Methods of isolation and purification of therapeutic bacteriophages.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"1483",leadTitle:null,fullTitle:"Soybean - Biochemistry, Chemistry and Physiology",title:"Soybean",subtitle:"Biochemistry, Chemistry and Physiology",reviewType:"peer-reviewed",abstract:"Soybean is an agricultural crop of tremendous economic importance. Soybean and food items derived from it form dietary components of numerous people, especially those living in the Orient. The health benefits of soybean have attracted the attention of nutritionists as well as common people.",isbn:null,printIsbn:"978-953-307-219-7",pdfIsbn:"978-953-51-4495-3",doi:"10.5772/1952",price:159,priceEur:175,priceUsd:205,slug:"soybean-biochemistry-chemistry-and-physiology",numberOfPages:656,isOpenForSubmission:!1,isInWos:1,isInBkci:!0,hash:"840eecadb478078f679536ed332de9da",bookSignature:"Tzi-Bun Ng",publishedDate:"April 26th 2011",coverURL:"https://cdn.intechopen.com/books/images_new/1483.jpg",numberOfDownloads:172231,numberOfWosCitations:182,numberOfCrossrefCitations:65,numberOfCrossrefCitationsByBook:4,numberOfDimensionsCitations:208,numberOfDimensionsCitationsByBook:6,hasAltmetrics:1,numberOfTotalCitations:455,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 19th 2010",dateEndSecondStepPublish:"June 16th 2010",dateEndThirdStepPublish:"September 21st 2010",dateEndFourthStepPublish:"November 20th 2010",dateEndFifthStepPublish:"February 3rd 2011",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,8,9",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"21099",title:"Prof.",name:"Tzi-Bun",middleName:null,surname:"Ng",slug:"tzi-bun-ng",fullName:"Tzi-Bun Ng",profilePictureURL:"https://mts.intechopen.com/storage/users/21099/images/system/21099.jpg",biography:"T. B. Ng obtained his Ph.D. degree from the Memorial University of Newfoundland in Canada. He pursued postdoctoral training at the University of California in San Francisco. He is currently a professor of biochemistry at the School of Biomedical Sciences, Faculty of Medicine, the Chinese University of Hong Kong, Hong Kong, China. His research interests encompass biologically active proteins and peptides of animal, plant, fungal and bacterial origins; polysaccharide-peptide complexe; polysaccharides;melatonin and derivatives; and natural products. He has supervised a large number of postdoctoral fellows and graduate students.He has published over five hundred papers in international journals and a number of book chapters.Some of these papers are about leguminous lectins, antifungal proteins, ribosome inactivating proteins, protease inhibitors, and peroxidases. He serves as the editorial board memeber of several journals including International Journal of Peptides, Journal of Biochemistry and Molecular Biology in the Post Genomic Era,and Frontiers in Cellulose Biotechnology. He has reviewed research grant applications and manuscripts submitted to various journals for publications.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"2",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"324",title:"Food Chemistry",slug:"agricultural-and-biological-sciences-bromatology-food-chemistry"}],chapters:[{id:"15698",title:"Hypersensitivity Reaction to Generic Drug-Containing Soybean Oil",doi:"10.5772/10543",slug:"hypersensitivity-reaction-to-generic-drug-containing-soybean-oil",totalDownloads:2613,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Fernando Pineda, Alicia Armentia, Antonio Dueñas-Laita, Blanca Martín and Ricardo Palacios",downloadPdfUrl:"/chapter/pdf-download/15698",previewPdfUrl:"/chapter/pdf-preview/15698",authors:[null],corrections:null},{id:"15699",title:"Safety Aspects in Soybean Food and Feed Chains: Fungal and Mycotoxins Contamination",doi:"10.5772/14693",slug:"safety-aspects-in-soybean-food-and-feed-chains-fungal-and-mycotoxins-contamination",totalDownloads:3216,totalCrossrefCites:1,totalDimensionsCites:7,hasAltmetrics:0,abstract:null,signatures:"Germán G. 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Larramendy"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"76569",title:"Therapeutic Efficacy of Bacteriophages",doi:"10.5772/intechopen.97619",slug:"therapeutic-efficacy-of-bacteriophages",body:'Bacteriophages (phage) are bacterial viruses that are also known as ‘natural killer phages’ may take over their bacterial host and use it to grow and multiply. The phage may recognise, infect, and kill specific bacteria or groups of bacteria, as well as their host cells of unrelated bacteria. As a result, they play an important role in bacterial population regulation. Bacteriophages are used to (a) identify specific pathogens to help in pathogen detection and (b) destroy bacterial infections in a process known as lysogeny, in which one bacterium kills another through phage particles [1, 2, 3, 4]. Since he first discovered bacteriophages in 1917, and later in 1919, a phage treatment was offered to cure a child suffering from dysentery, and the child was cured of the illness after a single dose of phage administration, D’Herelle is widely regarded as the father of bacteriophages. Since then, the phage cocktail’s protection has been verified by administering it to a number of other healthy people [3, 4]. He also noted in 1919 that bacteriophages provided between chickens effectively reduce the mortality of chickens suffering from
Bacteriophages are found all over the world, have many uses, and have contributed significantly to medicine, biotechnology, and molecular biology. Traditional antibiotic treatments are often replaced or supplemented by bacteriophage therapies and such alternative therapies has had a significant effect on revenues. In 2017, the global bacteriophage market was worth $567.9 million, and it is projected to grow at a 3.9% annual rate annual rate from 2018 to 2026. Globally, 600 million people are believed to be affected by foodborne diseases, with 420,000 people dying each year. In contrast, foodborne disease is said to affect 40% of children, resulting in 125,000 deaths per year [24]. The fastest-growing market will be for clinical applications of bacteriophages in phage therapy, diagnostics, drug development and manufacturing, phage display technology, antibacterial, vaccines, and biocontrol agents. Food and beverages currently hold the largest share of the global bacteriophage industry. Lytic bacteriophages are commonly used to control the spread of harmful infectious agents in foods such as fruits, vegetables, dairy products, and meals. Increased use of bacteriophages in such safe and healthy food items increased market potential. As a result, bacteriophages are being accepted for use in food safety applications in greater numbers. Companies are developing bacteriophage platforms and phagebanks (The Israeli Phage Bank (IPB) is a member of a global network of phage banks that provides a large assortment of purified bacteriophages) to treat multidrug-resistant bacteria in emergency situations [24]. Microgen, Amplify Bioscience Corporation, Ambiotics, and Phage Biotech Ltd. are some of the leading players in the bacteriophage industry. According to Amplify Biosciences Corporation, clinical trials for phage therapy against
Seclusion, identification and propagation of the patient’s infecting bacterial strain are critical for successful phage treatment. In medical practice, once a patient is suspected of having a contagious incurable infection, effective bacteriophages should be isolated, identified and purified from isolates of pathogenic bacteria occurring in the samples of urine, blood, and chronic wounds of patients. The bacterial colonies shall be picked up from selective Agar/LB agar plates according to their colony morphology, size, and pigmentation variability. The isolates are subjected to the staining procedures, biochemical and molecular tests and are cultured in various media to identify the genus and species of bacteria with the help of
Availability of a library with a range of therapeutic bacteriophages is the foundation for the success of phage therapy. Bacteriophages are observed to show off a narrow to broad host specificity [30, 31, 32]. The lytic bacteriophages ought to have the capacity to kill strange bacterial species even as a range of bacteriophages can kill the identical bacterial strain (Figures 1–4) [33]. For a safe medical use of the phage, genes of toxins, antibiotic-resistance, and multidrug-resistant genes should not be present in the genome of the phage’, whilst the lytic phage must have the potential to kill the multidrug-resistant bacteria such as
Transmission electron micrograph (TEM) bacteriophages infected Bacillus. Note the capsid, nucleic acid, tail fibers [
A magnified portion of a Bacillus infected with bacteriophages is seen in this Transmission electron micrograph (TEM). The capsid, nucleic acid, tail fibers should all be noted [
TEM showing
Electron micrograph showing
Appropriate cultural media used for the growth, proliferation, and fermentation process of cells of bacterial hosts of bacteriophages for therapeutic applications. The fundamental processing of bacteriophages consists of several stages of purification (Table 1). These are broth specifications with low-speed centrifugation or filtering, cell removal, and cellular debris. Chloroform will be added to the lysate to form lysis and release the phage from non-lytic cells. Specified bacteriophage lysate can be used in many applications but clinical applications require additional purification of the lysate to eliminate endotoxins, metabolites, hydrophilic O-specific polysaccharide, phosphorylated oligosaccharides, phage, bacterial cells, and other wastes. Impure preparations of bacteriophages should not be used for injection [41, 47]. Occurrences of such as endotoxins in the bacteriophage preparations may aggravate the immune system responses viz. fever, leucocytosis, leukopenia, fatal endotoxin shock, can open up macrophages, and release inflammatory mediators such as TNF-α, IL-6, and IL-1 and cause serious side effects. The final limit of endotoxins recommended for intravenous administration is 5 Endotoxin Unit (100 pg) (EU)/kg. The elimination of endotoxin from bacteriophages is a multidisciplinary procedure. Two-Phase fluid extraction processes viz. LPS affinity resins, ultrafiltration, and chromatographic methods for removal of well-charged endotoxin proteins. Ion exchange, size exclusion chromatography, interaction with histidine or polymyxin B, and anion-exchange chromatographic exchange were methods used for further phage purification. Diafiltration was used to exchange phage particles from lysate media with a suitable buffer. Cesium chloride density gradient centrifugation, ultracentrifugation, PEG precipitation, and ultrafiltration used for the removal of endotoxins and purification of phages. Bacteriophage CM8-1/SJT-2 stock solution mixed with bacterial culture in the mid-log phase spread on a double-layer agar Petri plate, Sodium magnesium (SM) buffer added after the bacteriophage had grown of the entire Petri plate and placed on a shaker at 120 rpm/min for 2 hours. The SM-bacteriophage lysate solution was filtered through a 0.22 μm filter, PEG8000 (10%) was once added to the bacteriophage stock solution, left the solution overnight at 4°C, and centrifuged at 10,000 × g for 10 min to obtain bacteriophage precipitation [46]. By contrast, T4 bacteriophages had prepared by using a stepwise gradient of anion-exchange quaternary amine (QA) CIM column and NaCl elution buffer [48, 49]. Purified bacteriophages of
S.no | Therapeutic bacteriophages | Type of bacteria/disease | Units of phages | Methods of isolation and purification | Therapeutic effects | Reference |
---|---|---|---|---|---|---|
1 | Bacteriophages of | Bacterial infection of | A single production run can produce up to 64,000 treatment doses at 109 PFUs | Protocol used an aggregate of modified traditional techniques, membrane filtration processes, and no organic solvents to yield on average 23 mL of 1011 plaque-forming devices (PFUs)/milliliter for | The protocol is beneficial for large scale standardized cultivation, purification, and manufacturing of bacteriophages. The approach emphases’ eliminating endotoxins by up to 106-fold in phage preparations. | 2020 Tiffany Luong [41] |
2 | T4-like coliphages or a commercial Russian coliphage | Bacterial diarrhea | 3.6 × 108 PFU of T4-like coliphage cocktail (T) | 1 gm stool in 5 ml TS (8.5 g NaCl, 1 g tryptone/l), centrifuged at 14,500 g for 15 minutes. Filtered in a Millex AP20 prefilter and a Minisart filter. The presence of phages was determined in E. coli strains WG5 and K803, a K-12. | Fecal coliphage increased in treated over control children, however the titers did no longer show substantial intestinal phage replication. Lack of clinical efficacy of oral phages. No adverse events are attributable to oral phage application. | 2016 Shafiqul Alam Sarker [42] |
3 | 1. Βϕ-R2096 2.YMC 13/03/ R2096 ABA BP (phage Βϕ-R2096) lytic phages family Myoviridae | carbapenem-resistant Serious nosocomial infection | Treated with concentrated phage Bϕ-R2096(1 × 1010 PFU) at two MOIs (MOI 100 and10)30 min after infection with CRAB (1 × 108 CFU). | Carbapenem-resistant | Bacteria-only-infection group died rapidly. A sizable reduction in mortality in both | 2019 Jongsoo Jeon, [43] |
4 | Lytic bacteriophage, phage 1513 | Multidrug Resistance Pneumonia | Intranasal administration of a single dose of 2 × 109 PFU/mouse 2 h after KP 1513 inoculation | Centrifuged sewage sample, supernatant was supplemented with CaCl2. 10 mL supernatant, 10 mL 2 LB broth, and 2 mL bacteria solution [ | Mice were protected from lethal pneumonia. When compared to untreated controls, phage-treated mice had a lower K. pneumoniae burden in the lungs. The phage KP 1513 has a significant antibacterial effect in vitro and in vivo, indicating that it could be used instead of antibiotics to treat pneumonia caused by multidrug-resistant K. pneumoniae. | 2014 Fang Cao [44] |
4 | A. baumannii phages | Wound Infections | 106 PFU. For cocktail synergy studies-108 PFU per well for an MOI of 100 | After growing AB5075 or AB5075P to exponential phase, 1 ml of each strain was added to 100-ml aliquots of the TSB-sewage mixture, inoculated with | The phages cocktail reduces bioburden in the wound, prevents infection and necrosis from spreading to adjacent tissue, and reduces infection-related morbidity. | 2016 James M. Regeimbal [45] |
5 | CM8-1 and SJT-2 Bacteriophage | mastitis in dairy cattle | Bacteriophages bMECs were treated with or without K. pneumoniae (MOI, a 10:1 ratio of K. pneumoniae to bMECs), bacteriophages CM8-1, or SJT-2 (MOI, ratio of bacteriophage to K. pneumoniae was 1:10) | Bacteriophages CM8-1 and SJT-2 were isolated from dairy wastewater and mixed with a mid-log phase bacterial solution before being spread over a double-layer agar plate. Sodium magnesium (SM) buffer was applied after the bacteriophage had spread across the entire plate. A 0.22 m filter was used to filter the bacteriophage SM solution. PEG8000 (10%) was applied to the bacteriophage stock solution and stored at 4 o C overnight before being centrifuged for 10 minutes at 10,000 g. | Bacteriophages bMECs decreased bacterial adhesion, invasion, and cytotoxicity. The bacteriophage significantly reduced morphological damage and decreased TNF- and IL-1 concentrations, which were visible 4 to 8 hours after infection with | 2021 Yuxiang Shi, [46] |
Methods of isolation and purification of therapeutic bacteriophages.
Phage preparations for clinical use ought to be (i) endotoxin-free, (ii) phage must be intact with high titers [53, 54, 55]. (iii) Suitable storage and transport are crucial. (iv) protected from high temperature, extremely acidic, or alkaline conditions [56], and (v) phage stock should not be refrozen and rethawed [57]. The usefulness of preparation of phage lysate, modified treatment methods evolved and accepted for long-term storage of phage was elucidated. In a study that demonstrated the infectivity of the phages remained unaffected with chloroform and DMSO treatments and storage for 30 days to a year at 4°C − 40°C [10, 58, 59, 60]. Infectivity of long-term stored bacteriophages at −80°C can be increased by adding 15%-25% glycerol to phage lysate preparations, and by rapid freezing and storage of phage infected bacteria at −70°C. Similarly, phage was shown to remain highly stable underneath normal storage conditions or also stable in NaCl and MgSO4 due to its stabilizing effect. Considerable numbers of viable phage have been described to occur even after storage in distilled water. Phage isolates were found to remain stable upon storage at 4°C, or a rapid loss of phage infectivity was encountered with repeated freezing and thawing at −70°C. Phage infectivity could not be inhibited with trypsin, protease, ribonuclease treatments, or chloroform whilst the infectivity over the phage was inhibited together with lysozyme and SDS treatments [10, 59, 60]. The enzymatic treatments and inhibition of phage infectivity of several bacteriophages had been reported. Similarly,
A bacteriophage therapy is a treatment for a patient’s bacterial disease illness that is provided after the patient has been diagnosed. Bacteriophages are the most valuable and ubiquitous (1031) organisms in the world, and are known to infect >140 bacterial genera. Description of phages and their antibacterial activity has initially been set up [6]. Bacteriophage therapy exhibits precise antibacterial lytic activities that have turned out to be a really useful concept to kill even an intracellular pathogenic bacterium and guarantee future development and consequently the therapeutic phages are re-emerging. As a substitute to antibiotics, experimental bacteriophage therapy might replace them when they fail to treat chronic infections, and such successful eradication of drug-resistant bacteria has been properly identified and demonstrated [65, 66, 67, 68, 69, 70, 71, 72]. A single dose of phage has been shown to be more effective treatment than many doses of antibiotics such as amphetamines, tetracycline but chloramphenicol [73]. Moreover, careful phage collection, propagation, and purification requires complete experimental conditions. Such a focus ought to assist in the improvement of medical phage therapy utilized to a variety of systems, which is viewed an attribute on an emerging choice to antibiotic therapy and vaccination. The consequences of phage therapy are dependent on the plan of preparations and rout of administration of bacteriophage. The best possible administration route for phage preparations which should facilitate sufficient phages coming into direct contact with the bacteria. Routes of phage administration vary from oral, intravenous to multiple topical applications. There are different types of bacteriophage preparations developed to facilitate direct contact of the phage with the pathogenic bacterium for special bacterial infections and they are: (i) a phage powder, phage-containing lotion or dry gauze layer containing phages could be used for skin infections [74]. (ii) bacteriophages that have been sprayed dry become phages that can be inhaled as powder [75, 76, 77]. (iii) aerosolized phage preparations may be chosen for respiratory tract infections [76, 77, 78]. (iv) cream of phage preparations for skin infections. (v) injectable types of phage formulations [41, 47, 79]. (vi) phage infusion preparations may be considered for bloodstream infection [80, 81]. (vii) capsules containing phages (encapsulation/micro-encapsulation) that can protect particles from stomach acid inactivation should be preferred for gastrointestinal infections [75, 82]. An improved understanding of how synergic interactions of bacteriophages, cocktails with antibiotics impact bacterial infection is needed to stop unintentional inhibition of phage replication. Aerophages and IV phages each rescued 50% of animals from severe MRSA pneumonia. A mixture of aerophages and IV phages rescued 91% of animals, which was higher than either monotherapy or cocktail phage therapy [12]. Phage alone or a mixture of phages with antibiotics were treated against several bacterial infections in skin, blood, lung, and chronic otitis [36, 66, 80]. In contrast, other clinical reports have shown that some phages do not work due to constant infection and ETEC (Enterotoxic
The term “personalised phage therapy” refers to the preparation and precise targeting of phage(s) against bacteria isolated from infected patients. Phage therapy has made extensive use of such a precise approach [80, 96], (Table 3). The patient’s conditions need to be observed regularly to evaluate whether or not they are improving, and clinical samples from bacterial infection sites should be assessed in a timely manner to evaluate therapeutic efficacy, the emergence of phage-resistant strains and efficient phage titers. Phage should be replaced once a particular phage-resistant bacterium emerges [96]. If there are no phage in the library that kill a phage-resistant bacterial strain, the bacterial strain can be further used as a host bacterium to screen various types of samples (e.g., soils, faeces, urine) to isolate new effective phage. Such new bacteriophages can be added continuously to enrich the phage library if they meet the criteria. Phage therapy can be considered as an example of personalized medicine for bacterial infections [80]. Phage resistance may also be accompanied by changes in antibiotic resistance [99]. Therefore, the antibiotic resistance profile of phage-resistant strains should be simultaneously tested. The synergistic bactericidal activity of combining phage and antibiotics in the clinical cases should be considered [100] and further treatment strategies using phage alone and/or in combination with antibacterial drugs should be considered based on the results. The development of phage-sensitive and -resistant strains should be monitored regularly during phage therapy to see if phage therapy is a viable choice for successfully dealing with this issue. A clinical trial demonstrating the therapy’s beneficial effects is critical in verifying its medical importance.
S.no | Therapeutic bacteriophages | Type of bacteria/disease | Units of phages used | Therapeutic effects | Reference |
---|---|---|---|---|---|
1. | Two novel bacteriophages, PBAB08 and PBAB25 | (MDR) Nasal infection | 1 × 109 PFU of phage cocktail, intranasally injected | Mice treated with the phage cocktail showed a 2.3-fold higher survival rate than those untreated in 7 days post infection. 1/100 reduction of the number of | 2018 Kyoungeun Cha [88] |
2. | PP1131 -phage cocktail | Endocarditis | 1010 PFU | Single-dose phage therapy was enough to control | 2016 Frank Oechslin [89] |
3. | Caudovirales phage strains, MPK1 and MPK6 | Pseudomonas aeruginosa Peritonitis-sepsis caused by intraperitoneal (i.p.) infection | Mouse-2 × 106 or 2 × 107 PFU, | Mice treated with phage had lower bacterial burdens in their livers, lungs, and spleens. Both phages significantly delayed the PAO1-induced killing of | 2009 Yun-Jeong Heo [90] |
4. | Bacteriophage (MSa) | Bacteriophage (MSa) (108 PFU) | All mice in the control group and the group treated with the lowest phage dose 107 PFU /mouse, died within 4 days (10/10 mice). mice treated with an intermediate dose 108 PFU/mouse were incompletely protected (2/5 mice survived). mice treated with the highest dose 109 PFU/mouse were all protected from the infection of | 2007 Rosanna Capparelli [91] | |
5. | A range of phages | Chronic bilateral otitis externa | Approximately 400 PFU of phage (in 0.2 ml saline) were instilled into the right auditory canal. | No adverse effects were observed | 2006 J.A. Sivera Marza [92] |
6. | Phage WSa | Local and Systemic Disease | 108 PFU | Infected mice with | 2002 Karen E. Cerveny [93] |
7. | Enterococcus phages ENB6 and C33 | Vancomycin-Resistant Gastrointestinal tract infection-VRE bacteremia and endocarditis | 3 × 108 PFU of the phage strain | ENB6 phage formed plaques on 57% of the VRE clinical isolates and inhibited the bacterial growth of an additional 22% of the strains, thus exhibited an antibacterial effect against 79% of the strains. At higher doses of phage, 100% of the animals survived with minimal signs of illness such as mild lethargy in the first 24 hours | 2001 Biswajit Biswas [94] |
8. | Cocktail of four phages provided by Texas A&M and the San Diego-based biotech company AmpliPhi | Multidrug-Resistant Bacterial Infection. | Phage cocktail is normally applied topically or taken orally. Phages were injected intravenously and into the abdominal cavity through catheters. | The bacteria gradually gained resistance to the phages, but the team compensated by constantly tweaking treatment with new phage strains and antibiotics, some of which they had obtained from sewage. The road to recovery has not been without bumps. There have been setbacks that have nothing to do with the phages. | 2017 Scott LaFee and Heather Buschman [95] |
Efficacy of therapeutic bacteriophages treatment of antibiotic resistant bacterial infections.
S.no | Therapeutic bacteriophages | Type of bacteria/disease | Units of phages used | Therapeutic effects | Reference |
---|---|---|---|---|---|
1. | Φ2 (KpJH46Φ2) | Prosthetic joint infection (PJI) | The patient received daily infusions of 6.3 × 1010 phages in 50 mL of normal saline each weekday for a total of 40doses. | Local symptoms, signs of infection, and recovery were all improved with phage therapy. The patient had no medication-related side effects and was asymptomatic 34 weeks after finishing treatment. | 2020 Edison J Cano [81] |
2. | Bacteriophage OMKO1 | Prosthetic vascular graft infections | 1,000 PFU phage OMKO1 (10e7 PFU/ml) in 10 ml phage OMKO1 | The infection tended to resolve after a single treatment of phage OMKO1 and ceftazidime, with no signs of recurrence. | 2018 Chan, B. K. [97] |
3. | Cocktail of 2 bacteriophages | Multidrug-resistant | Dose of 3.5 × 10 5 PFU every 6 hours. | When the patient resumed bacteriophage therapy, blood cultures that had reverted to positive for many days surprisingly, reproducibly reverted to sterile, which coincided with clinical progress. | 2018 C. Duplessis [98] |
4. | Multidrug-Resistant Craniectomy Site Infection | 2 × 1010 PFU/mL, with an endotoxin level of 3.5 × 105 endotoxin units (eu)/mL. The phage dose given was 2.14 × 107 PFU/mL | While the craniotomy site and skin flap healed well, fevers and leukocytosis continued. After surgical debridement, there were no more signs of infection at the craniotomy site, and no purulence to send for a repeat culture. | 2018 Stephanie LaVergne [34] |
Therapeutic bacteriophages for personalized treatments.
Gangrene is the death of body tissue due to bacterial infection or lack of blood flow. Gas gangrene is caused by infection with a bacterium called
Burn wounds of patients have risks of bacterial infections. The floor of burn wound areas of sufferers may exhibit sepsis, lymphopenia, and intoxication. The use of phage therapy was shown to be superb in eradication of pneumonia, the drug-resistant (MDR)
S.no | Therapeutic bacteriophages | Type of bacteria/ disease | Units of phages used | Therapeutic effects | Reference |
---|---|---|---|---|---|
1. | Lytic anti- | Burn infections | PP1131; 1 × 106 PFU per mL | At very low concentrations, PP1131 decreased bacterial burden in burn wounds than standard of care | 2017 Patrick Jault [83] |
2. | 109 PFU/ml of each phage | No adverse events, clinical abnormalities or changes in laboratory test results that could be related to the application of phages were observed. | 2014 Thomas Rose [106] | ||
3. | P. aeruginosa phages | P Burn Wound | 10 8 PFU/100 μl inoculum of each of the following phages: Pa1 (ATCC 12175-B1); Pa2 (ATCC 14203-B1), and Pa11 (ATCC 14205-B1) (ATCC catalogue of bacteria and bacteriophages, | All the thermally injured mice that were not infected with PAO1Rif but administered the phage cocktail survived. The phage cocktail was not toxic to traumatized mice | 2007 Catherine S. McVay [108] |
Therapeutic bacteriophages for antibiotic-resistant burn infections.
Psoriasis is a common chronic skin disease causing red and itchy scaly patches on the scalp, knees, elbows, and trunk. The “Phagoburn project” aims to reduce bacterial growth and reduce the incidence of psoriasis in patients with severe inflammation and infection. “Phagobon” has been used in the treatment of phage cures to treat
Exposed non-healing wounds on the feet are considered “chronic ulcers”. Chronic ulcers show up in sufferers with diabetes, atherosclerosis, and varicosity of the limbs (Figure 5). The healing processes of such chronic diabetic foot ulcers (DFU) depends on the coexisting infection of aerobic and anaerobic microorganisms’ viz.
Diabetic chronic non-healing wounds (NHW).
S.no | Therapeutic bacteriophages | Type of bacteria/disease | Units of phages used | Therapeutic effects | Reference |
---|---|---|---|---|---|
1. | Pyo bacteriophage cocktail | Urinary tract infections | Intravesical Pyo bacteriophage (Pyophage; 20 mL) or/intravesical placebo solution (20 mL) twice daily for 7 days in a double-blind fashion | Intravesical bacteriophage therapy was found to be comparable to regular antibiotic therapy. In terms of eptitude and protection in treating UTIs in patients undergoing TURP, however, it was not superior to placebo bladder irrigation. | 2021 Lorenz Leitner et al., [112] |
2. | Pyo bacteriophage | (Streptococci group D renamed as | The bacteriophages have 107–109 PFU/mL. The solution was given twice every 24 hours, at 8 a.m. and 20 a.m., for seven days, beginning the day after surgery. The patients were advised to keep the solution for 30–60 minutes in their bladders. | Four patients had no noticeable bacterial growth after treatment, while | 2018 Aleksandre Ujmajuridze [113] |
3. | Necrotizing pancreatitis complicated by an MDR | Average endotoxin levels of bacteriophage cocktails PC, IV, and IVB were 2.4x103 EU/ml, 5.89x103 EU/ml, and 1.64x103 EU/ml, respectively 4 x109 PFU of bacteriophages, 5x109 PFU of bacteriophages PC AC4, C1P12, C2P21, C2P24, Intracavitary, Intravenous 2 | The administration of bacteriophages intravenously and percutaneously into the abscess cavities was linked to the patient’s clinical course being reversed, clearance of the | 2017 Robert T. Schooley [80] | |
4. | Lytic bacteriophages | Six lytic bacteriophages, each at a titre of 106 PFU ml − 1 ….20 ml (∼2 × 107 p.f.u.) Pyophage | The bacteriophage infection was self-sustaining and self-limiting, with the phage’s number declining in tandem with the number of viable target species in which it replicated. | 2011A. Khawaldeh [114] |
Therapeutic bacteriophages for antibiotic-resistant Urinary tract bacterial infections.
Bacterial pneumonia is an infection of
Bacterial diarrhea occurs in humans if infected with bacteria such as
Tuberculosis (TB) is a lung infection caused by the endogenous bacterium
Endolysin therapy is a major part of phage therapy. Endolysins are considered protein-based antibiotics or antimicrobials. The purified endolysin is a powerful antibacterial agent for curing bacterial infections in human beings and animals. The efficacy of endolysin enzyme, host bacteria, bacterial disease and the therapuetic use in experimental animal models is listed in Table 6. Endolysin is an enzyme used by the bacteriophages to degrade the bacterial host’s peptidoglycan from the inside, resulting in the release of cell lysis and offspring virions [23, 115].
S.no | Enzyme | Sources/bacteriophages | Bacteria/disease | Unit of enzyme | Therapuetic effects | Reference |
---|---|---|---|---|---|---|
1. | Depolymerase KP34p57 | Lytic phage KP34 | KP34p57 depolymerase was evaluated at four different concentrations: 7.5 ng/ml, 75 ng/ml, 750 ng/ml, and 7500 ng/ml. | After 2 hours of incubation with the enzyme, none of the concentrations examined showed major improvements in colony count. | 2020 Latka, A., [127] | |
2. | Two capsule depolymerases (Dpo42 and Dpo43) | Phage IME205 isolated from a raw sewage | Carbapenem resistant | Dpo42 or Dpo43 (20 ng) | Both Dpo42 and Dpo43 depolymerases rendered the host bacteria prone to serum complement killing. Anti-virulent capsule depolymerases show promise in the battle against CRKP infections. | 2020 Liu, Y., [128] |
3. | LysSS | LysSS recombinant protein was purified from the host cells of | MHB was used to incorporate freshly grown bacteria (104 CFU/well) and purify them. LysSS was added at different concentrations (20–200 g/well) along with 200 L of 1 MHB per well in each well. 1.25 mg/mL LysSS was applied at the end. | Without pre-treatment with an outer membrane permeabiliser, LysSS demonstrated activity against MDR LysSS stopped methicillin-resistant | 2020 Kim, S., [129] | |
4. | Tripleacting staphylolytic peptidoglycan hydrolases (Lysostaphin and LysK-) | Recombinant phage lysin proteins | Lysostaphin 0.77 g/ml (27 nM); LysK, 47 g/ml (840 nM); Lysostaphin and LysK (L + K) in combination 0.2 g/ml (7 nM and 3 nM, respectively); triple fusion K-L, 7 g/ml (97 nM); triple fusion L-K, 7.8 g/ml (107 nM); triple fusion L- | Nasal colonisation was decreased by 87 percent when 200 g lysostaphin was used. In cultured mammary epithelial cells and a mouse model of | 2016 Becker, S. C., [130] | |
5. | PlyC holoenzyme, mediated by PlyCB subunit | C1 bacteriophage | Treatment with 50 μg/ml WT PlyC | Lower concentrations showed a dose response and reduced intracellular colonisation (CFUs) by 95% within 1 hour. The endolysins from the B30 and Ply700 streptococcal phages, on the other hand, failed to reduce intracellular Spy CFUs significantly. | 2016 Shen, Y., [131] | |
6. | Chimeric lysin | Phages infecting Gram-positive bacteria | methicillin-resistant | ClyF doses are 25, 37.5, and 50 mg/kg, with a maximum dose of 100 mg/kg. 6 × 107 CFU WHS11081 6 × 107 CFU WHS11081 /mouse model of MRSA WHS11081 infected burn wound (1 × 107 CFU/mouse) | Chimeric lysin is an effective antibacterial against MDR | 2017 Yang, H [132] |
λSA2-E-Lyso-SH3b and λSA2-E-LysK-SH3b | Bacteriophage endolysins (peptidoglycan hydrolases) | 100 μg/ml, λSA2-E-Lyso-SH3b and λSA2-E-LysK-, infusion of 25 μg of λSA2-E-Lyso-SH3b or λSA2-E-LysK-SH3b | Compared to control, SA2-E-Lyso-SH3b and SA2-E-LysK-SH3b decreased | 2012 Schmelcher, M. [23] | ||
7. | Chimeric Lysin (ClyS) | Staphylococcus-specific phage | Methicillin-Resistant and -Sensitive | Topical ClyS activity was tested in vitro by combining 1 ml of PBS with a dose of 10% ClyS in Aquaphor. The mixture was centrifuged for 10 minutes at 4,000 rpm. | ClyS killed more methicillin-susceptible bacteria (MSSA) and methicillin-resistant S. aureus (MRSA) than mupirocinl, with a 2-log reduction with mupirocinl compared to a 3-log reduction with ClyS. In vitro, the use of ClyS reduced the ability for MRSA and MSSA species to develop resistance relative to the use of mupirocin. | 2011 Pastagia, M. [133] |
8. | ClyS | Fusion of N-terminal catalytic domain of | Methicillin-Resistant | A single treatment with ClyS, 200 U/mg or 7.1 U/nM One intraperitoneal dose of ClyS, ClyS and oxacillin at doses (A unit of ClyS activity per millilitre was described as the reciprocal of the highest lysin dilution that reduced absorbance by 50% in 15 minutes. | In a mouse nasal decolonization model, a single treatment with ClyS decreased the viability of MRSA cells by two logs in one hour. MRSA-infected septicemia mice were given a single intraperitoneal dose of ClyS and survived. In a mouse model of MRSA septic death, ClyS, in addition to oxacillin, offered synergistic defence against septic death. | 2010 Daniel, A [134] |
9. | Endolysin LysH5 and nisin | Staphylococcal bacteriophage phi-SauS-IPLA88 | 300 nM Lys109 | When LysH5 was combined with nisin, a bacteriocin, a significant synergistic effect was observed. Nisin and LysH5 minimum inhibitory concentrations were decreased by 64 and 16 times, respectively. On cell suspensions, Nisin increased LysH5’s lytic activity by an order of magnitude. | 2010 García, P [135] | |
10. | Pneumococcal lysins | Streptococcal bacteriophage | Antibiotic-resistant S.pneumoniae/ acute otitis media (AOM), septicemia,bronchitis,meningitis | A 2,000 μg2,000-μg dose of Cpl-1, mouse | Cpl-1-treated mice survived a fatal pneumonia infection 100 percent of the time. At 24 hours after infection, treated mice recovered quickly. | 2009 Witzenrath, M. [117] |
11. | Lysin Ply700 | Ply700 (50 μg/ml) | Activity against | 2008 Celia, L. K. | ||
12. | PlyGBS | Streptococcal bacteriophage | Prophylactic for Group B streptococcal (GBS) vaginal colonization in pregnant women | Single dose of PlyGBS, 100 μl of purified PlyC | Single dose of PlyGBS could cause a 3 log10 reduction of the bacterial cellsnin mice that had been vaginally challenged with GBS. PlyGBS can be used as a decontaminant to eliminate GBS from new-borns. Can reduce the rate of neonatal meningitis and sepsis | 2005 Cheng Q. |
13. | PlyV12 | VRE (Vancomycin-Resistant Enterococcus) | 100 μl of PlyV12 at 25 U/ml. | The lysin exhibited lytic activityagainst | 2004 Yoong, P. [138] | |
14. | PlyC lysin | Streptococcal bacteriophage C1 | Groups A, C and E streptococci. Group A streptococci (GAS) S. pyogenes/ pharyngitis rheumatic fever | 10 ng of PlyC, mouse | PlyC lysin successfully eliminated upper respiratory colonization of GAS in mice. None of the lysin treated mice were colonized compared to 100% of the control mice. | 2001 Nelson, D. [139] |
Endolysin therapy: therapeutic effects of Enzymes on bacterial diseases.
Most of the drug resistance in bacteria studies had been carried out on the use of
In this chapter, the lytic bacteriophages’ efficacy has been reported. Therapeutic bacteriophages have been shown to prevent the growth and replication of a variety of pathogenic bacteria in humans, resulting in improved recovery, health, and survival of infected individuals. Since no or few side effects have been reported, phage therapy is medically safe and effective against bacterial infections. Personalized treatment is presented for phage-resistant gangrene bacterial strains, burn wounds, chronic ulcers, psoriasis, bacterial diarrhoea, urinary tract infections, pneumonia and tuberculosis. Producing higher-quality phage cocktails against specific bacteria groups and making them readily available in all areas, regardless of geography, economics, or climatic conditions, is, however, advantageous. Phage therapy is one of the most effective methods for controlling microbial infections that occur in a variety of species at different times. Expanding research to other organisms may be one of the most useful techniques for collecting evidence and validating the phage therapy’s utility and therapeutic potential. Understanding infection mechanisms, phage tolerance, phage therapy effectiveness on targeted pathogens, and their effects on the normal microbiome can all aid in improving biocontrol strategies. A scientific logical approach is needed to develop long term storage and transport of therapeutic bacteriophages with a common guideline for the use and safety of phage therapy. The production of new medicines, innovative methods, and management practises to mitigate the risk of infectious agents being introduced and to reduce predisposing factors may be needed in the future to control bacterial diseases. The discovery of novel phage-host interaction methods and the understanding of how bacteriophages control their hosts will be aided by future studies on the complexities of phage lifestyles and dynamics, bionomics in natural systems, genome and viriome analysis, proteome analysis, genes coding for their proteins, and DNA polymerase phylogeny. To reduce the risk of infectious agents being introduced and to reduce predisposing factors, future bacterial disease control would depend on the development of new drugs, methods, and management practises. In response to the threat posed by multiresistant “super bugs,” the use of phage endolysins, as well as possible applications of these enzymes in medicine, food protection, agriculture and veterinary medicine, biotechnology, and environmental sciences, has increased significantly. The significance and trend of research on bacteriophages and their applications is expected to continue as the quest for new antimicrobials intensifies in the near future.
The authors thank Ms. Janana Priya for her assistance in the work. The authors also acknowledge support from Sree Balaji Medical College and Hospital for providing facilities and encouragement to complete the work. Govindan Dayanithi belongs to the “Centre National de la Recherche Scientifique-CNRS-French Ministry of Science and Higher Education”.
The authors (PR, GD) declare that there is no financial or conflict of interests.
Both the authors (Palaniappan Ramasamy, Govindan Dayanidhi) have made equal contributions in the conception, design, and execution of the described study and in drafting the manuscript writing and discussion.
Over the last couple of decades, there has been a growing trend in the use of minimally invasive techniques in spine surgery because of low rates of complications, reduced hospital length of stay, lower estimated blood loss, and minimal soft tissue trauma [1]. With the growing prevalence of low back pain and lumbar degenerative spine disease, spine surgeons have found the need to expand their surgical armamentarium in treating degenerative spondylosis and spondylolisthesis [2]. Current surgical techniques to fuse two vertebral levels include posterolateral fusion, posterior lumbar interbody fusion (PLIF), transforaminal lumbar interbody fusion (TLIF), and extreme lateral interbody fusion associated with pedicle-screw fixation/instrumentation [3, 4, 5, 6, 7]; however, all these methods have drawbacks, such as increased operative time, risk of serious complications, and increased stiffness of the fused motion segment which may cause pathologic stresses at the adjacent levels [7]. These drawbacks of pedicle screw fixation (PSF) techniques have necessitated surgeons to explore novel and even more minimally invasive methods to achieve comparable levels of stability and fusion rates. Spinous process fixation (SPF)/interspinous process fixation (ISPF) achieved through the use of interspinous fusion devices (IFD) is not as widely used or known in the spine surgical community as PSF. Such devices aim to secure plates to the lateral aspects of two adjacent spinous processes thereby preventing motion at that segment. It is imperative that IFDs are not mistaken for similar other interspinous devices that offer “dynamic stabilization” such as X-STOP or DIAM etc. IFD placement has been successfully applied as an adjunct to posterolateral fusion and anterior fusion techniques and has shown similar rates of stability and fusion rates as PSF and has also been associated with improved or comparable patient-outcome scores [8].
In this chapter, we present the current evidence behind interspinous process fixation/fusion devices. We describe the primary biomechanical evidence and then present a discussion on clinical evidence of some case–control, case-series, and outcome studies. We then discuss the results of a recently completed randomized control trial of the Aspen® MIS Spinous Process Fusion System (Zimmer Biomet Spine, Westminster, Colorado) and their implications in the use of IFDs in the future. At the end of the chapter, we describe in detail the components of the Aspen® MIS Spinous Process Fusion System and outline the basic surgical technique of placing this IFD successfully.
Ex-vivo biomechanical studies have demonstrated that IFDs provide comparable rigidity to PSF in flexion-extension [9]. The data are less clear in lateral bending and axial rotation. Techy et al. in 2013 specifically studied the Aspen interspinous device in comparison to pedicle screw fixation and found that the stability provided by the device was statistically equivalent to both bilateral or unilateral pedicle screw/rod construct in flexion-extension; however, lateral bending and axial rotation tests showed pedicle screw fixation to have significantly greater stability [9]. In contrast, an earlier biomechanical study by Karahalios et al. in 2010 showed no difference in stability provided by IFDs compared to PSF in flexion-extension, lateral bending or axial rotation [10]. Papp et al. showed IFDs preserve adjacent facet joint anatomy [11]; other studies have even suggested IFDs may reduce load on intervertebral discs and potentially reduce the risk of adjacent segment disease [12, 13]. Yu et al. in 2014 studied their own novel IFD and found that interspinous process fixation combined with posterior lumbar interbody fusion (PLIF) was equivalent in biomechanical stability to bilateral pedicle screw/rod fixation with PLIF [14]. In short, it seems that cadaveric studies have shown IFDs to fare pretty well in restricting motion through flexion-extension comparable to the current gold-standard pedicle screw fixation but are likely unable to stabilize a motion segment against shearing forces.
Tomii et al. studied the S-plate (Kisco DIR, Osaka, Japan) in a series of 15 patients who underwent PLIF and subsequent IFD placement and found no complications and increase in mean JOA scores from 12.1 to 21.9 with a study follow-up period of 1.5–4 years [15]. Kim et al. showed decreased operative time for IFD placement and PLIF versus PS fixation and PLIF (135.8 minutes versus 170.8 minutes) and lower blood loss. The same study also showed decreased visual analog scale (VAS) scores in the immediate post-operative period of IFD and PLIF compared with PS and PLIF (4.6 vs. 7.0) [13]. However, VAS scores at 1 year follow-up showed no significant differences between the two groups. The Korean Oswestry Disability Index (ODI) scores also showed no significant differences between the two techniques [13].
To assess the value of IFDs in fusion rates, Vokshoor et al. [16] analyzed a sub-cohort of 50 patients who underwent IFD with PLIF or TLIF and showed 94% of them showed interspinous process fusion and 86% of those levels showed solid interbody fusion based on Burkus criteria [17]. Kim et al. [13] also studied fusion rates in their paper by either looking at 6-month post-operative flexion-extension films and/or assessing for trabecular bone on the 6 month post-operative CT scan; they found that IFD with PLIF showed a 92.5% fusion rate, which was similar to 91.6% fusion rates for PLIF with PS fixation. The same paper also reported adjacent segment disease in 12.5% of patients who underwent PLIF with IFD versus 36% in PLIF with PS fixation.
Lastly, Panchal et al. [8] in 2016 reported results from the first randomized, prospective, controlled, multi-center trial comparing outcomes from patients receiving anterior (ALIF) or lateral (LLIF) interbody fusion with adjunctive interspinous fusion with the Aspen® MIS device or pedicle screw fixation. Patients were followed pre-operatively and post-operatively at 6 weeks, 3 months, 6 months, 12 months, and even 24 months. The primary study endpoint was the comparison of the Oswestry Disability Index (ODI) score from the pre-operative time period to that of the 12-month post-operative time period. The primary hypothesis of the trial was noninferiority of the ODI score change by the Aspen® MIS IFD group (investigation) compared to the pedicle screw fixation group (control).
103 subjects underwent single-level interbody fusion via ALIF or LLIF approach. Sixty-six of them underwent adjunctive interspinous fusion with Aspen MIS spinous process fixation device. Thirty-seven of them were supplemented with pedicle screw fixation. All patients had degenerative disc disease and/or Grade 1 or 2 spondylolisthesis. The trial demonstrated no significant differences between the two groups with respect to patient-reported outcome scores (ODI, SF-36, or VAS) at 1.5, 3, 6, or 12-month time points. Interbody fusion was assessed at 12 months by evaluating computed tomography (CT) scans and scoring them according to the Brantigan, Stelfee, Fraser (BSF) criteria [18]; the authors found no significant difference in the BSF scores, even after adjusting for potential confounders such as anterolateral plating and/or interbody technique. Furthermore, 92% of the patients who had the Aspen® MIS device placed showed bone formation between the device plates bridging the spinous processes [8]. Operative times (47.6 minutes vs. 70.2 minutes), fluoroscopy times (12.2 seconds vs. 58.4 seconds), and blood loss (57.5 cc versus 103.7 cc) were also significantly less between the groups. Notably, no device breakage or dislodgement occurred in the study; however, 6 patients (3.1%) did have spinous process fractures and 3 patients (1.5%) needed to be reoperated due to new or worsening postoperative back and/or leg pain that may have been related to IFD placement.
In short, Panchal et al. was the first randomized multi-center trial to report that interspinous rigid fixation used as a supplement to anterior or lateral interbody fusion techniques is comparable to adjunctive pedicle screw fixation in terms of fusion rates and patient-reported outcomes and has a better intra-operative risk profile.
The Aspen® Minimally Invasive Fusion System is a collection of spinous process fixation devices that are designed for rigid posterior fixation from T1 to S1 levels (see Figure 1). Each device consists of spinous process plates that come in three configurations (standard, medium, “Flared 5-1”), a “post plate” (a cylindrical device that is threaded in between the interspinous ligament and eventually joins the two spinous process plates) and a set screw that locks the system together. The cylindrical barrel in between the two plates can also hold approximately 0.5 cc to 3 cc of bone graft material. The system also has its own set of surgical tools to facilitate the insertion.
Aspen® MIS fusion system standard size spinous process plate [
The final assembled Aspen® Minimally Invasive Fusion System interspinous fixation device is shown in Figure 2. The system is FDA approved and indicated for use in the United States as an adjunct to interbody and/or posterior fusion or as a standalone fixation device from T1 – S1 levels [8] in degenerative, traumatic, and deformity pathologies.
Aspen® minimally invasive fusion system fully assembled [
The Aspen MIS system is placed with a patient in prone position through a 3–5 cm incision, enough to expose the length of the spinous process. Subperiosteal dissection is used to elevate the paraspinal muscles of the spinous process and lamina. The fusion site should be clear of connective and soft tissue then decorticated. The supraspinous ligament (SSL) can be removed or kept intact. Keeping the SSL intact helps preserves the natural anatomy and can prevent over distraction. The interspinous ligament is pierced as anterior as possible with a dilator (Figure 3).
Dilator is used to create space between the interspinous ligament [
A fluoroscopy image can be taken at this point to confirm anterior placement and appropriate level of dilator. The interspinous space is opened with a lamina spreader and measured to determine implant size. The interspinous space is decorticated with a rasp (Figure 4).
Rasp for decortication [
The barrel diameter is selected based on the fit of the rasp or spreader. The barrel length comes in a standard 21 mm size, appropriate for thick spinous processes or medium 18 mm when there are hypertrophied facets. The post plate implant is attached first to the left of the spinous process, then the barrel which is packed with graft material through the interspinous space, and finally the locking plate to the right of the spinous process (Figure 5).
Attachment of the post plate [
Autograft and/or allograft can be placed posterior to the graft between the spinous process and across the lamina. The device should sit in the proper anterior placement and not protrude above the lumbodorsal fascia before compressing the plates and tightening the set screw. If the implant is placed too far posterior there is an increased risk of spinous process fracture. The spikes should be fully seated into the bone, but care should be taken to not over-compress and weaken the cortex.
The Aspen® MIS Fusion System should be removed in the case of nonunion or if any components loosen or break. The provided set-screwdriver or a T10 Torque driver can be used to loosen the locking set screw. The plates can then be lifted with a Cobb elevator and removed from the spinous process. Figure 6 shows lateral and antero-posterior radiographs of a full assembled Aspen® MIS Fusion System.
A/P and lateral images of Aspen MIS fusion system at L4-L5.
Until recently, IFDs have had only biomechanical and some prospective clinic studies in evaluating their role as an adjunct to thoracolumbar fusion. However, the randomized control trial by Panchal et al. [8] showed outcomes of interspinous process fixation to be comparable and even, in some cases, more favorable to those of pedicle screw fixation. The relative ease with which a surgeon can minimally invasively implant this device combined with a relatively short operative times, low blood loss, and reduce hospital length of stay provides an attractive alternative to pedicle screw fixation.
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Integrity - We are consistent and dependable, always striving for precision and accuracy in the true spirit of science.
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\n\nIntechOpen is a dynamic, vibrant company, where exceptional people are achieving great things. We offer a creative, dedicated, committed, and passionate environment but never lose sight of the fact that science and discovery is exciting and rewarding. We constantly strive to ensure that members of our community can work, travel, meet world-renowned researchers and grow their own career and develop their own experiences.
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