Neurotrophins enhance electric field-directed growth cone guidance and directed nerve branching

Electrical stimulation via repeated biphasic conducting materials for peripheral nerve regeneration

Improved materials for peripheral nerve repair are needed for the advancement of new surgical techniques in fields spanning from oncology to trauma. In this study, we developed bioresorbable materials capable of producing repeated electric field gradients spaced 600 μm apart to assess the impact on neuronal cell growth, and migration. Electrically conductive, biphasic composites comprised of poly (glycerol) sebacate acrylate (PGSA) alone, and doped with poly (pyrrole) (PPy), were prepared to create alternating segments with high and low electrically conductivity. Conductivity measurements demonstrated that 0.05% PPy added to PSA achieved an optimal value of 1.25 × 10-4 S/cm, for subsequent electrical stimulation. Tensile testing and degradation of PPy doped and undoped PGSA determined that 35-40% acrylation of PGSA matched nerve mechanical properties. Both fibroblast and neuronal cells thrived when cultured upon the composite. Biphasic PGSA/PPy sheets seeded with neuronal cells stimulated for with 3 V, 20 Hz demonstrated a 5x cell increase with 1 day of stimulation and up to a 10x cell increase with 3 days stimulation compared to non-stimulated composites. Tubular conduits composed of repeated high and low conductivity materials suitable for implantation in the rat sciatic nerve model for nerve repair were evaluated in vivo and were superior to silicone conduits. These results suggest that biphasic conducting conduits capable of maintaining mechanical properties without inducing compression injuries while generating repeated electric fields are a promising tool for acceleration of peripheral nerve repair to previously untreatable patients.

Possible Synergies of Nanomaterial-Assisted Tissue Regeneration in Plasma Medicine: Mechanisms and Safety Concerns

Cold atmospheric plasma and nanomedicine originally emerged as individual domains, but are increasingly applied in combination with each other. Most research is performed in the context of cancer treatment, with only little focus yet on the possible synergies. Many questions remain on the potential of this promising hybrid technology, particularly regarding regenerative medicine and tissue engineering. In this perspective article, we therefore start from the fundamental mechanisms in the individual technologies, in order to envision possible synergies for wound healing and tissue recovery, as well as research strategies to discover and optimize them. Among these strategies, we demonstrate how cold plasmas and nanomaterials can enhance each other's strengths and overcome each other's limitations. The parallels with cancer research, biotechnology and plasma surface modification further serve as inspiration for the envisioned synergies in tissue regeneration. The discovery and optimization of synergies may also be realized based on a profound understanding of the underlying redox- and field-related biological processes. Finally, we emphasize the toxicity concerns in plasma and nanomedicine, which may be partly remediated by their combination, but also partly amplified. A widespread use of standardized protocols and materials is therefore strongly recommended, to ensure both a fast and safe clinical implementation.

Glial-Neuronal Interactions in Pathogenesis and Treatment of Spinal Cord Injury

Traumatic spinal cord injury (SCI) elicits an acute inflammatory response which comprises numerous cell populations. It is driven by the immediate response of macrophages and microglia, which triggers activation of genes responsible for the dysregulated microenvironment within the lesion site and in the spinal cord parenchyma immediately adjacent to the lesion. Recently published data indicate that microglia induces astrocyte activation and determines the fate of astrocytes. Conversely, astrocytes have the potency to trigger microglial activation and control their cellular functions. Here we review current information about the release of diverse signaling molecules (pro-inflammatory vs. anti-inflammatory) in individual cell phenotypes (microglia, astrocytes, blood inflammatory cells) in acute and subacute SCI stages, and how they contribute to delayed neuronal death in the surrounding spinal cord tissue which is spared and functional but reactive. In addition, temporal correlation in progressive degeneration of neurons and astrocytes and their functional interactions after SCI are discussed. Finally, the review highlights the time-dependent transformation of reactive microglia and astrocytes into their neuroprotective phenotypes (M2a, M2c and A2) which are crucial for spontaneous post-SCI locomotor recovery. We also provide suggestions on how to modulate the inflammation and discuss key therapeutic approaches leading to better functional outcome after SCI.

Effect of Intraoperative Electrical Stimulation on Recovery after Rat Sciatic Nerve Isograft Repair

Peripheral nerve injuries, associated with significant morbidity, can benefit from electrical stimulation (ES), as demonstrated in animal studies through improved axonal growth. This study combined the clinical gold standard of isograft repair in a rat model of sciatic nerve injury to evaluate the effects of intraoperative ES on functional tests and histology. Forty rats underwent a surgically induced gap injury to the right sciatic nerve and subsequent repair with an isograft. Half of these rats were randomly selected to receive 10 min of intraoperative ES. Functional testing, including response time to a heat stimulus and motor functional tests, were conducted. Histology of the sciatic nerves and gastrocnemius muscles were analyzed after 6 and 12 weeks of recovery. Rats that underwent ES treatment showed incremental improvements in motor function between weeks 2 and 12, with a significantly higher push-off response than the no-ES controls after 6 weeks. Although no differences were detected between groups in the sensory testing, significant improvements over time were noted in the ES group. Histology parameters, sciatic nerve measures, and gastrocnemius muscle weights demonstrated nerve recovery over time for both the ES and no-ES control groups. Although ES promoted improvements in motor function comparable to that in previous studies, the benefits of intraoperative ES were not detectable in other metrics of this rat model of peripheral nerve injury. Future work is needed to optimize sensory testing in the rodent injury model and compare electrical activity of collagen scaffolds to native tissue to detect differences.

Does low-frequency pelvic nerves stimulation in people with spinal cord injury allow for the formation of electrical pathways responsible for the recovery of walking functions?

Over the last ten years, we have published various manuscripts on the recovery of assisted voluntary walking in people with chronic spinal chord injuries (SCI), following laparoscopic implantation of stimulation electrodes on the pelvic somatic nerves - the LION procedure. Although at the beginning of this research the objective was to allow "robotic" walking by stimulating the muscles, we realized relatively quickly that continuous low frequency stimulation of the pelvic nerves might allow the recovery of voluntary functions of the lower limbs and of the trunk necessary for walking: Seventeen out of a total of twenty-five complete motor chronic SCI-patients (68%) developed enough recovery of supra-spinal control of leg movements, that voluntary walking became feasible, even though a minimal amount of stimulation may be required. All current theories for recovery these voluntary functions below the spinal cord lesion are based on the induced regrowth or reconnection of nerves or at least the recovery of functional anatomical pathways. In this manuscript we formulate the hypothesis that electrical stimulation could be responsible for inducing the formation of "electrical pathways" within the body, which under conditions of electrical stimulation might enable the transport of necessary information from the brain to below the spinal cord lesion allowing voluntary movements of the lower limbs.

Effectiveness of electrical stimulation on nerve regeneration after crush injury: Comparison between invasive and non-invasive stimulation

Several studies have investigated the use of invasive and non-invasive stimulation methods to enhance nerve regeneration, and varying degrees of effectiveness have been reported. However, due to the use of different parameters in these studies, a fair comparison between the effectiveness of invasive and non-invasive stimulation methods is not possible. The present study compared the effectiveness of invasive and non-invasive stimulation using similar parameters. Eighteen Sprague Dawley rats were classified into three groups: the iES group stimulated with fully implantable device, the tES group stimulated with transcutaneous electrical nerve stimulation (TENS), and the injury group (no stimulation). The iES and tES groups received stimulation for 6 weeks starting immediately after the injury. Motor function was evaluated using the sciatic functional index (SFI) every week. The SFI values increased over time in all groups; faster and superior functional recovery was observed in the iES group than in the tES group. Histological evaluation of the nerve sections and gastrocnemius muscle sections were performed every other week. The axon diameter and muscle fiber area in the iES group were larger, and the g-ratio in the iES group was closer to 0.6 than those in the tES group. To assess the cause of the difference in efficiency, a 3D rat anatomical model was used to simulate the induced electric fields in each group. A significantly higher concentration and intensity around the sciatic nerve was observed in the iES group than in the tES group. Vector field distribution showed that the field was orthogonal to the sciatic nerve spread in the tES group, whereas it was parallel in the iES group; this suggested that the tES group was less effective in nerve stimulation. The results indicated that even though rats in the TENS group showed better recovery than those in the injury group, it cannot replace direct stimulation yet because rats stimulated with the invasive method showed faster recovery and superior outcomes. This was likely attributable to the greater concentration and parallel distribution of electric field with respect to target nerve.

Memory and Cognition-Related Neuroplasticity Enhancement by Transcranial Direct Current Stimulation in Rodents: A Systematic Review

Brain stimulation techniques, including transcranial direct current stimulation (tDCS), were identified as promising therapeutic tools to modulate synaptic plasticity abnormalities and minimize memory and learning deficits in many neuropsychiatric diseases. Here, we revised the effect of tDCS on the modulation of neuroplasticity and cognition in several animal disease models of brain diseases affecting plasticity and cognition. Studies included in this review were searched following the terms (“transcranial direct current stimulation”) AND (mice OR mouse OR animal) and according to the PRISMA statement requirements. Overall, the studies collected suggest that tDCS was able to modulate brain plasticity due to synaptic modifications within the stimulated area. Changes in plasticity-related mechanisms were achieved through induction of long-term potentiation (LTP) and upregulation of neuroplasticity-related proteins, such as c-fos, brain-derived neurotrophic factor (BDNF), or N-methyl-D-aspartate receptors (NMDARs). Taken into account all revised studies, tDCS is a safe, easy, and noninvasive brain stimulation technique, therapeutically reliable, and with promising potential to promote cognitive enhancement and neuroplasticity. Since the use of tDCS has increased as a novel therapeutic approach in humans, animal studies are important to better understand its mechanisms as well as to help improve the stimulation protocols and their potential role in different neuropathologies.

Neural responses to electrical stimulation in 2D and 3D in vitro environments

Electrical stimulation (ES) to manipulate the central (CNS) and peripheral nervous system (PNS) has been explored for decades, recently gaining momentum as bioelectronic medicine advances. The application of ES in vitro to modulate a variety of cellular functions, including regenerative potential, migration, and stem cell fate, are being explored to aid neural degeneration, dysfunction, and injury. This review describes the materials and approaches for the application of ES to the PNS and CNS microenvironments, towards an improved understanding of how ES can be harnessed for beneficial clinical applications. Emphasized are some recent advances in ES, including conductive polymers, methods of charge transfer, impact on neural cells, and a brief overview of alternative methodologies for cellular targeting including magneto, ultrasonic, and optogenetic stimulation. This review will examine how heterogenous cell populations, including neurons, glia, and neural stem cells respond to a wide range of conductive 2D and 3D substrates, stimulation regimes, known mechanisms of response, and how cellular sources impact the response to ES.

Epidural oscillating field stimulation as an effective therapeutic approach in combination therapy for spinal cord injury

BACKGROUND

Traumatic spinal cord injury (SCI) causes partial or total loss of sensory and motor functions. Despite enormous efforts, there is still no effective treatment which might improve patients' neurological status.The application of electric current to the injured spinal cord is known to promote healing and tissue regeneration. The use of this modality in treating the injured spinal cord to improve neurological recovery has been introduced as a potential treatment.

NEW METHOD

Here we describe the method of epidural implantation of a miniature oscillating field (OF) stimulator designed in our laboratory immediately after Th9 spinal compression in Wistar rats. Three groups of animals were analyzed (intact; SCI only; OFS + SCI; n = 8 each). Histological, immunohistological and behavioral analysis were used to show the favorable effect of epidural OF stimulation on axonal regeneration and modulation of astrogliosis.

RESULTS

Our study revealed considerable differences in white matter integrity in animals with an implanted OF stimulator. Moreover, we detected significantly increased numbers of neurofilaments and massive reduction in activated forms of astrocytes in the group of stimulated animals compared to the animals without stimulation.

COMPARISON WITH EXISTING METHOD(S)

Compared with previous research, our study revealed that epidural implantation of an OF stimulator immediately after spinal compression effectively reduced the expression of inflammatory response and suppressed activated astrocyte formation.

CONCLUSIONS

Our finding confirms that implanting an OF stimulator is safe, stable and suitable for future combined therapy which could effectively promote and accelerate regeneration and functional restoration after spinal trauma.

Anodal Transcranial Direct Current Stimulation Enhances Survival and Integration of Dopaminergic Cell Transplants in a Rat Parkinson Model

Restorative therapy concepts, such as cell based therapies aim to restitute impaired neurotransmission in neurodegenerative diseases. New strategies to enhance grafted cell survival and integration are still needed to improve functional recovery. Anodal direct current stimulation (DCS) promotes neuronal activity and secretion of the trophic factor BDNF in the motor cortex. Transcranial DCS applied to the motor cortex transiently improves motor symptoms in Parkinson’s disease (PD) patients. In this proof-of-concept study, we combine cell based therapy and noninvasive neuromodulation to assess whether neurotrophic support via transcranial DCS would enhance the restitution of striatal neurotransmission by fetal dopaminergic transplants in a rat Parkinson model. Transcranial DCS was applied daily for 20 min on 14 consecutive days following striatal transplantation of fetal ventral mesencephalic (fVM) cells derived from transgenic rat embryos ubiquitously expressing GFP. Anodal but not cathodal transcranial DCS significantly enhanced graft survival and dopaminergic reinnervation of the surrounding striatal tissue relative to sham stimulation. Behavioral recovery was more pronounced following anodal transcranial DCS, and behavioral effects correlated with the degree of striatal innervation. Our results suggest anodal transcranial DCS may help advance cell-based restorative therapies in neurodegenerative diseases. In particular, such an assistive approach may be beneficial for the already established cell transplantation therapy in PD.

Recovery of supraspinal control of leg movement in a chronic complete flaccid paraplegic man after continuous low-frequency pelvic nerve stimulation and FES-assisted training

INTRODUCTION

More than 30 years ago, functional electrical stimulation (FES) was developed as an orthotic system to be used for rehabilitation for SCI patients. In the present case report, FES-assisted training was combined with continuous low-frequency stimulation of the pelvic somatic nerves in a SCI patient.

CASE PRESENTATION

We report on unexpected findings in a 41-year-old man with chronic complete flaccid paraplegia, since he was 18 years old, who underwent spinal stem cell therapy and a laparoscopic implantation of neuroprosthesis (LION procedure) in the pelvic lumbosacral nerves. The patient had complete flaccid sensomotoric paraplegia T12 as a result of a motor vehicle accident in 1998. In June 2011, he underwent a laparoscopic implantation of stimulation electrodes to the sciatic and femoral nerves for continuous low-frequency electrical stimulation and functional electrical stimulation of the pelvic nerves. Neither intraoperative direct stimulation of the pelvic nerves nor postoperative stimulation induced any sensation or muscle reactions. After 2 years of passive continuous low-frequency stimulation, the patient developed progressive recovery of electrically assisted voluntary motor functions below the lesions: he was first able to extend the right knee and 6 months later, the left. He is currently capable of voluntary weight-bearing standing and walking (with voluntary knee movements) about 50 m with open cuff crutches and drop foot braces.

DISCUSSION

Our findings suggest that continuous low-frequency pelvic nerve stimulation in combination with FES-assisted training might induce changes that affect both the upper and the lower motor neuron and allow supra- and infra-spinal inputs to engage residual spinal and peripheral pathways.

Electric field-mediated growth of osteoblasts - the significant impact of dynamic flow of medium

The endogenous electric field plays an important role in accomplishing various functions including communication with the brain and with different parts of the physiological system, wound healing, and cellular functions. Furthermore, the endogenous electric field can be modified using the external electric field to induce changes in cell functionality. Given that the cells grow in contact with the dynamic flow of blood and nutrients, the objective of the study is to elucidate the effect of media flow (dynamic conditions) on osteoblast functions at a pulsed DC (direct current) electric field of strength of 0.5-1 V cm(-1) and compared with the static conditions (no flow of media and in the presence of an electric field). The electric field provided a guiding cue to cells to move towards the cathode. An interesting aspect of the electric field was the migration of cells towards the cathode with the axis parallel to the direction of the electric field such that the lamellipodia was aligned. Furthermore, there was an absence of membrane blebbing or necrosis at the cathode. However, cell growth and expression of proteins (actin and vinculin) were higher than the anode. In contrast, at the anode, while the cells were healthy, the cell growth was less such that the expression of vinculin was relatively low together with less densely packed actin stress fibers. It is underscored that the biological functionality is favorably altered in the presence of an electrical field under dynamic conditions with a consequent effect on cell proliferation, growth, and expression level of prominent proteins, actin and vinculin.

New design of hydrogels with tuned electro-osmosis: a potential model system to understand electro-kinetic transport in biological tissues

A series of charged polymer gels with precisely controlled magnitude and direction of electro-osmotic flow was prepared and opens up the possibility for understanding the contribution of electro-osmosis to transport phenomenon in native biological tissues.

Influence of Electric Fields and Conductivity on Pollen Tube Growth assessed via Electrical Lab-on-Chip

Pollen tubes are polarly growing plant cells that are able to rapidly respond to a combination of chemical, mechanical, and electrical cues. This behavioural feature allows them to invade the flower pistil and deliver the sperm cells in highly targeted manner to receptive ovules in order to accomplish fertilization. How signals are perceived and processed in the pollen tube is still poorly understood. Evidence for electrical guidance in particular is vague and highly contradictory. To generate reproducible experimental conditions for the investigation of the effect of electric fields on pollen tube growth we developed an Electrical Lab-on-Chip (ELoC). Pollen from the species Camellia displayed differential sensitivity to electric fields depending on whether the entire cell or only its growing tip was exposed. The response to DC fields was dramatically higher than that to AC fields of the same strength. However, AC fields were found to restore and even promote pollen growth. Surprisingly, the pollen tube response correlated with the conductivity of the growth medium under different AC frequencies—consistent with the notion that the effect of the field on pollen tube growth may be mediated via its effect on the motion of ions.

Electrical stimuli in the central nervous system microenvironment

Electrical stimulation to manipulate the central nervous system (CNS) has been applied as early as the 1750s to produce visual sensations of light. Deep brain stimulation (DBS), cochlear implants, visual prosthetics, and functional electrical stimulation (FES) are being applied in the clinic to treat a wide array of neurological diseases, disorders, and injuries. This review describes the history of electrical stimulation of the CNS microenvironment; recent advances in electrical stimulation of the CNS, including DBS to treat essential tremor, Parkinson's disease, and depression; FES for the treatment of spinal cord injuries; and alternative electrical devices to restore vision and hearing via neuroprosthetics (retinal and cochlear implants). It also discusses the role of electrical cues during development and following injury and, importantly, manipulation of these endogenous cues to support regeneration of neural tissue.

The morphological and molecular changes of brain cells exposed to direct current electric field stimulation

BACKGROUND

The application of low-intensity direct current electric fields has been experimentally used in the clinic to treat a number of brain disorders, predominantly using transcranial direct current stimulation approaches. However, the cellular and molecular changes induced by such treatment remain largely unknown.

METHODS

Here, we tested various intensities of direct current electric fields (0, 25, 50, and 100V/m) in a well-controlled in vitro environment in order to investigate the responses of neurons, microglia, and astrocytes to this type of stimulation. This included morphological assessments of the cells, viability, as well as shape and fiber outgrowth relative to the orientation of the direct current electric field. We also undertook enzyme-linked immunosorbent assays and western immunoblotting to identify which molecular pathways were affected by direct current electric fields.

RESULTS

In response to direct current electric field, neurons developed an elongated cell body shape with neurite outgrowth that was associated with a significant increase in growth associated protein-43. Fetal midbrain dopaminergic explants grown in a collagen gel matrix also showed a reorientation of their neurites towards the cathode. BV2 microglial cells adopted distinct morphological changes with an increase in cyclooxygenase-2 expression, but these were dependent on whether they had already been activated with lipopolysaccharide. Finally, astrocytes displayed elongated cell bodies with cellular filopodia that were oriented perpendicularly to the direct current electric field.

CONCLUSION

We show that cells of the central nervous system can respond to direct current electric fields both in terms of their morphological shape and molecular expression of certain proteins, and this in turn can help us to begin understand the mechanisms underlying the clinical benefits of direct current electric field.

Cellular and molecular mechanisms of action of transcranial direct current stimulation: evidence from in vitro and in vivo models

Transcranial direct current stimulation is a noninvasive technique that has been experimentally tested for a number of psychiatric and neurological conditions. Preliminary observations suggest that this approach can indeed influence a number of cellular and molecular pathways that may be disease relevant. However, the mechanisms of action underlying its beneficial effects are largely unknown and need to be better understood to allow this therapy to be used optimally. In this review, we summarize the physiological responses observed in vitro and in vivo, with a particular emphasis on cellular and molecular cascades associated with inflammation, angiogenesis, neurogenesis, and neuroplasticity recruited by direct current stimulation, a topic that has been largely neglected in the literature. A better understanding of the neural responses to transcranial direct current stimulation is critical if this therapy is to be used in large-scale clinical trials with a view of being routinely offered to patients suffering from various conditions affecting the central nervous system.

Therapeutic Application of Electric Fields in the Injured Nervous System

Significance: Nervous system injuries, both in the peripheral nervous system (PNS) and central nervous system are a major cause for pain, loss-of-function, and impairment of daily life. As nervous system injuries commonly heal slowly or incompletely, new therapeutic approaches may be required. Recent Advances: The observation that cultured neurons are able to respond to exogenous electric fields (EFs) by sprouting more neurites and directing growth along the field, along with the presence of endogenous EFs in the developing vertebrate nervous system have led to the suggestion of the use of EFs in a regenerative therapeutic setting. This review discusses the effects of EFs on nervous cells, and their use in the treatment of nervous injuries in the eye, limb nerves, and the spinal cord. Exogenous EFs have been shown to be neuroprotective in various injury models of the eye, including traumatic injury, congenital degenerative retinopathy, and glaucoma. In the PNS, EFs are able to stimulate regrowth and functional recovery in damaged limb nerves. In the spinal cord, axonal regeneration and improved quality of life may be achieved using EF stimulation. Critical Issues: The optimal paradigm for electrical stimulation has not been determined, and the mechanisms behind the effect of EF are still largely unknown. Future Directions: Although the therapeutic use of EFs in the nervous system is still in its infancy, it is a promising therapeutic avenue for otherwise hard to treat injuries. The cellular/molecular mechanisms of such regulation need to be fully investigated, and the efficiency of applied EFs during wound healing needs to be optimized in a systematic approach in both animal models and future clinical trials.

Evaluation of EGFR and RTK signaling in the electrotaxis of lung adenocarcinoma cells under direct-current electric field stimulation

Physiological electric field (EF) plays a pivotal role in tissue development and regeneration. In vitro, cells under direct-current electric field (dcEF) stimulation may demonstrate directional migration (electrotaxis) and long axis reorientation (electro-alignment). Although the biophysical models and biochemical signaling pathways behind cell electrotaxis have been investigated in numerous normal cells and cancer cells, the molecular signaling mechanisms in CL1 lung adenocarcinoma cells have not been identified. Two subclones of CL1 cells, the low invasive CL1-0 cells and the highly invasive CL 1-5 cells, were investigated in the present study. CL1-0 cells are non-electrotactic while the CL 1-5 cells are anodally electrotactic and have high expression level of epidermal growth factor receptor (EGFR), in this study, we investigated the generally accepted hypothesis of receptor tyrosine kinase (RTK) activation in the two cell lines under dcEF stimulation. Erbitux, a therapeutic drug containing an anti-EGFR monoclonal antibody, cetuximab, was used to investigate the EGFR signaling in the electrotaxis of CL 1-5 cells. To investigate RTK phosphorylation and intracellular signaling in the CL1 cells, large amount of cellular proteins were collected in an airtight dcEF stimulation device, which has advantages of large culture area, uniform EF distribution, easy operation, easy cell collection, no contamination, and no medium evaporation. Commercial antibody arrays and Western blotting were used to study the phosphorylation profiles of major proteins in CL1 cells under dcEF stimulation. We found that electrotaxis of CL 1-5 cells is serum independent and EGFR independent. Moreover, the phosphorylation of Akt and S6 ribosomal protein (rpS6) in dcEF-stimulated CL1 cells are different from that in EGF-stimulated cells. This result suggests that CL1 cells' response to dcEF stimulation is not through EGFR-triggered pathways. The new large-scale dcEF stimulation device developed in the present work will aid the sample preparation for protein-based experiments.

A review of oscillating field stimulation to treat human spinal cord injury

OBJECTIVE

To report the results of use of a human oscillating field stimulator (OFS) in a phase 1 trial of 14 human patients with complete motor and sensory spinal cord injury.

METHODS

Entry criteria were complete spinal cord injury between C5 and T10 in patients 18-65 years old with no transection on magnetic resonance imaging. All patients received the National Acute Spinal Cord Injury Study III methylprednisolone protocol. Cord compression or instability was treated before entry. All patient injuries remained complete (based on American Spinal Cord Injury scoring) with no somatosensory evoked potentials (SSEPs) below the injury after surgery or for 48 hours. All patients were implanted with the OFS within 18 days. Patients were checked every 2 weeks after implantation. The OFS was explanted at 15 weeks. Independent neurologic examinations (American Spinal Cord Injury score, visual analog scale for pain, and SSEPs) were done at 6 weeks, 6 months, and 1 year. Statistical analyses were done by Wilcoxon rank sum test and analysis of variance (ANOVA).

RESULTS

There were no complications at insertion, and one wound infection occurred after explant for a 3.5% infection rate. One patient was lost to follow-up after 6 months. All 14 patients had a mean visual analog scale score of 8 at implant and 2 at 6 months, and 13 remained a mean score of 2 at 1 year. Mean improvement in light touch score at 1 year was 25.9 points (ANOVA, P < 0.001; Wilcoxon, P = 0.02). Mean improvement in pinprick score at 1 year was 15.2 points (ANOVA, P < 0.001; Wilcoxon, P = 0.02). Mean improvement in motor score was 6.9 (ANOVA, P < 0.01; Wilcoxon, P = 0.02). Of eight patients with cervical cord injuries, six had improvement in arm SSEPs, and one recovered a tibial SSEP. Of six patients with thoracic injuries, one recovered an abnormal lower SSEP.

CONCLUSIONS

Treatment of human spinal cord injury with an OFS is safe, reliable, and easy. Compared with National Acute Spinal Cord Injury Study III compliant paralyzed patients, our results suggest efficacy.

Strict perpendicular orientation of neural crest-derived neurons in vitro is dependent on an extracellular gradient of voltage

We report extraordinary perpendicular orientations of neurons dependent on the presence of an external direct current (DC) voltage gradient. We chose chick dorsal root and postganglionic sympathetic neurons to evaluate. These were cultured in observation chambers in which the cells were separated from electrode products or substrate effects and maintained at 35°C. Both types of neurons showed a rapid restructuring of their anatomy. Typically, neurites that were not perpendicular to the voltage gradient were quickly resorbed into the cell body within a few minutes. Over 3-6 hr, significant new neurite growth occurred and was patterned perpendicular to the DC electrical field (Ef). This preferred asymmetry was dependent on the Ef, as was the initial retrograde degeneration of fibers. At 400-500 mV/mm, over 90% of the cells in culture assumed this orientation. Removal of the DC Ef led to a loss of the preferred orientation, with further random growth within the chambers. This is the first report of such responses in dorsal root ganglion neurons. We also used sympathetic neurons as a meaningful comparison to analyze whether there were any qualitative or quantitative differences between these two cell types of neural crest origin. We discuss the means by which these orientations were achieved.

A review of the responses of two- and three-dimensional engineered tissues to electric fields

The application of external biophysical signals is one approach to tissue engineering that is explored less often than more traditional additions of exogenous biochemical and chemical factors to direct cell and tissue outcomes. The study of bioelectromagnetism and the field of electrotherapeutics have evolved over the years, and we review biocompatible electric stimulation devices and their successful application to tissue growth. Specifically, information on capacitively coupled alternating current, inductively coupled alternating current, and direct current devices is described. Cell and tissue responses from the application of these devices, including two- and three-dimensional in vitro studies and in vivo studies, are reviewed with regard to cell proliferation, adhesion, differentiation, morphology, and migration and tissue function. The current understanding of cellular mechanisms related to electric stimulation is detailed. The advantages of electric stimulation are compared with those pf other techniques, and areas in which electric fields are used as an adjuvant therapy for healing and regeneration are discussed.

Synthesis and characterization of a hydrogel with controllable electroosmosis: a potential brain tissue surrogate for electrokinetic transport

Electroosmosis is the bulk fluid flow initiated by application of an electric field to an electrolyte solution in contact with immobile objects with a nonzero ζ-potential such as the surface of a porous medium. Electroosmosis may be used to assist analytical separations. Several gel-based systems with varying electroosmotic mobilities have been made in this context. A method was recently developed to determine the ζ-potential of organotypic hippocampal slice cultures (OHSC) as a representative model for normal brain tissue. The ζ-potential of the tissue is significant. However, determining the role of the ζ-potential in solute transport in tissue in an electric field is difficult because the tissue's ζ-potential cannot be altered. We hypothesized that mass transport properties, namely the ζ-potential and tortuosity, could be modulated by controlling the composition of a set of hydrogels. Thus, poly(acrylamide-co-acrylic acid) gels were prepared with three compositions (by monomer weight percent): acrylamide/acrylic acid 100/0, 90/10, and 75/25. The ζ-potentials of these gels at pH 7.4 are distinctly different, and in fact vary approximately linearly with the weight percent of acrylic acid. We discovered that the 25% acrylic acid gel is a respectable model for brain tissue, as its ζ-potential is comparable to the OHSC. This series of gels permits the experimental determination of the importance of electrokinetic properties in a particular experiment or protocol. Additionally, tortuosities were measured electrokinetically and by evaluating diffusion coefficients. Hydrogels with well-defined ζ-potential and tortuosity may find utility in biomaterials and analytical separations, and as a surrogate model for OHSC and living biological tissues.

Electric field-guided neuron migration: a novel approach in neurogenesis

Effective directional neuron migration is crucial in development of the central nervous system and for neurogenesis. Endogenous electrical signals are present in many developing systems and crucial cellular behaviors such as neuronal cell division, cell migration, and cell differentiation are all under the influence of such endogenous electrical cues. Preclinical in vivo studies have used electric fields (EFs) to attempt to enhance regrowth of damaged spinal cord axons with some success. Recent evidence shows that small EFs not only guide axonal growth, but also direct the earlier events of neuronal migration and neuronal cell division. This raises the possibility that applied or endogenous EFs, perhaps in combination, may direct transplanted neural stem cells, or regenerating neurons, to the desired site after brain injury or neuron degeneration. The high complexity of both structure and function of the nervous system, however, poses significant challenges to techniques for applying EFs to promote neurogenesis. The evolution of functional biomaterials and nanotechnology may provide promising solutions for the application of EFs in guiding neuron migration and neurogenesis within the central nervous system.

The influence of electric fields on hippocampal neural progenitor cells

The differentiation and proliferation of neural stem/progenitor cells (NPCs) depend on various in vivo environmental factors or cues, which may include an endogenous electrical field (EF), as observed during nervous system development and repair. In this study, we investigate the morphologic, phenotypic, and mitotic alterations of adult hippocampal NPCs that occur when exposed to two EFs of estimated endogenous strengths. NPCs treated with a 437 mV/mm direct current (DC) EF aligned perpendicularly to the EF vector and had a greater tendency to differentiate into neurons, but not into oligodendrocytes or astrocytes, compared to controls. Furthermore, NPC process growth was promoted perpendicularly and inhibited anodally in the 437 mV/mm DC EF. Yet fewer cells were observed in the DC EF, which in part was due to a decrease in cell viability. The other EF applied was a 46 mV/mm alternating current (AC) EF. However, the 46 mV/mm AC EF showed no major differences in alignment or differentiation, compared to control conditions. For both EF treatments, the percent of mitotic cells during the last 14 h of the experiment were statistically similar to controls. Reported here, to our knowledge, is the first evidence of adult NPC differentiation affected in an EF in vitro. Further investigation and application of EFs on stem cells is warranted to elucidate the utility of EFs to control phenotypic behavior. With progress, the use of EFs may be engineered to control differentiation and target the growth of transplanted cells in a stem cell-based therapy to treat nervous system disorders.

Three-dimensional conductive constructs for nerve regeneration

The unique electrochemical properties of conductive polymers can be utilized to form stand-alone polymeric tubes and arrays of tubes that are suitable for guides to promote peripheral nerve regeneration. Noncomposite, polypyrrole (PPy) tubes ranging in inner diameter from 25 microm to 1.6 mm as well as multichannel tubes were fabricated by electrodeposition. While oxidation of the pyrrole monomer causes growth of the film, brief subsequent reduction allowed mechanical dissociation from the electrode mold, creating a stand-alone, conductive PPy tube. Conductive polymer nerve guides made in this manner were placed in transected rat sciatic nerves and shown to support nerve regeneration over an 8-week time period.

Electrical dimensions in cell science

Cells undergo a variety of physiological processes, including division, migration and differentiation, under the influence of endogenous electrical cues, which are generated physiologically and pathologically in the extracellular and sometimes intracellular spaces. These signals are transduced to regulate cell behaviours profoundly, both in vitro and in vivo. Bioelectricity influences cellular processes as fundamental as control of the cell cycle, cell proliferation, cancer-cell migration, electrical signalling in the adult brain, embryonic neuronal cell migration, axon outgrowth, spinal-cord repair, epithelial wound repair, tissue regeneration and establishment of left-right body asymmetry. In addition to direct effects on cells, electrical gradients interact with coexisting extracellular chemical gradients. Indeed, cells can integrate and respond to electrical and chemical cues in combination. This Commentary details how electrical signals control multiple cell behaviours and argues that study of the interplay between combined electrical and chemical gradients is underdeveloped yet necessary.

Determination of zeta-potential and tortuosity in rat organotypic hippocampal cultures from electroosmotic velocity measurements under feedback control

Extracellular translational motion in the brain is generally considered to be governed by diffusion and tortuosity. However, the brain as a whole has a significant zeta-potential, thus translational motion is also governed by electrokinetic effects under a naturally occurring or applied electric field. We have previously measured zeta-potential and tortuosity in intact brain tissue; however, the method was tedious. In this work, we use a four-electrode potentiostat to control the potential difference between two microreference electrodes in the tissue, creating a constant electric field. Additionally, some alterations have been made to simplify our previous procedure. The method entails simultaneously injecting two 70 kDa dextran conjugated fluorophores into rat organotypic hippocampal cultures and observing their mobility using fluorescence microscopy. We further present two methods of data analysis: regression and two-probe analysis. Statistical comparisons are made between the previous and current methods as well as between the two data analysis methods. In comparison to the previous method, the current, simpler method with data analysis by regression gives statistically indistinguishable mean values of zeta-potential and tortuosity, with a similar variability for zeta-potential, -21.3 +/- 2.8 mV, and a larger variability for the tortuosity, 1.98 +/- 0.12. On the other hand, we find that the current method combined with the two-probe analysis produces accurate and more precise results, with a zeta-potential of -22.8 +/- 0.8 mV and a tortuosity of 2.24 +/- 0.10.

A retrograde neuronal survival response: target-derived neurotrophins regulate MEF2D and bcl-w

Survival and maturation of dorsal root ganglia sensory neurons during development depend on target-derived neurotrophins. These target-derived signals must be transmitted across long distances to alter gene expression. Here, we address the possibility that long-range retrograde signals initiated by target-derived neurotrophins activate a specialized transcriptional program. The transcription factor MEF2D is expressed in sensory neurons; we show that expression of this factor is induced in response to target-derived neurotrophins that stimulate the distal axons. We demonstrate that MEF2D regulates expression of an anti-apoptotic bcl-2 family member, bcl-w. Expression of mef2d and bcl-w is stimulated in response to activation of a Trk-dependent ERK5/MEF2 pathway, and our data indicate that this pathway promotes sensory neuron survival. We find that mef2d and bcl-w are members of a larger set of retrograde response genes, which are preferentially induced by neurotrophin stimulation of distal axons. Thus, activation of an ERK5/MEF2D transcriptional program establishes and maintains the cellular constituents of functional sensory circuits.

Applied electric field enhances DRG neurite growth: influence of stimulation media, surface coating and growth supplements

Electrical therapies have been found to aid repair of nerve injuries and have been shown to increase and direct neurite outgrowth during stimulation. This enhanced neural growth existed even after the electric field (EF) or stimulation was removed, but the factors that may influence the enhanced growth, such as stimulation media or surface coating, have not been fully investigated. This study characterized neurite outgrowth and branching under various conditions: EF magnitude and application time, ECM surface coating, medium during EF application and growth supplements. A uniform, low-magnitude EF (24 or 44 V m(-1)) was applied to dissociated chick embryo dorsal root ganglia seeded on collagen or laminin-coated surfaces. During the growth period, cells were either exposed to NGF or N2, and during stimulation cells were exposed to either unsupplemented media (Ca(2+)) or PBS (no Ca(2+)). Parallel controls for each experiment included cells exposed to the chamber with no stimulation and cells remaining outside the chamber. After brief electrical stimulation (10 min), neurite length significantly increased 24 h after application for all conditions studied. Of particular interest, increased stimulation time (10-100 min) further enhanced neurite length on laminin but not on collagen surfaces. Neurite branching was not affected by stimulation on any surface, and no preferential growth of neurites was noted after stimulation. Overall, the results of this report suggest that short-duration electric stimulation is sufficient to enhance neurite length under a variety of conditions. While further data are needed to fully elucidate a mechanism for this increased growth, these data suggest that one focus of those investigations should be the interaction between the growth cone and the substrata.

Regulation of cell cytoskeleton and membrane mechanics by electric field: role of linker proteins

Cellular mechanics is known to play an important role in the cell homeostasis including proliferation, motility, and differentiation. Significant variation in the mechanical properties between different cell types suggests that control of the cell metabolism is feasible through manipulation of the cell mechanical parameters using external physical stimuli. We investigated the electrocoupling mechanisms of cellular biomechanics modulation by an electrical stimulation in two mechanically distinct cell types--human mesenchymal stem cells and osteoblasts. Application of a 2 V/cm direct current electric field resulted in approximately a twofold decrease in the cell elasticity and depleted intracellular ATP. Reduction in the ATP level led to inhibition of the linker proteins that are known to physically couple the cell membrane and cytoskeleton. The membrane separation from the cytoskeleton was confirmed by up to a twofold increase in the membrane tether length that was extracted from the cell membrane after an electrical stimulation. In comparison to human mesenchymal stem cells, the membrane-cytoskeleton attachment in osteoblasts was much stronger but, in response to the same electrical stimulation, the membrane detachment from the cytoskeleton was found to be more pronounced. The observed effects mediated by an electric field are cell type- and serum-dependent and can potentially be used for electrically assisted cell manipulation. An in-depth understanding and control of the mechanisms to regulate cell mechanics by external physical stimulus (e.g., electric field) may have great implications for stem cell-based tissue engineering and regenerative medicine.

Membrane potential controls adipogenic and osteogenic differentiation of mesenchymal stem cells

BACKGROUND

Control of stem cell behavior is a crucial aspect of developmental biology and regenerative medicine. While the functional role of electrophysiology in stem cell biology is poorly understood, it has become clear that endogenous ion flows represent a powerful set of signals by means of which cell proliferation, differentiation, and migration can be controlled in regeneration and embryonic morphogenesis.

METHODOLOGY/PRINCIPAL FINDINGS

We examined the membrane potential (V(mem)) changes exhibited by human mesenchymal stem cells (hMSCs) undergoing adipogenic (AD) and osteogenic (OS) differentiation, and uncovered a characteristic hyperpolarization of differentiated cells versus undifferentiated cells. Reversal of the progressive polarization via pharmacological modulation of transmembrane potential revealed that depolarization of hMSCs prevents differentiation. In contrast, treatment with hyperpolarizing reagents upregulated osteogenic markers.

CONCLUSIONS/SIGNIFICANCE

Taken together, these data suggest that the endogenous hyperpolarization is a functional determinant of hMSC differentiation and is a tractable control point for modulating stem cell function.

Role of electrical stimulation for rehabilitation and regeneration after spinal cord injury: an overview

Structural discontinuity in the spinal cord after injury results in a disruption in the impulse conduction resulting in loss of various bodily functions depending upon the level of injury. This article presents a summary of the scientific research employing electrical stimulation as a means for anatomical or functional recovery for patients suffering from spinal cord injury. Electrical stimulation in the form of functional electrical stimulation (FES) can help facilitate and improve upper/lower limb mobility along with other body functions lost due to injury e.g. respiratory, sexual, bladder or bowel functions by applying a controlled electrical stimulus to generate contractions and functional movement in the paralysed muscles. The available rehabilitative techniques based on FES technology and various Food and Drug Administration, USA approved neuroprosthetic devices that are in use are discussed. The second part of the article summarises the experimental work done in the past 2 decades to study the effects of weakly applied direct current fields in promoting regeneration of neurites towards the cathode and the new emerging technique of oscillating field stimulation which has shown to promote bidirectional regeneration in the injured nerve fibres. The present article is not intended to be an exhaustive review but rather a summary aiming to highlight these two applications of electrical stimulation and the degree of anatomical/functional recovery associated with these in the field of spinal cord injury research.

Determination of zeta-potential in rat organotypic hippocampal cultures

zeta-potentials of entities such as cells and synaptosomes have been determined, but zeta of brain tissue has never been measured. Electroosmotic flow, and the resulting transport of neuroactive substances, would result from naturally occurring and experimentally or clinically induced electric fields if zeta is significant. We have developed a simple method for determining zeta in tissue. An electric field applied across a rat organotypic hippocampal slice culture (OHSC) drives fluorescent molecules through the tissue by both electroosmotic flow and electrophoresis. Fluorescence microscopy is used to determine each molecule's velocity. Independently, capillary electrophoresis is used to measure the molecules' electrophoretic mobilities. The experiment yields zeta-potential and average tissue tortuosity. The zeta-potential of OHSCs is -22 +/- 2 mV, and the average tortuosity is 1.83 +/- 0.06. In a refined experiment, zeta-potential is measured in various subregions. The zeta-potentials of the CA1 stratum pyramidale, CA3 stratum pyramidal, and dentate gyrus are -25.1 +/- 1.6 mV, -20.3 +/- 1.7 mV, and -25.4 +/- 1.0 mV, respectively. Simple dimensional arguments show that electroosmotic flow is potentially as important as diffusion in molecular transport.

Electric field effects on human spinal injury: Is there a basis in the in vitro studies?

An important basis for the clinical application of small DC electric current to mammalian spinal injury is the responses of neurons in culture to applied electric fields. Our recent finding that zebrafish neurons were unresponsive to applied fields prompted us to critically examine previous results. We conclude that compelling evidence for neuronal guidance and directional stimulation of growth toward either the cathode or anode in an electric field exists only for cultured Xenopus neurons, and not for any mammalian neurons. No basis for the reported success in treating spinal injury exists in the in vitro studies, and considerable research will be required if the conditions of field application in mammalian spinal injury are to be optimized.

Pursuing a 'turning point' in growth cone research

Growth cones are highly motile structures found at the leading edge of developing and regenerating nerve processes. Their role in axonal pathfinding has been well established and many guidance cues that influence growth cone behavior have now been identified. Many studies are now providing insights into the transduction and integration of signals in the growth cone, though a full understanding of growth cone behavior still eludes us. This review focuses on recent studies adding to the growing body of literature on growth cone behavior, focusing particularly on the level of autonomy the growth cone possesses and the role of local protein synthesis.

Simultaneous application of two neurotrophic factors after spinal cord injury

We have studied the application of voltage gradients to injured spinal cord which enhanced regeneration of axons and reduced their retrograde degeneration after injury. This led to an implanted electronic device producing electrical fields sufficient to induce regeneration in both ascending and descending tracts of white matter (called oscillating field stimulation [OFS]), which has been associated with behavioral recovery in animal models of spinal cord injury (SCI). OFS has also proven to benefit neurologically complete spinal cord injured dogs and humans in clinical trials. These studies, however, have failed to confirm benefit if applied after the sub-acute period of SCI. Here we report on combining OFS with the application of a non-toxic neurotrophic factor, inosine, using a behavioral model for "chronic" SCI, the cutaneous trunci muscle (CTM) reflex in adult guinea pigs. Inosine was delivered subcutaneously in guinea pigs for 28 days using implantable "osmotic pumps"--alone or in combination with OFS. In all animals, experimental and control treatments were withheld for three months after a right lateral hemisection of the thoracic spinal cord. Both inosine and the combination therapy produced a statistically significant recovery of CTM receptive fields silenced permanently by spinal cord hemisection in controls--though the combination therapy enhanced the time of the appearance of recovered regions of skin. Retransection of the cord in three recovered animals eliminated the CTM recovery confirming changes in neural connections were restricted to the cord and not due to changes in cutaneous peripheral innervation. Morphometry of anterogradely labeled white matter revealed a statistically enhanced regeneration of ascending and descending projections in animals treated with the combination "therapy" compared to inosine alone. These data suggest that combining neurotrophic factors of differing modes of action likely enhance the outcome from "chronic" SCI.

Temporally and spatially coordinated roles for Rho, Rac, Cdc42 and their effectors in growth cone guidance by a physiological electric field

Although it is known that neuronal growth cones migrate towards the cathode of an applied direct current (DC) electric field (EF), resembling the EF present in the developing nervous system, the underlying mechanism remains unclear. Here, we demonstrate temporally and spatially coordinated roles for the GTPases Rac, Cdc42 and Rho and their effectors. Growth cones of cultured Xenopus embryonic spinal neurons turned towards the cathode but collective inhibition of Rho, Rac and Cdc42 attenuated turning. Selective inhibition of Rho, Cdc42 or Rac signalling revealed temporally distinct roles in steering by an electrical gradient. Rho, Rac and Cdc42 are each essential for turning within the initial 2 hours (early phase). Later, Rho and Cdc42 signals remain important but Rac signalling dominates. The EF increased Rho immunofluorescence anodally. This correlated spatially with collapsed growth cone morphology and reduced anodal migration rates, which were restored by Rho inhibition. These data suggest that anodally increased Rho activity induces local cytoskeletal collapse, biasing growth cone advance cathodally. Collapse might be mediated by the Rho effectors p160 Rho kinase and myosin light chain kinase since their inhibition attenuated early turning. Inhibitors of phosphoinositide 3-kinase, MEK1/2 or p38 mitogen-activated protein kinase (MAPK) did not affect turning behaviour, eliminating them mechanistically. We propose a mechanism whereby Rac and Cdc42 activities dominate cathodally and Rho activity dominates anodally to steer growth cones towards the cathode. The interaction between Rho GTPases, the cytoskeleton and growth cone dynamics is explored in the companion paper published in this issue. Our results complement studies of growth cone guidance by diffusible chemical gradients and suggest that growth cones might interpret these co-existing guidance cues selectively.

Short-duration, DC electrical stimulation increases chick embryo DRG neurite outgrowth

This study aimed to reveal the influence of brief DC electric stimulation on neurite outgrowth and outgrowth rates after application. Chick embryo dorsal root ganglia neurite outgrowth, rates, and overall alignment to EF were measured before stimulation and at two time points after stimulation. The presence of a 25 V/m EF for 10 min increased overall neurite outgrowth over controls for up to 48 h after stimulation and all growth was symmetric. These results demonstrate that even 10 min of stimulation, which is approximately 80% shorter than previous studies, promotes enhanced nerve growth.

Controlling cell behavior electrically: current views and future potential

Direct-current (DC) electric fields are present in all developing and regenerating animal tissues, yet their existence and potential impact on tissue repair and development are largely ignored. This is primarily due to ignorance of the phenomenon by most researchers, some technically poor early studies of the effects of applied fields on cells, and widespread misunderstanding of the fundamental concepts that underlie bioelectricity. This review aims to resolve these issues by describing: 1) the historical context of bioelectricity, 2) the fundamental principles of physics and physiology responsible for DC electric fields within cells and tissues, 3) the cellular mechanisms for the effects of small electric fields on cell behavior, and 4) the clinical potential for electric field treatment of damaged tissues such as epithelia and the nervous system.

Oscillating field stimulation for complete spinal cord injury in humans: a phase 1 trial

OBJECT

An electrical field cathode (negative pole) has trophic and tropic effects on injured spinal cord axons in in vitro and in vivo models of sea lamprey, rodent, and canine spinal cord injury (SCI) and it improves functional outcome. A human oscillating field stimulator (OFS) was built, a Food and Drug Administration (FDA) exemption number was obtained, and institutional review board approval was given for a Phase 1 trial to study 10 humans with complete motor and sensory SCI.

METHODS

Entry criteria were complete SCI between C-5 and T-10 in patients 18 to 65 years of age and no transection demonstrated on magnetic resonance imaging. All participants received the National Acute Spinal Cord Injury Study (NASCIS) III methylprednisilone protocol. Cord compression and/or vertebral instability was treated before study entry. After treatment complete SCI (according to the American Spinal Injury Association [ASIA] score) remained in all patients with no somatosensory evoked potentials (SSEPs) below the injury level after surgery or for 48 hours. All patients underwent implantation of the OFS within 18 days. Patients underwent evaluation every 2 weeks postimplantation; the OFS was explanted at 15 weeks. Independent neurological status was assessed based on the ASIA score, visual analog scale (VAS) pain score, and SSEPs at 6 weeks, 6 months, and 1 year. Statistical analyses were performed using the two-tailed Wilcoxon test and analysis of variance (ANOVA). There were no complications at insertion of the OFS; there was one case of wound infection after explantation (5% infection rate). One patient was lost to follow up after 6 months. In all 10 patients the mean VAS pain score was 8 at implantation, 2 at 6 months, and in the nine attending follow up for 1 year it remained 2. At 1 year, the mean improvement in light touch was 25.5 points (ANOVA p < 0.001, Wilcoxon test p = 0.02), the mean improvement in pinprick sensation was 20.4 points (ANOVA p < 0.001, Wilcoxon test p = 0.02), and the mean improvement in motor status was 6.3 points (ANOVA p < 0.01, Wilcoxon test p = 0.02). Of five cases involving cervical cord injuries, bilateral upper-extremity SSEPs were normal in one, unilateral upper-extremity SSEPs were recovered in four, bilateral upper-extremity SSEPs were recovered in one, and abnormal lower-extremity SSEPs resolved in one case. In one of the five cases involving thoracic injuries an abnormal lower-extremity SSEP resolved.

CONCLUSIONS

The use of OFS treatment in patients with SCI is safe, reliable, and easy. Compared with the outcomes obtained in compliant NASCIS III plegic patients, the results of the present study indicate efficacy, and the FDA has given permission for enrollment of 10 additional patients.