Acetyl-L-carnitine (ALCAR) to enhance nerve regeneration in carpal tunnel syndrome: study protocol for a randomized, placebo-controlled trial

Background

Carpal tunnel syndrome (CTS) is the most common form of peripheral nerve injury, affecting approximately 3 % of the population. While surgery is effective in mild and moderate cases, nerve and functional recovery are often not complete in severe cases. Therefore, there is a need for adjuvant methods to improve nerve regeneration in those cases. Acetyl-L-carnitine (ALCAR) is involved in lipid transport, vital for mitochondrial function. Although it has been shown to be effective in various forms of neuropathies, it has not been used in traumatic or compressive peripheral nerve injury.

Methods

In this pilot study we will utilize a double-blind, randomized, placebo-controlled design. Inclusion criteria will include adult patients with severe CTS. This will be confirmed by nerve conduction studies and motor unit number estimation (MUNE). Only those with severe motor unit loss in the thenar muscles (2 standard deviations [SD] below the mean for the age group) will be included. Eligible patients will be randomized to receive 3,000 mg/day of ALCAR orally or placebo following carpal tunnel release surgery for 2 months. The primary outcome will be MUNE with supplementary secondary outcome measures that include: 1) two-point discrimination; 2) Semmes-Weinstein monofilaments for pressure sensitivity; 3) cold and pain threshold for small fiber function; 4) Boston self-assessment Carpal Tunnel Questionnaire and 5) Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for symptom severity; and 6) Purdue Pegboard Test for hand functional performance. To follow post treatment recovery and monitor safety, patients will be seen at 3 months, 6 months and 1 year. The outcome measures will be analyzed using two-way ANOVA, with treatment assignment and time points being the independent factors. If significant associations are detected, a post hoc analysis will be completed. We aim to recruit ten patients into each of the two groups. Data from this pilot will provide the basis for power calculation for a full-scale trial.

Discussion

ALCAR is a physiologic peptide crucial for fatty acid transport. ALCAR has been shown to be effective in neuroprotection in the central nervous system and increase peripheral nerve regeneration. This has been applied clinically to various systemic peripheral neuropathies including diabetic neuropathy, antiretroviral toxic neuropathy, and chemotherapy-induced peripheral neuropathy. While animal evidence exists for the benefit of ALCAR in compression neuropathy, there have been no human studies to date. This trial will represent the first use of ALCAR in peripheral nerve injury/compression neuropathy.

Trial registration

NCT02141035; 20 April 2015

Electrical Stimulation to Enhance Axon Regeneration After Peripheral Nerve Injuries in Animal Models and Humans

Injured peripheral nerves regenerate their lost axons but functional recovery in humans is frequently disappointing. This is so particularly when injuries require regeneration over long distances and/or over long time periods. Fat replacement of chronically denervated muscles, a commonly accepted explanation, does not account for poor functional recovery. Rather, the basis for the poor nerve regeneration is the transient expression of growth-associated genes that accounts for declining regenerative capacity of neurons and the regenerative support of Schwann cells over time. Brief low-frequency electrical stimulation accelerates motor and sensory axon outgrowth across injury sites that, even after delayed surgical repair of injured nerves in animal models and patients, enhances nerve regeneration and target reinnervation. The stimulation elevates neuronal cyclic adenosine monophosphate and, in turn, the expression of neurotrophic factors and other growth-associated genes, including cytoskeletal proteins. Electrical stimulation of denervated muscles immediately after nerve transection and surgical repair also accelerates muscle reinnervation but, at this time, how the daily requirement of long-duration electrical pulses can be delivered to muscles remains a practical issue prior to translation to patients. Finally, the technique of inserting autologous nerve grafts that bridge between a donor nerve and an adjacent recipient denervated nerve stump significantly improves nerve regeneration after delayed nerve repair, the donor nerves sustaining the capacity of the denervated Schwann cells to support nerve regeneration. These reviewed methods to promote nerve regeneration and, in turn, to enhance functional recovery after nerve injury and surgical repair are sufficiently promising for early translation to the clinic.

Functional, electrophysiological recoveries of rats with sciatic nerve lesions following transplantation of elongated DRG cells

OBJECTIVES

Functional data are essential when confirming the efficacy of elongated dorsal root ganglia (DRG) cells as a substitute for autografting. We present the quantitative functional motor, electrophysiological findings of engineered DRG recipients for the first time.

METHODS

Elongated DRG neurons and autografts were transplanted to bridge 1-cm sciatic nerve lesions of Sprague Dawley (SD) rats. Motor recoveries of elongated DRG recipients (n=9), autograft recipients (n=9), unrepaired rats (n=9) and intact rats (n=6) were investigated using the angle board challenge test following 16 weeks of recovery. Electrophysiology studies were conducted to assess the functional recovery at 16 weeks. In addition, elongated DRGs were subjected to histology assessments.

RESULTS

At threshold levels (35° angle) of the angle board challenge test, the autograft recipients', DRG recipients' and unrepaired group's performances were equal to each other and were less than the intact group (p<0.05). However, during the subthreshold (30°) angle board challenge test, the elongated DRG recipients' performance was similar to both the intact group and the autograft nerve recipients, and was better (p<0.05) than the unrepaired group. The autograft recipients' performance was similar to the unrepaired group and was significantly different (p<0.05) compared with the performance of the intact group. During electrophysiological testing, the rats with transplanted engineered DRG constructs had intact signal transmission when recorded over the lesion, while the unrepaired rats did not. It was observed that elongated DRG neurons closely resembled an autograft during histological assessments.

CONCLUSION

Performances of autograft and elongated DRG construct recipients were similar. Elongated DRG neurons should be further investigated as a substitute for autografting.

Neurogenic potential of engineered mesenchymal stem cells overexpressing VEGF

Numerous signaling molecules are altered following nerve injury, serving as a blueprint for drug delivery approaches that promote nerve repair. However, challenges with achieving the appropriate temporal duration of recombinant protein delivery have limited the therapeutic success of this approach. Genetic engineering of mesenchymal stem cells (MSCs) to enhance the secretion of proangiogenic molecules such as vascular endothelial growth factor (VEGF) may provide an alternative. We hypothesized that the administration of VEGF-expressing human MSCs would stimulate neurite outgrowth and proliferation of cell-types involved in neural repair. When cultured with dorsal root ganglion (DRG) explants in vitro, control and VEGF-expressing MSCs (VEGF-MSCs) increased neurite extension and proliferation of Schwann cells (SCs) and endothelial cells, while VEGF-MSCs stimulated significantly greater proliferation of endothelial cells. When embedded within a 3D fibrin matrix, VEGF-MSCs maintained overexpression and expressed detectable levels over 21 days. After transplantation into a murine sciatic nerve injury model, VEGF-MSCs maintained high VEGF levels for 2 weeks. This study provides new insight into the role of VEGF on peripheral nerve injury and the viability of transplanted genetically engineered MSCs. The study aims to provide a framework for future studies with the ultimate goal of developing an improved therapy for nerve repair.

Neural Ablation and Regeneration in Pain Practice

A nerve block is an effective tool for diagnostic and therapeutic methods. If a diagnostic nerve block is successful for pain relief and the subsequent therapeutic nerve block is effective for only a limited duration, the next step that should be considered is a nerve ablation or modulation. The nerve ablation causes iatrogenic neural degeneration aiming only for sensory or sympathetic denervation without motor deficits. Nerve ablation produces the interruption of axonal continuity, degeneration of nerve fibers distal to the lesion (Wallerian degeneration), and the eventual death of axotomized neurons. The nerve ablation methods currently available for resection/removal of innervation are performed by either chemical or thermal ablation. Meanwhile, the nerve modulation method for interruption of innervation is performed using an electromagnetic field of pulsed radiofrequency. According to Sunderland's classification, it is first and foremost suggested that current neural ablations produce third degree peripheral nerve injury (PNI) to the myelin, axon, and endoneurium without any disruption of the fascicular arrangement, perineurium, and epineurium. The merit of Sunderland's third degree PNI is to produce a reversible injury. However, its shortcoming is the recurrence of pain and the necessity of repeated ablative procedures. The molecular mechanisms related to axonal regeneration after injury include cross-talk between axons and glial cells, neurotrophic factors, extracellular matrix molecules, and their receptors. It is essential to establish a safe, long-standing denervation method without any complications in future practices based on the mechanisms of nerve degeneration as well as following regeneration.

What Do We Know About the Pathophysiology of Chronic Pain? Implications for Treatment Considerations

We discuss the complex features of the pathophysiology of chronic pain and the implications for treatment and provide an overview of nociceptive processes, neuropathic pain, cold hyperalgesia, peripheral nerve injury, wind-up pain, central sensitization, and common clinical presentation and diagnostic criteria. Advanced medicine has proven that chronic pain need not involve any structural pathology as pain is a complex biopsychosocial experience. Treatment of the specific mechanisms responsible for pain should be aimed at preventing and or reducing dysfunctional neuro-plasticity resulting from poorly controlled chronic pain. Further study is needed to reduce the probability and of persistent changes that cause chronic pain.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees

BACKGROUND

Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation.

METHODS

The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees (206 amputations) from the Iran-Iraq war were evaluated, and a detailed questionnaire was also administered.

RESULTS

The most common level of amputation was the finger or wrist level (108, 52.4 %). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis (65, 31.6 %), rotator cuff injury (24, 11.7 %), bicipital tendonitis (69, 33.5 %), shoulder drop (42, 20.4 %) and muscle atrophy (19, 9.2 %). Peripheral nerve disorders included carpal tunnel syndrome in 13 (6.3 %) and unilateral brachial plexus injury in 1 (1 %). Fifty-three (51.5 %) were diagnosed with facet joint syndrome at the level of the cervical spine (the most frequent site). Using a prosthesis was reported by 65 (63.1 %), both left and right sides. The back was the most common site of pain (71.8 %).

CONCLUSION

The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Tissue-engineered conduit promotes sciatic nerve regeneration following radiation-induced injury as monitored by magnetic resonance imaging

PURPOSE

To observe the longitudinal changes in peripheral nerve repaired with chitosan conduits in a rat model of radiation-induced neuropathy.

MATERIALS AND METHODS

Four months after 40 Gy radiation to the right lower limbs, forty-two rats were divided randomly into three groups. Chitosan conduits were implanted with (group A, n=12) or without (group B, n=12) mesenchymal stem cells (MSCs), and untreated controls (group C, n=12). Following sciatic nerve MR imaging (including T2WI and Gd-DTPA enhanced T1WI), functional evaluation and electrophysiological exam were performed two-monthly, final histological assessments were done at the end of one year. The differences among the experimental and control groups were statistically analysed with Fisher's PLSD or t-test.

RESULTS

The compound muscle action potentials (CMAPs) and sciatic function index (SFI) had declined since 4 months after radiation injury. The focal nerve enlargement and hyperintensity, the perineurium and connecting muscle enhancement were demonstrated by MR neurography images. After chitosan tube implantation, the normalized signal intensities (SIs) in group A were declined more rapidly than SIs in other groups. The histological assessments indicated that group A had better remyelination, combined with higher CMAPs amplitude and SFI score than other groups.

CONCLUSION

A single fraction dose of 40 Gy can be used to establish a rat model of sciatic nerve injury. Longitudinal electrophysiological examination and MR neurography are useful to evaluate the post-irradiation sciatic neuropathy. The rats with tissue-engineered conduits implantation showed some improvement of lower limb function, accompanied by a normalization of (T1W/T2W) MR signal.

Decellular Nerve Allografts

Multiple treatment options are available for patients who have peripheral nerve injuries with a gap. Decellular nerve allografts are one option and provide an extracellular scaffold for neuronal cells to migrate for axonal regrowth. Immunosuppression is not needed because improved nerve processing technologies have rendered decellular nerve allografts nonimmunogenic. These allografts have also shown promising results in both animal and human studies as an alternative repair option.

The regulatory roles of non-coding RNAs in nerve injury and regeneration

Non-coding RNAs (ncRNAs), especially microRNAs (miRNAs) and long non-coding RNAs (lncRNAs), have attracted much attention since their regulatory roles in diverse cell processes were recognized. Emerging studies demonstrate that many ncRNAs are differentially expressed after injury to the nervous system, significantly affecting nerve regeneration. In this review, we compile the miRNAs and lncRNAs that have been reported to be dysregulated following a variety of central and peripheral nerve injuries, including acquired brain injury, spinal cord injury, and peripheral nerve injury. We also list investigations on how these miRNAs and lncRNAs exert the regulatory actions in neurodegenerative and neuroregenerative processes through different mechanisms involving their interaction with target coding genes. We believe that comprehension of the expression profiles and the possible functions of ncRNAs during the processes of nerve injury and regeneration will help understand the molecular mechanisms responsible for post-nerve-injury changes, and may contribute to the potential use of ncRNAs as a diagnostic marker and therapeutic target for nerve injury.

Experimental study of the functional reserve of median nerve in rats

OBJECTIVE

To study the functional changes of median nerve after removing a certain bundle of it and to explore the functional reserve of median nerves.

METHODS

220 three-month old SD rats were randomly divided into experimental groups and sham groups. And the experimental group was further divided as 1/8 group, 1/4 group, 1/3 group, 1/2 group, and 2/3 group according to ratio of the resection portion, with 22 rats in each group. The section of the lowest level on median nerve trunks were exposed, and a certain portion of it were separated and resected in experimental group, while in sham groups, the nerve was only separated without resection. The general state of health of all rats were observed, and the α motor neurons in cornu anterior medullae spinalis were studied 1 week, 2 weeks and 2 months postoperatively. Neuro-electrophysiology and function of dominated muscles were studied 2 weeks, 2 months, 3 months, and 4 months postoperatively.

RESULTS

All rats survived without infection and obvious ulcer. The number of the α motor neurons in cornuanterior medullae spinalis didn't change (P>0.05), and obvious superstructure changes were observed in early stage in 1/2 and 2/3 group, but restored after 2 months. There was no significant changes in latencies of motor neuron evoked potentials between experimental groups and sham group (P>0.05), however, there is significant difference if the 2 week group was compared with 2 month, 3 month and 4 month group (P<0.05). Moreover, there is also significant difference in terms of the wave amplitude of evoked potential of motor neurons, the maximum wave amplitude and the persistence time of its innervated muscle if the 2 week group was compared with those in 2 month, 3 month and 4 month group (P<0.05), and there is significant difference between different proportion resection groups (P<0.05).

CONCLUSIONS

Median nerve has a certain amount of functional reserve, and the quantity of the functional reserve of median nerve without compromise is the 1/3 of the whole trunk.

G Protein-Coupled Estrogen Receptor Levels After Peripheral Nerve Injury in an Experimental Rat Model

OBJECTIVE

To assess whether G protein-coupled estrogen receptor (GPER) levels were altered during crush-induced peripheral nerve injury in an experimental rat model.

METHODS

Male Wistar rats (N = 80) were allocated to 1 sham and 6 study groups, and crush-type peripheral nerve injury was performed using a clamp on the sciatic nerves of study groups. In the sham group, the sciatic nerve was exposed only, and the wound was closed primarily without any surgical interventions. Peripheral nerve samples were obtained at 1 hour, 6 hours, 12 hours, 24 hours, 3 days, and 7 days. After analysis of nerve tissues by protein analysis and Western blotting, the groups were compared in terms of expression of GPER levels.

RESULTS

The average levels of GPER in the sham group and study groups at 1 hour, 6 hours, 12 hours, 24 hours, 3 days, and 7 days were 15.06 ng/mL ± 2.91, 3.31 ng/mL ± 0.91, 4.06 ng/mL ± 0.87, 11.94 ng/mL ± 1.15, 10.76 ng/mL ± 1.76, 9.16 ng/mL ± 2.60, and 8.49 ng/mL ± 3.55. All study groups displayed significantly lower levels of GPER compared with the sham group.

CONCLUSIONS

Our results demonstrate that a basal level of GPER expression occurs in peripheral nerve tissue. The lowest level was detected 1 hour after crush injury, and the highest levels of GPER were detected 12 hours and 24 hours after trauma. Further trials on larger series are required to elucidate the role of GPER in terms of protection and treatment after nerve injury.

Regional tissue immune responses after sciatic nerve injury in rats

Inflammatory cells play a critical role during nerve regeneration following peripheral nerve injury. In this study, we investigated immune responses in rat sciatic nerve after injury. Wistar rats were randomly divided into the sciatic nerve injury (model) group and control group. The right sciatic nerve of rats in the model group was transected and sutured end-to-end. Our results showed that rats in the model group functionally recovered following sciatic nerve injury. We detected inflammatory cell infiltration in the remaining sciatic nerves following injury. In addition, expression of interferon-γ (INF-γ), interleukin-10 (IL-10), and the INF-γ/IL-10 ratio was significantly elevated one week following nerve injury, but gradually decreased thereafter. Our findings demonstrate that immune responses and inflammatory cell activation are involved during recovery from sciatic nerve injury.

Effect of low-level laser therapy (LLLT) on peripheral nerve regeneration using fibrin glue derived from snake venom

OBJECTIVES

The purpose of this study was to assess whether the adhesive permits the collateral repair of axons originating from a vagus nerve to the interior of a sural nerve graft, and whether low-level laser therapy (LLLT) assists in the regeneration process.

MATERIALS AND METHODS

Study sample consisted of 32 rats randomly separated into three groups: Control Group (CG; n=8), from which the intact sural nerve was collected; Experimental Group (EG; n=12), in which one of the ends of the sural nerve graft was coapted to the vagus nerve using the fibrin glue; and Experimental Group Laser (EGL; n=12), in which the animals underwent the same procedures as those in EG with the addition of LLLT. Ten weeks after surgery, the animals were euthanized. Morphological analysis by means of optical and electron microscopy, and morphometry of the regenerated fibers were employed to evaluate the results.

RESULTS

Collateral regeneration of axons was observed from the vagus nerve to the interior of the autologous graft in EG and EGL, and in CG all dimensions measured were greater and presented a significant difference in relation to EG and EGL, except for the area and thickness of the myelin sheath, that showed significant difference only in relation to the EG.

CONCLUSIONS

The present study demonstrated that the fibrin glue makes axonal regeneration feasible and is an efficient method to recover injured peripheral nerves, and the use of low-level laser therapy enhances nerve regeneration.

Evaluating the effect of polytetrafluoroethylene and extractum cepae-heparin-allantoin gel in peripheral nerve injuries in a rat model

BACKGROUND

Peripheral nerves can be injured by congenital, mechanical, thermal or chemical causes. Peripheral nerve injuries are increasing in frequency, particularly in countries that are becoming more industrialized. Nerve and extremity injuries result in work loss and high treatment costs, and can lead to separation of patients from their social environment. Failure of nerve repair causes muscle functional losses, sensory losses and painful neuropathies.

OBJECTIVES

To compare the effects of condensed polytetrafluoroethylene (cPTFE) and cPTFE-extractum cepae-heparin-allantoin (cPTFE-EHA) gel compound on nerve and functional recovery, and the prevention of adhesion and scar tissue formation after total peripheral nerve injury repaired by primary suture in a rat model.

RESULTS

cPTFE alone and cPTFE-EHA gel was found to provide better functional recovery and nerve regeneration compared with primary repair only. In the macroscopic evaluation, the cPTFE-EHA gel was found to have no negative effect on wound healing and, despite increasing extra-neural scar tissue and adhesions, it had no negative effect on nerve function; in addition, it facilitated functional recovery.

CONCLUSIONS

Compared with the cPTFE application alone, the application of perineural cPTFE-EHA gel during peripheral nerve surgery appeared to provide better functional recovery without causing any significant changes in epineural and extraneural scar tissue formation.

Differences in AMPA and GABAA/B receptor subunit expression between the chronically reorganized cortex and brainstem of adult squirrel monkeys

The primate somatosensory neuraxis provides a highly translational model system with which to investigate adult neural plasticity. Here, we report immunohistochemical staining data for AMPA and GABAA/B receptor subunits of area 3b cortex and cuneate nucleus of adult squirrel monkeys one to five years after median and ulnar nerve transection. In Area 3B cortex, the expression of GluR1 AMPAR subunits in reorganized regions are significantly increased, while the expression of GluR2/3 AMPAR subunits are not. GABAA α1 subunit expression in the reorganized region is not significantly different from control regions. Presynaptic GABABR1a subunit expression was also not significantly different between reorganized and control regions, while postsynaptic GABABR1b subunit expression was significantly decreased. In the cuneate nucleus of the brainstem, the expression of GluR1 AMPAR subunits in reorganized regions was not significantly different, while GluR2/3 AMPAR subunit expression was significantly elevated. GABAA α1 subunit expression in the reorganized region was significantly decreased. Presynaptic GABABR1a subunit expression was not significantly different, while postsynaptic GABABR1b subunit expression was significantly decreased. When subunit expression is compared, brainstem and cortical patterns diverge over longer periods of recovery. Persistent patterns of change in the cortex are stable by 1-year. Alternatively, subunit expression in the cuneate nucleus one to five years after nerve injury is similar to that seen 1-month after a reorganizing injury. This suggests that cortical plasticity continues to change over many months as receptive field reorganization occurs, while brainstem plasticity obtains a level of stable persistence by one month.

Neurite outgrowth in normal and injured primary sensory neurons reveals different regulation by nerve growth factor (NGF) and artemin

Neurotrophic factors have been intensively studied as potential therapeutic agents for promoting neural regeneration and functional recovery after nerve injury. Artemin is a member of the glial cell line-derived neurotrophic factor (GDNF) family of ligands (GFLs) that forms a signalling complex with GFRα3 and the tyrosine kinase Ret. Systemic administration of artemin in rodents is reported to facilitate regeneration of primary sensory neurons following axotomy, improve recovery of sensory function, and reduce sensory hypersensitivity that is a cause of pain. However, the biological mechanisms that underlie these effects are mostly unknown. This study has investigated the biological significance of the colocalisation of GFRα3 with TrkA (neurotrophin receptor for nerve growth factor [NGF]) in the peptidergic type of unmyelinated (C-fibre) sensory neurons in rat dorsal root ganglia (DRG). In vitro neurite outgrowth assays were used to study the effects of artemin and NGF by comparing DRG neurons that were previously uninjured, or were axotomised in vivo by transecting a visceral or somatic peripheral nerve. We found that artemin could facilitate neurite initiation but in comparison to NGF had low efficacy for facilitating neurite elongation and branching. This low efficacy was not increased when a preconditioning in vivo nerve injury was used to induce a pro-regenerative state. Neurite initiation was unaffected by artemin when PI3 kinase and Src family kinase signalling were blocked, but NGF had a reduced effect.

Comparison of two electrophysiological methods for the assessment of progress in a rat model of nerve repair

There are 2 critical steps in neural regeneration: nerve fibres successfully crossing the suture and restoration of neuromuscular transmission. For the second step, the compound muscle action potential (CMAP) is the standard electrophysiological technique used to assess regeneration, but it is difficult to detect changes in the CMAP during early regeneration after nerve repair. There is a need for better, noninvasive quantitative electrophysiological techniques to assess regeneration in an earlier stage after nerve repair. In this study, we utilized 2 measures, CMAP and single-fibre electromyography (SFEMG), in a rat model of nerve repair. The model was generated by separating the sciatic nerve of the rat hindlimb from the tibial nerve in Sprague-Dawley rats. CMAP and SFEMG were measured in each rat at 1, 2, 3, 4, and 6 weeks after the operation. The muscle weight was measured and both the general structure of the muscle and the changes in muscle atrophy were examined using haematoxylin and eosin staining protocols. The nerve electrophysiological data could be detected at 2 weeks after surgery initially and more data could be collected with passing time. During the period ranging from 2 to 4 weeks after surgery, parameters of SFEMG recordings changed significantly while the CMAP amplitude did not increase until 6 weeks after surgery. While the fibre density (FD) at 2 weeks after surgery was 0.27 ± 0.31, there was a significant increase at 3 weeks relative to 2 weeks (P < 0.01), and the FD increased further at 4 weeks (P < 0.01). The action potential mean consecutive difference (MCD) was significantly higher (60.50 ± 3.53 μs) in the second week relative to the third week (41.12 ± 5.08 μs) after the operation. The results indicated that SFEMG was more sensitive than CMAP amplitudes in detecting neuromuscular transmission after nerve repair. The findings of nerve electrophysiological experiments were consistent with the observed degree of muscle recovery. The SFEMG can be used to detect the very early reinnervation of the muscle more sensitively than CMAP. The ratio of affected muscle weight to unaffected muscle weight was decreased at 2 weeks after surgery (59.01%), continued to decrease significantly at 3 weeks (51.24%), and was restored at 6 weeks. A combination of SFEMG and CMAP can show the dynamic progression of the muscle reinnervation process.

Dendritic spine dysgenesis in neuropathic pain

The failure of neuropathic pain to abate even years after trauma suggests that adverse changes to synaptic function must exist in a chronic pathological state in nociceptive pathways. The chronicity of neuropathic pain therefore underscores the importance of understanding the contribution of dendritic spines--micron-sized postsynaptic structures that represent modifiable sites of synaptic contact. Historically, dendritic spines have been of great interest to the learning and memory field. More recent evidence points to the exciting implication that abnormal dendritic spine structure following disease or injury may represent a "molecular memory" for maintaining chronic pain. Dendritic spine dysgenesis in dorsal horn neurons contributes to nociceptive hyperexcitability associated with neuropathic pain, as demonstrated in multiple pain models, i.e., spinal cord injury, peripheral nerve injury, diabetic neuropathy, and thermal burn injury. Because of the relationship between dendritic spine structure and neuronal function, a thorough investigation of dendritic spine behavior in the spinal cord is a unique opportunity to better understand the mechanisms of sensory dysfunction after injury or disease. At a conceptual level, a spinal memory mechanism that engages dendritic spine remodeling would also contribute to a broad range of intractable neurological conditions. Molecules involved in regulating dendritic spine plasticity may offer novel targets for the development of effective and durable therapies for neurological disease.

Current progress in use of adipose derived stem cells in peripheral nerve regeneration

Unlike central nervous system neurons; those in the peripheral nervous system have the potential for full regeneration after injury. Following injury, recovery is controlled by schwann cells which replicate and modulate the subsequent immune response. The level of nerve recovery is strongly linked to the severity of the initial injury despite the significant advancements in imaging and surgical techniques. Multiple experimental models have been used with varying successes to augment the natural regenerative processes which occur following nerve injury. Stem cell therapy in peripheral nerve injury may be an important future intervention to improve the best attainable clinical results. In particular adipose derived stem cells (ADSCs) are multipotent mesenchymal stem cells similar to bone marrow derived stem cells, which are thought to have neurotrophic properties and the ability to differentiate into multiple lineages. They are ubiquitous within adipose tissue; they can form many structures resembling the mature adult peripheral nervous system. Following early in vitro work; multiple small and large animal in vivo models have been used in conjunction with conduits, autografts and allografts to successfully bridge the peripheral nerve gap. Some of the ADSC related neuroprotective and regenerative properties have been elucidated however much work remains before a model can be used successfully in human peripheral nerve injury (PNI). This review aims to provide a detailed overview of progress made in the use of ADSC in PNI, with discussion on the role of a tissue engineered approach for PNI repair.

Gene expression profiling studies in regenerating nerves in a mouse model for CMT1X: uninjured Cx32-knockout peripheral nerves display expression profile of injured wild type nerves

X-linked Charcot-Marie-Tooth disease (CMT1X) is an inherited peripheral neuropathy caused by mutations in GJB1, the human gene for Connexin32 (Cx32). This present study uses Ilumina Ref8-v2 BeadArray to examine the expression profiles of injured and uninjured sciatic nerves at 5, 7, and 14 days post-crush injury (dpi) from Wild Type (WT) and Cx32-knockout (Cx32KO) mice to identify the genes and signaling pathways that are dysregulated in the absence of Schwann cell Cx32. Given the assumption that loss of Schwann cell Cx32 disrupts the regeneration and maintenance of myelinated nerve leading to a demyelinating neuropathy in CMT1X, we initially hypothesized that nerve crush injury would result in significant increases in differential gene expression in Cx32KO mice relative to WT nerves. However, microarray analysis revealed a striking collapse in the number of differentially expressed genes at 5 and 7 dpi in Cx32KO nerves relative to WT, while uninjured and 14 dpi time points showed large numbers of differentially regulated genes. Further comparisons within each genotype showed limited changes in Cx32KO gene expression following crush injury when compared to uninjured Cx32KO nerves. By contrast, WT nerves exhibited robust changes in gene expression at 5 and 7 dpi with no significant differences in gene expression by 14dpi relative to uninjured WT nerve samples. Taken together, these data suggest that the gene expression profile in uninjured Cx32KO sciatic nerve strongly resembles that of a WT nerve following injury and that loss of Schwann cell Cx32 leads to a basal state of gene expression similar to that of an injured WT nerve. These findings support a role for Cx32 in non-myelinating and regenerating populations of Schwann cells in normal axonal maintenance in re-myelination, and regeneration of peripheral nerve following injury. Disruption of Schwann cell-axonal communication in CMT1X may cause dysregulation of signaling pathways that are essential for the maintenance of intact myelinated peripheral nerves and to establish the necessary conditions for successful regeneration and remyelination following nerve injury.

A quantitative study of vibration injury to peripheral nerves-introducing a new longitudinal section analysis

PURPOSE

Long-term vibrations are known to cause neurovascular diseases, which are common in workers who operate handheld power tools or motor vehicles. Understanding the neuropathology of vibration-induced nerve injury is critical to its prevention and treatment. This study aims to evaluate whether light microscopy of longitudinal nerve sections can be used as a simple yet effective method for quantifying nerve injury.

METHODS

The rats were split into two groups that were subjected to vibration (4 h/day) for 7 or 14 days. They were then allowed to rest for varying periods of time. Longitudinal sections of the tail nerves were examined under light microscopy. Injuries to the nerves were classified into three types, counted, tallied, and then divided by the length of the nerve being studied.

RESULTS

Both 7 and 14 days of vibration showed significant damage when no recovery time was given. After 1 month of rest, the 7-day group began to show signs of recovery, but the 14-day group did not. After 2 months of rest, the 7-day vibration group showed almost complete recovery, while the 14-day vibration group still showed significant damage when compared to the sham control groups.

CONCLUSION

The amount of damage to the myelin sheath directly correlated with vibration duration. When vibrated for longer than 7 days, nerve recovery was limited. This study also demonstrated that light microscopy of longitudinal slices is a simple yet effective method of quantifying the nerve damage.

Evidence-based medicine for ultrasound-guided regional anesthesia

Available evidence favoring the use of ultrasound for regional anesthesia is reviewed, updated, and critically assessed. Important outcome advantages include decreased time to block onset; decreased risk of local anesthetic systemic toxicity; and, depending on the outcome definition, increased block success rates. Ultrasound guidance, peripheral nerve blocks, and central neuraxial blocks are discussed.

Peripheral nerve injuries: advancing the field through research, collaboration, and education

The Andrew J. Weiland Medal is presented each year by the American Society for Surgery of the Hand and the American Foundation for Surgery of the Hand for a body of work related to hand surgery research. This essay, awarded the Weiland Medal in 2013, focuses on advancing the field of peripheral nerve injuries through research, collaboration, and education.

Improving peripheral nerve regeneration: from molecular mechanisms to potential therapeutic targets

Peripheral nerve injury is common especially among young individuals. Although injured neurons have the ability to regenerate, the rate is slow and functional outcomes are often poor. Several potential therapeutic agents have shown considerable promise for improving the survival and regenerative capacity of injured neurons. These agents are reviewed within the context of their molecular mechanisms. The PI3K/Akt and Ras/ERK signaling cascades play a key role in neuronal survival. A number of agents that target these pathways, including erythropoietin, tacrolimus, acetyl-l-carnitine, n-acetylcysteine and geldanamycin have been shown to be effective. Trk receptor signaling events that up-regulate cAMP play an important role in enhancing the rate of axonal outgrowth. Agents that target this pathway including rolipram, testosterone, fasudil, ibuprofen and chondroitinase ABC hold considerable promise for human application. A tantalizing prospect is to combine different molecular targeting strategies in complementary pathways to optimize their therapeutic effects. Although further study is needed prior to human trials, these modalities could open a new horizon in the clinical arena that has so far been elusive.