Nerve regeneration chamber: evaluation of exogenous agents applied by multiple injections

Improvement of functional recovery of transected peripheral nerve by means of chitosan grafts filled with vitamin E, pyrroloquinoline quinone and their combination

Effects of vitamin E and pyrroloquinoline quinone on peripheral nerve regeneration were studied using a rat sciatic nerve transection model. Ninety male healthy White Wistar rats were divided into three experimental groups (n = 15), randomly: Sham-operation (SHAM), transected control (TC), chitosan conduit (Chit) and three treatment groups (Vit E, PQQ and PQQ + Vit E). In SHAM group after anesthesia, left sciatic nerve was exposed through a gluteal muscle incision and after homeostasis muscle was sutured. In Chit group left sciatic nerve was exposed the same way and transected proximal to tibio-peroneal bifurcation leaving a 10-mm gap. Proximal and distal stumps were each inserted into a chitosan tube. In treatment groups the tube was implanted the same way and filled with Vit E, PQQ and PQQ + Vit E. Each group was subdivided into three subgroups of six animals each and were studied 4, 8, 12 weeks after surgery. Functional and electrophysiological studies, and gastrocnemius muscle mass measurement confirmed faster and better recovery of regenerated axons in Vit E + PQQ combination compared to Vit E or PQQ solely (P < 0.05). Morphometric indices of regenerated fibers showed number and diameter of the myelinated fibers in PQQ + Vit E was significantly higher than in other treatment groups. In immunohistochemistry, location of reactions to S-100 in PQQ + Vit E was clearly more positive than in other treatment groups. Response to PQQ + Vit E treatment demonstrates that it influences and improves functional recovery of peripheral nerve regeneration.

EXPERIMENTAL NERVE GRAFTING — TOWARDS FUTURE SOLUTIONS OF A CLINICAL PROBLEM

Restoration of function following complete nerve injuries with subsequent nerve repair is still not satisfactory and in many cases poor, especially when a gap has to be bridged by a graft. In such situations, there may be insufficient access to autologous graft material. Alternatives have to be developed and a close collaboration between basic scientists and clinicians is required. In the present article, current studies on experimental nerve grafts are discussed and some new alternatives to autologous nerve grafts are reviewed.

Regeneration and repair of peripheral nerves with different biomaterials: review

Peripheral nerve injury may cause gaps between the nerve stumps. Axonal proliferation in nerve conduits is limited to 10-15 mm. Most of the supportive research has been done on rat or mouse models which are different from humans. Herein we review autografts and biomaterials which are commonly used for nerve gap repair and their respective outcomes. Nerve autografting has been the first choice for repairing peripheral nerve gaps. However, it has been demonstrated experimentally that tissue engineered tubes can also permit lead to effective nerve repair over gaps longer than 4 cm repair that was previously thought to be restorable by means of nerve graft only. All of the discoveries in the nerve armamentarium are making their way into the clinic, where they are, showing great potential for improving both the extent and rate of functional recovery compared with alternative nerve guides.

Chondrotinase ABC enhances axonal regeneration across nerve gaps

We evaluated the effects of chondroitinase ABC on axonal regeneration across peripheral nerve gaps. We compared axonal regeneration after 15-mm tibial nerve resection and repair with a silicone tube filled with type I collagen gel (negative control group), with a silicone tube filled with type I collagen gel containing chondroitinase ABC at three different concentrations (2.5 units/mL, 5 units/mL, 10 units/mL) (chondroitinase ABC groups), and with an autologous nerve segment (nerve autograft group). Electrophysiological and histological assessments were carried out 12 weeks after surgery. In the electrophysiological study, compound muscle action potentials (CMAPs) and nerve conduction velocities (NCVs) were recorded in all groups except the negative control group. Although both CMAPs and NCVs were highest in the nerve autograft group, there were no significant differences among the three chondroitinase ABC groups in either parameter. Histological findings were consistent with electrophysiological results. Based on these findings, we conclude that topical injection of chondroitinase ABC can significantly increase the critical length of nerve gap repair by tubulization or artificial nerve placement.

Luminal fillers in nerve conduits for peripheral nerve repair

The use of nerve conduits as an alternative for nerve grafting has a long experimental and clinical history. Luminal fillers, factors introduced into these nerve conduits, were later developed to enhance the nerve regeneration through conduits. Though many luminal fillers have been reported to improve nerve regeneration, their use has not been subjected to systematic review. This review categorizes the types of fillers used, the conduits associated with fillers, and the reported performance of luminal fillers in conduits to present a preference list for the most effective fillers to use over specific distances of nerve defect.

Nerve regeneration across a 2-cm gap in the rat median nerve using a resorbable nerve conduit filled with Schwann cells

Object. In a rat model, nerve regeneration was evaluated across a 2-cm defect in the median nerve by using a resorbable artificial nerve conduit. The aim of this study was to develop an artificial, biocompatible nerve guide to induce regeneration in the peripheral nervous system.

Methods. The authors compared a nerve conduit of trimethylenecarbonate-co-epsilon-caprolactone (TMC/CL) filled with autologous Schwann cells with both an empty hollow conduit and an autologous nerve graft. Animals that did not undergo surgery served as the control group. Nerve regeneration was evaluated with the grasping test, histological analysis of the nerve, muscle weight analysis (flexor digitorum superficialis muscle), and electrophysiological examination.

After an observation period of 9 months, regeneration occurred only in animals that had received an autologous graft or a Schwann cell containing nerve conduit. No signs of regeneration were found in animals supplied with the empty conduit.

Conclusions. Results of this study reveal the important role of Schwann cells in the regeneration process across a 2-cm defect in the rat median nerve. Furthermore, Schwann cell—filled nerve conduits induced functional recovery, as demonstrated in the grasping test, that was comparable with that of the autologous graft 9 months after implantation.

Peripheral nerve regeneration through guidance tubes

Biological nerve grafts have been extensively utilized in the past to repair peripheral nerve injuries. More recently, the use of synthetic guidance tubes in repairing these injuries has gained in popularity. This review focuses on artificial conduits, nerve regeneration through them, and an account of various synthetic materials that comprise these tubes in experimental animal and clinical trials. It also lists and describes several biomaterial considerations one should regard when designing, developing, and manufacturing potential guidance channel candidates. In the future, it it likely that the most successful synthetic nerve conduit will be one that has been fabricated with some of these strategies in mind.

Beneficial effect of nerve growth factor-7S on peripheral nerve regeneration through inside-out vein grafts: An experimental study

This study investigated the effect of local administration of nerve growth factor-7S (NGF-7S) on the axonal regrowth of mixed peripheral nerves through inside-out vein grafts. Sixty male Wistar rats were randomized into two groups (n = 30). A defect 12 mm long in the right sciatic nerve was created and repaired with an inside-out vein graft from the right jugular vein. NGF-7S (group A) or phosphate-buffered saline (group B; control) was locally administered daily during the first 3 weeks. Walking-track analysis and electrophysiological and histological-morphometric studies were carried out 4, 6, 8, 10, and 12 weeks postoperatively (subgroups a, b, c, d, and e, respectively, n = 6 each). Data analysis showed that 1) the recovery of motor function, as measured by walk pattern analysis and evoked muscle action potential, and 2) the orientation, number, myelin thickness, and diameter of myelinated fibers were better in the NGF-7S than in the control group. These findings present strong evidence of the beneficial effect of NGF-7S on peripheral nerve regeneration through inside-out vein grafts.

Effects of human amniotic fluid on peripheral nerve scarring and regeneration in rats

OBJECT

Peripheral nerve repair surgery is still replete with challenges. Despite technical improvements in microsurgery, classic methods of nerve repair have failed to provide satisfactory results. The purpose of this study was to investigate the effects of amniotic fluid from humans on peripheral nerve scarring and regeneration in rats.

METHODS

Forty adult Sprague-Dawley rats were used in this study. After the right sciatic nerve in each rat was transected and repaired using an epineural suture procedure, the nerves were divided into two groups according to the solution applied around the repair site: experimental group, 0.3 ml human amniotic fluid (HAF); and control group, 0.3 ml saline. Macroscopic and histological evaluations of peripheral nerve scarring were performed 4 weeks postsurgery. Nerves treated with HAF demonstrated a significant reduction in the amount of scar tissue surrounding the repair site (p < 0.05). No evidence of a reaction against HAF was noted. Functional nerve regeneration was measured once every 2 weeks by using a sciatic function index until 12 weeks postsurgery. Functional recovery in nerves treated with amniotic fluid occurred significantly faster than that in nerves treated with saline (p < 0.05). Peripheral nerve regeneration was evaluated histomorphologically at 12 weeks postsurgery. Nerves treated with amniotic fluid showed significant improvement with respect to the indices of fiber maturation (p < 0.05).

CONCLUSIONS

Preliminary data show that HAF enhances peripheral nerve regeneration. The preventive effect of HAF on epineural scarring and the rich content of neurotrophic and neurite-promoting factors possibly contribute to this result.

An injectable nerve regeneration chamber for studies of unstable soluble growth factors

Modern surgical techniques cannot guarantee functional recovery following peripheral nerve injuries. Research into factors that may influence nerve regeneration has therefore assumed a prominent potential therapeutic role. We report here on the development of an approach to allow for direct manipulation of the microenvironment of regenerating peripheral nerve axons. We show that solutions can be delivered directly to this local milieu in vivo and that such a delivery can be performed multiple times over an extended period, potentially facilitating studies of multiple molecular players that act locally. We also demonstrate that the bundle of regenerated axons are amenable to morphological analysis by 21 days and that the injection system remains patent for at least 21 days.

Silicone rubber tubulization in peripheral sensory nerve reconstruction: an experimental study in rabbits

Silicone rubber (polydimethyl siloxane) tubes are used clinically in peripheral nerve reconstruction. A disadvantage of this procedure is that the material often has to be removed owing to its mechanical properties. The aim of our study was to investigate the healing of reconstructed sensory nerves tubulized by silicone rubber in an animal model. In our experiments, we reconstructed the saphenous nerves in 27 rabbits. In series 1 (n = 12), silicone rubber tubes were slid over a nerve suture without a gap. In series 2 (n = 12), silicone rubber tubes were slid over a 10-mm nerve gap. In series 3 (n = 12), conventional suturing was performed in the collateral saphenous nerves of the animals of the series 1. Epineurial suturing was performed. Three other collateral nonoperated saphenous nerves served as controls. The healing was studied after 3, 6, and 12 months. Morphometric analysis of the regenerating axons was performed by using our new method for quantification of nerve fibers in cross sections stained by immunohistochemistry and using confocal laser scanning microscopy. Data analysis was carried out using a software program especially developed for this purpose. Our results showed in the silicone procedures that at 12 months significantly fewer axons per fascicle area were present compared with conventional suturing. However, mean axon diameters in the distal nerve stump of the silicone procedures did not differ significantly compared with the conventional suturing procedure. The ratio of total axon area to total fascicle area in the distal nerve stumps of the silicone procedure without gap was significantly smaller compared with the conventionally sutured nerve. The percentage outgrowing axons from the proximal nerve stump into the distal one in the silicone rubber procedure without gap was 57%. This was significantly higher than in the silicone rubber procedure with 10-mm gap (48%). However, in conventional suturing, the percentage of outgrowing axons (99%) was significantly higher than in both tubulization procedures. It appeared that tubulization by silicone rubber of sutured nerves without gap did not enhance axon regeneration. Conventional suturing gave significantly better results. If a gap was present, the use of a silicone rubber tube was preferable to non-suturing.

VEGF enhances intraneural angiogenesis and improves nerve regeneration after axotomy

Whilst there is an increased understanding of the cell biology of nerve regeneration, it remains unclear whether there is a direct interrelationship between vascularisation and efficacy of nerve regeneration within a nerve conduit. To establish this is important as in clinical surgery peripheral nerve conduit grafting has been widely investigated as a possible alternative to the use of nerve autografts. The aim of this study was to assess whether vascular endothelial growth factor (VEGF), a highly specific endothelial cell mitogen, can enhance vascularisation and, indirectly, axonal regeneration within a silicone nerve regeneration chamber. Chambers containing VEGF (500-700 ng/ml) in a laminin-based gel (Matrigel) were inserted into 1 cm rat sciatic nerve defects and nerve regeneration examined in relation to angiogenesis between 5 and 180 d. Longitudinal sections were stained with antibodies against endothelial cells (RECA-1), axons (neurofilament) and Schwann cells (S-100) to follow the progression of vascular and neural elements. Computerised image analysis demonstrated that the addition of VEGF significantly increased blood vessel penetration within the chamber from d 5, and by d 10 this correlated with an increase of axonal regeneration and Schwann cell migration. The pattern of increased nerve regeneration due to VEGF administration was maintained up to 180 d, when myelinated axon counts were increased by 78 % compared with plain Matrigel control. Furthermore the dose-response of blood vessel regeneration to VEGF was clearly reflected in the increase of axonal regrowth and Schwann cell proliferation, indicating the close relationship between regenerating nerves and blood vessels within the chamber. Target organ reinnervation was enhanced by VEGF at 180 d as measured through the recovery of gastrocnemius muscle weights and footpad axonal terminal density, the latter showing a significant increase over controls (P < 0.05). The results demonstrate an overall relationship between increased vascularisation and enhanced nerve regeneration within an acellular conduit, and highlight the interdependence of the 2 processes.

A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance

In spite of an enormous amount of new experimental laboratory data based on evolving neuroscientific concepts during the last 25 years peripheral nerve injuries still belong to the most challenging and difficult surgical reconstructive problems. Our understanding of biological mechanisms regulating posttraumatic nerve regeneration has increased substantially with respect to the role of neurotrophic and neurite-outgrowth promoting substances, but new molecular biological knowledge has so far gained very limited clinical applications. Techniques for clinical approximation of severed nerve ends have reached an optimal technical refinement and new concepts are needed to further increase the results from nerve repair. For bridging gaps in nerve continuity little has changed during the last 25 years. However, evolving principles for immunosuppression may open new perspectives regarding the use of nerve allografts, and various types of tissue engineering combined by bioartificial conduits may also be important. Posttraumatic functional reorganizations occurring in brain cortex are key phenomena explaining much of the inferior functional outcome following nerve repair, and increased knowledge regarding factors involved in brain plasticity may help to further improve the results. Implantation of microchips in the nervous system may provide a new interface between biology and technology and developing gene technology may introduce new possibilities in the manipulation of nerve degeneration and regeneration.

Local administration of neurotrophic growth factor in subcutaneous silicon chambers enhances the regeneration of the sensory component of the rat sciatic nerve

An experimental model for local administration of neurotrophic growth factor (NGF) in peripheral nerve lesions is tested. The model consists of a subcutaneous reservoir connected to the sciatic nerve neurorrhaphy. The right sciatic nerves were exposed, severed, and repaired at a level 1.5 cm proximal to their trifurcation. Then, a dome-shaped silicone reservoir connected to the proximal end of a silicone tube was placed subcutaneously in the dorsum of the experimental animal. The distal end of the connecting tube was located in the nerve neurorrhaphy. Two experimental groups were made: Group A (n = 90) received daily doses of a solution containing NGF-7S during the first 4 weeks after surgery and a single weekly dose thereafter. Within this group, three subgroups of 30 rats each were made: A-4 sacrificed 4 weeks after surgery, A-8 sacrificed after 8 weeks, and A-12 after 12 weeks. Group B (n = 90) received the same vehicle solution without NGF under the same schedule and volume as in Group A. Three subgroups were also made as in Group A depending on the survival period. In order to locate the neurons in the dorsal root ganglia, the retrograde tracer horseradish peroxidase was administered at the proximal stump of the sciatic nerve (tibialis branch), which was severed 1 cm distal to the sciatic trifurcation. In respect of the nonoperated side, the percentage between the number of dorsal root ganglia neurons in the NGF-treated group was significantly higher than in the control group (P < 0.001). These results demonstrate that percutaneous administration of multiple doses of NGF in this model enhances sensory nerve regeneration after sciatic lesions evaluated by horseradish peroxidase labeling of dorsal root ganglia neurons.

Autologous tendons used as grafts for bridging peripheral nerve defects

This study was performed to investigate whether autologous collagen and other extracellular matrix components could be used in nerve repair by bridging a 10 mm defect in the rat sciatic nerve. Three models of repair were examined. In the first model, a rat tail tendon was teased and subsequently rolled to form a loose collagen roll which was sutured over the defect. In the second model, an intact tendon was used. In the third model, a teased tendon was pretreated with attachment of nerve segments to each end for 4 weeks before grafting. Both teased and intact tendons supported regeneration, to some extent. Pretreatment resulted in migration of Schwann cells into the graft, and enhanced regeneration.

Evaluation of peripheral nerve regeneration by nerve growth factor locally administered with a novel system

An experimental model is presented for the local administration of neurotrophic substances at the site of peripheral nerve lesion. The model consists of a subcutaneously implanted silicone reservoir and a connecting tube with its distal end facing the severed and repaired nerve. Wistar rats (n = 180) were divided into two groups: a control group (saline-treated) (n = 90) and an NGF-treated group (n = 90). After sciatic nerve axotomy, an epineural repair was performed. NGF or saline were injected daily into the subcutaneous reservoir for the first 4 weeks after axotomy and weekly single dose between the 8th and 12th weeks. Both groups were divided into three subgroups of 30 animals each. The animals were sacrificed at 4, 8 and 12 weeks. Myelinated and non-myelinated axonal and thickness of myelin sheaths were quantified at the tibialis branch 25 mm distal to the nerve repair site. Axonal counts showed statistically significant differences between the treated and control groups at 4, 8 and 12 weeks. Finally, at 4 weeks the myelinated axons in the NGF group had significantly thicker myelin sheaths than in the control group. In comparison with other models of administration of different neurotrophic agents, NGF delivered through this system demonstrates a significant capacity for improving nerve regeneration without the problems inherent in multiple anesthesia, device exchange, or short half-life of the NGF single-dose administration.

Influence of collagen and laminin gels concentration on nerve regeneration after resection and tube repair

In order to assess the usefulness of collagen and laminin gels prefilling nerve chambers to enhance nerve regeneration, we compared reinnervation of target organs after sciatic nerve resection leaving gaps of 4 or 6 mm followed by repair with silicone tubes in different groups of mice. Tubes were prefilled with saline solution, collagen gels, or laminin-containing gels at different concentrations. Functional reinnervation was assessed by noninvasive methods to quantitate recovery of sweating, nociceptive, sensory, and motor functions in the hindpaw repeatedly during 4-5 months postoperation. The increase in gap length between nerve stumps delayed the beginning and reduced the degree of functional recovery achieved. Reinnervation started earlier and achieved slightly higher levels with collagen gel diluted at 1.28 mg/ml than with more concentrated (1.92 and 2.56 mg/ml) collagen gels and with saline-prefilled tubes bridging a 4-mm gap. Recovery was also better with diluted (4 mg/ml) than with concentrated (12 mg/ml) laminin-containing gel, although lower than with collagen gels and saline. By prefilling silicone tubes bridging a 6-mm gap, a length considered limiting for regeneration in the mouse sciatic nerve, with diluted collagen or laminin gels, both matrices allowed for higher levels of recovery and for successful regeneration in a higher proportion of mice than saline solution. The laminin gel performed slightly better than the collagen gel.

Enhancing nerve regeneration across a silicone tube conduit by using interposed short-segment nerve grafts

Isolated nerve segments may inherently contain all of the necessary factors required to support regeneration within a silicone tube conduit placed across a nerve gap. Thirty-six adult Lewis rats each weighing approximately 250 g were randomized into three groups. A sciatic nerve gap (13-15 mm in length) was bridged by an empty silicone tube (Group I), a silicone tube containing a short 2-mm interposed nerve segment (Group II), or a nerve autograft (Group III). At 16 weeks postoperatively, no regeneration was observed through the empty silicone tube. In contrast, regeneration across the silicone tube containing the isolated nerve segment was equivalent to that noted through nerve autografts as assessed by histological, electrophysiological, and functional criteria. Thus, an interposed nerve segment will extend the length of successful nerve regeneration through a silicone tube conduit.

A new type of "bioartificial" nerve graft for bridging extended defects in nerves

In the rat sciatic nerve, a gap of around 10 mm in nerve continuity seems to be the maximal distance which can be successfully repaired by silicone tubes. In this study we tested if a new artificial nerve graft, composed of eight polyamide filaments (diameter 250 microns) placed inside silicone tubes (1.8 mm inner diameter), could be used to bridge an extended gap (15 mm) in rat sciatic nerve. Silicone tubes containing eight polyamide sutures were found to support regeneration across such a gap. After 4 weeks sensory fibres had bridged the gap and grown into the distal nerve segment as revealed by a positive pinch reflex test as well as positive staining for neurofilaments in the distal nerve segment. Myelinated axons could be observed in the tissue matrix formed in between and peripheral to the synthetic filaments along the whole length of the tube. In contrast, when silicone tubes without filaments were used to bridge the 15 mm gap, the tubes contained only fluid or in two cases a thin tissue strand. No positive pinch reflex response was elicited in the nerve segment distal to such a tube. We conclude that the new artificial nerve graft can be used to support regeneration across extended gaps in nerves.

Inter-relationships between angiogenesis and nerve regeneration: a histochemical study

Whilst increases in capillary number and permeability occurring during nerve regeneration suggest an interaction between regenerating axons and blood vessels, clinical attempts to improve nerve regeneration by augmenting nerve graft vascularisation have produced conflicting results and the nature of their relationship remains obscure. A better understanding of the process might be exploited in the development of a synthetic alternative to the autologous nerve graft and bring an improvement in the clinical results of nerve repair. To clarify this relationship the growth of axons and blood vessels through mats of orientated fibronectin grafted in rat sciatic nerves was assessed morphologically. Fibronectin, which supports axonal regeneration, is initially acellular, ensuring all vascular and neural elements within the graft are newly formed. To follow the progression of the elements, grafts were harvested between 3 and 30 days and stained with antibodies against endothelial cells (RECA-1), Schwann cells (S-100) and axons (a polyclonal or monoclonal panaxonal marker). Dual fluorescence staining combined with double exposure photography allowed the simultaneous visualisation of these elements and the demonstration of their true relative positions. Graft vascularisation came initially from the adjacent muscle bed. A neovascularisation front preceded axonal regeneration, although vessel and axonal orientation appeared similar. Schwann cells and axons extended together, never exceeding the area of vascularisation and appeared most numerous in well vascularised areas containing longitudinally orientated vessels. These results suggest that provision of a well vascularised, longitudinally orientated conduit may enhance nerve regeneration.

Rat sciatic nerve regeneration through a micromachined silicon chip

The capacity of regenerating nerve fibres to grow through a perforated silicon chip was tested using the silicone chamber model for nerve regeneration. The chips were fabricated as circular membranes, 4 mm in diameter, thickness 60 microns, with a perforated area, 2 mm in diameter, in the centre. Three types of chips were fabricated utilizing anisotropic etching. The chips were glued with silicone adhesive between two halves of silicone rubber tubing (total length 8 mm, inner diameter 1.8 mm, outer diameter 3.0 mm) which was used to bridge a 4 mm gap between the proximal and distal nerve stumps of a transected rat sciatic nerve. The capacity of regenerating nerve fibres to grow through the holes of the chip was analysed by light and scanning electron microscopy after 4 or 16 weeks of regeneration. Furthermore, the muscle contractility force of the gastrocnemius muscle was measured after 16 weeks of regeneration and compared as a percentage of the contralateral uninjured side. Nerves generated through chips with hole diameters of 10 or 50 microns were morphological and functional failures. The nerve structures distal to chips with hole diameters of 100 microns contained many myelinated nerve fibres in a minifascicular pattern after both 4 and 16 weeks of regeneration. The muscle contractility force was 56% of that of contralateral control muscles.

Axonal regeneration

Axons damaged in a peripheral nerve are often able to regenerate from the site of injury along the degenerate distal segment of the nerve to reform functional synapses. Schwann cells play a central role in this process. However, in the adult mammalian central nervous system, from which Schwann cells are absent, axonal regeneration does not progress to allow functional recovery. This is due to inhibitors of axonal growth produced by both oligodendrocytes and astrocytes and also to the decreased ability of adult neurons to extend axons during regeneration compared to embryonic neurons during development. However once provided with a substrate conducive to axonal growth, such as a peripheral nerve graft, many central neurons are able to regenerate axons over long distances. Over the past year this response has been utilised in experimental models to produce a degree of behavioural recovery.

Regeneration across a partial defect in rat sciatic nerve encased in a silicone chamber

Forty-four rat sciatic nerves with partial defects were repaired with a silicone chamber. Each partial defect was created by resecting a 10 mm segment from the tibial fascicle leaving the peroneal fascicle intact. The proximal and the distal stumps of the tibial fascicle together with the intact peroneal fascicle were encased in a single silicone chamber. After seven days a fibrin matrix had surrounded the peroneal fascicle and spanned the defect between the tibial stumps. This matrix was later invaded by non-neuronal cells and regenerating axons. Non-myelinated nerve fibres had almost regenerated across the defect by 16 days. The tetanic force of the gastrocnemius muscle 120 days after repair showed 80% recovery, which was no different from that of partial defects repaired with conventional nerve grafts. The results suggest that the silicone chamber technique could be applicable to the treatment of partially transected nerve trunks.

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.

Experimental model for local administration of nerve growth factor in microsurgical nerve reconnections

An experimental model for local administration of neuronotrophic substances at the site of peripheral nerve lesion is presented. The model consists of a subcutaneously located silicone reservoir and a connecting tube with its distal end fixed in the proximity of the severed and repaired nerve. The results of the preliminary tests of the model are presented. Sixty Sprague-Dawley rats were divided into two groups: control (saline-treated) (n = 30) and NGF-treated (n = 30). After axotomy of the sciatic nerve, an epineurial repair is performed. NGF or saline is injected daily into the subcutaneous reservoir during the first 3 weeks after axotomy and a single dose in the fourth week. The regenerated nerve observed in the NGF-treated group after four weeks of treatment presents a greater percentage of myelinated axons, thicker myeline sheaths, and more mature endoneurial layers. This experimental model provides a reliable and quantitative way to deliver neuronotrophic substances in site and at different administration rates.

Regeneration across 'stepping-stone' nerve grafts

The ability of small nerve segments interposed between synthetic conduits to increase the total nerve gap distance across which successful nerve regeneration would occur was studied. Fifty adult male Lewis rats were randomized into five groups. In Group I a segment of resected sciatic nerve was repaired by a nerve graft. Group II had alternating silicone tubing/nerve graft/silicone tubing replacement of the resected nerve segment (single stepping stone group). Group III had silicone tubing/nerve graft/silicone tubing/nerve graft/silicone tubing repair of the nerve deficit (double stepping stone). Group IV had a single long silicone conduit repair. Group V control underwent a sham operation. Nerve regeneration was evaluated using walking track pattern analysis, electrophysiologic assessment and histomorphological evaluation. 'Stepping stone nerve grafts' enhanced regeneration across nerve gaps in comparison to a single long conduit, but were inferior to a single long nerve graft. In the repair of long nerve gaps, the use of multiple short conduits with interposed short nerve segments could provide a source of trophic factors to enhance regeneration.

Glial and neuronal marker proteins in the silicone chamber model for nerve regeneration

In the present study, neuronal and Schwann cell marker proteins were used to biochemically characterize the spatiotemporal progress of degeneration/regeneration in the silicone chamber model for nerve regeneration. Rat sciatic nerves were transected and the proximal and distal stumps were inserted into a bridging silicone chamber with a 10-mm interstump gap. Using dot immunobinding assays, S-100 protein and neuronal intermediate filament polypeptides were measured in different parts of the nerve 0-30 days after transection. In the most proximal nerve segment, all the measured proteins were transiently increased. In the proximal and distal stumps adjacent to the transection, the studied proteins were decreased indicating degeneration of the nerve. Within the silicone chamber, the regenerating nerve expressed the Schwann cell S-100 protein already at 7 days, whereas the neurofilament polypeptides appeared later. These observations are corroborated by previous morphological studies. The biochemical method described provides a new and fast approach to the study of nerve regeneration.

Specificity of muscle reinnervation following repair of the transected sciatic nerve. A comparative study of different repair techniques in the rat

Specificity of muscle reinnervation and the recovery of muscle contractility were studied after repair of the transected rat sciatic nerve. Six different techniques were compared: epineurial suture, perineural suture, whole nerve graft, interfascicular grafts, skeletal muscle bridge and tubulization. Muscle tetanic force and specificity of reinnervation were evaluated 12 weeks after nerve repair. Recovery of tetanic force was superior after repair with epineurial sutures. There was no statistical significance between the other methods in respect of tetanic force. The specificity of muscle reinnervation was best after tubulization, repair with interfascicular grafts and perineurial suture.

Neurotropism, frozen muscle grafts and other conduits

Axonal regeneration following nerve transection requires a number of cellular and biochemical phenomena in the axons as well as the nerve cell bodies. The nerve cells must survive the trauma. Since axonal severance means amputation of a large axoplasmic volume from the remaining parts of the nerve cell, the cell body must prepare for increased synthesis of axoplasm to replace the missing parts. A sprouting process must be initiated at the level of transection. Regenerating axonal processes are to regenerate towards peripheral targets, a process regulated by an interaction between genetic mechanisms in the nerve cell body and biochemical information at the molecular level along the pathway.

Glia maturation factor beta stimulates axon regeneration in transected rat sciatic nerve

Rat sciatic nerves were bilaterally transected and repaired with an entubulation technique. The nerve interstump gap was filled with either collagen gel or collagen gel mixed with a putative neurotrophic factor (leupeptin, 4-aminopyridine, lipid angiogenic factor or glia maturation factor beta (GMF-beta]. Six weeks after nerve transection, the myelinated distal stump axons were quantified for each nerve. Only the nerves treated with GMF-beta had significantly more axons than the control side.

Accuracy of reinnervation by peripheral nerve axons regenerating across a 10-mm gap within an impermeable chamber

The axon regeneration following a peripheral nerve injury often fails to restore a complete functional recovery. One of the causes of this unsatisfactory result has been attributed to regrowth of regenerating fibers to inappropriate peripheral targets. The accuracy of reinnervation by axons regenerating across a 10-mm gap within an impermeable chamber has been studied by using a sequential retrograde double-labeling technique. Despite the long gap between the nerve stumps, at 4 weeks a mean of 30.5% of the regenerating axons can reinnervate the original muscular area. These data confirm previous studies in which a preferential reinnervation is reported not to be absolutely dependent on the axon's mechanical alignment.

Nerve regeneration through a two-ply biodegradable nerve guide in the rat and the influence of ACTH4-9 nerve growth factor

Biodegradable polyurethane-based (PU) nerve guides, instilled with or without ACTH4-9 analog (a melanocortin) were used for bridging an 8 mm gap in the rat sciatic nerve and were evaluated for function and histological appearance after 16 weeks of implantation. Autologous nerve grafts functioned as controls. The guides successfully enabled the sciatic nerve to regenerate across the 8 mm gap, thus effectively reestablishing the contact between the proximal and distal nerve ends. The mean conduction velocity, motor latency, and muscle action potentials of all the nerve guides did not differ significantly from the autografts. The histological quality of the regeneration in the nerve guides was significantly better than in the autografts; in the nerve guides, a well-defined nerve cable of normal architecture had regenerated without extensive endoneural scarring as seen in the autografts. ACTH4-9 instilled in the nerve guides showed a slight, but significant, increase in the number of myelinated axons. It is concluded that biodegradable PU nerve guides result in similar functional recovery when compared with autografts, but their histological quality is significantly better. ACTH4-9 showed only slight, but significant, improved nerve growth promoting activity. Therefore biodegradable PU nerve guides with ACTH4-9 would appear to be promising alternatives to autografts for bridging nerve defects.

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.

Effects of dibutyryl cyclic adenosine monophosphate, ACTH(4-10) and gangliosides on nerve fiber regeneration after rat sciatic nerve tubulization

Tubulization of sectioned rat sciatic nerves was used to evaluate the effect of dibutyryl cyclic adenosine monophosphate (db-cAMP), a fragment of the adrenocorticotrophic hormone (ACTH(4-10] and gangliosides on the regrowth of injured nerve processes. Four weeks post-operative, the number of myelinated fibers was counted at different levels of the lesioned sciatic nerves and the endoneurium surface of the bridging structure in the tube was measured. Animals treated with gangliosides and db-AMPc showed statistically significant differences compared to vehicle treated rats. The gangliosides have shown a beneficial effect but db-cAMP diminished the number of myelinated fibers. In this case, an implication of Schwann cell mitosis and migration is discussed. In spite of better results obtained in ACTH(4-10)-treated animals compared to controls, the differences did not attain a statistically significant level. These experiments confirm the beneficial effect of gangliosides on peripheral nerve regeneration and reveal a negative effect of db-cAMP in the regeneration chamber model.

Regeneration in the peripheral nervous system

Mammalian peripheral nerve fibres can regenerate after injury. Repair is most likely to succeed if axons are simply crushed or have only a very short (less than 0.5 cm) interstump gap to cross and most likely to fail if the interstump gap is long (greater than 1 cm) and associated with soft tissue damage. Whereas reactive axonal sprouting appears to be an intrinsic neuronal response to injury, the subsequent organization of the axonal sprouts, in particular their orderly outgrowth in minifascicles towards a distant distal stump does not occur unless Schwann cells are present. During the injury response, Schwann cells proliferate; co-migrate with regrowing axons (when the proximal stump is separated from the distal stump); respond to axonal cues by transient upregulation or re-expression of molecules which provide a favourable substrate for axonal extension; and attract bundles of regrowing axons and their associated Schwann cells across interstump gaps up to 1 cm in length. Recruited macrophages remove myelin debris from the Schwann cell tubes; they probably interact with Schwann cells in other ways during the injury response, e.g. by presenting mitogens and cytokines.

Phosphorylation of superior cervical ganglion proteins during regeneration

The incorporation of radioactive phosphate into proteins of both normal and regenerating ganglia of the sympathetic nervous system of the rat is reported. The incorporation reactions were carried out in vitro by incubating homogenates of excised ganglia with [gamma-32P]ATP under various conditions. It was found that incorporation of phosphate into proteins of regenerating ganglia in the molecular mass range 10,000-100,000 daltons increased up to 40% over incorporation into proteins from control ganglia during the first 3 days following injury and returned to control levels after 14 days. Analysis of the proteins by two-dimensional electrophoresis revealed that only few, i.e., less than 20, became radioactively labelled in homogenates of superior cervical ganglia in the presence of Ca2+, and even fewer in the presence of cyclic AMP. Furthermore, all these proteins fell within a narrow pI range of 4-6. The growth-associated protein, variously designated GAP-43, B-50, F-1, and pp46, has an enhanced level of expression and phosphorylation in regenerating ganglia compared with controls at day 3. Injury also caused consistently higher levels of incorporation into two other proteins with molecular masses at positions 55,000 and 85,000 and pI values of 5.1 and 4.5, respectively; the former protein most probably is beta-tubulin. The fact that both proteins are found in the 15,000 g pellet after the tissue has been solubilized in 0.5% nonionic detergent indicates that they may indeed by components of filament assemblies. Thus, the results suggest that protein phosphorylation is a mechanism involved in cytoskeletal function in regenerating nerve.

Therapeutic strategies in promoting peripheral nerve regeneration

Currently, regeneration chambers, adrenocorticotropic hormone (ACTH) and related peptides, and gangliosides appear to be the most promising therapies in the promotion of peripheral nerve regeneration, growth, and repair. Regeneration chambers enhance rat sciatic nerve regeneration in vivo after transection by providing a structurally organized and protected preformed space within which nerve fibers are exposed to macromolecular compounds which direct and enhance nerve growth. ACTH and related peptides, independent of their corticotropic activities, increase the availability of structural proteins to the axon terminal in rats subjected to nerve crush injuries and demonstrate inotropic effects in adrenalectomized and/or hypophysectomized rats. Exogenously administered gangliosides promote neuronal sprouting, regeneration, and reinnervation in experimental situations and have undergone clinical testing in acute and chronic peripheral nerve disorders. At the current dosage levels and schedules, the clinical results of ganglioside therapy have been mixed. The success of the experimental studies supports further clinical testing of these therapies in peripheral nerve disorders.

Tubulation for peripheral nerve gap: its history and possibility

A large gap in peripheral nerve will not allow effective regeneration unless a grafting conduit is used to bridge the defect. Conventionally, nerve tissue has been used as such a conduit in nerve reconstruction; however, results from techniques using these grafts are often unsatisfactory. A number of recent investigations have indicated that nerve fibers will regenerate through a non-neural tube. The purpose of this review is: 1) to provide an overview of the various tubulation techniques previously reported for peripheral nerve gap repair; 2) to investigate new possibilities for enhancing the regenerative capacity of nerves following these tubulation techniques by drawing from technical innovations in microsurgery and recent progress in immunology and neurobiology. The interposed graft thus may perform a more positive role, not merely as a pathway for deregenerating axons, but as a source for neuronotrophic factors and neurite-promoting factors, which would nurture and guide the neurons and axons. Such modifications in graft materials may lead to clinical applications of tubulation of nerve defects that would result in an improvement in clinical results.

Fibroblast growth factor effects on peripheral nerve regeneration in a silicone chamber model

We have developed a silicone nerve regeneration chamber that is partitioned into two compartments by a strip of nitrocellulose paper. The modified two-compartment chamber allows the investigation of the effects on rat sciatic nerve regeneration of trophic or growth factors that are initially bound to the nitrocellulose partition. In this study we compared the effects of untreated nitrocellulose, a siliconized nitrocellulose strip, and a strip that had been soaked in a basic fibroblast growth factor (FGF) solution. FGF is a known angiogenic factor and a mitogen for endothelial cells, fibroblasts, and Schwann cells. All of these cell types are present in the peripheral nerve. In vitro analyses, using 3T3 cells as test cells, showed that some of the bound FGF remained active on the nitrocellulose paper for at least 8-10 days. In vivo experiments, examined at 16 days post-implantation, revealed that spatial migration of all cellular elements (perineurial-like cells, vasculature, and Schwann cells) across the chamber gap was slower with untreated nitrocellulose strips than with siliconized strips but was most advanced with FGF-treated ones. Most striking was the well-developed vascular arborization of the regenerate within the FGF chambers. Histologic sections from the proximal one-half of the chamber revealed that the regenerate in untreated strip chambers consisted of fibrin matrix and erythrocytes, whereas a well-developed structure with all the cellular elements of a regenerating nerve was seen in several of the FGF strip chambers. We conclude that FGF stimulates peripheral nerve regeneration in this model.

Rat amnion membrane matrix as a substratum for regenerating axons from peripheral and central neurons: effects in a silicone chamber model

An extracellular matrix preparation, the human amnion membrane matrix (hAMM) can serve as a neurite-promoting substratum for cultured peripheral and central neurons, and also as a support for axonal growth in experimentally injured adult brain in vivo. In the present study, we tested similar materials as bridges in a silicone chamber model for the regeneration of sciatic nerve in the adult rat. Since hAMM elicited an inflammatory response, we developed a rat amnion membrane matrix (rAMM), which proved to be an excellent neurite-promoting substratum for cultured ganglionic and spinal cord neurons. The rAMM was coiled and inserted in the 10 mm gap between the two nerve stumps from the silicone chambers. At 16 days after implantation, temporal progress of regeneration was grossly similar as in saline-prefilled control chambers. However, rAMM-prefilled chambers displayed significantly higher number of vessels and a markedly different geometry of the regenerate: an endoneurium, surrounded by a perineurial-like cell layer, was formed outside the largely preserved central portion of the rAMM coil. After longer regeneration times (28 days), a rAMM core was no longer detected, but some rAMM-like materials remained interspersed in the endoneurium. The overall organization of the regenerate and the number of myelinated axons at this time were similar to those of control chambers, although the endoneurial cross-sectional area was larger in the rAMM chambers. One specimen, however, displayed the very patterns for which the experiments were designed, namely an array of numerous, myelinated axons tracing the spiraling spaces between consecutive lamellae of the rAMM coil.

A two-compartment modification of the silicone chamber model for nerve regeneration

In the nerve regeneration silicone chamber model, the regenerate which forms across a 10-mm gap between proximal and distal nerve stumps is a monofascicular structure with an outer perineurial-like cell sheath. Recent work has provided indications that the geometry of the regenerate within a silicone chamber can be altered by experimental modifications of the chamber matrix. In the present study we modified the standard silicone chamber into a two-compartment chamber by inserting a 6- or 10-mm-long siliconized nitrocellulose strip in order to obtain two separate regenerates. Light microscopy 16 days after implantation revealed that two separate nerve structures had formed, one on each side of the nitrocellulose partition and adjacent to it, and each with its own perineurial-like cell sheath. In chambers with 6-mm-long strips a monofascicular regenerate started from the proximal stump and divided into two separate structures as it approached the proximal end of the strip: the two fascicles joined again into a monofascicular structure in the distal portion of the chambers. The new two-compartment silicone chamber model appears suitable for future examinations of experimental fasciculation. In addition, the nitrocellulose partition should allow one to study specific effects of growth factors on axonal regeneration in vivo, as growth factors bind strongly to untreated nitrocellulose while retaining their biological activity.

Exogenous matrix precursors promote functional nerve regeneration across a 15-mm gap within a silicone chamber in the rat

When silicone regeneration chambers are implanted empty, axonal regeneration fails if the interstump gap length is greater than 10 mm. Previous experiments using the 10-mm gap model demonstrated that regeneration success correlated with the dimension and/or consistency of the naturally formed acellular fibrin matrix. Both spatial and temporal parameters of regeneration could be stimulated through modifications of the fibrin matrix by prefilling the chambers at the time of implantation either with phosphate-buffered saline or plasma dialyzed against phosphate-buffered saline. In the present experiments, similar modification of matrix formation was found to promote successful regeneration across 15-mm and 20-mm interstump gap lengths. In addition, prefilling 15-mm-gap chambers with dialyzed plasma resulted in a 3.5-fold increase in the incidence of functional restitution detected at 8 weeks after implantation over the outcome with chambers prefilled with phosphate-buffered saline.