10的孔径大小可大得足以允许白蛋白大小通过的蛋白质运动，以使能够除去不合需要的化合物，例如介质、降解产物和毒素。
然而，多孔材料10可在多孔材料10的内部或在不与脊髓组织7接触的多孔材料10的任何其它位置具有更大的孔径大小(例如大于成纤维细胞和脊髓细胞的大小)。例如，多孔材料110可包含具有非向内生长层(non-ingrowth layer)112的多层结构，其具有足够小的孔径大小以防止组织在其中生长而替代脊髓，并且还可具有不同材料的额外层114，其具有与非向内生长层112接触的相对更大的孔径大小。
或者，多孔材料10在组成和/或形态学方面可以是均匀的。在远离与脊髓7的界面的位置，多孔材料10可具有大到足以在脊髓7的周围空间中的其它组织促进形成肉芽组织的孔径大小，例如在已经发生脊髓破裂的区域促进形成肉芽组织。另外，多孔材料10可具有其中多孔材料10的一个或多个侧面或表面被密封以防止通过这样密封的表面传输负压，而同时具有至少一个可通过其传输负压的表面的结构。多孔材料10的这样的结构可在多孔材料10的一个侧面存在优先处理的组织而不处理其它侧面。例如，脊髓7的实质可用多孔材料10的一个侧面时的非密封界面处理。
多孔材料10可包含需要在给予负压疗法后除去的材料，其可需要二次手术。或者，多孔材料10可包含经过时间可生物吸收或无害降解以避免二次手术的材料，例如胶原。另外，多孔材料10可包含非金属材料，以便可实施MRI而同时多孔材料10在原有位置上。多孔材料10也可包含足够顺应性的材料以致于如果其压紧脊髓7，则多孔材料10不影响脊髓功能。同时，多孔材料10可包含足够坚实的材料，以使多孔材料10不塌陷到产生可影响脊髓功能的拉伸或扭曲“正常脊髓”的程度。
为了向多孔材料10传输负压以分布到脊髓7，管路20可在管路20的远端22直接或间接地与多孔材料10以气体连通的方式连接。例如，管路20的远端22可被包埋在多孔材料10中或者可被置于多孔材料10上。管路20的远端22也可包含一个或多个穿孔以帮助向多孔材料10和脊髓7传输负压。管路20可通过皮肤和皮下组织2中的开口延伸，其可用缝合线8固定在管路20周围以帮助在管路20周围提供密封。管路20的近端24可被可操作地连接于真空源30，例如真空泵，以提供通过管路20向多孔材料10和脊髓7传输的负压。
真空源30可包含控制器32以调节负压的产生。例如，真空源30可被成形以连续或间歇地产生负压；例如真空源30可断断续续地循环以提供产生和不产生负压的交替循环。在产生与不产生之间的忙闲度可在1:10(开/关)-10:1(开/关)之间。另外，间歇负压可经定期性或循环性波形例如正弦波施加。真空源30可在初始处理以模拟更多的生理状态后进行循环，例如每分钟几次。负压可在需要时如经监测脊髓7的压力测定的那样时断时续地循环。通常，真空源30可被成形以在大气压与低于大气压75mm Hg之间传输负压，以使负压可导致出血进入脊髓7或相反对脊髓7有害的机会减至最小。可操纵施加这样的负压以自脊髓7除去水肿，因此保护神经功能以增加更多的生理保护状态恢复和存活的概率。
为了有助于保持脊髓7的负压，可在接近脊髓7处提供柔性保护层/片50或者刚性(或半刚性)保护层40，以在脊髓7的周围提供一个可保持负压的区域，图4、5。具体地讲，参照图4和5，通过使保护层40、50粘附于接近脊髓7的组织以在脊髓7与多孔材料10的周围限定封闭的区域48、58，可在脊髓7与多孔材料10上提供保护层40、50。例如，保护层40、50可采用粘合剂42例如纤维蛋白胶被粘到脊椎5、肌肉组织4和/或其它合适的组织上。粘合剂42可包含自聚合胶(auto-polymerizing glue)和/或可合乎需要地包含填充剂，以提供具有足够体积的粘合剂42，以使粘合剂42能够符合粘合剂42接触的潜在不规则表面的形状。粘合剂42可作为分开的组分或者作为保护层40、50的部分提供，以提供半胶粘的保护层40、50。例如，保护层50可包含柔性半胶粘片，其在其一个或多个表面上包含合适的粘合剂。
对于柔性保护层50，柔性保护层50的外边缘或边缘可卷在脊髓7下(或向)脊髓7卷起。或者，柔性保护层50可卷离脊髓7，以致于然后保护层50的下面(侧面面对着多孔材料10)可与脊椎5和周围肌肉及软组织接触，图5。如果柔性保护层50在脊髓7下卷起，那么粘合剂52可涂布在保护层50与脊椎5之间的保护层50的外面、周围肌肉和软组织，以帮助促进气密密封。如果柔性保护层卷离脊髓7，粘合剂可涂布到保护层50与脊椎5之间的保护层50的下面和周围肌肉及软组织以产生气密密封。
负压可在保护层40、50下面经保护层40、50与管路20之间的合作传输。具体地讲，保护层40(或柔性保护层50)可包含与管路20的远端22连接的真空气门43，以提供管路20与保护层40下面脊髓7上面的空间48之间的气体连通，图7。或者，保护层50(或保护层40)可包含管路20通过的通路52，以使管路20的远端22被配置在保护层50下面脊髓7上面的空间58内并与空间58气体连通，图5。
保护层40、50可用于进一步限定保持负压的脊髓7周围的皮下区域。即如同在图4和5中图解说明的那样，保护层40、50在脊髓7周围于保护层40、50下面提供了封闭的空间/区域48、58，其可用于隔离组织在保护层40、50的外面而不暴露于施加给脊髓7的负压。相反，如同在图2和3中图解说明的那样，在无保护层的情况下，被传输给多孔材料10与脊髓7的负压可沿着在图2中显示的箭头方向向内朝着管路20与多孔材料10吸引周围组织，例如肌肉3、4，导致在图3中图解显示的组织结构。在这方面，伸展和/或移动组织例如肌肉3、4可帮助将所施加的负压限定在肌肉4与脊髓7之间的区域。另外，保护层40、50可进一步保护脊髓7免于已经由多孔材料10和缝合的皮肤2提供的无法保护的外源性感染和污染。同样，保护层40、50可进一步保护周围组织免于来自脊髓7的感染例如脊髓脓肿、脑膜炎和脊髓组织感染的扩散。
在其另一个方面，本发明也提供了用于通过例如在图1-5中图解说明的装置，采用负压治疗损伤的脊髓组织的方法。具体地讲，方法可包括将多孔材料10置于接近损伤的脊髓组织7，以在多孔材料10的一个或多个孔隙与损伤的脊髓组织7之间提供气体连通。多孔材料10可在接近损伤的脊髓组织7被就地密封，以在损伤的脊髓组织7周围提供一个用于在损伤的脊髓组织7保持负压的区域。在这方面，肌肉3、4与皮下组织可松散地在多孔材料10的顶部与通过皮肤2和缝合密封的皮肤2离去的管路20再接近。另一个气密密封的敷料可被任选地置于缝合位置以促进气密密封。多孔材料10可被可操作地连接于真空系统30，用于在损伤的脊髓组织7产生负压，并且真空系统30被驱动以在损伤的脊髓组织7提供负压。例如，负压可保持在约低于大气压25-75mm Hg。负压可被保持在损伤的脊髓组织7足以降低脊髓7的水肿或控制脊髓液渗漏的时间。另外，负压可被保持在损伤的脊髓组织7足以调节脊髓组织7的时间，以达到痊愈和细菌记数减少的阶段，以致于接受二次治疗(例如瓣(flaps)、皮肤移植)可以是成功的。方法可使用至少4小时，或者可使用多天。在真空治疗结束时，可除去缝合线8并使皮肤2再开口。然后可除去多孔材料10并且再次缝合密封皮肤2。
方法也可包括将保护层40、50置于损伤的脊髓组织7上面并将保护层40、50密封于接近损伤的脊髓组织7的组织用于在损伤的脊髓组织7保持负压。将保护层40、50密封于损伤的脊髓组织7周围的组织的步骤可包括将保护层40、50胶着地密封和粘附于损伤的脊髓组织7周围的组织。保护层50可以自附着片(self-adhesive sheet)50的形式提供，其可位于损伤的脊髓组织7上面。在这样的情况中，密封保护层50的步骤可包括将自附着片50胶着地密封和粘附于损伤的脊髓组织7周围的组织，以在片50与损伤的脊髓组织7周围的组织之间形成密封。另外，可操作地以气体连通的形式连接真空系统30与多孔材料10的步骤可包括连接真空系统30与保护层40的真空气门42。
实施例
大鼠脊髓损伤与负压暴露
实验1
实施一系列实验以确定负压对大鼠挫伤损伤后脊髓的作用。在第一个动物方案中，获得250-300克Sprague Dawley大鼠并建立脊髓挫伤模型且证实。产生损伤并评价恢复的方法是基于Wrathall等，大鼠的脊髓挫伤损伤：分级，可重复，损伤组的产生，实验神经学(Spinal Cord Contusion in the Rat：Production of Graded，Reproducible，Injury Groups，Experimental Neurology 88，108-122(1985))中脊髓挫伤损伤的描述。发展手术技术用于暴露麻醉大鼠的脊髓并通过自5cm高度经玻璃管落下10克重量的圆拄体始终如一地产生挫伤损伤。半数大鼠为未治疗的对照组，而另一半具有暴露于4小时负压(低于大气压25mm Hg)的挫伤区域。然而，损伤的程度在对照动物中不产生显著损伤(它们迅速恢复)，并且因此不能比较治疗组动物与对照组动物。
实验2
建立第二个方案，其中在脊髓上遭受更严重的损伤(10克重量自更高的高度-7.5cm落下)。28只大的(300克)Sprague Dawley大鼠被采购一段时间并使之适应关养条件。在手术当天，使动物镇静并在其背部刮毛和清洗以用于手术。使经脊柱制备的中线切开通过皮肤和皮下组织及皮肤大肌(maximus muscle)与筋膜延伸暴露更深的背部肌肉。在中线分离于中线(斜方肌和潜藏的背阔肌)会合的成对肌肉并对侧缩回(retracted laterally)。深部’姿势’肌肉例如被连接于脊柱骨结构的脊斜肌(spinotrapezius)和/或竖脊肌(sacrospinal)本身也在中线分隔并对侧缩回。这暴露了棘突和潜藏的一些横突。在T7-T9水平，除去在两个连续脊椎之间的棘突和小的横突棘肌，暴露出脊髓表面(硬膜)。在T-8实施椎板切除术。基于Wrathall等的方法，使脊柱稳定在T-7与T-9并自7.5cm高度落下10克重量以产生中等程度的脊髓损伤。5只动物分别死于其初始手术当天(3只在对照组和2只在真空治疗组)，并且在实验的早期对照组中的1只动物死亡，进入实验后2天剩下22只动物。到实验结束时，11只动物已被随机分配到对照组和25mm Hg真空组中的每一组。
对于对照组大鼠，没有提供治疗，并且损伤被缝合密封。对于真空治疗组大鼠，聚乙烯醇真空敷料(Vacuseal Plus，Polymedics，Belgium)被置于脊髓上并且皮肤被缝合密封，真空管通过切口延伸。在1天延迟后，向真空治疗组的每一只动物施加低于大气压25mm Hg的真空(负压)4小时。在该时间结束时，使动物再次镇静，除去真空敷料，并且皮肤切口用单丝缝合线再次缝合。
每天检查切口部位。检查动物自身排泄其膀胱能力的体征。任何不能排泄的动物每天以8小时间隔接受手工辅助设备3次。每天检查动物的自噬代谢(auto-cannibalism)、褥疮和水化度(挤捏试验(pinchtest))。动物被关养在轻施胶(soft shavings)中以使褥疮发展的可能性减至最小。食物被置于笼子底部以便于食用。动物被每天检查后肢运动功能的恢复，对每个后肢采用改进的Tarlov评分系统(0＝无运动，无承重；1＝轻微运动，无承重；2＝频繁运动，无承重；3＝承重，1-2步；4＝有缺陷的行走；5＝无缺陷的行走)。动物被每天在倾斜平面上实验(在该角度它们可不再能够抓牢且从该平面上滑落下去)，并检查后肢握力(grip strength)。动物在手术后14天被安乐死并除去脊柱和进行组织学检查。
实验结果在表1和2中提供，“0”天为手术当天。几只动物呈现最小的损伤/缺陷并且在重物下落期间不能有足够的损伤。(对照动物1、2、11和治疗组动物3、9、10。参见表1和2)。2只动物呈现严重的/完全损伤并且未恢复。(对照动物5和治疗组动物2。参见表1和2)。确信该剩下的全部7只对照动物与7只治疗组动物具有足够的损伤但是不是严重的/完全损伤。
为了分析的目的，认为动物“恢复”是其达到至少4/4记分那天。在7只对照动物中，到手术后8天时3只动物没有恢复到至少4/4记分(右腿/左腿-有缺陷的行走(walking with deficit))。(动物3、6、7，表1)。在剩余的4只对照动物中(动物4、8、9、10)，3只动物在第4、6和13天达到了4/4记分，并且1只动物在第7天达到了4/5记分。因此，4只对照动物在平均7.5+/-3.35天达到了至少4/4记分。对于治疗组动物，全部7只动物(动物1、4、5、6、7、8、11)在平均5.14+/-1.24天达到了至少4/4记分。因此，显而易见的是对损伤的脊柱施加25mm Hg真空能够增加功能恢复的速率(p＝0.059)。
Figure BPA00001159958200141
表1.对照组
Figure BPA00001159958200142
Figure BPA00001159958200151
表2.真空治疗组
实验3
制定另一种其中产生仍然更严重的将导致不可恢复(永久性)功能缺陷的损伤的方案。挫伤范例基于W.M.Keck神经科学合作研究中心(Center for Collaborative Neuroscience)-脊髓损伤研究项目(The Spinal Cord Injury Project)开发的采用NYU脊髓挫伤系统的技术。这些系统(目前称为“MASCIS”)被常规建立并可通过the BiologyDepartment at Rutgers University(W.M.Keck神经科学合作研究中心(Center for Collaborative Neuroscience)，皮斯卡塔韦(Piscataway)，美国新泽西州(New Jersey))购得。
在上述实验中，动物依体重而定进行手术，但是在该实验中动物依年龄而定进行手术。Long Evans hooded大鼠在77天龄时进行手术以使损伤严重性标准化。在手术前1和6天之间，一些动物被镇静并运送至Wake Forest医学院的小动物MRI成象机构(the SmallAnimal MRI Imaging Facility of Wake Forest University School ofMedicine)，并且采用Bruker Biospin Horizontal Bore 7Tesla小动物扫描器(埃特林根(Ettlingen)，德国(Germany))在T9-T10水平扫描脊髓。然后使被扫描的动物在加热的笼子中自麻醉中恢复。在手术的当天麻醉动物，并且动物背部被刮毛和采用脱毛膏。采用无菌技术，在T9-T10水平实施椎板切除术。采用NYU脊髓挫伤系统撞击体(impactor)并在T9-T10用自25mm高度落下的10克棒状物撞击脊髓。对照组的动物具有缝合密封的切口，并使动物在加热的笼子中恢复。对于治疗组动物，聚乙烯醇真空敷料(VersaFoam，Kinetic Concepts，Inc.，San Antonio，TX)被置于脊髓上，切口缝合密封，并且施加25mm Hg真空即低于大气压25mm Hg 8小时。在该时间后治疗组动物被再次镇静，打开切口，除去真空敷料并再次缝合密封切口。如果动物接受术后MRI，动物在撞击后被扫描8小时。
功能恢复用BBB评分，即来自W.M.Keck神经科学合作研究中心(Center for Collaborative Neuroscience)的22点评分进行评价。(表3)。动物被监测21天，然后经暴露于致死量的CO2使安乐死。膀胱被每天挤压并且动物被监测自噬代谢、褥疮、皮肤损害等的体征。自研究中除去任何呈现自噬代谢体征的动物并使安乐死。褥疮和皮肤损害在合适时并咨询ARP兽医工作人员进行治疗。尽管有这种护理，在该实验的过程中，一些动物死亡，而其它的动物由于其它问题被排除在外。
 数值             状况0   没有可观察到的后肢运动1   一个或两个关节的轻微运动，通常是髋&/或膝2   一个关节的伸展运动或者一个关节的伸展运动与另一个关节的轻微运动3   两个关节的伸展运动4   HL全部3个关节的轻微运动5   两个关节的轻微运动和第三个关节的伸展运动6   两个关节的伸展运动和第三个关节的轻微运动7   HL的全部3个关节的伸展运动8   没有重量支撑的翅曲(Sweeping)或没有重量支撑的脚爪足底平放(Plantarplacement)9   仅在站立姿态(即当静止时)具有重量支撑的脚爪足底平放或者偶尔、时
     常或始终如一地重量支撑的背部跨步和非足底跨步10 偶尔重量支撑的足底；非前肢(FL)-HL协调11 时常至始终如一的重量支撑的足底跨步和非FL-HL协调12 时常至始终如一的重量支撑的足底跨步和偶尔的FL-HL协调13 时常至始终如一的重量支撑的足底跨步和时常的FL-HL协调14 当它与表面初始接触以及恰好在站立姿态结束时离地之前或者时常的足底跨步时，始终如一的重量支撑的足底跨步，始终如一的FL-HL协调和在运动期间主要的足爪位置(pawposition)为转动(向内或向外)；始终如一的FL-HL协调；和偶尔的背侧跨步15 始终如一的足底跨步和始终如一的FL-HL协调；和肢体向前运动期间无足趾间隙(Toe clearance)或偶有足趾间隙；主要的足爪位置为与初始接触的身体平行16 在步态期间始终如一的足底跨步和始终如一的FL-HL协调；和肢体向前运动期间时常发生足趾间隙；主要的足爪位置为在初始接触时平行和离地时转动17 在步态期间始终如一的足底跨步和始终如一的FL-HL协调；和肢体向前运动期间时常发生足趾间隙；主要的足爪位置为在初始接触和离地时平行18 在步态期间始终如一的足底跨步和始终如一的FL-HL协调；和肢体向前运动期间始终如一地发生足趾间隙；主要的足爪位置为在初始接触时平行和离地时转动19 在步态期间始终如一的足底跨步和始终如一的FL-HL协调；和肢体向前运动期间始终如一地发生足趾间隙；主要的足爪位置为在初始接触和离地时平行；并且尾部在部分或全部时间向下20 始终如一的足底跨步和始终如一的协调步态；始终如一的足趾间隙；主要的足爪位置为在初始接触和离地时平行；并且躯干不稳定；尾部始终如一地向上21 始终如一的足底跨步和始终如一的协调步态；始终如一的足趾间隙；主要的足爪位置为在整个站立姿态期间平行；始终如一的躯干稳定性；尾部始终如一地向上
表3.BBB运动评分量表
对于永久性损伤的这些研究，36只具有完整硬膜的大鼠完成研究并被分析。开始研究11只(11)真空治疗的动物，由于尿道感染和肾衰竭，1只动物在5周时除去和1只动物在8周时除去。因此，9只真空治疗的动物完成12周的研究。27只对照组动物开始并完成研究。真空治疗的动物在损伤后3周时呈现更大的功能恢复率(p＜0.072)：BBB评分＝12.818+/-1.401(n＝11)真空治疗组对11.704+/-2.391(n＝27)对照组。真空治疗的动物在损伤后4周时呈现显著更大的功能恢复率(p＜0.001)：BBB评分＝13.625+/-1.303(n＝11)真空治疗组对11.500+/-0.707对照组(n＝27)。图6和7。真空治疗动物的恢复率为稳定的水平，且对照组动物的恢复水平逐渐接近真空治疗动物的水平。图6和7。(附注，一些动物被研究3周(通常在研究早期)，而一些动物被观察功能恢复12周)。
除了BBB评价以外，采用对该实验以上列出的方法，2只具有完整硬膜的动物被分析损伤MRI扫描前和后脊髓的截面积变化(例如以mm2表示)(对真空治疗的动物在治疗后实施损伤后扫描)。在进行该分析的4只动物中，只有1只真空治疗的动物不具有任何技术或撞击误差并且可被使用。在对照动物中，1只具有较小的高度误差，其在脊髓挫伤系统的脱出销(release pin)自其关养处拉下时发生；所有其它对照动物具有显著的撞击误差，其妨碍脊髓截面积的分析。机器记录对真空治疗的大鼠重物落下的高度为24.8mm，和对于对照组大鼠的高度为25.782mm。
转到图8，当扫描沿着脊柱(向尾部)进行时，对照组动物显示截面积稍微增加。这对撞击前扫描和撞击后扫描两者是显而易见的。在损伤以上和损伤以下部位两者，截面积在撞击前扫描和撞击后扫描之间没有显著不同。损伤以上撞击前平均值为5.49mm2+/-0.2(n＝5)对撞击后平均值5.32mm2+/-0.23(n＝4)：p＜0.211)(损伤以下撞击前平均值为6.81mm2+/-0.25(n＝3)对撞击后平均值6.46mm2+/-0.78(n＝4)：p＜0.464)。然而，在撞击部位，对于对照组动物撞击后截面积显著大于(p＜0.001)撞击前截面积：撞击前面积平均值5.63mm2+/-0.24(n＝5扫描)对平均撞击后面积6.43mm2+/-0.32(n＝4扫描)。这最可能是由于因硬膜的限制造成脊髓肿胀，因为将成为对脊髓直径限制因素的骨头已被除去。
不象对照组动物，真空治疗的动物在真空治疗后未显示损伤部位脊髓的平均直径增加，图9。在损伤水平的平均撞击前面积为7.28mm2+/-0.73(n＝4扫描)对平均撞击后面积7.03mm2+/-0.99(n＝4扫描)(p＜0.73)。脊髓在损伤部位撞击前和治疗后大小的相似性最可能是由于自硬膜中除去流体，因此脊髓保持初始直径。
在损伤以上面积撞击前和治疗后扫描是相似的(没有显著差异)。在撞击前损伤以上面积为7.79+/-0.64(n＝3扫描)对治疗后面积8.33+/-1.11(n＝5扫描)(p＜0.48)。对于真空治疗的动物损伤以下扫描，治疗后脊髓的截面积显著大于撞击前的截面积：撞击前面积7.61+/-0.43(n＝4扫描)对治疗后面积10.76+/-0.35(n＝4扫描)，p＜0.001。对损伤以下脊髓截面积增加的可能解释可能是可归因于静脉充血。或者，所施加的真空可能已经自动地自周围脊髓吸取脑脊液，使得脊髓膨胀以填充椎体中的椎管面积。该扩展将起使硬膜内压力减至最小的作用并有助于保护细胞活力。
本领域技术人员自以上说明书中将清楚地理解本发明的这些和其它优点。因此，本领域技术人员应认识到，对以上描述的实施方案可作出变化或改进而不背离本发明的广泛发明理念。因此应该理解本发明不限于在此描述的具体实施方案，而是打算包括所有变化和改进，这些变化和改进在权利要求中阐述的本发明的范围和精神内。

Claims (42)

1.一种用于治疗损伤的脊髓组织的装置，其包含：
多孔生物可结合材料，该材料具有被成形以允许在多孔生物可结合材料的一个或多个孔隙与所治疗的脊髓组织之间气体连通的孔隙结构，多孔生物可结合材料至少在邻近损伤的脊髓组织放置的多孔生物可结合材料所选择的表面具有足够小的孔隙以防止组织在其中生长；和
用于产生负压的真空源，其以与多孔生物可结合材料气体连通的方式向所治疗的脊髓组织分布负压。
2.依据权利要求1的装置，其中多孔生物可结合材料包含开室胶原蛋白。
3.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含聚二醇枸橼酸酯。
4.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含聚二醇枸橼酸酯和胶原蛋白。
5.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含弹性蛋白、透明质酸或藻酸盐，及其联合。
6.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含电纺材料。
7.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含铸塑材料。
8.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含印刷材料。
9.依据前述权利要求中任何一项权利要求的装置，其中多孔生物可结合材料至少在对邻近损伤的脊髓组织放置的多孔生物可结合材料所选择的表面具有小于成纤维细胞和脊髓细胞大小的孔径大小。
10.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料在生物可结合材料的内部具有大于成纤维细胞和脊髓细胞的孔径大小。
11.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料在除所选择的表面以外的位置具有大于成纤维细胞和脊髓细胞的孔径大小。
12.依据前述权利要求中任何一项权利要求的装置，其中多孔生物可结合材料的孔径大小大到足以允许白蛋白大小可通过的蛋白质运动。
13.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含至少一个被密封以防止负压从中传输的表面。
14.依据前述权利要求中任何一项的装置，其中多孔生物可结合材料包含大到足以在除多孔材料的选择的表面以外的表面促使形成肉芽组织的孔径大小。
15.依据前述权利要求中任何一项的装置，其中真空源包括真空泵。
16.依据前述权利要求中任何一项的装置，其包含被成形以覆盖损伤的脊髓组织的保护层以在损伤脊髓组织的保护层下保持负压。
17.依据权利要求16的装置，其中保护层包含自身附着片。
18.一种采用负压治疗损伤的脊髓组织的方法，该方法包括：
i.将多孔材料置于接近损伤的脊髓组织处，以在多孔材料的一个或多个孔隙与损伤的脊髓组织之间提供气体连通；
ii.将多孔材料就地密封在接近损伤的脊髓组织处，以在损伤的脊髓组织周围提供使损伤的脊髓组织保持负压的区域；
iii.将真空系统以气体连通方式可操作地连接于多孔材料，以在损伤的脊髓组织产生负压；和
iv.启动真空系统以在损伤的脊髓组织提供负压。
19.依据权利要求18的治疗损伤的脊髓组织的方法，其中安置多孔材料的步骤包括安置至少在多孔材料的选择的表面包含足够小的孔隙以防止组织在其中生长的多孔材料。
20.依据权利要求18或19的治疗损伤的脊髓组织的方法，其中安置多孔材料的步骤包括安置至少在多孔材料的选择的表面包含小于成纤维细胞大小的孔径大小的多孔材料。
21.依据权利要求19或20的治疗损伤的脊髓组织的方法，其中所选择的表面被布置于邻近损伤脊髓组织的界面。
22.依据权利要求18-21中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括安置包含大到足以促进在损伤脊髓组织周围空间的其它组织形成肉芽组织的孔径大小的多孔材料。
23.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置多孔的、开室胶原蛋白材料。
24.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置多孔的、开室生物可结合的材料。
25.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置聚二醇枸橼酸酯材料。
26.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置包含聚二醇枸橼酸酯和胶原蛋白的材料。
27.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置包含弹性蛋白、透明质酸、藻酸盐，或其组合的材料。
28.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置聚乙醇酸和/或聚乳酸材料。
29.依据权利要求18-28中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置多孔的、电纺材料。
30.依据权利要求18-28中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置多孔的、铸塑材料。
31.依据权利要求18-28中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置多孔的、打印材料。
32.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置泡沫、多孔的合成高分子材料、聚乙烯醇泡沫和开室聚合物泡沫中的至少一种。
33.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置多孔片和柔性片样筛孔中的至少一种。
34.依据权利要求18-22中任何一项的治疗损伤脊髓组织的方法，其中安置多孔材料的步骤包括在邻近损伤的脊髓组织安置聚乙烯和/或聚酯材料。
35.依据权利要求18-34中任何一项的治疗损伤脊髓组织的方法，该方法包括在损伤的脊髓组织保持负压足以减少脊髓水肿的时间。
36.依据权利要求18-34中任何一项的治疗损伤脊髓组织的方法，该方法包括保持低于大气压约25mm Hg的负压。
37.依据权利要求18-34中任何一项的治疗损伤脊髓组织的方法，该方法包括保持低于大气压至少约25mm Hg的负压。
38.依据权利要求18-34中任何一项的治疗损伤脊髓组织的方法，该方法包括在损伤的脊髓组织保持低于大气压约25-75mm Hg之间的负压。
39.依据权利要求18-34中任何一项的治疗损伤脊髓组织的方法，其中就地密封多孔材料的步骤包括在损伤的脊髓组织上安置保护层并将保护层密封与损伤的脊髓组织的邻近组织，以维持损伤的脊髓组织的负压。
40.权利要求39的治疗损伤脊髓组织的方法，其中保护层包含用于自真空系统接受负压的真空气门，并且其中以气体连通的方式可操作地连接真空系统与多孔材料的步骤包括连接真空系统与真空气门。
41.权利要求39的治疗损伤脊髓组织的方法，其中将保护层密封于损伤脊髓组织周围组织的步骤包括将保护层胶着地密封和粘附于损伤脊髓组织周围的组织。
42.权利要求39的治疗损伤脊髓组织的方法，其中安置保护层的步骤包括将自粘合片安置于损伤的脊髓组织上，并且其中密封保护层的步骤包括将自粘合片胶着地密封和粘附于损伤脊髓组织周围的组织，以在片与损伤脊髓组织周围的组织之间形成密封。
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