Reinnervation of mechanoreceptors in the human glabrous skin following peripheral nerve repair

Coordinated NADPH oxidase/hydrogen peroxide functions regulate cutaneous sensory axon de- and regeneration

Tissue wounding induces cutaneous sensory axon regeneration via hydrogen peroxide (H2O2) that is produced by the epithelial NADPH oxidase, Duox1. Sciatic nerve injury instead induces axon regeneration through neuronal uptake of the NADPH oxidase, Nox2, from macrophages. We therefore reasoned that the tissue environment in which axons are damaged stimulates distinct regenerative mechanisms. Here, we show that cutaneous axon regeneration induced by tissue wounding depends on both neuronal and keratinocyte-specific mechanisms involving H2O2 signaling. Genetic depletion of H2O2 in sensory neurons abolishes axon regeneration, whereas keratinocyte-specific H2O2 depletion promotes axonal repulsion, a phenotype mirrored in duox1 mutants. Intriguingly, cyba mutants, deficient in the essential Nox subunit, p22Phox, retain limited axon regenerative capacity but display delayed Wallerian degeneration and axonal fusion, observed so far only in invertebrates. We further show that keratinocyte-specific oxidation of the epidermal growth factor receptor (EGFR) at a conserved cysteine thiol (C797) serves as an attractive cue for regenerating axons, leading to EGFR-dependent localized epidermal matrix remodeling via the matrix-metalloproteinase, MMP-13. Therefore, wound-induced cutaneous axon de- and regeneration depend on the coordinated functions of NADPH oxidases mediating distinct processes following injury.

Outcome following nerve repair of high isolated clean sharp injuries of the ulnar nerve

OBJECTIVE

The detailed outcome of surgical repair of high isolated clean sharp (HICS) ulnar nerve lesions has become relevant in view of the recent development of distal nerve transfer. Our goal was to determine the outcome of HICS ulnar nerve repair in order to create a basis for the optimal management of these lesions.

METHODS

High ulnar nerve lesions are defined as localized in the area ranging from the proximal forearm to the axilla just distal to the branching of the medial cord of the brachial plexus. A meta-analysis of the literature concerning high ulnar nerve injuries was performed. Additionally, a retrospective study of the outcome of nerve repair of HICS ulnar nerve injuries at our institution was performed. The Rotterdam Intrinsic Hand Myometer and the Rosén-Lundborg protocol were used.

RESULTS

The literature review identified 46 papers. Many articles presented outcomes of mixed lesion groups consisting of combined ulnar and median nerves, or the outcome of high and low level injuries was pooled. In addition, outcome was expressed using different scoring systems. 40 patients with HICS ulnar nerve lesions were found with sufficient data for further analysis. In our institution, 15 patients had nerve repair with a median interval between trauma and reconstruction of 17 days (range 0-516). The mean score of the motor and sensory domain of the Rosen's Scale instrument was 58% and 38% of the unaffected arm, respectively. Two-point discrimination never reached less then 12 mm.

CONCLUSION

From the literature, it was not possible to draw a definitive conclusion on outcome of surgical repair of HICS ulnar nerve lesions. Detailed neurological function assessment of our own patients showed that some ulnar nerve function returned. Intrinsic muscle strength recovery was generally poor. Based on this study, one might cautiously argue that repair strategies of HICS ulnar nerve lesions need to be improved.

Permanent reorganization of Ia afferent synapses on motoneurons after peripheral nerve injuries

After peripheral nerve injuries to a motor nerve, the axons of motoneurons and proprioceptors are disconnected from the periphery and monosynaptic connections from group I afferents and motoneurons become diminished in the spinal cord. Following successful reinnervation in the periphery, motor strength, proprioceptive sensory encoding, and Ia afferent synaptic transmission on motoneurons partially recover. Muscle stretch reflexes, however, never recover and motor behaviors remain uncoordinated. In this review, we summarize recent findings that suggest that lingering motor dysfunction might be in part related to decreased connectivity of Ia afferents centrally. First, sensory afferent synapses retract from lamina IX, causing a permanent relocation of the inputs to more distal locations and significant disconnection from motoneurons. Second, peripheral reconnection between proprioceptive afferents and muscle spindles is imperfect. As a result, a proportion of sensory afferents that retain central connections with motoneurons might not reconnect appropriately in the periphery. A hypothetical model is proposed in which the combined effect of peripheral and central reconnection deficits might explain the failure of muscle stretch to initiate or modulate firing of many homonymous motoneurons.

Redirection of cutaneous sensation from the hand to the chest skin of human amputees with targeted reinnervation

Amputees cannot feel what they touch with their artificial hands, which severely limits usefulness of those hands. We have developed a technique that transfers remaining arm nerves to residual chest muscles after an amputation. This technique allows some sensory nerves from the amputated limb to reinnervate overlying chest skin. When this reinnervated skin is touched, the amputees perceive that they are being touched on their missing limb. We found that touch thresholds of the reinnervated chest skin fall within near-normal ranges, indicating the regeneration of large-fiber afferents. The perceptual identity of the limb and chest was maintained separately even though they shared a common skin surface. A cutaneous expression of proprioception also occurred in one reinnervated individual. Experiments with peltier temperature probes and surface electrical stimulation of the reinnervated skin indicate the regeneration of small diameter temperature and pain afferents. The perception of an amputated limb arising from stimulation of reinnervated chest skin may allow useful sensory feedback from prosthetic devices and provides insight into the mechanisms of neural plasticity and peripheral regeneration in humans.

Pathophysiology of nerve injury

The response to nerve injury is a complex and often poorly understood mechanism. An in-depth and current command of the relevant neuroanatomy, classifications systems, and responses to injury and regeneration are critical to current clinical success. Continued progress must be made in our current understanding of these varied physiologic mechanisms of neuro-regeneration if any significant progress in clinical treatments or outcome is to be expected in the future. Reconstructive surgeons have in many ways maximized the technical aspects of peripheral nerve repair. However, advances in functional recovery may be seen with improvements in sensory and motor rehabilitation after peripheral nerve surgery and with a combined understanding of the neurobiology and neurophysiology of nerve injury and regeneration.

Properties of human skin mechanoreceptors in peripheral neuropathy

OBJECTIVES

To investigate the properties of mechanoreceptors in patients with peripheral neuropathy. The skin mechanoreceptor is a terminal organ of the primary sensory neuron, which is likely to be affected earlier and more severely than is the nerve trunk by peripheral neuropathies.

METHODS

Single sensory unit responses to air-puff and electric stimulation were recorded using the microneurographic technique in the glabrous skin of the hand. Receptor transduction time was estimated by a latency difference between electric- and air-puff-induced responses.

RESULTS

A total of 38 mechanoreceptive units were obtained from 14 normal subjects. All the units responded to air-puff stimuli irrespective of the receptor type, and receptor transduction time was approximately 2 ms. A total of 32 units were recorded from 11 patients with neuropathy of variable causes. Seven (22%) of the 32 neuropathic units did not respond to air-puffs despite their ability to respond to electric stimulation. Compared to normal ones, units from patients with peripheral neuropathy had significantly higher mechanical thresholds, but receptor transduction times did not differ significantly.

CONCLUSIONS

Changes in receptor properties in human neuropathy are characterized by increased mechanical threshold without prolongation of receptor transduction time, possibly due to a high threshold for generating receptor potentials.

Evaluation of hand sensibility: a review

Many assessment devices and measures have been described to evaluate sensibility, with little consensus on the optimal measurement tool. The purpose of this paper is to review the assessment methods and devices used in the evaluation of hand sensibility. Consideration is given to the characteristics of each measurement tool, the information necessary for complete patient evaluation, and the battery of valid and reliable measurements that provide the most complete and accurate patient assessment.

Single unit responses of human cutaneous mechanoreceptors to air-puff stimulation

OBJECTIVE

To investigate responsiveness of human cutaneous mechanoreceptor to selective tactile stimuli produced by brief air-puff stimulation.

METHODS

Using percutaneous microneurography, activities of single sensory units innervating glabrous skin of the hand were recorded, and air-puff stimuli with a short rise time (0.5 ms), generated by a high-speed air control system, were applied to the receptive field. Receptor activation time was estimated as the latency difference between electrically and air-puff evoked responses.

RESULTS

Thirty units were analyzed: all 4 kinds of mechanoreceptors of human glabrous skin (fast adapting type 1 [FA I, n=7], fast adapting type 2 [FA II, n=4], slowly adapting 1 [SA I, n=5] and slowly adapting 2 [SA II, n=14]) were activated by air-puff stimulation. Estimated receptor activation times were 0.6-6.2 ms (mean 2.2 ms). FA II units occasionally responded twice or more to a single air-puff stimulus.

CONCLUSIONS

Brief air-puffs can activate all 4 human cutaneous mechanoreceptors, and the receptor transduction time is estimated as approximately 2.0 ms. Properties of human mechanoreceptors can be studied using air-puff stimulation and microneurography.

Trigeminal ganglion cell response to mental nerve transection and repair in the rat

PURPOSE

Animal studies have suggested that peripheral nerve transection results in substantial loss of ganglion cells and the selective survival of cells based on size. The implications are that subsequent repair of peripheral nerve injuries will be determined by the numerical density and character of the surviving cells. The purpose of this study was twofold: First, to determine the effect of mental nerve transection without repair on trigeminal ganglion cell density and morphology in adult rats, and second, to determine the variation of trigeminal ganglion cell density and morphology after immediate and delayed repair.

MATERIALS AND METHODS

In the first part of the study, 12 adult male Sprague-Dawley rats had their mental nerves exposed bilaterally (n = 24). Twelve mental nerves were then transected and prevented from regenerating, and the remaining 12 nerves were uninjured. Ninety and 180 days after transection or sham surgery, the trigeminal ganglia were serially cut into 5 microm longitudinal sections along the dorsoventral axis. The volume and volume density of the mandibular mental subdivision containing sensory cells was determined at each section level with point-counting methods. The numerical density and total number of cells was estimated on the same section, using an unbiased three-dimensional stereological probe, the dissector. Cell size and shape determinants were estimated using the dissector and computerized planimetry. In the second part of the study, six rats had the mental nerves transected bilaterally and immediately repaired by microscopic sutures. In six additional rats, the repair was delayed for 90 days. In both groups, the trigeminal ganglia were serially cut at 30, 60, and 90 days post-repair and stereologic estimates of numerical density and histomorphometry were examined using the dissector and computed planimetry.

RESULTS

In the trigeminal ganglia of the 12 sham-operated animals, the mean number of cells was 20.6 x 10(3) (+/-2.9 X 10(3)). After nerve section, the mean number of cells was 10.88 X 10(3) (+/-0.9 X 10(3)), representing a 47% reduction. The mean volume of the mandibular subdivision cells in the ganglia of the sham surgery animals was 0.3 mm3 (+/-0.05) and 0.22 mm3 (+/-0.04) in nerve-sectioned ganglia, a 38% difference. There were no ganglia cell size or shape differences between the two groups. The mean number of cells in the ganglia of immediately repaired nerves was 10.66 x 10(3)(+/-1.1 X 10(3)), and it was 12.45 x 10(3) (+/-0.9 x 10(3)) after delayed repair. The numerical density was significantly less than in the sham surgery ganglia but not different from that of the transection/no repair ganglia. The weighted mean reference volume of the mandibular subdivision after immediate and delayed repair was similar and was significantly greater than the transection/no repair group, but not different from the sham surgery group. The cell size was slightly larger in delayed-repair ganglia compared with immediate-repair ganglia, but the differences were not significant. There were no significant differences in any of the stereologic estimates when analyzed across treatment time.

CONCLUSIONS

The results of this study agree with previous reports that peripheral nerve transection produces a substantial loss of nerve cells within specified regions of sensory ganglions. However, the results conflict with evidence that cells survive transection based on size and shape. These findings also indicate that in the adult rat the substantial loss of nerve cells was unaltered by the reconnection of their severed axons. Neither immediate or delayed repair of the transected nerve altered the spectrum of surviving cells based on size or shape. The reestablishment of the mean reference volume of the mandibular subdivision after section and repair suggests that demands made on regenerating axons appear to result in the restoration of ganglionic volume normally lost after axotomy, probably the result of axo

The methodology and scope of human microneurography

Microneurography was introduced in 1967 and has developed into an invaluable tool for investigating human somatosensory, motor and cardiovascular physiology and pathophysiology. It involves percutaneous insertion of a metal microelectrode into fascicles of limb and facial nerves. This review covers the procedures and equipment necessary for microneurography and provides a current circuit for a preamplifier. Evidence is presented that (i) most recordings from myelinated axons involve an effective penetration of the myelin by the electrode; (ii) based on physiological criteria, microstimulation through the electrode can be used to activate single axons although the probability of this is relatively low and (iii) despite 'micro' lesions caused by the electrode insertion into the nerve and its fascicles, the morbidity with the procedure is acceptably low.

Responsiveness of the somatosensory system after nerve injury and amputation in the human hand

We studied the responsiveness of the somatosensory system in humans after prolonged deprivation of peripheral input. Eight patients with traumatic transection of the median or ulnar nerve and 6 patients with amputation of a finger or hand underwent microneurography and intraneural stimulation. Bundles of nerve fibers were electrically stimulated through a microelectrode placed in the affected nerve proximally to the site of damage or in the case of amputees, in a nerve fascicle supplying the stump. During intraneural stimulation the subjects with nerve injuries reported distinct percepts in the hypoesthetic skin. Their projections were usually confined to the territory of a single or two adjacent palmar digital nerves, similar to the fascicular territories of healthy nerves in control subjects, but there was much less microneurographically recordable afferent activity than in normal subjects. In amputees intraneural stimulation evoked sensations in a phantom digit or digits in over three fourths of the fascicles studied. We conclude that (1) the somatosensory system remains able to process information from a nerve fascicle that has lost its cutaneous territory, and (2) somatosensory localization remains accurate despite the presumed central reorganization that takes place after nerve division or amputation. This lack of functional adaptation has important implications with regard to our understanding of human central nervous system plasticity.

Nerve innervation of the hand and associated nerve dominance aggregates in the somatosensory cortex of a primate (squirrel monkey)

The cutaneous innervation territories of the median, ulnar, and radial nerves to the hand were determined from neurophysiological recordings of peripheral mechanoreceptor axons in adult squirrel monkeys. These territories were then related to cutaneous receptive fields of cortical area 3b neurons to determine how low-threshold inputs from each hand nerve map onto the primary somatosensory cortex. The results indicate that mechanoreceptor axons in each nerve innervate a continuous skin territory covering about 40% of the hand surface. The total territory of each nerve contains subregions of skin that are either autonomously innervated by that nerve or that receive overlapping innervation from more than one nerve. The autonomous, overlap, and total territories of each nerve are relatively constant from hand to hand. In the area 3b cortex, low-threshold afferents from each nerve provide inputs to aggregates of cortical neurons. The cortical aggregates relating to the median and ulnar nerves are arranged as continuous, rostrocaudally oriented bands, whereas aggregates relating to the radial nerve are discontinuous and more patch-like. Similar patterns of bands and patches, and similar compression ratios of skin/cortical area, are seen across different monkeys. These findings demonstrate that the primary somatosensory cortex of normal adult primates contains bands or patches of neurons that are dominantly activated by low-threshold inputs from specific hand nerves. This approach of delineating nerve territories and their related cortical dominance aggregates provides a useful means of analyzing cortical images of nerves and of quantitating peripheral and central patterns of deprivation after nerve injury.

Changes in sensation after nerve injury or amputation: the role of central factors

Dynamic changes in somatosensory cortical maps are known to occur in experimental animals subjected to peripheral nerve transection or amputation. To study the sensory effects of central nervous system adaptation to temporary or permanent loss of input from a part of the hand, multimodality quantitative sensory tests were carried out in 11 patients with complete traumatic division and repair of the median or ulnar nerves and in six patients who had undergone amputation of one or more digits. As expected, vibration, two point discrimination, and tactile thresholds were raised in the territory of the injured nerve in a graded fashion, sensitivity being poorest in the patients with the most recent injuries. Surprisingly, localisation was better in the tips than at the base of the hypoaesthetic fingers, suggesting a central attentional gradient. Stimulus-response curves conformed to a power function whose exponent was higher in denervated than in normal skin. Changes in psychophysical functions were also discernible in the intact hand. There was no hyperaesthesia in the territory of the nerve adjacent to the injured one or in the stump in the case of amputees. Central factors contribute to the sensory changes seen after nerve injury, but the functional effects of the cortical reorganisation that follows partial deafferentation are more subtle than a simple heightening of sensitivity in the surrounding skin.

Number, size, and class of peripheral nerve fibers regenerating after crush, multiple crush, and graft

Morphometric characterization of fiber regeneration in a distal nerve after focal proximal nerve injury may provide useful clinical information and insights about underlying neurobiologic mechanisms. The myelinated (MF) and unmyelinated (UF) fibers of peroneal nerve of groups of mice were assessed 9 months after crush, graft, and multiple crush injury of the proximal sciatic nerve: number and size distribution of axon areas, myelin areas, and fiber diameters. After crush, number of regenerated MF and UF was almost identical to that of controls. Their size distribution had almost returned to normal. After graft and multiple crush, fiber number had returned to normal or was significantly increased beyond normal but there were only a few large fibers present. This may be explained by: (a) disproportionate regeneration of small-diameter compared to large-diameter classes of fibers; (b) misdirected regrowth of fibers, so that functional reinnervation was not established, resulting in failure of development or retrograde atrophy and degeneration; or (c) cellular alterations at the site of injury or in the distal nerve which inhibited neural outgrowth or elongation or did not inhibit outgrowth but retarded or prevented maturation. We conclude that explanation (b) is involved, and that there is some evidence favoring the roles of (a) and (c).

Painful dysaesthesias following peripheral nerve injury: a clinical and electrophysiological study

Thirty-three patients with complete median, ulnar or digital nerve transections were studied 4 months to 13 years subsequent to suture or nerve grafting. In all cases, sensory disturbances, in terms of paraesthesia or hypaesthesia, were encountered. Painful or unpleasant symptoms, allodynia or hyperpathia, were observed most frequently in patients with poor recovery. The clinical findings and the patients' subjective complaints were correlated to microneurographic single fibre recordings of regenerated cutaneous mechanoreceptors. In more than 80% of the recordings, discharge properties of regenerated receptors, thresholds and a variety of other electrophysiological data were similar or equal to normal controls. Less than 20% of the receptors exhibited atypical properties suggesting defective steady-state regeneration. The ratio of rapidly adapting (RA-units) to slowly adapting mechanoreceptors (SA-units) was inverse in relation to normals. The density of regenerated RA-receptors was higher in the proximal than in the distal part of the reinnervated area. This paralleled the clinical finding of reduced sensory discrimination in these cases and suggests that SA-units may regenerate preferentially. In painful conditions no single fibres could be recorded, reflecting the relative paucity of fibres and probably the atrophy of the nerve. The results of the microstimulation experiments, although less reliable, revealed some evidence that the central processing of regenerated units is abnormal. Clinical and electrophysiological data supported this concept of central changes underlying some of the phenomena observed during peripheral nerve regeneration.

Sensory nerve crush and regeneration and the receptive fields and response properties of neurons in the primary somatosensory cerebral cortex of cats

Extracellular recordings were made of activity evoked in neurons of the forepaw focus of somatosensory cerebral cortex by electrical stimulation of each paw in control cats and cats that had undergone crush injury of all cutaneous sensory nerves to the contralateral forepaw 31 to 63 days previously. Neurons responding only to stimulation of the contralateral forepaw were classified as sa; neurons responding to stimulation of both forepaws were classified as sb; neurons responding to stimulation of both contralateral paws were classified as sc; and neurons responding to stimulation of at least three paws were classified as m. The ratio sa:sb:sc:m neurons was 46:3:0:0 in control cats and 104:15:3:26 in cats that had undergone nerve crush 1-2 months prior to study. sa neurons from experimental cats had depth distributions similar to those in controls and responded to contralateral forepaw stimulation with more spikes per discharge, longer latency, and higher threshold than sa neurons in control cats. m neurons from experimental cats were distributed deeper in the cortex than sa neurons, and, when compared to experimental sa neurons, they responded with longer latency and poorer frequency-following ability; however, the number of spikes per discharge and threshold were not significantly different. The appearance of wide-field neurons in this tissue may be explained in terms of strengthening of previously sub-threshold inputs to neurons in the somatosensory system. If the neurons in sensory cortex play a requisite role in cutaneous sensations and if changes similar to those reported here occur and persist in human cortex after nerve crush, then "complete" recovery of sensation in such patients may occur against a background of changed cortical neuronal responsiveness.

Axonal conduction velocity and force of single human motor units

Tungsten microelectrodes of the type used for microneurography have been used to record motor units selectively from the first dorsal interosseous and abductor pollicis brevis muscles of normal subjects and patients who had had complete sections of the ulnar or median nerve. After determining the recruitment threshold and the twitch tension (spike-triggered averaging) of a single unit, its nerve was stimulated at the wrist and the elbow using surface electrodes. By adjusting the position of the surface electrode and the stimulus intensity and by using computerized subtraction of responses just above and below threshold for a given unit, the same motor unit could often be identified in response to stimulation at both sites and its conduction velocity determined. The twitch tension and recruitment threshold of the motor units were closely correlated with the conduction velocity of the motor axons in normal subjects. Preliminary data from patients suggests that this method should be applicable to patients with a number of neuromuscular disorders.

Patterns of reinnervation and motor unit recruitment in human hand muscles after complete ulnar and median nerve section and resuture

Following complete ulnar or above-elbow median nerve sections, there was no significant correlation between motor unit size (twitch amplitude) and recruitment threshold, as assessed by spike triggered averaging. This absence of orderly recruitment was attributed to misdirection of motor axons during regeneration. Following median nerve section at wrist level, where the reinnervated muscles have more synergistic actions, orderly recruitment by size appeared to be re-established. Thus, the size principle of motor unit recruitment can be re-established after nerve section in humans, if motor axons innervate their original muscles or ones with closely synergistic functions.

Sensorimotor performance of the hand during peripheral nerve regeneration

Conventional neurological testing procedures outline the sensory and motor incapasities which occur following peripheral nerve injury, but they provide little practical information on the ability of the patient to use the injured part in daily life activities. In the present study functional tests are introduced which lend themselves to statistical analysis and can be routinely and universally applied. The tests did also permit a study of the role of sensation in motor performance. The tests were able to distinguish between nerve-damaged and normal hands; with all differences being statistically significant. Rating scales were devised to indicate how much a motor or sensory performance deviated from normal: function was assessed as poor, satisfactory, or good. No correlation could be established between the results obtained from functional and routine neurological tests nor between sensorimotor performance and the response behavior of single afferents recorded in the same patients. The results indicate that the functional tests are useful and promising for a more general application. The results do also underline the need for sensation in the successful execution of a sequence of coordinated, skillful movements.

Re-innervation pattern of heterotopically transposed lingual flaps

Pedicled tongue flaps have proved to be an effective method of repairing defects due to tissue loss in the oral cavity. No histological investigations have been done in respect of the longterm fate of these flaps after section of their nutrient pedicle. The histological pattern of the re-innervation process of heterotopically transposed lingual flaps in the oral cavity is evaluated in this paper. Two cases are reported: in the first, the tongue flap was used to repair the vermilion of the lower lip and in the second, for the closure of a post-traumatic defect of the hard palate. The histological findings are similar in the two cases: myelinated and unmyelinated fibres, free nerve endings and encapsulated receptors are present.

Degeneration and regeneration of peripheral nerve in the rat trigeminal system. II. Response to nerve lesions

The course of vibrissa sensory receptor denervation and subsequent reinnervation was studied following transection or crush of the rat infraorbital nerve. Eighteen hours after nerve lesion, the large-diameter myelinated nerves supplying the lanceolate receptors of the intermediary zone and the Merkel cells of the stratum basale contained areas of focal axoplasmic abnormalities, and some of the nerve terminals exhibited vacuolization, mitochondrial swelling, and disruption of the neurofilament pattern. The Merkel cells and lanceolate receptors of the intermediary zone were completely deafferented by 24 hours after the nerve injuries. The Ruffini complex, free nerve endings and lanceolate receptors of the inner conical body, as well as the free nerve endings and lanceolate receptors of the connective tissue below the Ringwulst, were completely normal 24 hours after crush or transection of the nerve. These receptors underwent progressive degeneration from days 2 through 6 and the vibrissa was totally denervated by day 7. Regenerating axons were first seen entering the vibrissae 2 weeks after the crush lesion and 1 month following nerve transection. Except for a slight decrease in the percentage of Merkel cells innervated, vibrissae from post-crush animals were virtually indistinguishable from normal by 3 months. In contrast, vibrissae from rats subjected to the transection lesion exhibited evidence of misdirected axons and abnormally reinnervated receptors throughout the course of regeneration. Axons entering the hairs with the main vibrissal nerve were observed contributing to the innervation of the inner conical body, an area normally supplied exclusively by the conus nerve. Many of the lanceolate receptors contained multiple unmyelinated axons, and the usually highly ordered circular innervation of the inner conical body was markedly abnormal. It is suggested that these results may help explain the faulty sensory localization and abnormal sensations reported by patients suffering a peripheral nerve injury.

Long-term cortical consequences of reinnervation errors after nerve regeneration in monkeys

Sensory innervation patterns are commonly altered after nerve regeneration, but the long-term consequences of these peripheral changes on the central nervous system are not understood. We report here that when innervation patterns to the hands of two adult monkeys were changed by cross-repair of nerves, topographical features that were clearly related to the new innervation pattern remained apparent in primary somatosensory cortical area 3b as long as 2.9 years after repair. These findings indicate that peripheral innervation changes are not easily corrected by central circuits leading to primary cortex.

Innervation and function of hind-limb muscles in the cat after cross-union of the tibial and peroneal nerves

Peripheral nerves to flexor (common peroneal) and extensor (tibial) nerves in a hind limb of seven 2-6 month old cats were cut and cross-united to study the plasticity in the spinal cord. The extent to which motoneurones from extensor and flexor motor pools were misdirected to their antagonistic muscles was determined by measuring the potentials generated at the spinal roots from the crossed nerves. The axons contributing to the extensor nerves normally leave the cord in the L7 and S1 ventral and dorsal roots while the axons contributing to the flexor nerves normally leave the cord in the L6 and L7 ventral and dorsal roots. Following cross-union, medial gastrocnemius (m.g.) and lateral gastrocnemius-soleus (l.g.s.) nerves were primarily supplied by L6 and L7 ventral and dorsal roots, and common peroneal (c.p.) nerves were primarily supplied by L7 and S1 ventral and dorsal roots. A method for quantifying the completeness of cross-reinnervation was developed. The pattern of e.m.g. activity in cross-reinnervated muscles during locomotion was primarily determined by the innervating nerve with the reinnervated flexor muscles being activated during the extensor phase. However, the cross-reinnervated extensor muscles showed evidence of extensor activity in addition to the double-burst pattern typical of flexor nerves. This extensor activity was more prominent when the nerve cross was less complete. We conclude that during locomotion the activity of spinal motoneurones was not substantially modified by inappropriate peripheral connexions, even when the nerve cross was carried out in young animals. This conclusion is discussed in relation to previous studies which suggested some degree of functional modification.

Human cutaneous mechanoreceptors during regeneration: physiology and interpretation

Percutaneous microneurography was used to record activity from single cutaneous afferents reinnervating the glabrous skin of the hand. Recordings were obtained from 6 months to 10 years after complete transsection of the median and/or ulnar nerves with subsequent repair. Transitional properties in the discharge behavior and receptive field characteristics of regenerating afferents were detected during the early stages of regeneration, when axonal maturation was still in progress; these may contribute to the slow time course of sensory recovery. Properties of reinnervated receptors long after nerve repair, when regeneration can be considered complete, indicated a correlation between electrophysiological findings and the final state of clinical recovery. The insights into the neural basis of sensory deficits provided by single-unit microneurography are not yielded by conventional study of the compound action potentials. This technique reveals new information about the pathophysiological nature of peripheral nerve injury and leads to a reinterpretation of clinical deficits.

Properties of cutaneous mechanosensitive afferents during the early stages of regeneration in man

The technique of percutaneous microneurography was used to record single unit activity from 75 regenerated primary afferents innervating the glabrous skin of the human hand. Thirteen patients were studied, who had suffered complete transection, with subsequent suture or graft, of the median or ulnar nerves. The recordings were obtained from 7 to 23 months postoperatively (early regeneration). Three types of mechanoreceptive afferents (RA, SAI, SAII) and many deep units of unknown origin were found. No regenerated PC units could be identified. The reinnervated receptors were predominantly located in the palm and proximal fingers, comparable to those found 3 years or more postoperatively (late regeneration). Response thresholds and in general, discharge and receptive field characteristics of the majority of afferents were largely comparable to late regeneration and normal. The properties of SAII units were like normal in all respects. However, several distinct abnormalities were encountered early during regeneration: multiple receptive fields innervated by a single afferent (2/9 RA and 2/9 SAI), unusually small or large receptive fields (RA and SAI), pronounced fatigue on repetitive stimulation (7/15 SAI, 4/6 deep). Responses of reinnervated skin to sustained and repeated indentations were found to be similar to those of normal skin, and therefore, could not account for the abnormal discharge behavior. It is suggested that the transitional properties of regenerating afferents reflect unstable axon-end organ connections and immature axonal properties. Both factors would contribute to the slow course of sensory recovery, making prognosis on tactile recovery unpredictable.

Multiple axon terminals in reinnervated Pacinian corpuscles of adult rat

The ultrastructure of Pacinian corpuscles localized beneath the crural interosseous membrane was examined two weeks to 18 months after crushing the sciatic nerve in adult rats. The Pacinian inner core and capsule remained preserved during the transient period of denervation. Regenerating axons reached Pacinian corpuscles approximately three weeks after nerve crush. Up to 15 axonal sprouts entered a single corpuscle at the initial stage of reinnervation, but only 1-3 axons increased in size, myelinated and formed axon terminals in the inner core, the excess sprouts being eliminated. Most corpuscles of the crural group were reinnervated by the end of the first month. Three to 19 months after nerve crush, 10% of corpuscles examined were found to be monoaxonal and monoterminal as before the operation; 74% contained multiple terminals; 16% remained denervated. Over half the multiterminal corpuscles were supplied with a single myelinated axon that branched inside the corpuscles; the rest received two or three myelinated axons which formed several terminals. The terminals were distributed at random, usually in the axial region between the lamellae of the inner core. They were cylindrical, with an oval profile; the larger terminals were filled with mitochondria and microtubules at their circumference and contained a core of neurofilaments. Lateral processes of the terminals were filled with vesicles and had membrane specializations as in normal corpuscles. The mean number of terminals in reinnervated corpuscles was 4.07 +/- 0.37 (S.E.M.) at three months, and 3.26 +/- 0.49 (S.E.M.) 6-18 months after nerve crush. This small decrease was apparently the result of degeneration occasionally observed in some axon terminals at later stages of reinnervation. These experiments thus demonstrate that most rat Pacinian corpuscles become reinnervated with multiple terminals after nerve injury and maintain multiterminal innervation permanently.

Transitional properties of afferents reinnervating mechanoreceptors in the human glabrous skin

The technique of percutaneous microneurography was used to record in man from single mechanoreceptive afferents during the early stages of reinnervation. Although response properties were in several ways comparable to normal and to those of afferents studied long after nerve repair, two abnormalities were found: multiple receptive field innervation by single afferents (RA, SAI), and response fatigue with repeated stimulation (SAI). These abnormalities are considered transitional, disappearing when reinnervation is complete.