Tubulation for peripheral nerve gap: its history and possibility

Engineering topography: effects on nerve cell behaviors and applications in peripheral nerve repair

There have been extensive studies on the application of topography in the field of tissue repair. A common feature of these studies is that the existence of topological structures in tissue repair scaffolds can effectively regulate a series of behaviors of cells and play a positive role in a variety of tissue repair and regeneration processes. This review focuses on the application of topography in the field of peripheral nerve repair. The integration of the topological structure and biomaterials to construct peripheral nerve conduits to mimic a natural peripheral nerve structure has an important role in promoting the recovery of peripheral nerve function. Therefore, in this review, we systematically analysed the structure of peripheral nerves and summarized the effects of topographic cues of different scales and shapes on the behaviors of nerve cells, including cell morphology, adhesion, proliferation, migration and differentiation. Furthermore, the application and performance of scaffolds with different topological structures in peripheral nerve repair are also discussed. This systematic summary may help to provide more effective strategies for peripheral nerve regeneration (PNR) and shed light on nervous tissue engineering and regenerative medicine.

Facial Nerve Repair by Muscle-Vein Conduit in Rats: Functional Recovery and Muscle Reinnervation

The facial nerve is the most frequently damaged nerve in head and neck traumata. Repair of interrupted nerves is generally reinforced by fine microsurgical techniques; nevertheless, regaining all functions is the exception rather than the rule. The so-called "postparalytic syndrome," which includes synkinesia and altered blink reflexes, follows nerve injury. The purpose of this study was to examine if nerve-gap repair using an autologous vein filled with skeletal muscle would improve axonal regeneration, reduce neuromuscular junction polyinnervation, and improve the recovery of whisking in rats with transected and sutured right buccal branches of the facial nerve. Vibrissal motor performance was studied with the use of a video motion analysis. Immunofluorescence was used to visualize and analyze target muscle reinnervation. The results taken together indicate a positive effect of muscle-vein-combined conduit (MVCC) on the improvement of the whisking function after reparation of the facial nerve in rats. The findings support the recent suggestion that a venal graft with implantation of a trophic source, such as autologous denervated skeletal muscle, may promote the monoinnervation degree and ameliorate coordinated function of the corresponding muscles.

Biological and Synthetic Conduits in Peripheral Nerve Repair: A Comparative Experimental Study

Two different types of conduits, one biological, obtained with homologous glutaraldehyde preserved vein segments and the other synthetic bioabsorbable, made with Poly [L-lactide-co-6-caprolactone], were evaluated as guides for nerve repair in alternative to autologous grafts in an experimental animal model. Under general anesthetic, the ischiatic nerve of a number Wistar rats was transected to create a 1 cm gap, which was then repaired by means of the conduits or autologous grafts. Controls were performed at 1, 3 and 6 months; nerve regeneration was effective with both conduits, but the count of myelinated axons showed a significant difference between the synthetic and biological tubes (p<0.001). The Poly [L-lactide-co-6-caprolactone] guide was still intact 30 days after implant; progressive signs of degradation were present at 90 and 180 days. These results show that the synthetic conduits are better than those obtained with preserved vein segments and might be considered in alternative to autologous grafts in peripheral nerve reconstruction

The effects of venous ensheathment on facial nerve repair in the rat

OBJECTIVE

To investigate the protective effect of autologous venous ensheathment on sutured rat facial nerve and to test whether the ensheathment could improve the functional recovery of repaired nerve and accuracy of axonal growth.

STUDY DESIGN

In vivo study.

METHODS

Forty-six rats were examined, with six rats serving as normal controls and 40 receiving facial nerve transection and suture repair (SR) or transection and suture repair with an additional venous ensheathment (VE). The rats were then subjected to functional testing, histological assessment of nerve specimens, or retrograde tracing, respectively.

RESULTS

At the postoperative day (POD) 60, the venous ensheathment showed no adhesion at the surrounding tissues. No significant difference in neuroma formation was found between the two surgical manipulations (SR and VE groups) (P < 0.05). Retrogradely labeled motoneurons in facial nuclei were extremely disorganized after the facial nerve undertook surgical manipulation. In all manipulated groups, double retrogradely labeled neurons, indicative of aberrant axonal branching during regeneration, could be observed after peripheral manipulation across all time points. With the two facial surgical manipulations, the average count of double-labeled neurons at POD 60 was significantly less than at POD 21 (P < 0.05).

CONCLUSION

Autologous venous ensheathment could not help with the functional recovery of facial nerve or improve the accuracy of axonal regeneration. Further studies are warranted to elucidate the effects of venous ensheathment in other motor and sensory nerve models.

LEVEL OF EVIDENCE

NA. Laryngoscope, 127:1558-1564, 2017.

Peripheral Nerve Reconstruction with Bioabsorbable Polyphosphazene Conduits

Tubes of poly[bis(ethylalanato)phosphazene], obtained by evaporating the polymer around a 1.3 mm diameter capillary, were evaluated as guides for nerve regeneration in an experimental animal model. In six Wistar rats, under general anesthesia and with microsurgical technique, the ischiatic nerve was bilaterally isolated. On the right side, a segment was removed to create a defect of 10 mm, that was repaired with the conduit; on the left side the defect was repaired with harvested nerve segment from the right side. Controls at 30, 90, 180 days showed slow and gradual absorption of the conduit without signs of local or general toxicity. Nerve fiber regeneration in the conduits was not significantly different from that obtained with autologous grafts. Polyphosphazene conduits may be considered effective as a guide for nerve regeneration mainly in the perspective of using the polymer matrix as a carrier for neurite-promoting factors.

Nanobiocomposite of poly(lactide-co-glycolide)/chitosan electrospun scaffold can promote proliferation and transdifferentiation of Schwann-like cells from human adipose-derived stem cells

The transdifferentiation of human adipose-derived stem cells (ADSCs) into Schwann-like cells on biocomposite scaffolds may be a critical issue in nerve regeneration medicine. In this study, tissue-engineered scaffold with chitosan (CS) nanopowders and poly(lactide-co-glycolide) (PLGA) was investigated for its potential Schwann cells (SCs) transdifferentiation. The differentiation of human ADSCs into S-like cells was induced with different CS content and direction of nanofibers on PLGA/CS scaffolds. Cell morphology and proliferation of differentiated cells were investigated by scanning electron microscopy and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay respectively. For assessment efficiency of transdifferentiation, the expression of SC markers (glial fibrillary acidic protein and S100), and myelinogenic marker (myelin basic protein) was investigated in different nanochitosan content and direction of nanofibers scaffolds, using immunocytochemistry technique. The nanochitosan can significantly promote cell proliferation of differentiated cells (p < 0.05). The mean percentage of S-like cells on greater CS content nanofibers scaffold was significantly higher than others (p < 0.05). In addition, the align orientation of nanofibers in scaffolds guided the differentiation of ADSCs toward myelinating S-like cells on the constructs. Overall, we found that high CS content and aligned-orientation of nanofibers in biocomposite scaffold (70/30A) can promote differentiation and myelinogenic capacity of S-like cells induced from human ADSCs.

Challenges for nerve repair using chitosan-siloxane hybrid porous scaffolds

The treatment of peripheral nerve injuries remains one of the greatest challenges of neurosurgery, as functional recover is rarely satisfactory in these patients. Recently, biodegradable nerve guides have shown great potential for enhancing nerve regeneration. A major advantage of these nerve guides is that no foreign material remains after the device has fulfilled its task, which spares a second surgical intervention. Recently, we studied peripheral nerve regeneration using chitosan-γ-glycidoxypropyltrimethoxysilane (chitosan-GPTMS) porous hybrid membranes. In our studies, these porous membranes significantly improved nerve fiber regeneration and functional recovery in rat models of axonotmetic and neurotmetic sciatic nerve injuries. In particular, the number of regenerated myelinated nerve fibers and myelin thickness were significantly higher in rat treated with chitosan porous hybrid membranes, whether or not they were used in combination with mesenchymal stem cells isolated from the Wharton's jelly of the umbilical cord. In this review, we describe our findings on the use of chitosan-GPTMS hybrids for nerve regeneration.

Use of bioabsorbable nerve conduits as an adjunct to brachial plexus neurorrhaphy

PURPOSE

The use of bioabsorbable conduits in digital nerve repair has demonstrated increased efficacy compared to direct repair (for gaps ≤ 4mm) and nerve grafting (for gaps ≥ 8 mm) for sensory recovery in a level 1 human trial. Although nonhuman primate studies on mixed motor-sensory nerves have documented comparable efficacy of the bioabsorbable nerve conduits when compared to nerve repair or grafting, there is minimal human clinical data on motor recovery following bioabsorbable nerve conduit repair. This study investigates the outcomes of bioabsorbable nerve conduits in pure motor nerve reconstruction for adult traumatic brachial plexus injuries.

METHODS

Over a 3-year period, 21 adult patients had 1 or more nerve-to-nerve transfers for traumatic brachial plexus palsy performed using the operative microscope. Ten nerve transfers were performed by advancing the nerve ends into a semi-permeable type I collagen conduit stabilized with 8-0 nylon sutures (conduit-assisted neurorrhaphy). Twenty-eight concurrent nerve transfers were performed using standard end-to-end neurorrhaphy and 8-0 or 9-0 nylon sutures. Clinical evaluation using the Medical Research Council grading system (MRC) was performed at 1 and 2 years postoperatively. Postoperative electromyographic studies were performed in 28 of 38 transfers at final follow-up.

RESULTS

Thirty transfers (17 patients) were available for 2-year follow-up evaluation. All 10 transfers performed with nerve conduits demonstrated clinical recovery and electromyographic reinnervation at 2 years. Eighteen of 20 transfers performed without conduits demonstrated clinical recovery.

CONCLUSIONS

Although no statistical difference in functional recovery was seen in nerve transfers performed with collagen nerve conduits or by traditional neurorrhaphy, this pilot series demonstrated clinical and electromyographic recovery in 10 of 10 motor nerve repairs performed using conduits. These findings warrant continued investigation into the efficacy of conduit-assisted repair for motor nerves, especially in regards to operative time, precision of repair, and speed of nerve recovery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Controlled delivery of glial cell line-derived neurotrophic factor enhances motor nerve regeneration

PURPOSE

To determine the effect of a motor-specific neurotrophic factor, glial-derived neurotrophic factor (GDNF) on motor nerve regeneration.

METHODS

We used a nerve conduit filled with a fibrin-based delivery system that provided controlled release of GDNF during nerve regeneration. The motor branch of the rat femoral nerve was used to assess motor nerve regeneration across a 5-mm gap. Four experimental groups (n = 4 to n = 8) were evaluated. These included GDNF with the fibrin-based delivery system (GDNF-DS), fibrin alone, empty conduit (negative control), and nerve isograft (positive control). Nerves were harvested at 5 weeks for analysis by histomorphometry and electron microscopy.

RESULTS

At 5 mm distal to the conduit or isografts, the GDNF-DS group was not significantly different from the nerve isograft group in the following histomorphometric measures: total nerve fibers, percentage of neural tissue, and nerve density. Both the GDNF-DS and isograft groups had significantly more fibers and a higher percentage of neural tissue than fibrin alone and empty conduit groups. There were no differences in fiber width among all groups. By electron microscopy, the GDNF-DS and isograft groups also demonstrated more organized nerve architecture than the fibrin alone and empty conduit groups.

CONCLUSIONS

The delivery of GDNF from the fibrin-based delivery system promotes motor nerve regeneration at a level similar to an isograft in the femoral motor nerve model. This study gives insight into the potential beneficial role of GDNF in the treatment of motor nerve injuries.

Electrospun micro/nanofibrous conduits composed of poly(epsilon-caprolactone) and small intestine submucosa powder for nerve tissue regeneration

Three-dimensional biocompatible and biodegradable scaffolds play important roles in tissue engineering. In this study, fibrous mats composed of electrospun poly(epsilon-caprolactone) (PCL)/small intestine submucosa (SIS) tubes were fabricated with a high degree of longitudinal alignment as a conduit for peripheral nerves. Fourier transform infrared analyses of electrospun PCL/SIS mats with various amounts of SIS showed that the SIS was well embedded within the PCL matrix. The diameter of the PCL/SIS fibers with the 3 wt % of SIS in the PCL solution decreased 40% relative to that of pure PCL fibers due to increased electrical conductivity and decreased surface tension. PCL/SIS (3 wt %) electrospun mats exhibited various synergistic effects, including stronger mechanical properties (Young's modulus = more than 80%) and enhanced hydrophilicity (water contact angle at 30 min = 54 degrees ) relative to pure PCL (water contact angle at 30 min = 142 degrees ). Cell attachment and proliferation experiments demonstrated that the interactions between nerve cells (PC-12) and the PCL/SIS conduits were more favorable than those between PC-12 cells and a pure PCL conduit. This study contributes to the understanding of the effects of including SIS in electrospun composite mats. The ability to fabricate highly aligned tubes of PCL/SIS with appropriate mechanical properties and cellular interactions shows great potential for the design of nerve regeneration conduits.

Functional recovery after peripheral nerve injury and implantation of a collagen guide

Although surgery techniques improved over the years, the clinical results of peripheral nerve repair remain unsatisfactory. In the present study, we compare the results of a collagen nerve guide conduit to the standard clinical procedure of nerve autografting to promote repair of transected peripheral nerves. We assessed behavioral and functional sensori-motor recovery in a rat model of peroneal nerve transection. A 1cm segment of the peroneal nerve innervating the Tibialis anterior muscle was removed and immediately replaced by a new biodegradable nerve guide fabricated from highly purified type I+III collagens derived from porcine skin. Four groups of animals were included: control animals (C, n=12), transected animals grafted with either an autologous nerve graft (Gold Standard; GS, n=12) or a collagen tube filled with an acellular skeletal muscle matrix (Tube-Muscle; TM, n=12) or an empty collagen tube (Collagen-Tube; CT, n=12). We observed that 1) the locomotor recovery pattern, analyzed with kinetic parameters and peroneal functional index, was superior in the GS and CT groups; 2) a muscle contraction was obtained in all groups after stimulation of the proximal nerve but the mechanical muscle properties (twitch and tetanus threshold) parameters indicated a fast to slow fiber transition in all operated groups; 3) the muscular atrophy was greater in animals from TM group; 4) the metabosensitive afferent responses to electrically induced fatigue and to two chemical agents (KCl and lactic acid) was altered in GS, CT and TM groups; 5) the empty collagen tube supported motor axonal regeneration. Altogether, these data indicate that motor axonal regeneration and locomotor recovery can be obtained with the insertion of the collagen tube RevolNerv. Future studies may include engineered conduits that mimic as closely as possible the internal organization of uninjured nerve.

The early history of tubulation in nerve repair

The first experiments for bridging peripheral nerve gaps using nerve tubulation emerged in the 19th century. Because Gluck (1853-1942) is said to have performed the first animal experiment of nerve tubulation in 1880, it is interesting to explore the background and veracity of this claim. The original documents on nerve tubulation in the 19th century were studied. We conclude that the conduit that was initially used for nerve tubulation was derived from a resorbable decalcified bone tube developed for wound drainage by Neuber (1850-1932) in 1879. Gluck proposed the use of the bone tube as a guided conduit for regenerating nerves in 1881 but stated briefly that his experiments failed because of scar formation. Vanlair (1839-1914) documented the first successful application of nerve tubulation using a bone tube to bridge a 3 cm sciatic nerve defect in a dog in 1882.

Post-injury regeneration in rat sciatic nerve facilitated by neurotrophic factors secreted by amniotic fluid mesenchymal stem cells

Amniotic fluid mesenchymal stem cells have the ability to secrete neurotrophic factors that are able to promote neuron survival in vitro. The purpose of this study was to evaluate the effects of neurotrophic factors secreted by rat amniotic fluid mesenchymal stem cells on regeneration of sciatic nerve after crush injury. Fifty Sprague-Dawley rats weighing 250-300 g were used. The left sciatic nerve was crushed with a vessel clamp. Rat amniotic fluid mesenchymal stem cells embedded in fibrin glue were delivered to the injured nerve. Enzyme-linked immunosorbent assay (ELISA) and immunocytochemistry were used to detect neurotrophic factors secreted by the amniotic fluid mesenchymal stem cells. Nerve regeneration was assessed by motor function, electrophysiology, histology, and immunocytochemistry studies. Positive CD29/44, and negative CD11b/45, as well as high levels of expression of brain-derived neurotrophic factor, glia cell line-derived neurotrophic factor, ciliary neurotrophic factor (CNTF), nerve growth factor, and neurotrophin-3 (NT-3) were demonstrated in amniotic fluid mesenchymal stem cells. Motor function recovery, the compound muscle action potential, and nerve conduction latency showed significant improvement in rats treated with amniotic fluid mesenchymal stem cells. ELISA measurement in retrieved nerves displayed statistically significant elevation of CNTF and NT-3. The immunocytochemical studies demonstrated positive staining for NT-3 and CNTF in transplanted cells. The histology and immunocytochemistry studies revealed less fibrosis and a high level of expression of S-100 and glial fibrillary acid protein at the crush site. Rat amniotic fluid mesenchymal stem cells may facilitate regeneration in the sciatic nerve after crush injury. The increased nerve regeneration found in this study may be due to the neurotrophic factors secreted by amniotic fluid mesenchymal stem cells.

Collagen biomaterial doped with colominic acid for cell culture applications with regard to peripheral nerve repair

Colominic acid (CA) is a homopolymer of sialic acid residues and is solely composed of polymerised units of alpha-2,8-linked N-acetylneuraminic acid. CA is a specific derivative of polysialic acid (PSA), produced as the capsular polysaccharide of Escherichia coli K1 derived molecule of PSA. PSA in vivo plays a significant role in synaptic plasticity and neural development. The use of collagen materials doped with defined CA is presented for the cultivation of various cell lines relevant for possible applications in Tissue Engineering. First, the release behaviour under culture conditions of the collagen-based (C-CA) materials was investigated by thiobarbituric acid assay. Additionally, the established cell lines, PC-12 and immortalised Schwann cells (ISC), used for neurobiological and neurochemical studies and the model liver cell line Hep-G2 as indicator for biocompatibility testing, were cultured on the C-CA matrix. Cell proliferation (MTT-test) and cell adhesion (DAPI-staining) of the cell lines on the matrices were observed. Likewise, gene expression of the marker genes thyrosine hydroxylase for the PC-12 cells, and albumin, transferrin and CYP3A4 for the Hep-G2 cells was evaluated via RT-PCR. The results indicate that CA integration in established biomaterial constructs enhances cell proliferation and offers promising features as conduits additive in regarding peripheral nerve regeneration.

Diverse types of epineural conduits for bridging short nerve defects. An experimental study in the rabbit

In this study the process of peripheral nerve regeneration through an epineural flap conduit was examined using four groups of 126 New Zealand rabbits. There were three study groups (A, B, and C) and 1 control group (D). A 10-mm long sciatic nerve defect was bridged either with 3 variations of an epineural flap (Groups A, B, and C) or with a nerve autograft (Group D). Animals from all groups were examined 21, 42, and 91 days postoperatively to evaluate nerve regeneration employing light microscopy and immunocytochemistry. Nerve regeneration was studied in transverse sections at 3, 6, and 9 mm from the proximal stump. The gastrocnemius muscle contractility was also examined prior to euthanasia at 91 days postsurgery in all groups using electromyography. Immunohistochemical, histochemical and functional evaluation showed the presence of nerve regeneration resembling the control group D, especially in group A, where an advancement epineural flap was used. In this experimental model an epineural flap can be used to bridge a nerve defect successfully.

Nerve regeneration along bioengineered scaffolds

Tissue engineering has recently seen great advancements in many medical fields, including peripheral nerve reconstruction. In the rat median nerve model, we investigated nerve repair by means of bioengineered tissue scaffolds (muscle-vein-combined tubes) focusing on changes in the neuregulin-1/ErbB-receptor system which represents one of the main regulatory systems of axo-glial interaction in peripheral nerves. Repaired nerves were withdrawn at 5, 15, and 30 days postoperative and processed for morphological and retro-transcriptase polymerase chain reaction (RT-PCR) analysis. Results revealed an early and progressive increase in the expression of NRG1alpha isoform only, while the appearance of the beta isoform of NRG1, which is normally present in peripheral nerves, was delayed. In regards to ErbB2 and ErbB3 receptors, their expression increased progressively inside the muscle-vein-combined scaffolds, though with different kinetics. Taken together, these results suggest that variations in neuregulin-1/ErbB system activation play a key role in peripheral nerve regeneration along bioengineered muscle-vein-combined scaffolds. Since similar variations are also detectable in denervated skeletal muscles, it can be hypothesized that the existence of a NRG1's autocrine/paracrine trophic loop shared by both glial and muscle fibers could be responsible for the effectiveness of muscle-vein-combined conduits for repairing nerve defects.

A new technique of autogenous conduits for bridging short nerve defects. An experimental study in the rabbit

BACKGROUND

[corrected] Nerve grafting is the most reliable used procedure to bridge a neural defect, but it is associated with donor site morbidity. In experimental surgery the search for an optimal nerve conduit led to the use of biological and artificial material. Nerve regeneration through epineural conduits for bridging short nerve defect was examined.

METHODS

Four groups including 126 New Zealand rabbits were used. There were 3 study groups (A, B and C) and 1 control group (D). A 10-mm long sciatic nerve defect was bridged either with 3 variations of an epineural flap (Groups A, B and C) or with a nerve graft (Group D). Animals from all groups were examined 21, 42 and 91 days postoperatively to evaluate nerve regeneration employing light microscopy and immunocytochemistry. Nerve regeneration was studied in transverse sections at 3, 6 and 9 mm from the proximal stump. Using muscle stimulator the gastrocnemius contractility was examined at 91 days post surgery in all groups.

FINDINGS

Immunohistochemical and functional evaluation showed nerve regeneration resembling the control group, especially in group A, were an advancement epineural flap was used.

CONCLUSION

An epineurial flap can be used to bridge a nerve defect with success.

Metabosensitive Afferent Fiber Responses after Peripheral Nerve Injury and Transplantation of an Acellular Muscle Graft in Association with Schwann Cells

Studies dedicated to the repair of peripheral nerve focused almost exclusively on motor or mechanosensitive fiber regeneration. Poor attention has been paid to the metabosensitive fibers from group III and IV (also called ergoreceptor). Previously, we demonstrated that the metabosensitive response from the tibialis anterior muscle was partially restored when the transected nerve was immediately sutured. In the present study, we assessed motor and metabosensitive responses of the regenerated axons in a rat model in which 1 cm segment of the peroneal nerve was removed and immediately replaced by an autologous nerve graft or an acellular muscle graft. Four groups of animals were included: control animals (C, no graft), transected animals grafted with either an autologous nerve graft (Gold Standard-GS) or an acellular muscle filled with Schwann Cells (MSC) or Culture Medium (MCM). We observed that (1) the tibialis anterior muscle was atrophied in GS, M(SC) and M(CM) groups, with no significant difference between grafted groups; (2) the contractile properties of the reinnervated muscles after nerve stimulation were similar in all groups; (3) the metabosensitive afferent responses to electrically induced fatigue was smaller in M(SC) and MCM groups; and (4) the metabosensitive afferent responses to two chemical agents (KCl and lactic acid) was decreased in GS, M(SC) and M(CM) groups. Altogether, these data indicate a motor axonal regeneration and an immature metabosensitive afferent fiber regrowth through acellular muscle grafts. Similarities between the two groups grafted with acellular muscles suggest that, in our conditions, implanted Schwann cells do not improve nerve regeneration. Future studies could include engineered conduits that mimic as closely as possible the internal organization of uninjured nerve.

Permeable guidance channels containing microfilament scaffolds enhance axon growth and maturation

Successful peripheral nerve regeneration is still limited in artificial conduits, especially for long lesion gaps. In this study, porous poly(L-lactide-co-DL-lactide, 75:25) (PLA) conduits were manufactured with 16 poly(L-lactide) (PLLA) microfilaments aligned inside the lumen. Fourteen and 18 mm lesion gaps were created in a rat sciatic nerve lesion model. To evaluate the combined effect of permeable PLA conduits and microfilament bundles on axon growth, four types of implants were tested for each lesion gap: PLA conduits with 16 filaments; PLA conduits without filaments; silicone conduits with 16 filaments; and silicone conduits without filaments. Ten weeks following implantation, regeneration within the distal nerve was compared between corresponding groups. Antibodies against the markers S100, calcitonin gene related peptide (CGRP), RMDO95, and P0 were used to identify Schwann cells, unmyelinated axons, myelinated axons, and myelin, respectively. Results demonstrated that the filament scaffold enhanced tissue cable formation and Schwann cell migration in all groups. The filament scaffold enhanced axonal regeneration toward the distal stump, especially across long lesion gaps, but significance was only achieved with PLA conduits. When compared to corresponding silicone conduits, permeable PLA conduits enhanced myelinated axon regeneration across both lesion gaps and achieved significance only in combination with filament scaffolds. Myelin staining indicated PLA conduits supported axon myelination with better myelin quantity and quality when compared to silicone conduits.

La réparation nerveuse périphérique : 30 siècles de recherche

INTRODUCTION

Nerve injury compromises sensory and motor functions. Techniques of peripheral nerve repair are based on our knowledge regarding regeneration. Microsurgical techniques introduced in the late 1950s and widely developed for the past 20 years have improved repairs. However, functional recovery following a peripheral mixed nerve injury is still incomplete.

STATE OF ART

Good motor and sensory function after nerve injury depends on the reinnervation of the motor end plates and sensory receptors. Nerve regeneration does not begin if the cell body has not survived the initial injury or if it is unable to initiate regeneration. The regenerated axons must reach and reinnervate the appropriate target end-organs in a timely fashion. Recovery of motor function requires a critical number of motor axons reinnervating the muscle fibers. Sensory recovery is possible if the delay in reinnervation is short. Many additional factors influence the success of nerve repair or reconstruction. The timing of the repair, the level of injury, the extent of the zone of injury, the technical skill of the surgeon, and the method of repair and reconstruction contribute to the functional outcome after nerve injury.

CONCLUSION

This review presents the recent advances in understanding of neural regeneration and their application to the management of primary repairs and nerve gaps.

Nerve repair by means of tubulization: literature review and personal clinical experience comparing biological and synthetic conduits for sensory nerve repair

Nerve repair is usually accomplished by direct suture when the two stumps can be approximated without tension. In the presence of a nerve defect, the placement of an autologous nerve graft is the current gold standard for nerve restoration. However, over the last 20 years, an increasing number of research articles reported on the use of non-nervous tubes (tubulization) for repairing nerve defects. The clinical employment of tubes (both biological and synthetic) as an alternative to autogenous nerve grafts is mainly justified by the limited availability of donor tissue for nerve autografts and the related morbidity. In addition, tubulization was proposed as an alternative to direct nerve sutures in order to create optimal conditions for nerve regeneration over the short empty space intentionally left between two nerve stumps. This paper outlines recent important advances in this field. Different tubulization techniques proposed so far are described, focusing in particular on studies that reported on the employment of tubes with patients. Our personal clinical experience on tubulization repair of sensory nerve lesions (digital nerves), using both biological and synthetic tubes, is presented, and the clinical results are compared. In our case series, both types of tubes led to good clinical results. Finally, we speculate about the prospects in the clinical application of tubulization for peripheral nerve repair.

Peripheral nerve regeneration by microbraided poly(L-lactide-co-glycolide) biodegradable polymer fibers

Tiny tubes with fiber architecture were developed by a novel method of fabrication upon introducing some modification to the microbraiding technique, to function as nerve guide conduit and the feasibility of in vivo nerve regeneration was investigated through several of these conduits. Poly(L-lactide-co-glycolide) (10:90) polymer fibers being biocompatible and biodegradable were used for the fabrication of the conduits. The microbraided nerve guide conduits (MNGCs) were characterized using scanning electron microscopy to study the surface morphology and fiber arrangement. Degradation tests were performed and the micrographs of the conduit showed that the degradation of the conduit is by fiber breakage indicating bulk hydrolysis of the polymer. Biological performances of the conduits were examined in the rat sciatic nerve model with a 12-mm gap. After implantation of the MNGC to the right sciatic nerve of the rat, there was no inflammatory response. One week after implantation, a thin tissue capsule was formed on the outer surface of the conduit, indicating good biological response of the conduit. Fibrin matrix cable formation was seen inside the MNGC after 1 week implantation. One month after implantation, 9 of 10 rats showed successful nerve regeneration. None of the implanted tubes showed tube breakage. The MNGCs were flexible, permeable, and showed no swelling apart from its other advantages. Thus, these new poly(L-lactide-co-glycolide) microbraided conduits can be effective aids for nerve regeneration and repair and may lead to clinical applications.

Copolymers of trimethylene carbonate and epsilon-caprolactone for porous nerve guides: synthesis and properties

Copolymers of trimethylene carbonate and epsilon-caprolactone were synthesized and characterized with the aim of assessing their potential in the development of a flexible and slowly degrading artificial nerve guide for the bridging of large nerve defects. The effect of the monomer ratio on the physical properties of the polymers and its influence on the processability of the materials was investigated. Under the applied polymerization conditions (130 degrees C, 3 days using stannous octoate as a catalyst) high molecular weight polymers (Mn above 93 000) were obtained. All copolymers had glass transition temperatures below room temperature. At trimethylene carbonate contents higher than 25 mol% no crystallinity was detected. A decrease in crystallinity resulted in the loss of strength and decrease in toughness, as well as in an increased polymer wettability. Amorphous poly(trimethylene carbonate), however, showed excellent ultimate mechanical properties due to strain-induced crystallization (Tm = 36 degrees C). Low crystallinity copolymers could be processed into dimensionally stable porous structures by means of immersion precipitation and by combination of this technique with the use of porosifying agents. Porous membranes of poly(trimethylene carbonate) could be prepared when blended with small amounts of high molecular weight poly(ethylene oxide). Poly(trimethylene carbonate) and poly(trimethylene carbonate-co-epsilon-caprolactone) copolymers with high epsilon-caprolactone content possess good physical properties and are processable into porous structures. These materials are most suitable for the preparation of porous artificial nerve guides.

Fabrication of poly(phosphoester) nerve guides by immersion precipitation and the control of porosity

Immersion precipitation was employed as a method for the fabrication of polymeric conduits from P(BHET-EOP/TC), a poly(phosphoester) with an ethylene terephthalate backbone, to be applied as guidance channels for nerve regeneration. Coatings of various porosities could be obtained by immersing mandrels coated with a solution of the polymer in chloroform into non-solvent immersion baths, followed by freeze or vacuum-drying. The porosity of the coatings decreased with an increase in polymer molecular weight, drying time before precipitation and concentration of polymer solution. The effects of these parameters can be rationalized by employing ternary phase diagrams, where porosity is directly related to the degree of phase separation available to the system before gelation occurs. To afford improved porosity control, a new system was developed which employed the contrasting phase-separation behavior of P(BHET-EOP/TC)/chloroform solution in methanol and water. As water is essentially a non-solvent for the polymer, the demixing boundary of the P(BHET-EOP/TC)-CHCl3-H2O system is located close to the polymer-solvent edge of the phase diagram, while that of the P(BHET-EOP/TC)-CHCl3-MeOH system is located further away. A mixture of methanol and water allows the demixing boundary to be shifted to intermediate coordinates. By immersing P(BHET-EOP/TC) coatings in immersion baths containing different ratios of water and methanol, then gradually titrating the bath with methanol to a concentration of 70% (v/v) methanol, surface porosities ranging from 2 to 58% could be achieved.

Heparan sulphates upregulate regeneration of transected sciatic nerves of adult guinea-pigs

The increased content of soluble glycosaminoglycan-containing forms in sciatic nerves during recovery from crush injury [Shum & Chau (1996) J. Neurosci. Res., 46, 465] suggests that the glycosaminoglycans modulate the environment for post-traumatic tissue remodelling and axonal regrowth. To test this, defined amounts of soluble heparan sulphates from bovine kidney or guinea-pig nerve were introduced into the regenerating environment via silicone conduits that bridged 8-mm gaps of transected sciatic nerves of adult guinea-pigs. Controls were bridged using the phosphate-buffered saline (PBS) vehicle or a chondroition sulphate preparation from whale cartilage. After timed periods of recovery, the animals were assessed for electromyographic signals at the target gastrocnemius muscle to determine the conduction velocity across the bridged nerve. Sections of the bridge were also histologically examined for nerve fibres. Transected sciatic nerves bridged with heparan sulphates or chondroitin sulphate showed earlier stimulated myelination of axons (week 5-6) than PBS-bridged nerves (week 9). Initial electromyographic indication of reconnection with the target was at week 9 post-transection. In the course of 20 weeks, transected sections of the bridge indicated similar numbers of unmyelinated axons irrespective of bridge material, but distinctly higher numbers of myelinated axons in heparan sulphate-bridged nerves than either PBS- or chondroitin sulphate-bridged nerves. At the end of the same period, heparan sulphate-bridged nerves resumed normal conduction velocities, but both PBS- and chondroitin sulphate-bridged nerves remained at 50% of that of the intact contralateral nerves. These results are the first to demonstrate that supplementation of soluble heparan sulphate to the fluid regenerative neural environment can restore functional, axonal reconnection of the severed nerve with the target muscle.

Facial nerve rehabilitation after radical parotidectomy

OBJECTIVE

Examine functional outcomes in patients undergoing radical parotidectomy and facial nerve grafting. Identify factors that may affect rehabilitation in these patients.

STUDY DESIGN

Retrospective chart review and photographic analyses of 12 patients undergoing radical parotidectomy with interposition nerve grafts for facial nerve reconstruction.

METHODS

Data obtained for each patient regarding age, sex, histology of parotid neoplasm, cable graft source, administration of postoperative radiotherapy, and treatment for eye rehabilitation. Functional outcomes were assessed with the House-Brackmann grading system at 6 months, 1 year, and 2 years after surgery.

RESULTS

All nerve grafts were harvested from cervical plexus sensory nerves with microscopic epineural repair performed for all neurorrhaphies. Overall, 9 of 12 patients achieved a grade III 2 years after surgery. All patients under age 30 obtained a grade III. Of the seven patients receiving postoperative radiation, five achieved a grade III. Older patients often required surgical procedures to facilitate eye closure.

CONCLUSIONS

Facial nerve rehabilitation after radical parotidectomy can be successfully achieved with cervical plexus interposition nerve grafts. Postoperative radiotherapy did not appear to affect return of function, and younger patients consistently achieved good functional outcomes after nerve grafting. Older patients frequently require surgical procedures for eye rehabilitation after radical parotidectomy.

A comparison of peripheral nerve repair using an absorbable tubulization device and conventional suture in primates

Median nerve regeneration was studied in 30 adult primates after repair by microsurgical suture or tubulization with a nonwoven, bioabsorbable, polyglycolic acid device. The two methods were compared electrophysiologically and histologically 6 and 12 months after repair. The electrophysiology included recording of electrically evoked compound action potentials and subsequent determination of threshold, conduction velocity, amplitude, and area above the baseline for each component. Measurements were obtained before nerve transection and at the time of biopsy by stimulating both proximal and distal to the transection site. Analysis of all electrophysiological parameters revealed no statistically significant differences (p less than 0.05) between the two repair techniques. Histopathology included examination of cross sections proximal and distal to the repair sites and longitudinal sections through the coaptation site. End organs (Meissner's and Pacinian corpuscles and muscle) were sectioned to determine the degree of reinnervation. No significant differences between the repair techniques were observed by histological analysis of these sections. These evaluations indicated that the tubulization repair technique produced results comparable to that of the suture technique.

Sciatic nerve regeneration through venous or nervous grafts in the rat

This study analyses the interest of isologous venous grafts filled with saline or with Schwann cells versus nerve grafts as guides for regeneration of the sciatic nerve in 35 Wistar rats. Electrophysiological parameters (conduction velocities and distal latencies of motor responses) and the functional index of De Medinacelli were measured several times from 1 month to 1 year after surgery. An histological analysis was performed on 2 control rats and on 3 rats killed 6 or 12 months after surgery: the total number of fibers was counted on a montage photoprint of the whole nerve, and the diameters of axons and the thickness of the myelin sheath were measured on digitized images. With a portion of nerve as guide, the regeneration is faster than with a vein. However, regeneration after 6 months is at least as good with a venous graft filled with Schwann cells, as assessed by electrophysiological, functional, and histological analysis. The addition of Schwann cells in grafted veins allows the nerve to regenerate through longer gaps than previously described (25 vs 15 mm). In order to assess the quality of nerve regeneration, functional, electrophysiological, and histological analysis are complementary.

Gel matrix vehicles for growth factor application in nerve gap injuries repaired with tubes: a comparison of biomatrix, collagen, and methylcellulose

The repair of nerve gap injuries with tubular nerve guides has been used extensively as an in vivo test model in identifying substances which may enhance nerve regeneration. The model has also been used clinical nerve repair. The objective of this study was to compare three different gel matrix-forming materials as potential vehicles for growth factors in this system. The vehicles included a laminin containing extracellular matrix preparation (Biomatrix), collagen, and a 2% methylcellulose gel. The growth factor test substance consisted of a combination of platelet-derived growth factor BB (PDGF-BB) and insulin-like growth factor I (IGF-I). An 8-mm gap in rat sciatic nerve was repaired with a silicone tube containing each of the vehicles alone or with a combination of each vehicle plus PDGF-BB and IGF-I. At 4 weeks after injury, the application of the growth factor combination significantly stimulated axonal regeneration when applied in methylcellulose or collagen, but not in Biomatrix. A similar trend was present between the vehicle control groups. By 8 weeks after injury, nerves repaired with methylcellulose as a vehicle had significantly greater conduction velocity than either collagen or Biomatrix. It was concluded that a 2% methylcellulose gel was the best of the three matrices tested, both in its effects on nerve regeneration and flexibility of formulation.

Effectiveness of a bioabsorbable conduit in the repair of peripheral nerves

A new conduit made with a bioabsorbable copolymer, poly (L-lactide-co-6-caprolactone), was evaluated in an animal model as a guide for nerve regeneration. The conduit had an inner diameter of 1.3 mm and a wall thickness of 175 microns. Segments of length 1.2 cm were interposed between the proximal and distal stumps of transected ischiatic nerves in Wistar rats, bridging a nerve gap of 1 cm. All of the procedure was performed under general anaesthesia using microsurgical techniques. Controls were performed at 1, 3 and 6 months and it was demonstrated that the conduit was still undamaged after 30 d. Progressive signs of degradation appeared at 90 and 180 d. Nerve regeneration in the lumen was effective as confirmed by histological and electron microscopical investigations. These preliminary results emphasize the interesting properties of the conduit with regard to the achievement of a neural prosthesis.

Recent advances in tissue synthesis in vivo by use of collagen-glycosaminoglycan copolymers

Biologically active analogues of the extracellular matrix (ECM) are synthesized by grafting glycosaminoglycan (GAG) chains onto type I collagen, and by controlling the physicochemical properties of the resulting graft copolymer. Collagen-GAG ECM analogues have previously been shown to induce regeneration of the dermis in humans and the guinea pig, and of the rat sciatic nerve. Current studies have emphasized elucidation of the molecular mechanism through which tissue-specific ECM analogues induce regeneration. The contribution of the GAGs to the biological activity of the skin regeneration template was confirmed by studying the contribution of several GAGs to the inhibition of wound contraction in guinea pigs. The interaction between cells and the porous structure of an ECM analogue was studied with emphasis on the deformation of pores which occurs during wound contraction. The synthesis of scar, as well as of partly regenerated tissue which has a morphology between that appropriate for scar and for normal dermis, was quantitatively assayed for the first time using a laser light scattering technique. An ECM analogue which has been shown to be capable of inducing regeneration of functional sciatic nerve in the rat over a gap larger than 10 mm was incorporated in the design of a biodegradable implant for peripheral nerve regeneration.

The role of conduits in nerve repair: a review

The restoration of effective and meaningful axonal function following peripheral nerve injury continues to be a considerable clinical challenge. The use of conduits to bridge the gap between severed ends is a contemporary experimental maneuver that isolates the microenvironment of regenerating axons. Entubulation has allowed analysis and manipulation of putative influences upon nerve regeneration. A review is provided of the research efforts that have explored the neurobiological and mechanical factors that guide nerve regeneration within conduits. Levels of specificity, from tissue specific growth to end-organ specific growth, are outlined within the framework of the theories of Neurotropism, Contact Guidance and Neurotrophism. Included are investigations utilizing different conduit materials and the few clinical applications of these conduits. A number of chamber manipulations, extra-cellular matrix substrates and growth factors and their molecular receptors have been implicated in enhanced regeneration specificity. This information has been extended to the conduit model. The interposition of healthy nerve segments into conduits is proposed as a means of extending the length of successful nerve regeneration.

Hyaluronic acid through a new injectable nerve guide delivery system enhances peripheral nerve regeneration in the rat

The use of non-neural conduits to bridge gaps in peripheral nerves has been noted in the literature for many years. A logical extension of this concept is the introduction of neurotrophic or growth promoting factors into the lumen. We present here an injectable nerve guide that allows percutaneous access to the microenvironment of the regenerating peripheral nerve within the guide's lumen. Hyaluronic acid, a compound associated with decreased scarring and improved fibrin matrix formation, is added sequentially to the regenerating peripheral rat sciatic nerve via this injectable nerve guide. Assessment of nerve regeneration and reinnervation shows better conduction velocity, higher axon counts, and a trend toward earlier myelination with hyaluronic acid compared with saline. This work not only implies hyaluronic acid's role as an agent that aids nerve growth but also describes a new tool that allows percutaneous access to the milieu of a regenerating nerve.

Arterial bridging for repair of peripheral nerve gap: a comparative study

A new experimental model was designed in which the regeneration of rat femoral nerve across a 8 mm excised gap was investigated after insertion of the distal and proximal stumps into the anatomically and functionally intact femoral artery (AIAB). This model was compared with groups of free artery and autologous nerve grafting. After a period of 12 weeks, a histological and electrophysiological analysis was carried out, which demonstrated that the AIAB and autologous nerve grafting group had a significantly higher percentage of regeneration compared with the free artery-graft group. The nerve regeneration and intraneural vascular reconstruction that occurred within AIAB group were more successful than those that occurred in the artery and nerve-grafting groups.

The quest for better recovery from peripheral nerve injury: current status of nerve regeneration research

The author reviews relevant nerve regeneration research in the past half-century to give the reader familiarity with the background of current research efforts. Recent research has been aided by newer knowledge of the biology of nerve regeneration. Early efforts to improve nerve regeneration centered on improvements in technical or surgical repairs, with only modest gains. Although current technical improvements with lasers or fibrin glue to repair nerves may show promise, the approach of deMedinaceli et al. combines several new ideas with some improvement experimentally. With the discovery of nerve growth factors and a host of newer nerve growth promoting factors, the biochemical arena has explored. Special tubes to repair nerves enable easy manipulation of the environment to study the effects of various factors on nerve regeneration. Silastic and bioresorbable tubes show the most promise to enhance nerve regeneration by tubulization. Because of the explosion of knowledge and high levels of activity of research, it is apparent that further improvements of nerve regeneration are on the horizon.

Bridging nerve defects with combined skeletal muscle and vein conduits

The use of vein or muscle grafts to bridge nerve defects longer than 1-1.5 cm gives poor results. Veins collapse and in muscle grafts axons may regrow outside the graft. We used veins (to guide regeneration) filled with muscle (to avoid vein collapse). Nerve regeneration through 1 and 2 cm grafts made of vein plus muscle was compared with similarly long traditional nerve grafts, free fresh muscle grafts, and empty vein grafts. Regeneration was assessed clinically and histologically (qualitative and quantitative evaluation) in the graft and distal nerve stumps. Vein plus muscle grafts were superior to vein and fresh muscle grafts both functionally and histologically. Functional results were similar to those found in traditional nerve grafts, but axon number was superior in the veins filled with muscle. This suggests that vein filled with muscle might serve as a grafting conduit for the repair of peripheral nerve injuries and could give better results than traditional nerve grafting.

Inside-out vein graft promotes improved nerve regeneration in rats

Vein grafts have been used both experimentally and clinically to bridge gaps in peripheral nerves. This study describes a modification of the vein graft technique in which vein graft conduits are pulled inside-out before anastomosis with proximal and distal nerve stumps. This technique creates an autogenous vein conduit with the collagen-rich adventitial surface exposed to the regenerating axons. The inside-out technique is a fast and simple modification of the standard vein graft technique and produces an accelerated rate of nerve regeneration and significantly earlier myelination compared with the results obtained from the use of polyethylene nerve guides and standard vein graft conduits.

Total eye transplantation for the blind: a challenge for the future

Blindness is a human and social problem of incalculable weight. In the future, artificial 'bionic' prostheses and retinal grafts could achieve a long-sought cure. Several lines of evidence led to the speculation that a total eye transplantation for the cure of retinal blindness may become feasible in the near future. It is proposed that a brain dead patient's eye, whose retinal viability has been demonstrated with an electroretinogram recording, be transplanted into the blind's voided orbital socket, through a frontoorbitotemporal craniotomy and orbitozygomatic osteotomy. Regenerating optic nerve axons are channeled in a specially constructed guide to the homolateral corpus genicolatum laterale, while the retinal ganglion cells are adequately protected during the regrowth period. Aspects of this paradigm are reviewed and discussed.

Histochemical discrimination of fibers in regenerating rat infraorbital nerve

In rat dorsal root ganglia, histochemical staining of carbonic anhydrase (CA) and cholinesterase (CE) yields a reciprocal pattern of activity: Sensory processes are CA positive and CE negative, whereas motor processes are CA negative and CE positive. In rat infraorbital nerve (a sensory peripheral nerve), we saw extensive CA staining of nearly 100% of the myelinated axons. Although CE reactivity in myelinated axons was extremely rare, we did observe CE staining of unmyelinated autonomic fibers. Four weeks after transection of infraorbital nerves, CA-stained longitudinal sections of the proximal stump demonstrated 3 distinct morphological zones. A fraction of the viable axons retained CA activity to within 2 mm of the distal extent of the stump, and the stain is capable of resolving growth sprouts being regenerated from these fibers. Staining of unmyelinated autonomic fibers in serial sections shows that CE activity was not retained as far distally as is the CA sensory staining.

Peripheral nerve repair with collagen conduits

This paper describes the repair of peripheral nerves with a tubular conduit fabricated from collagen. The tubular collagen matrix was made semipermeable to permit nutrient exchange and accessibility of neurotrophic factors to the axonal growth zone during regeneration. In-vitro studies showed that the semipermeable collagen conduit allowed rapid diffusion of molecules the size of bovine serum albumin and was adequately cross-linked for controlled resorption in vivo. Studies on primates suggest that collagen conduits worked as effectively as nerve autografts in terms of physiological recovery of motor and sensory responses. The results of in-vitro and in-vivo studies of the collagen conduit represent a significant step towards our specific aim of developing suitable off-the-shelf prostheses for clinical repair of damaged peripheral nerves.

Enhancement of peripheral nerve regeneration

Numerous factors external to the nerve cell can support and enhance nerve regeneration after injury. The definition of these factors and the elucidation of their mechanisms of action are the central goals of much contemporary neurobiologic research. This research will hopefully lead to the discovery of factors that will prove to be therapeutically beneficial for patients with either peripheral nervous system (PNS) injury or central nervous system (CNS) injury. This article reviews the biology of the regeneration response of the nerve to injury and discusses many of the factors that enhance nerve growth. Finally, the nerve guide or nerve regeneration chamber model for the evaluation of putative nerve regeneration enhancing agents in vivo is also discussed.