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Leis A, Smetana BS, Strohl AB, Styron JF. Comparative Effectiveness Systematic Review and Meta-analysis of Peripheral Nerve Repair Using Direct Repair and Connector-assisted Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5927. [PMID: 38983950 PMCID: PMC11233104 DOI: 10.1097/gox.0000000000005927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/01/2024] [Indexed: 07/11/2024]
Abstract
Background This clinical literature systematic review and meta-analysis were performed to assess differences in outcomes between nerves repaired with direct repair (DR) and connector-assisted repair (CAR). Methods A systematic literature review for DR and CAR was performed. Studies from 1980 through August 2023 were included if DR or CAR repairs were performed in upper extremities with nerve gaps less than 5 mm and reported sensory Medical Research Council Classification (MRCC) outcomes or equivalent. Comparative analyses were planned for meaningful recovery (MR) rate (at both S3 and S3+ or better), postsurgical neuroma, cold intolerance, altered sensation, pain, and revision rate. Results There were significant differences in MR rates for CAR and DR. At the MRCC S3 threshold, 96.1% of CAR and 81.3% of DR achieved MR (P < 0.0001). At the MRCC S3+ threshold, 87.1% of CAR and 54.2% of DR achieved this higher threshold of MR (P < 0.0001). There were no differences in neuroma rate or pain scores in our dataset. Altered sensation (dysesthesia, paresthesia, hyperesthesia, or hypersensitivity) was not discussed in any CAR studies, so no analysis could be performed. The revision rate for both procedures was 0%. The proportion of patients with cold intolerance was 46.2% in the DR studies, which was significantly higher than the 10.7% of patients in the CAR group. Conclusions Significantly more patients achieved sensory MR and fewer had cold intolerance when the CAR technique, instead of the DR technique, was performed to repair peripheral nerve injuries.
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Affiliation(s)
- Amber Leis
- From UCI Health, Orange, Calif
- Indiana Hand to Shoulder Center, Indianapolis, Ind
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2
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Solomevich SO, Oranges CM, Kalbermatten DF, Schwendeman A, Madduri S. Natural polysaccharides and their derivatives as potential medical materials and drug delivery systems for the treatment of peripheral nerve injuries. Carbohydr Polym 2023; 315:120934. [PMID: 37230605 DOI: 10.1016/j.carbpol.2023.120934] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/07/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023]
Abstract
Peripheral nerve repair following injury is one of the most serious problems in neurosurgery. Clinical outcomes are often unsatisfactory and associated with a huge socioeconomic burden. Several studies have revealed the great potential of biodegradable polysaccharides for improving nerve regeneration. We review here the promising therapeutic strategies involving different types of polysaccharides and their bio-active composites for promoting nerve regeneration. Within this context, polysaccharide materials widely used for nerve repair in different forms are highlighted, including nerve guidance conduits, hydrogels, nanofibers and films. While nerve guidance conduits and hydrogels were used as main structural scaffolds, the other forms including nanofibers and films were generally used as additional supporting materials. We also discuss the issues of ease of therapeutic implementation, drug release properties and therapeutic outcomes, together with potential future directions of research.
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Affiliation(s)
- Sergey O Solomevich
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA; Research Institute for Physical Chemical Problems of the Belarusian State University, Minsk, Belarus
| | - Carlo M Oranges
- Plastic, Reconstructive and Aesthetic Surgery Division, Department of Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Daniel F Kalbermatten
- Plastic, Reconstructive and Aesthetic Surgery Division, Department of Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland; Bioengineering and Neuroregeneration Laboratory, Department of Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Anna Schwendeman
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA; Biointerfaces Institute, University of Michigan, Ann Arbor, MI, USA
| | - Srinivas Madduri
- Plastic, Reconstructive and Aesthetic Surgery Division, Department of Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland; Bioengineering and Neuroregeneration Laboratory, Department of Surgery, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
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3
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Barham M, Andermahr J, Majczyński H, Sławińska U, Vogt J, Neiss WF. Treadmill training of rats after sciatic nerve graft does not alter accuracy of muscle reinnervation. Front Neurol 2023; 13:1050822. [PMID: 36742044 PMCID: PMC9893025 DOI: 10.3389/fneur.2022.1050822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/23/2022] [Indexed: 01/20/2023] Open
Abstract
Background and purpose After peripheral nerve lesions, surgical reconstruction facilitates axonal regeneration and motor reinnervation. However, functional recovery is impaired by aberrant reinnervation. Materials and methods We tested whether training therapy by treadmill exercise (9 × 250 m/week) before (run-idle), after (idle-run), or both before and after (run-run) sciatic nerve graft improves the accuracy of reinnervation in rats. Female Lewis rats (LEW/SsNHsd) were either trained for 12 weeks (run) or not trained (kept under control conditions, idle). The right sciatic nerves were then excised and reconstructed with 5 mm of a congenic allograft. One week later, training started in the run-run and idle-run groups for another 12 weeks. No further training was conducted in the run-idle and idle-idle groups. Reinnervation was measured using the following parameters: counting of retrogradely labeled motoneurons, walking track analysis, and compound muscle action potential (CMAP) recordings. Results In intact rats, the common fibular (peroneal) and the soleus nerve received axons from 549 ± 83 motoneurons. In the run-idle group, 94% of these motoneurons had regenerated 13 weeks after the nerve graft. In the idle-run group, 81% of the normal number of motoneurons had regenerated into the denervated musculature and 87% in both run-run and idle-idle groups. Despite reinnervation, functional outcome was poor: walking tracks indicated no functional improvement of motion in any group. However, in the operated hindlimb of run-idle rats, the CMAP of the soleus muscle reached 11.9 mV (normal 16.3 mV), yet only 6.3-8.1 mV in the other groups. Conclusion Treadmill training neither altered the accuracy of reinnervation nor the functional recovery, and pre-operative training (run-idle) led to a higher motor unit activation after regeneration.
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Affiliation(s)
- Mohammed Barham
- Department II of Anatomy, University of Cologne and University Hospital of Cologne, Cologne, Germany,*Correspondence: Mohammed Barham ✉
| | | | - Henryk Majczyński
- Nencki Institute of Experimental Biology, Polish Academy of Sciences, Warszawa, Poland
| | - Urszula Sławińska
- Nencki Institute of Experimental Biology, Polish Academy of Sciences, Warszawa, Poland
| | - Johannes Vogt
- Department II of Anatomy, University of Cologne and University Hospital of Cologne, Cologne, Germany,Cluster of Excellence for Aging Research (CECAD) and Center of Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Wolfram F. Neiss
- Department I of Anatomy, University of Cologne and University Hospital of Cologne, Cologne, Germany
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4
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Sensory Restoration in Abdominally Based Free Flaps for Breast Reconstruction Using Nerve Allograft. Plast Reconstr Surg 2023; 151:25-33. [PMID: 36194066 DOI: 10.1097/prs.0000000000009773] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Neurotization in breast reconstruction can be performed with the aid of nerve grafts and conduits to decrease the tedious dissection and overcome size mismatch. However, there has yet to be a formal analysis of this approach. The goal of this study was to evaluate sensory recovery after neurotized abdominally based free flaps for breast reconstruction using the authors' novel technique and analyze factors that could affect sensory recovery. METHODS A novel technique using processed nerve allograft in combination with a nerve conduit was used. Dynamic and static sensation recovery tests were performed in patients who underwent neurotized or nonneurotized abdominally based free flap reconstructions. Demographics, surgical details, and complications were analyzed. Statistical analyses were performed using chi-square and Mann-Whitney tests. RESULTS Fifty patients (78 breasts) were analyzed: 60 breasts with neurotized reconstruction and 18 breasts without. For patients with more than 12 months of follow-up, the neurotized cohort demonstrated improved dynamic tests compared to the nonneurotized cohort (38 ± 21.69 versus 56.17 ± 20.8, respectively; P = 0.014). Factors associated with decreased sensory return in patients who underwent neurotized reconstruction were diabetes, higher body mass index, skin-sparing mastectomy, higher American Society of Anesthesiologists class, history of radiation therapy, or history of hormonal therapy. CONCLUSIONS This is the first study to report on outcomes of neurotized autologous breast reconstruction using a nerve graft and conduit technique. The authors' approach resulted in improved sensory outcomes compared to those in patients who did not undergo sensory reconstruction. Importantly, factors that can interfere with sensory recovery were identified. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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5
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Abstract
BACKGROUND Acellular nerve allograft (ANA) occupies an increasingly prominent role in the treatment of peripheral nerve reconstruction. There is demonstrable efficacy; however, some grafts fail to support axonal regrowth and the reasons for this are unclear. This study examines the ANA experience in a specialized peripheral nerve surgery department to discuss the clinical and histological findings in failed cases. METHOD Failed ANA grafts were identified from a prospective database using Medical Research Council Classification (MRCC) S3 and M3 as thresholds for success. Cases in which ANA grafting was indicated for nerve related pain and dysesthesia but where no subjective improvement in symptoms occurred were also included. Patients requiring revision surgery after ANA grafting were also considered failures. Cases were then examined in conjunction with a literature review to identify possible mechanisms of failure, including detailed histological analysis in 2 cases. RESULTS Eight failed procedures were identified from a database of 99 separate allograft records on 74 patients. This included procedures for 2 tibial nerves, 2 superficial radial nerves, 2 median nerves, 1 digital nerve and a lateral cord brachial plexus injury (male/female, 5:3; age range, 24-54 years). Allograft length range 25 to 120 mm. One postoperative infection was identified. Histological findings in 2 cases included adequate vascularization of allograft material without subsequent axonal regeneration, a reduction of large myelinated fibers proximal to a tibial nerve allograft in the setting of a chronic injury, and a preference for small rather than large fiber regeneration. CONCLUSIONS This article reports instances of ANA graft failure in a variety of contexts, for which the primary reasons for failure remain unclear. The etiology is likely to be multifactorial with both patient, graft and surgeon factors contributing to failure. Further clinical and histological analysis of ANA failures will improve our understanding of the mechanisms of graft failure.
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Affiliation(s)
- Calum Thomson
- From the Department of Peripheral Nerve Surgery, Queen Elizabeth Hospital
| | | | - Ute Pohl
- Department of Cellular Pathology
| | - Dominic M Power
- The Birmingham Peripheral Nerve Injury Service, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Gong B, Zhang X, Zahrani AA, Gao W, Ma G, Zhang L, Xue J. Neural tissue engineering: From bioactive scaffolds and in situ monitoring to regeneration. EXPLORATION (BEIJING, CHINA) 2022; 2:20210035. [PMID: 37323703 PMCID: PMC10190951 DOI: 10.1002/exp.20210035] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 03/09/2022] [Indexed: 06/17/2023]
Abstract
Peripheral nerve injury is a large-scale problem that annually affects more than several millions of people all over the world. It remains a great challenge to effectively repair nerve defects. Tissue engineered nerve guidance conduits (NGCs) provide a promising platform for peripheral nerve repair through the integration of bioactive scaffolds, biological effectors, and cellular components. Herein, we firstly describe the pathogenesis of peripheral nerve injuries at different orders of severity to clarify their microenvironments and discuss the clinical treatment methods and challenges. Then, we discuss the recent progress on the design and construction of NGCs in combination with biological effectors and cellular components for nerve repair. Afterward, we give perspectives on imaging the nerve and/or the conduit to allow for the in situ monitoring of the nerve regeneration process. We also cover the applications of different postoperative intervention treatments, such as electric field, magnetic field, light, and ultrasound, to the well-designed conduit and/or the nerve for improving the repair efficacy. Finally, we explore the prospects of multifunctional platforms to promote the repair of peripheral nerve injury.
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Affiliation(s)
- Bowen Gong
- Beijing Laboratory of Biomedical MaterialsBeijing University of Chemical TechnologyBeijingChina
- State Key Laboratory of Organic–Inorganic CompositesBeijing University of Chemical TechnologyBeijingChina
| | - Xindan Zhang
- Beijing Laboratory of Biomedical MaterialsBeijing University of Chemical TechnologyBeijingChina
- State Key Laboratory of Organic–Inorganic CompositesBeijing University of Chemical TechnologyBeijingChina
| | - Ahmed Al Zahrani
- Department of Mechanical and Materials EngineeringUniversity of JeddahJeddahSaudi Arabia
| | - Wenwen Gao
- Department of RadiologyChina–Japan Friendship HospitalBeijingChina
| | - Guolin Ma
- Department of RadiologyChina–Japan Friendship HospitalBeijingChina
| | - Liqun Zhang
- Beijing Laboratory of Biomedical MaterialsBeijing University of Chemical TechnologyBeijingChina
- State Key Laboratory of Organic–Inorganic CompositesBeijing University of Chemical TechnologyBeijingChina
| | - Jiajia Xue
- Beijing Laboratory of Biomedical MaterialsBeijing University of Chemical TechnologyBeijingChina
- State Key Laboratory of Organic–Inorganic CompositesBeijing University of Chemical TechnologyBeijingChina
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7
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Clinical Outcomes of Symptomatic Neuroma Resection and Reconstruction with Processed Nerve Allograft. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3832. [PMID: 34616638 PMCID: PMC8489892 DOI: 10.1097/gox.0000000000003832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/22/2021] [Indexed: 01/10/2023]
Abstract
Background: Neuromas causing sensory disturbance can substantially affect nerve function and quality of life. Historically, passive termination of the nerve end and proximal relocation to muscle or bone has been performed after neuroma resection, but this method does not allow for neurologic recovery or prevent recurrent neuromas. The use of processed nerve allografts (PNAs) for intercalary reconstruction of nerve defects following neuroma resection is reasonable for neuroma management, although reported outcomes are limited. The purpose of this study was to assess the outcomes of pain reduction and functional recovery following neuroma resection and intercalary nerve reconstruction using PNA. Methods: Data on outcomes of PNA use for peripheral nerve reconstruction were collected from a multicenter registry study. The registry database was queried for upper extremity nerve reconstruction with PNA after resection of symptomatic neuroma. Patients completing both pain and quantitative sensory assessments were included in the analysis. Improvement in pain-related symptoms was determined via patient self-reported outcomes and/or the visual analog scale. Meaningful sensory recovery was defined as a score of at least S3 on the Medical Research Council Classification scale. Results: Twenty-five repairs involving 21 patients were included in this study. The median interval from injury to reconstruction was 386 days, and the average nerve defect length was 31 mm. Pain improved in 80% of repairs. Meaningful sensory recovery was achieved in 88% of repairs. Conclusion: Neuroma resection and nerve reconstruction using PNA can reduce or eliminate chronic peripheral nerve pain and provide meaningful sensory recovery.
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8
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Samadian H, Maleki H, Fathollahi A, Salehi M, Gholizadeh S, Derakhshankhah H, Allahyari Z, Jaymand M. Naturally occurring biological macromolecules-based hydrogels: Potential biomaterials for peripheral nerve regeneration. Int J Biol Macromol 2020; 154:795-817. [DOI: 10.1016/j.ijbiomac.2020.03.155] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 03/15/2020] [Accepted: 03/16/2020] [Indexed: 12/18/2022]
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9
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Rink S, Bendella H, Akkin SM, Manthou M, Grosheva M, Angelov DN. Experimental Studies on Facial Nerve Regeneration. Anat Rec (Hoboken) 2019; 302:1287-1303. [DOI: 10.1002/ar.24123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 10/09/2018] [Accepted: 11/02/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Svenja Rink
- Department of Prosthetic Dentistry, School of Dental and Oral MedicineUniversity of Cologne Cologne Germany
| | - Habib Bendella
- Department of NeurosurgeryUniversity of Witten/Herdecke, Cologne Merheim Medical Center (CMMC) Cologne Germany
| | - Salih Murat Akkin
- Department of Anatomy, School of MedicineSANKO University Gaziantep Turkey
| | - Marilena Manthou
- Department of Histology and EmbryologyAristotle University Thessaloniki Thessaloniki Greece
| | - Maria Grosheva
- Department of Oto‐Rhino‐LaryngologyUniversity of Cologne Cologne Germany
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10
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Minimally Invasive Corneal Neurotization With Acellular Nerve Allograft: Surgical Technique and Clinical Outcomes. Ophthalmic Plast Reconstr Surg 2019; 35:133-140. [DOI: 10.1097/iop.0000000000001181] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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11
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Duret C, Mazzoleni S. Upper limb robotics applied to neurorehabilitation: An overview of clinical practice. NeuroRehabilitation 2018; 41:5-15. [PMID: 28505985 DOI: 10.3233/nre-171452] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND During the last two decades, extensive interaction between clinicians and engineers has led to the development of systems that stimulate neural plasticity to optimize motor recovery after neurological lesions. This has resulted in the expansion of the field of robotics for rehabilitation. Studies in patients with stroke-related upper-limb paresis have shown that robotic rehabilitation can improve motor capacity. However, few other applications have been evaluated (e.g. tremor, peripheral nerve injuries or other neurological diseases). PURPOSE This paper presents an overview of the current use of upper limb robotic systems for neurorehabilitation, and highlights the rationale behind their use for the assessment and treatment of common neurological disorders. CONCLUSIONS Rehabilitation robots are little integrated in clinical practice, except after stroke. Although few studies have been carried out to evaluate their effectiveness, evidence from the neurosciences and indications from pilot studies suggests that upper limb robotic rehabilitation can be applied safely in various other neurological conditions. Rehabilitation robots provide an intensity, quality and dose of treatment that exceeds therapist-mediated rehabilitation. Moreover, the use of force fields, multi-sensory environments, feedback etc. renders such rehabilitation engaging and motivating. Future studies should evaluate the effectiveness of rehabilitation robots in neurological pathologies other than stroke.
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Affiliation(s)
- Christophe Duret
- Centre de Rééducation Fonctionnelle Les Trois Soleils, Médecine Physique et de Réadaptation, Unité de Neurorééducation, Boissise-Le-Roi, France.,Centre Hospitalier Sud Francilien, Neurologie, Corbeil-Essonnes, France
| | - Stefano Mazzoleni
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy.,Rehabilitation Bioengineering Laboratory, Volterra, Italy
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12
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Del Valle J, Santos D, Delgado-Martínez I, de la Oliva N, Giudetti G, Micera S, Navarro X. Segregation of motor and sensory axons regenerating through bicompartmental tubes by combining extracellular matrix components with neurotrophic factors. J Tissue Eng Regen Med 2018; 12:e1991-e2000. [PMID: 29266822 DOI: 10.1002/term.2629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/30/2017] [Accepted: 12/11/2017] [Indexed: 12/21/2022]
Abstract
Segregation of regenerating motor and sensory axons may be a good strategy to improve selective functionality of regenerative interfaces to provide closed-loop commands. Provided that extracellular matrix components and neurotrophic factors exert guidance effects on different neuronal populations, we assessed in vivo the potential of separating sensory and motor axons regenerating in a bicompartmental Y-type tube, with each branch prefilled with an adequate combination of extracellular matrix and neurotrophic factors. The severed rat sciatic nerve was repaired using a bicompartmental tube filled with a collagen matrix enriched with fibronectin (FN) and brain-derived neurotrophic factor (BDNF) encapsulated in poly-lactic co-glycolic acid microspheres (FN + MP.BDNF) in one compartment to preferentially attract motor axons and collagen enriched with laminin (LM) and nerve growth factor (NGF) and neurotrophin-3 (NT-3) in microspheres (LM + MP.NGF/NT-3) in the other compartment for promoting sensory axons regeneration. Control animals were implanted with the same Y-tube with a collagen matrix with microspheres (MP) containing PBS (Col + MP.PBS). By using retrotracer labelling, we found that LM + MP.NGF/NT-3 did not attract higher number of regenerated sensory axons compared with controls, and no differences were observed in sensory functional recovery. However, FN + MP.BDNF guided a higher number of regenerating motor axons compared with controls, improving also motor recovery. A small proportion of sensory axons with large soma size, likely proprioceptive neurons, was also attracted to the FN + MP.BDNF compartment. These results demonstrate that muscular axonal guidance can be modulated in vivo by the addition of fibronectin and BDNF.
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Affiliation(s)
- Jaume Del Valle
- Institute of Neurosciences and Department of Cell Biology, Physiology, and Immunology, Universitat Autònoma de Barcelona, Bellaterra, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain.,Catalan Institute of Nanoscience and Nanotechnology (ICN2), CSIC, and BIST, Bellaterra, Spain
| | - Daniel Santos
- Institute of Neurosciences and Department of Cell Biology, Physiology, and Immunology, Universitat Autònoma de Barcelona, Bellaterra, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
| | - Ignacio Delgado-Martínez
- Institute of Neurosciences and Department of Cell Biology, Physiology, and Immunology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Natàlia de la Oliva
- Institute of Neurosciences and Department of Cell Biology, Physiology, and Immunology, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Guido Giudetti
- The Biorobotics Institute, Scuola Superiore Sant'Anna, Pontedera, Italy
| | - Silvestro Micera
- The Biorobotics Institute, Scuola Superiore Sant'Anna, Pontedera, Italy.,Translational Neural Engineering Laboratory, Center for Neuroprosthetics and Institute of Bioengineering, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Xavier Navarro
- Institute of Neurosciences and Department of Cell Biology, Physiology, and Immunology, Universitat Autònoma de Barcelona, Bellaterra, Spain.,Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
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13
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Ducic I, Safa B, DeVinney E. Refinements of nerve repair with connector-assisted coaptation. Microsurgery 2016; 37:256-263. [DOI: 10.1002/micr.30151] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/03/2016] [Accepted: 12/16/2016] [Indexed: 01/12/2023]
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14
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Abstract
Manufactured conduits and allografts are viable alternatives to direct suture repair and nerve autograft. Manufactured tubes should have gaps less than 10 mm, and ideally should be considered as an aid to the coaptation. Processed nerve allograft has utility as a substitute for either conduit or autograft in sensory nerve repairs. There is also a growing body of evidence supporting their utility in major peripheral nerve repairs, gap repairs up to 70 mm in length, as an alternative source of tissue to bolster the diameter of a cable graft, and for the management of neuromas in non-reconstructable injuries.
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Affiliation(s)
- Bauback Safa
- The Buncke Clinic, 45 Castro Street #121, San Francisco, CA 94114, USA.
| | - Gregory Buncke
- The Buncke Clinic, 45 Castro Street #121, San Francisco, CA 94114, USA
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15
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Sakuma M, Gorski G, Sheu SH, Lee S, Barrett LB, Singh B, Omura T, Latremoliere A, Woolf CJ. Lack of motor recovery after prolonged denervation of the neuromuscular junction is not due to regenerative failure. Eur J Neurosci 2015; 43:451-62. [PMID: 26332731 DOI: 10.1111/ejn.13059] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/21/2015] [Accepted: 08/24/2015] [Indexed: 12/19/2022]
Abstract
Motor axons in peripheral nerves have the capacity to regenerate after injury. However, full functional motor recovery rarely occurs clinically, and this depends on the nature and location of the injury. Recent preclinical findings suggest that there may be a time after nerve injury where, while regrowth to the muscle successfully occurs, there is nevertheless a failure to re-establish motor function, suggesting a possible critical period for synapse reformation. We have now examined the temporal and anatomical determinants for the re-establishment of motor function after prolonged neuromuscular junction (NMJ) denervation in rats and mice. Using both sciatic transection-resuture and multiple nerve crush models in rats and mice to produce prolonged delays in reinnervation, we show that regenerating fibres reach motor endplates and anatomically fully reform the NMJ even after extended periods of denervation. However, in spite of this remarkably successful anatomical regeneration, after 1 month of denervation there is a consistent failure to re-establish functional recovery, as assessed by behavioural and electrophysiological assays. We conclude that this represents a failure in re-establishment of synaptic function, and the possible mechanisms responsible are discussed, as are their clinical implications.
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Affiliation(s)
- Miyuki Sakuma
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Grzegorz Gorski
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Shu-Hsien Sheu
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Department of Pathology and Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Stella Lee
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Lee B Barrett
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Bhagat Singh
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Takao Omura
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Alban Latremoliere
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Clifford J Woolf
- Department of Neurobiology, Harvard Medical School, Boston, MA, 02115, USA.,Kirby Neurobiology Center, Boston Children's Hospital, Boston, MA, 02115, USA
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16
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3D multi-channel bi-functionalized silk electrospun conduits for peripheral nerve regeneration. J Mech Behav Biomed Mater 2015; 41:43-55. [DOI: 10.1016/j.jmbbm.2014.09.029] [Citation(s) in RCA: 139] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/25/2014] [Accepted: 09/30/2014] [Indexed: 12/21/2022]
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17
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Sensory outcomes after reconstruction of lingual and inferior alveolar nerve discontinuities using processed nerve allograft--a case series. J Oral Maxillofac Surg 2014; 73:734-44. [PMID: 25530279 DOI: 10.1016/j.joms.2014.10.030] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 10/29/2014] [Accepted: 10/31/2014] [Indexed: 01/31/2023]
Abstract
PURPOSE The present study describes the results of using a processed nerve allograft, Avance Nerve Graft, as an extracellular matrix scaffold for the reconstruction of lingual nerve (LN) and inferior alveolar nerve (IAN) discontinuities. PATIENTS AND METHODS A retrospective analysis of the neurosensory outcomes for 26 subjects with 28 LN and IAN discontinuities reconstructed with a processed nerve allograft was conducted to determine the treatment effectiveness and safety. Sensory assessments were conducted preoperatively and 3, 6, and 12 months after surgical reconstruction. The outcomes population, those with at least 6 months of postoperative follow-up, included 21 subjects with 23 nerve defects. The neurosensory assessments included brush stroke directional sensation, static 2-point discrimination, contact detection, pressure pain threshold, and pressure pain tolerance. Using the clinical neurosensory testing scale, sensory impairment scores were assigned preoperatively and at each follow-up appointment. Improvement was defined as a score of normal, mild, or moderate. RESULTS The neurosensory outcomes from LNs and IANs that had been microsurgically repaired with a processed nerve allograft were promising. Of those with nerve discontinuities treated, 87% had improved neurosensory scores with no reported adverse experiences. Similar levels of improvement, 87% for the LNs and 88% for the IANs, were achieved for both nerve types. Also, 100% sensory improvement was achieved in injuries repaired within 90 days of the injury compared with 77% sensory improvement in injuries repaired after 90 days. CONCLUSIONS These results suggest that processed nerve allografts are an acceptable treatment option for reconstructing trigeminal nerve discontinuities. Additional studies will focus on reviewing the outcomes of additional cases.
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Abstract
Nerve conduits and acellular nerve allograft offer efficient and convenient tools for overcoming unexpected gaps during nerve repair. Both techniques offer guidance for migrating Schwann cells and axonal regeneration though utilizing very different scaffolds. The substantially greater amount of animal and clinical data published on nerve conduits is marked by wide discrepancies in results that may be partly explained by a still poorly defined critical repair gap and diameter size. The available information on acellular allografts appears more consistently positive though this tool is also hampered by a longer but also limited critical length. This article reviews the current relative literature and examines pertinent parameters for application of both acellular allograft and nerve conduits in overcoming short nerve gaps.
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de Ruiter GCW, Spinner RJ, Verhaagen J, Malessy MJA. Misdirection and guidance of regenerating axons after experimental nerve injury and repair. J Neurosurg 2014; 120:493-501. [DOI: 10.3171/2013.8.jns122300] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Misdirection of regenerating axons is one of the factors that can explain the limited results often found after nerve injury and repair. In the repair of mixed nerves innervating different distal targets (skin and muscle), misdirection may, for example, lead to motor axons projecting toward skin, and vice versa—that is, sensory axons projecting toward muscle. In the repair of motor nerves innervating different distal targets, misdirection may result in reinnervation of the wrong target muscle, which might function antagonistically. In sensory nerve repair, misdirection might give an increased perceptual territory. After median nerve repair, for example, this might lead to a dysfunctional hand.
Different factors may be involved in the misdirection of regenerating axons, and there may be various mechanisms that can later correct for misdirection. In this review the authors discuss these different factors and mechanisms that act along the pathway of the regenerating axon. The authors review recently developed evaluation methods that can be used to investigate the accuracy of regeneration after nerve injury and repair (including the use of transgenic fluorescent mice, retrograde tracing techniques, and motion analysis). In addition, the authors discuss new strategies that can improve in vivo guidance of regenerating axons (including physical guidance with multichannel nerve tubes and biological guidance accomplished using gene therapy).
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Affiliation(s)
| | | | - Joost Verhaagen
- 3Department of Neuroregeneration, Netherlands Institute for Neuroscience, Amsterdam
- 4Department of Molecular and Cellular Neurobiology, Center for Neurogenomics and Cognition Research, Vrije Universiteit Amsterdam, The Netherlands; and
| | - Martijn J. A. Malessy
- 1Department of Neurosurgery, Leiden University Medical Center, Leiden
- 3Department of Neuroregeneration, Netherlands Institute for Neuroscience, Amsterdam
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Owens CM, Marga F, Forgacs G, Heesch CM. Biofabrication and testing of a fully cellular nerve graft. Biofabrication 2013; 5:045007. [PMID: 24192236 DOI: 10.1088/1758-5082/5/4/045007] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rupture of a nerve is a debilitating injury with devastating consequences for the individual's quality of life. The gold standard of repair is the use of an autologous graft to bridge the severed nerve ends. Such repair however involves risks due to secondary surgery at the donor site and may result in morbidity and infection. Thus the clinical approach to repair often involves non-cellular solutions, grafts composed of synthetic or natural materials. Here we report on a novel approach to biofabricate fully biological grafts composed exclusively of cells and cell secreted material. To reproducibly and reliably build such grafts of composite geometry we use bioprinting. We test our grafts in a rat sciatic nerve injury model for both motor and sensory function. In particular we compare the regenerative capacity of the biofabricated grafts with that of autologous grafts and grafts made of hollow collagen tubes by measuring the compound action potential (for motor function) and the change in mean arterial blood pressure as consequence of electrically eliciting the somatic pressor reflex. Our results provide evidence that bioprinting is a promising approach to nerve graft fabrication and as a consequence to nerve regeneration.
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Affiliation(s)
- Christopher M Owens
- Department of Physics and Astronomy, University of Missouri, Columbia, MO 65211, USA
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Abstract
Major peripheral nerve injuries in the upper extremities can result in significant morbidity. Understanding the pathophysiology of these injuries aids in the assessment and planning of appropriate treatment. With limited nerve mobilization, tension-free repairs can often be performed using sutures, fibrin glue, or nerve connectors. Acellular allograft and autograft reconstruction are better for bridging any gaps greater than a few millimeters. Adherence to proper principles of nerve repair improves the chances of achieving a favorable result, although in general these injuries portend a guarded prognosis.
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Donzelli R, Maiuri F, Piscopo GA, de Notaris M, Colella A, Divitiis E. Role of extracellular matrix components in facial nerve regeneration: an experimental study. Neurol Res 2013; 28:794-801. [PMID: 17288733 DOI: 10.1179/016164106x110427] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the role of extracellular matrix components in nerve regeneration. Matrigel, a complex of extracellular matrix components such as laminin (the most abundant) heparan sulphate proteoglycans (HSPG), type IV collagen and fibronectin, was used. METHODS Forty male rabbits, which had undergone section of the right facial nerve, were later treated by reinnervation through an artificial graft of expanded polytetrafluoroethylene (ePTFE). In 20 animals the tubes of ePTFE were filled with Matrigel; in 20 control animals the tubes were filled with saline solution. RESULTS The Matrigel group showed a better axonal organization and a significantly higher number of regenerated axons in the early phases (at days 15 and 30 respectively) than the control group, whereas the difference of the axons number at day 60 was less significant; besides, the axon diameter and the myelin thickness were not significantly improved by Matrigel. DISCUSSION Our data suggest that Matrigel is an important factor in promoting and enhancing the early phases of the regeneration after nerve injuries. Tree neurite promoting agents, such as laminin, fibronectin and collagen, allow a more systematic and agonized regeneration. Extracellular matrix components may represent a direction guidance for axonal pathway.
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Affiliation(s)
- Renato Donzelli
- Department of Neurosurgery, University 'Federico II' School of Medicine, Naples, Italy.
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Blocking the P2X7 receptor improves outcomes after axonal fusion. J Surg Res 2013; 184:705-13. [PMID: 23731685 DOI: 10.1016/j.jss.2013.04.082] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/25/2013] [Accepted: 04/30/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Activation of the P2X7 receptor on peripheral neurons causes the formation of pannexin pores, which allows the influx of calcium across the cell membrane. Polyethylene glycol (PEG) and methylene blue have previously been shown to delay Wallerian degeneration if applied during microsuture repair of the severed nerve. Our hypothesis is that by modulating calcium influx via the P2X7 receptor pathway, we could improve PEG-based axonal repair. The P2X7 receptor can be stimulated or inhibited using bz adenosine triphosphate (bzATP) or brilliant blue (FCF), respectively. METHODS A single incision rat sciatic nerve injury model was used. The defect was repaired using a previously described PEG methylene blue fusion protocol. Experimental animals were treated with 100 μL of 100 μM FCF solution (n = 8) or 100 μL of a 30 μM bzATP solution (n = 6). Control animals received no FCF, bzATP, or PEG. Compound action potentials were recorded prior to transection (baseline), immediately after repair, and 21 d postoperatively. Animals underwent behavioral testing 3, 7, 14, and 21 d postoperatively. After sacrifice, nerves were fixed, sectioned, and immunostained to allow for counting of total axons. RESULTS Rats treated with FCF showed an improvement compared with control at all time points (n = 8) (P = 0.047, 0.044, 0.014, and 0.0059, respectively). A statistical difference was also shown between FCF and bzATP at d 7 (P < 0.05), but not shown with d 3, 14, and 21 (P > 0.05). CONCLUSIONS Blocking the P2X7 receptor improves functional outcomes after PEG-mediated axonal fusion.
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Boeltz T, Ireland M, Mathis K, Nicolini J, Poplavski K, Rose SJ, Wilson E, English AW. Effects of treadmill training on functional recovery following peripheral nerve injury in rats. J Neurophysiol 2013; 109:2645-57. [PMID: 23468390 DOI: 10.1152/jn.00946.2012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Exercise, in the form of moderate daily treadmill training following nerve transection and repair leads to enhanced axon regeneration, but its effect on functional recovery is less well known. Female rats were exercised by walking continuously, at a slow speed (10 m/min), for 1 h/day on a level treadmill, beginning 3 days after unilateral transection and surgical repair of the sciatic nerve, and conducted 5 days/wk for 2 wk. In Trained rats, both direct muscle responses to tibial nerve stimulation and H reflexes in soleus reappeared earlier and increased in amplitude more rapidly over time than in Untrained rats. The efficacy of the restored H reflex was greater in Trained rats than in Untrained controls. The reinnervated tibialis anterior and soleus were coactivated during treadmill locomotion in Untrained rats. In Trained animals, the pattern of activation of soleus, but not tibialis anterior, was not significantly different from that found in Intact rats. The overall length of the hindlimb during level and up- and downslope locomotion was conserved after nerve injury in both groups. This conservation was achieved by changes in limb orientation. Limb length was conserved effectively in all rats during downslope walking but only in Trained rats during level and upslope walking. Moderate daily exercise applied immediately after sciatic nerve transection is sufficient to promote axon regeneration, to restore muscle reflexes, and to improve the ability of rats to cope with different biomechanical demands of slope walking.
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Affiliation(s)
- Tiffany Boeltz
- Dept. of Cell Biology, Emory Univ. School of Medicine, 615 Michael St., Atlanta, GA 30322, USA
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Kumai Y, Aoyama T, Nishimoto K, Sanuki T, Minoda R, Yumoto E. Recurrent Laryngeal Nerve Regeneration through a Silicone Tube Produces Reinnervation without Vocal Fold Mobility in Rats. Ann Otol Rhinol Laryngol 2013; 122:49-53. [DOI: 10.1177/000348941312200109] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: We established an animal model of recurrent laryngeal nerve reinnervation with persistent vocal fold immobility following recurrent laryngeal nerve injury. Methods: In 36 rats, the left recurrent laryngeal nerve was transected and the stumps were abutted in a silicone tube with a 1-mm interspace, facilitating regeneration. The mobility of the vocal folds was examined endoscopically 5, 10, and 15 weeks later. Electromyography of the thyroarytenoid muscle was performed. Reinnervation was assessed by means of a quantitative immunohistologic evaluation with anti-neurofilament antibody in the nerve both proximal and distal to the silicone tube. The atrophy of the thyroarytenoid muscle was assessed histologically. Results: We observed that all animals had a fixed left vocal fold throughout the study. The average neurofilament expression in the nerve both distal and proximal to the silicone tube, the muscle area, and the amplitude of the compound muscle action potential recorded from the thyroarytenoid muscle on the treated side increased significantly (p < 0.05) over time, demonstrating regeneration through the silicone tube. Conclusions: Recurrent laryngeal nerve regeneration through a silicone tube produced reinnervation without vocal fold mobility in rats. The efficacy of new laryngeal reinnervation treatments can be assessed with this model.
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Klimaschewski L, Hausott B, Angelov DN. The pros and cons of growth factors and cytokines in peripheral axon regeneration. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2013; 108:137-71. [PMID: 24083434 DOI: 10.1016/b978-0-12-410499-0.00006-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Injury to a peripheral nerve induces a complex cellular and molecular response required for successful axon regeneration. Proliferating Schwann cells organize into chains of cells bridging the lesion site, which is invaded by macrophages. Approximately half of the injured neuron population sends out axons that enter the glial guidance channels in response to secreted neurotrophic factors and neuropoietic cytokines. These lesion-associated polypeptides create an environment that is highly supportive for axon regrowth, particularly after acute injury, and ensure that the vast majority of regenerating axons are directed toward the distal nerve stump. Unfortunately, most neurotrophic factors and neuropoietic cytokines are also strong stimulators of axonal sprouting. Although some of the axonal branches will withdraw at later stages, the sprouting effect contributes to the misdirection of reinnervation that results in the lack of functional recovery observed in many patients with peripheral nerve injuries. Here, we critically review the role of neuronal growth factors and cytokines during axon regeneration in the peripheral nervous system. Their differential effects on axon elongation and sprouting were elucidated in various studies on intraneuronal signaling mechanisms following nerve lesion. The present data define a goal for future therapeutic strategies, namely, to selectively stimulate a Ras/Raf/ERK-mediated axon elongation program over an intrinsic PI3K-dependent axonal sprouting program in lesioned motor and sensory neurons. Instead of modulating growth factor or cytokine levels at the lesion site, targeting specific intraneuronal molecules, such as the negative feedback inhibitors of ERK signaling, has been shown to promote long-distance regeneration while avoiding sprouting of regenerating axons until they have reached their target areas.
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Affiliation(s)
- Lars Klimaschewski
- Division of Neuroanatomy, Department of Anatomy and Histology, Innsbruck Medical University, Innsbruck, Austria
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Sexton KW, Pollins AC, Cardwell NL, Del Corral GA, Bittner GD, Shack RB, Nanney LB, Thayer WP. Hydrophilic polymers enhance early functional outcomes after nerve autografting. J Surg Res 2012; 177:392-400. [PMID: 22521220 DOI: 10.1016/j.jss.2012.03.049] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 03/07/2012] [Accepted: 03/22/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Approximately 12% of operations for traumatic neuropathy are for patients with segmental nerve loss, and less than 50% of these injuries obtain meaningful functional recovery. Polyethylene glycol (PEG) therapy has been shown to improve functional outcomes after nerve severance, and we hypothesized this therapy could also benefit nerve autografting. METHODS We used a segmental rat sciatic nerve injury model in which we repaired a 0.5-cm defect with an autograft using microsurgery. We treated experimental animals with solutions containing methylene blue (MB) and PEG; control animals did not receive PEG. We recorded compound action potentials (CAPs) before nerve transection, after solution therapy, and at 72 h postoperatively. The animals underwent behavioral testing at 24 and 72 h postoperatively. After we euthanized the animals, we fixed the nerves, sectioned and immunostained them to allow for quantitative morphometric analysis. RESULTS The introduction of hydrophilic polymers greatly improved morphological and functional recovery of rat sciatic axons at 1-3 d after nerve autografting. Polyethylene glycol therapy restored CAPs in all animals, and CAPs were still present 72 h postoperatively. No CAPS were detectable in control animals. Foot Fault asymmetry scores and sciatic functional index scores were significantly improved for PEG therapy group at all time points (P < 0.05 and P < 0.001; P < 0.001 and P < 0.01). Sensory and motor axon counts were increased distally in nerves treated with PEG compared with control (P = 0.019 and P = 0.003). CONCLUSIONS Polyethylene glycol therapy improves early physiologic function, behavioral outcomes, and distal axonal density after nerve autografting.
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Affiliation(s)
- Kevin W Sexton
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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29
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Hizay A, Ozsoy U, Demirel BM, Ozsoy O, Angelova SK, Ankerne J, Sarikcioglu SB, Dunlop SA, Angelov DN, Sarikcioglu L. Use of a Y-Tube Conduit After Facial Nerve Injury Reduces Collateral Axonal Branching at the Lesion Site But Neither Reduces Polyinnervation of Motor Endplates Nor Improves Functional Recovery. Neurosurgery 2012; 70:1544-56; discussion 1556. [DOI: 10.1227/neu.0b013e318249f16f] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND:
Despite increased understanding of peripheral nerve regeneration, functional recovery after surgical repair remains disappointing. A major contributing factor is the extensive collateral branching at the lesion site, which leads to inaccurate axonal navigation and aberrant reinnervation of targets.
OBJECTIVE:
To determine whether the Y tube reconstruction improved axonal regrowth and whether this was associated with improved function.
METHODS:
We used a Y-tube conduit with the aim of improving navigation of regenerating axons after facial nerve transection in rats.
RESULTS:
Retrograde labeling from the zygomatic and buccal branches showed a halving in the number of double-labeled facial motor neurons (15% vs 8%; P < .05) after Y tube reconstruction compared with facial-facial anastomosis coaptation. However, in both surgical groups, the proportion of polyinnervated motor endplates was similar (∼30%; P > .05), and video-based motion analysis of whisking revealed similarly poor function.
CONCLUSION:
Although Y-tube reconstruction decreases axonal branching at the lesion site and improves axonal navigation compared with facial-facial anastomosis coaptation, it fails to promote monoinnervation of motor endplates and confers no functional benefit.
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Affiliation(s)
- Arzu Hizay
- Department of Anatomy, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | - Umut Ozsoy
- Department of Anatomy, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | | | - Ozlem Ozsoy
- Department of Physiology, Akdeniz University Faculty of Medicine, Antalya, Turkey
| | | | - Janina Ankerne
- Anatomical Institute I, University of Cologne, Cologne, Germany
| | | | - Sarah A. Dunlop
- School of Animal Biology and Western Australian Institute for Medical Research, University of Western Australia, Crawley, Western Australia, Australia
| | | | - Levent Sarikcioglu
- Department of Anatomy, Akdeniz University Faculty of Medicine, Antalya, Turkey
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Hoyng SA, Tannemaat MR, De Winter F, Verhaagen J, Malessy MJA. Nerve surgery and gene therapy: a neurobiological and clinical perspective. J Hand Surg Eur Vol 2011; 36:735-46. [PMID: 21914696 DOI: 10.1177/1753193411420348] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Despite major microsurgical improvements the clinical outcome of peripheral nerve surgery is still regarded as suboptimal. Over the past decade several innovative techniques have been developed to extend the armamentarium of the nerve surgeon. This review evaluates the potential of gene therapy in the context of peripheral nerve repair. First the main challenges impeding peripheral nerve regeneration are presented. This is followed by a short introduction to gene therapy and an overview of its most important advantages over the classical delivery of therapeutic proteins. Next, this review focuses on the most promising viral vectors capable of targeting the peripheral nervous system and their first application in animal models. In addition, the challenges of translating these experimental results to the clinic, the limitations of current vectors and the further developments needed, are discussed. Finally, four strategies are presented on how gene therapy could help patients that have to undergo reconstructive nerve surgery in the future.
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Affiliation(s)
- S A Hoyng
- Laboratory for Neuroregeneration, Netherlands Institute for Neuroscience, Royal Academy of Arts and Sciences, Amsterdam, The Netherlands.
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English AW, Wilhelm JC, Sabatier MJ. Enhancing recovery from peripheral nerve injury using treadmill training. Ann Anat 2011; 193:354-61. [PMID: 21498059 PMCID: PMC3137663 DOI: 10.1016/j.aanat.2011.02.013] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 02/03/2011] [Accepted: 02/22/2011] [Indexed: 12/25/2022]
Abstract
Full functional recovery after traumatic peripheral nerve injury is rare. We postulate three reasons for the poor functional outcome measures observed. Axon regeneration is slow and not all axons participate. Significant misdirection of regenerating axons to reinnervate inappropriate targets occurs. Seemingly permanent changes in neural circuitry in the central nervous system are found to accompany axotomy of peripheral axons. Exercise in the form of modest daily treadmill training impacts all three of these areas. Compared to untrained controls, regenerating axons elongate considerably farther in treadmill trained animals and do so via an autocrine/paracrine neurotrophin signaling pathway. This enhancement of axon regeneration takes place without an increase in the amount of misdirection of regenerating axons found without training. The enhancement also occurs in a sex-dependent manner. Slow continuous training is effective only in males, while more intense interval training is effective only in females. In treadmill trained, but not untrained mice the extent of coverage of axotomized motoneurons is maintained, thus preserving important elements of the spinal circuitry.
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Affiliation(s)
- Arthur W English
- Department of Cell Biology, Emory University School of Medicine, 615 Michael Street, Atlanta, GA 30322, USA.
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Stump rotation in a nerve autograft by 2 factors: cross-connection and difference in diameter. J Craniofac Surg 2011; 22:1087-92. [PMID: 21586951 DOI: 10.1097/scs.0b013e31821076f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The aim of this study was to determine the influence of stump rotation (fascicular cross-connection) on nerve autograft functional recovery. Thirty rat sciatic nerves were transected and repaired by autograft. The rats were divided into 3 groups according to the number of stump rotations of the autograft: (1) plain graft (PG-g, with no change in fascicular orientation, no difference in diameter), (2) graft rotation (GR-g, with no change in fascicular orientation, and diameter difference between fascicles), (3) stump rotation (SR-g, with cross-connection and diameter difference between fascicles). Relative gastrocnemius muscle weight and nerve fiber count were examined as anatomic recovery indices, and autotomy score (ATS) and toe-out angle as functional recovery indices. The results showed that SR-g had a significantly low functional recovery compared with PG-g and GR-g. However, there was no difference found in the anatomic recovery. These findings suggest that the stump rotation in nerve autograft had no effect on neural regeneration and muscle reinnervation; however, it had a negative effect on functional recovery. Because GR-g was similar to PG-g rather than SR-g in functional recovery, the diameter difference between fascicles appears to have had little effect on the functional recovery. The results of this study suggest that a novel approach to ATS interpretation is needed. It is recommended that (1) ATS 2 be considered the onset of autotomy instead of ATS 1; and (2) the frequency of "ATS 2 and above" should be considered for the comparison of the autotomy rather than the mean ATS.
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Skouras E, Ozsoy U, Sarikcioglu L, Angelov DN. Intrinsic and therapeutic factors determining the recovery of motor function after peripheral nerve transection. Ann Anat 2011; 193:286-303. [PMID: 21458252 DOI: 10.1016/j.aanat.2011.02.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 02/03/2011] [Accepted: 02/04/2011] [Indexed: 01/01/2023]
Abstract
Insufficient recovery after peripheral nerve injury has been attributed to (i) poor pathfinding of regrowing axons, (ii) excessive collateral axonal branching at the lesion site and (iii) polyneuronal innervation of the neuromuscular junctions (NMJ). The facial nerve transection model has been used initially to measure restoration of function after varying therapies and to examine the mechanisms underlying their effects. Since it is very difficult to control the navigation of several thousand axons, efforts concentrated on collateral branching and NMJ-polyinnervation. Treatment with antibodies against trophic factors to combat branching improved the precision of reinnervation, but had no positive effects on functional recovery. This suggested that polyneuronal reinnervation--rather than collateral branching--may be the critical limiting factor. The former could be reduced by pharmacological agents known to perturb microtubule assembly and was followed by recovery of function. Because muscle polyinnervation is activity-dependent and can be manipulated, attempts to design a clinically feasible therapy were performed by electrical stimulation or by soft tissue massage. Electrical stimulation applied to the transected facial nerve or to paralysed facial muscles did not improve vibrissal motor performance and failed to diminish polyinnervation. In contrast, gentle stroking of the paralysed muscles (vibrissal, orbicularis oculi, tongue musculature) resulted in full recovery of function. This manual stimulation was also effective after hypoglossal-facial nerve suture and after interpositional nerve grafting, but not after surgical reconstruction of the median nerve. All these findings raise hopes that clinically feasible and effective therapies could be soon designed and tested.
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Affiliation(s)
- Emmanouil Skouras
- Department of Orthopedics and Traumatology, University of Cologne, Joseph-Stelzmann-Strasse 9, Cologne, Germany
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Siemionow M, Bozkurt M, Zor F. Regeneration and repair of peripheral nerves with different biomaterials: review. Microsurgery 2011; 30:574-88. [PMID: 20878689 DOI: 10.1002/micr.20799] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Maria Siemionow
- Department of Plastic Surgery, The Cleveland Clinic, Cleveland, OH 44195, USA.
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35
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Hamilton SK, Hinkle ML, Nicolini J, Rambo LN, Rexwinkle AM, Rose SJ, Sabatier MJ, Backus D, English AW. Misdirection of regenerating axons and functional recovery following sciatic nerve injury in rats. J Comp Neurol 2011; 519:21-33. [PMID: 21120925 PMCID: PMC3703664 DOI: 10.1002/cne.22446] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Poor functional recovery found after peripheral nerve injury has been attributed to the misdirection of regenerating axons to reinnervate functionally inappropriate muscles. We applied brief electrical stimulation (ES) to the common fibular (CF) but not the tibial (Tib) nerve just prior to transection and repair of the entire rat sciatic nerve, to attempt to influence the misdirection of its regenerating axons. The specificity with which regenerating axons reinnervated appropriate targets was evaluated physiologically using compound muscle action potentials (M responses) evoked from stimulation of the two nerve branches above the injury site. Functional recovery was assayed using the timing of electromyography (EMG) activity recorded from the tibialis anterior (TA) and soleus (Sol) muscles during treadmill locomotion and kinematic analysis of hindlimb locomotor movements. Selective ES of the CF nerve resulted in restored M-responses at earlier times than in unstimulated controls in both TA and Sol muscles. Stimulated CF axons reinnervated inappropriate targets to a greater extent than unstimulated Tib axons. During locomotion, functional antagonist muscles, TA and Sol, were coactivated both in stimulated rats and in unstimulated but injured rats. Hindlimb kinematics in stimulated rats were comparable to untreated rats, but significantly different from intact controls. Selective ES promotes enhanced axon regeneration but does so with decreased fidelity of muscle reinnervation. Functional recovery is neither improved nor degraded, suggesting that compensatory changes in the outputs of the spinal circuits driving locomotion may occur irrespective of the extent of misdirection of regenerating axons in the periphery.
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Affiliation(s)
- Shirley K. Hamilton
- Division of Physical Therapy, Emory University, School of Medicine, Atlanta, Georgia
| | - Marcus L. Hinkle
- Division of Physical Therapy, Emory University, School of Medicine, Atlanta, Georgia
| | - Jennifer Nicolini
- Department of Cell Biology, Emory University, School of Medicine, Atlanta, Georgia
| | - Lindsay N. Rambo
- Division of Physical Therapy, Emory University, School of Medicine, Atlanta, Georgia
| | - April M. Rexwinkle
- Division of Physical Therapy, Emory University, School of Medicine, Atlanta, Georgia
| | - Sam J. Rose
- Department of Cell Biology, Emory University, School of Medicine, Atlanta, Georgia
| | | | - Deborah Backus
- Division of Physical Therapy, Emory University, School of Medicine, Atlanta, Georgia
| | - Arthur W. English
- Department of Cell Biology, Emory University, School of Medicine, Atlanta, Georgia
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Treatment of acute peripheral nerve injuries: current concepts. J Hand Surg Am 2010; 35:491-7; quiz 498. [PMID: 20138714 DOI: 10.1016/j.jhsa.2009.12.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 12/06/2009] [Indexed: 02/02/2023]
Abstract
Although clinical outcomes of peripheral nerve injuries are often suboptimal, an adherence to well-established basic principles of evaluation and repair can optimize results of even the most complex injuries. Proper assessment of injury patterns both preoperatively and intraoperatively can guide treatment, and multiple repair techniques including strategies for overcoming both small and large gaps offer different advantages and disadvantages. New technologies and ideas address some unsolved problems, but more experience and research is necessary to elucidate fully their roles in the treatment algorithm.
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Kawamura DH, Johnson PJ, Moore AM, Magill CK, Hunter DA, Ray WZ, Tung THH, Mackinnon SE. Matching of motor-sensory modality in the rodent femoral nerve model shows no enhanced effect on peripheral nerve regeneration. Exp Neurol 2010; 223:496-504. [PMID: 20122927 DOI: 10.1016/j.expneurol.2010.01.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 01/21/2010] [Accepted: 01/23/2010] [Indexed: 11/27/2022]
Abstract
The treatment of peripheral nerve injuries with nerve gaps largely consists of autologous nerve grafting utilizing sensory nerve donors. Underlying this clinical practice is the assumption that sensory autografts provide a suitable substrate for motoneuron regeneration, thereby facilitating motor endplate reinnervation and functional recovery. This study examined the role of nerve graft modality on axonal regeneration, comparing motor nerve regeneration through motor, sensory, and mixed nerve isografts in the Lewis rat. A total of 100 rats underwent grafting of the motor or sensory branch of the femoral nerve with histomorphometric analysis performed after 5, 6, or 7 weeks. Analysis demonstrated similar nerve regeneration in motor, sensory, and mixed nerve grafts at all three time points. These data indicate that matching of motor-sensory modality in the rat femoral nerve does not confer improved axonal regeneration through nerve isografts.
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Affiliation(s)
- David H Kawamura
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, 660 South Euclid Ave, St. Louis, MO 63110-1010, USA
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Hood B, Levene HB, Levi AD. Transplantation of autologous Schwann cells for the repair of segmental peripheral nerve defects. Neurosurg Focus 2009; 26:E4. [PMID: 19435444 DOI: 10.3171/foc.2009.26.2.e4] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Peripheral nerve injuries are a source of chronic disability. Incomplete recovery from such injuries results in motor and sensory dysfunction and the potential for the development of chronic pain. The repair of human peripheral nerve injuries with traditional surgical techniques has limited success, particularly when a damaged nerve segment needs to be replaced. An injury to a long segment of peripheral nerve is often repaired using autologous grafting of "noncritical" sensory nerve. Although extensive axonal regeneration can be observed extending into these grafts, recovery of function may be absent or incomplete if the axons fail to reach their intended target. The goal of this review was to summarize the progress that has occurred in developing an artificial neural prosthesis consisting of autologous Schwann cells (SCs), and to detail future directions required in translating this promising therapy to the clinic. In the authors' laboratory, methods are being explored to combine autologous SCs isolated using cell culture techniques with axon guidance channel (AGC) technology to develop the potential to repair critical gap length lesions within the peripheral nervous system. To test the clinical efficacy of such constructs, it is critically important to characterize the fate of the transplanted SCs with regard to cell survival, migration, differentiation, and myelin production. The authors sought to determine whether the use of SC-filled channels is superior or equivalent to strategies that are currently used clinically (for example, autologous nerve grafts). Finally, although many nerve repair paradigms demonstrate evidence of regeneration within the AGC, the authors further sought to determine if the regeneration observed was physiologically relevant by including electrophysiological, behavioral, and pain assessments. If successful, the development of this reparative approach will bring together techniques that are readily available for clinical use and should rapidly accelerate the process of bringing an effective nerve repair strategy to patients with peripheral nerve injury prior to the development of pain and chronic disability.
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Affiliation(s)
- Brian Hood
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida 33136, USA
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39
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de Ruiter GCW, Spinner RJ, Yaszemski MJ, Windebank AJ, Malessy MJA. Nerve tubes for peripheral nerve repair. Neurosurg Clin N Am 2009; 20:91-105, vii. [PMID: 19064182 DOI: 10.1016/j.nec.2008.08.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The concept of the nerve tube has been a major topic of research in the field of peripheral nerve regeneration for more than 25 years. The first nerve tubes are currently available for clinical use. This article gives an overview of the experimental and clinical data on nerve tubes for peripheral nerve repair and critically analyzes the data on which the step from laboratory to clinical use is based. In addition, it briefly discusses the different modifications to the common single lumen nerve tubes that may improve the results of generation.
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Affiliation(s)
- Godard C W de Ruiter
- Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
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40
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de Ruiter GC, Spinner RJ, Malessy MJA, Moore MJ, Sorenson EJ, Currier BL, Yaszemski MJ, Windebank AJ. Accuracy of motor axon regeneration across autograft, single-lumen, and multichannel poly(lactic-co-glycolic acid) nerve tubes. Neurosurgery 2009; 63:144-53; discussion 153-5. [PMID: 18728579 DOI: 10.1227/01.neu.0000335081.47352.78] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE The accuracy of motor axon regeneration becomes an important issue in the development of a nerve tube for motor nerve repair. Dispersion of regeneration across the nerve tube may lead to misdirection and polyinnervation. In this study, we present a series of methods to investigate the accuracy of regeneration, which we used to compare regeneration across autografts and single-lumen poly(lactic-co-glycolic acid) (PLGA) nerve tubes. We also present the concept of the multichannel nerve tube that may limit dispersion by separately guiding groups of regenerating axons. METHODS The simultaneous tracing of the tibial and peroneal nerves with fast blue and diamidino yellow was performed 8 weeks after the repair of a 1-cm nerve gap in the rat sciatic nerve to determine the percentage of double-projecting motoneurons. Sequential tracing of the peroneal nerve with diamidino yellow 1 week before repair and fast blue 8 weeks after repair was performed to determine the percentage of correctly directed peroneal motoneurons. RESULTS In the cases in which there was successful regeneration across single-lumen nerve tubes, more motoneurons had double projections to both the tibial and peroneal nerve branches after single-lumen nerve tube repair (21.4%) than after autograft repair (5.9%). After multichannel nerve tube repair, this percentage was slightly reduced (16.9%), although not significantly. The direction of regeneration was nonspecific after all types of repair. CONCLUSION Retrograde tracing techniques provide new insights into the process of regeneration across nerve tubes. The methods and data presented in this study can be used as a basis for the development of a nerve tube for motor nerve repair.
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Affiliation(s)
- Godard C de Ruiter
- Cellular Neurobiology Laboratory and Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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41
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Matsuda K, Kakibuchi M, Kubo T, Tomita K, Fujiwara T, Hattori R, Yano K, Hosokawa K. A new model of end-to-side nerve graft for multiple branch reconstruction: end-to-side cross-face nerve graft in rats. J Plast Reconstr Aesthet Surg 2008; 61:1357-67. [DOI: 10.1016/j.bjps.2008.04.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 04/09/2008] [Accepted: 04/10/2008] [Indexed: 11/29/2022]
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42
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de Ruiter GC, Spinner RJ, Malessy MJ, Moore MJ, Sorenson EJ, Currier BL, Yaszemski MJ, Windebank AJ. ACCURACY OF MOTOR AXON REGENERATION ACROSS AUTOGRAFT, SINGLE-LUMEN, AND MULTICHANNEL POLY(LACTIC-CO-GLYCOLIC ACID) NERVE TUBES. Neurosurgery 2008. [DOI: 10.1227/01.neu.0000319521.28683.75] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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43
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Grosheva M, Guntinas-Lichius O, Arnhold S, Skouras E, Kuerten S, Streppel M, Angelova SK, Wewetzer K, Radtke C, Dunlop SA, Angelov DN. Bone marrow-derived mesenchymal stem cell transplantation does not improve quality of muscle reinnervation or recovery of motor function after facial nerve transection in rats. Biol Chem 2008; 389:873-88. [DOI: 10.1515/bc.2008.100] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
AbstractRecently, we devised and validated a novel strategy in rats to improve the outcome of facial nerve reconstruction by daily manual stimulation of the target muscles. The treatment resulted in full recovery of facial movements (whisking), which was achieved by reducing the proportion of pathologically polyinnervated motor endplates. Here, we posed whether manual stimulation could also be beneficial after a surgical procedure potentially useful for treatment of large peripheral nerve defects, i.e., entubulation of the transected facial nerve in a conduit filled with suspension of isogeneic bone marrow-derived mesenchymal stem cells (BM-MSCs) in collagen. Compared to control treatment with collagen only, entubulation with BM-MSCs failed to decrease the extent of collateral axonal branching at the lesion site and did not improve functional recovery. Post-operative manual stimulation of vibrissal muscles also failed to promote a better recovery following entubulation with BM-MSCs. We suggest that BM-MSCs promote excessive trophic support for regenerating axons which, in turn, results in excessive collateral branching at the lesion site and extensive polyinnervation of the motor endplates. Furthermore, such deleterious effects cannot be overridden by manual stimulation. We conclude that entubulation with BM-MSCs is not beneficial for facial nerve repair.
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44
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Acar M, Karacalar A, Ayyildiz M, Unal B, Canan S, Agar E, Kaplan S. The effect of autogenous vein grafts on nerve repair with size discrepancy in rats: An electrophysiological and stereological analysis. Brain Res 2008; 1198:171-81. [DOI: 10.1016/j.brainres.2008.01.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Revised: 01/02/2008] [Accepted: 01/03/2008] [Indexed: 12/21/2022]
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45
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de Ruiter GCW, Malessy MJA, Alaid AO, Spinner RJ, Engelstad JK, Sorenson EJ, Kaufman KR, Dyck PJ, Windebank AJ. Misdirection of regenerating motor axons after nerve injury and repair in the rat sciatic nerve model. Exp Neurol 2008; 211:339-50. [PMID: 18448099 DOI: 10.1016/j.expneurol.2007.12.023] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 12/14/2007] [Accepted: 12/15/2007] [Indexed: 10/22/2022]
Abstract
Misdirection of regenerating axons is one of the factors that can explain the poor results often found after nerve injury and repair. In this study, we quantified the degree of misdirection and the effect on recovery of function after different types of nerve injury and repair in the rat sciatic nerve model; crush injury, direct coaptation, and autograft repair. Sequential tracing with retrograde labeling of the peroneal nerve before and 8 weeks after nerve injury and repair was performed to quantify the accuracy of motor axon regeneration. Digital video analysis of ankle motion was used to investigate the recovery of function. In addition, serial compound action potential recordings and nerve and muscle morphometry were performed. In our study, accuracy of motor axon regeneration was found to be limited; only 71% (+/-4.9%) of the peroneal motoneurons were correctly directed 2 months after sciatic crush injury, 42% (+/-4.2%) after direct coaptation, and 25% (+/-6.6%) after autograft repair. Recovery of ankle motion was incomplete after all types of nerve injury and repair and demonstrated a disturbed balance of ankle plantar and dorsiflexion. The number of motoneurons from which axons had regenerated was not significantly different from normal. The number of myelinated axons was significantly increased distal to the site of injury. Misdirection of regenerating motor axons is a major factor in the poor recovery of nerves that innervate different muscles. The results of this study can be used as basis for developing new nerve repair techniques that may improve the accuracy of regeneration.
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46
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Vleggeert-Lankamp CLAM. The role of evaluation methods in the assessment of peripheral nerve regeneration through synthetic conduits: a systematic review. J Neurosurg 2007; 107:1168-89. [DOI: 10.3171/jns-07/12/1168] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
A number of evaluation methods that are currently used to compare peripheral nerve regeneration with alternative repair methods and to judge the outcome of a new paradigm were hypothesized to lack resolving power. This would too often lead to the conclusion that the outcome of a new paradigm could not be discerned from the outcome of the current gold standard, the autograft. As a consequence, the new paradigm would incorrectly be judged as successful.
Methods
An overview of the methods that were used to evaluate peripheral nerve regeneration after grafting of the rat sciatic nerve was prepared. All articles that were published between January 1975 and December 2004 and concerned grafting of the rat sciatic nerve (minimum graft length 5 mm) and in which the experimental method was compared with an untreated or another grafted nerve were included. The author scored the presence of statistically significant differences between paradigms.
Results
Evaluation of nerve fiber count, nerve fiber density, N-ratio, nerve histological success ratio, compound muscle action potential, muscle weight, and muscle tetanic force are methods that were demonstrated to have resolving power.
Conclusions
A number of evaluation methods are not suitable to demonstrate a significant difference between experimental paradigms in peripheral nerve regeneration. It is preferable to apply a combination of evaluation methods with resolving power to evaluate nerve regeneration properly.
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47
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Suarez V, Guntinas-Lichius O, Streppel M, Ingorokva S, Grosheva M, Neiss WF, Angelov DN, Klimaschewski L. The axotomy-induced neuropeptides galanin and pituitary adenylate cyclase-activating peptide promote axonal sprouting of primary afferent and cranial motor neurones. Eur J Neurosci 2007; 24:1555-64. [PMID: 17004919 DOI: 10.1111/j.1460-9568.2006.05029.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The neuropeptides galanin and pituitary adenylate cyclase-activating peptide (PACAP) are markedly up-regulated in response to peripheral nerve lesion. Both peptides are involved in neuronal differentiation and neurite outgrowth during development. In this study, we investigated the effects of galanin and PACAP on axonal elongation and sprouting by adult rat sensory neurones in vitro and facial motor neurones in vivo. Dissociated rat dorsal root ganglion neurones were plated on laminin substrate and analysed morphometrically. Both the mean axonal length and the number of branch points significantly increased in the presence of galanin or PACAP (2-5 microm). Effects on axonal collateralization were investigated in the rat facial nerve lesion model by direct application of the peptides to collagen-filled conduits entubulating the transected facial nerve stumps. Triple retrograde labelling of brainstem neurones confirmed that the peptides potently induce axonal sprouting of cranial motor neurones. The number of neurones regenerating into identified rami of the facial nerve increased up to fivefold. Biometrical analysis of whisking behaviour revealed that galanin and PACAP impaired the functional outcome when compared with vehicle-treated animals 8 weeks after surgery. In conclusion, although galanin and PACAP have been established as neurotrophic molecules with respect to axonal development and regeneration, their potential as treatments for peripheral nerve lesions appears limited because of the extensive stimulation of collateral axon branching. These branches are misrouted towards incorrect muscles and cause impairment in their coordinated activity.
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Affiliation(s)
- Victor Suarez
- Institut für Anatomie, Universität zu Köln, Köln, Germany
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48
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Tomita K, Kubo T, Matsuda K, Hattori R, Fujiwara T, Yano K, Hosokawa K. Effect of conduit repair on aberrant motor axon growth within the nerve graft in rats. Microsurgery 2007; 27:500-9. [PMID: 17596896 DOI: 10.1002/micr.20394] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
After peripheral nerve injury, minimizing axonal misdirection has been a matter of importance to obtain good functional outcomes. In general, it becomes more challenging as the nerve defect length is longer. As previous works suggested that a conduit repair leaving a short gap could induce some target-specific reinnervation, we expected that a distally placed conduit combined with nerve graft would enhance the specificity of reinnervation, especially in dealing with a long gap. To test this, a 14-mm-long gap was created in the rat sciatic nerves and repaired with either 1) whole nerve graft (WG), 2) interfascicular nerve grafts (FG), or 3) whole nerve graft combined with distally placed silicone tube leaving a 5-mm gap (TUBG). At the end of follow up, the extent of target specific reinnervation (measurement of the compound muscle action potentials evoked by stimulation of the sciatic nerve and its tibial and common peroneal fascicles) and the accuracy of motoneuronal projection (sequential retrograde labeling of the common peroneal motor pool) were assessed. Both assessments revealed that groups FG and TUBG had a similar selectivity, which was significantly higher than in group WG. Consistent with these results, the functional recovery as assessed by walking track analysis showed no significant difference between groups FG and TUBG, whereas those were significantly superior to group WG. In contrast, histomorphometric assessment of the regenerating axons and wet muscle weight showed no significant difference among the three groups. In conclusion, conduit repair would have some effects on reducing motor axonal misdirection, and it might be more effective when used in the management of a large defect in combination with nerve graft.
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Affiliation(s)
- Koichi Tomita
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
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Lago N, Rodríguez FJ, Guzmán MS, Jaramillo J, Navarro X. Effects of motor and sensory nerve transplants on amount and specificity of sciatic nerve regeneration. J Neurosci Res 2007; 85:2800-12. [PMID: 17455293 DOI: 10.1002/jnr.21286] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Nerve regeneration after complete transection does not allow for adequate functional recovery mainly because of lack of selectivity of target reinnervation. We assessed if transplanting a nerve segment from either motor or sensory origin may improve specifically the accuracy of sensory and motor reinnervation. For this purpose, the rat sciatic nerve was transected and repaired with a silicone guide containing a predegenerated segment of ventral root (VR) or dorsal root (DR), compared to a silicone guide filled with saline. Nerve regeneration and reinnervation was assessed during 3 months by electrophysiologic and functional tests, and by nerve morphology and immunohistochemistry against choline acetyltransferase (ChAT) for labeling motor axons. Functional tests showed that reinnervation was successful in all the rats. However, the two groups with a root allotransplant reached higher degrees of reinnervation in comparison with the control group. Group VR showed the highest reinnervation of muscle targets, whereas Group DR had higher levels of sensory reinnervation than VR and saline groups. The total number of regenerated myelinated fibers was similar in the three groups, but the number of ChAT+ fibers was slightly lower in the VR group in comparison with DR and saline groups. These results indicate that a predegenerated root nerve allotransplant enhances axonal regeneration, leading to faster and higher levels of functional recovery. Although there is not clear preferential reinnervation, regeneration of motor axons is promoted at early times by a motor graft, whereas reinnervation of sensory pathways is increased by a sensory graft.
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Affiliation(s)
- Natalia Lago
- Group of Neuroplasticity and Regeneration, Department of Cell Biology, Physiology and Immunology, and Institute of Neuroscience, Universitat Autònoma de Barcelona, Bellaterra, Spain
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50
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English AW, Chen Y, Carp JS, Wolpaw JR, Chen XY. Recovery of electromyographic activity after transection and surgical repair of the rat sciatic nerve. J Neurophysiol 2006; 97:1127-34. [PMID: 17122310 DOI: 10.1152/jn.01035.2006] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The recovery of soleus (SOL), gastrocnemius (GAS), and tibialis anterior (TA) electromyographic activity (EMG) after transection and surgical repair of the sciatic nerve was studied in Sprague-Dawley rats using chronically implanted stimulation and recording electrodes. Spontaneous EMG activity in SOL and GAS and direct muscle (M) responses to posterior tibial nerve stimulation persisted for < or =2 days after sciatic nerve transection, but SOL and GAS H-reflexes disappeared immediately. Spontaneous EMG activity began to return 2-3 wk after transection, rose nearly to pretransection levels by 60 days, and persisted for the duration of the study period (120 days). Recovery of stimulus-evoked EMG responses began about 30 days after sciatic nerve transection as multiple small responses with a wide range of latencies. Over time, the latencies of these fractionated responses shortened, their amplitudes increased, and they merged into a distinct short-latency component (the putative M response) and a distinct long-latency component (the putative H-reflex). The extent of recovery of stimulation-evoked EMG was modest: even 100 days after sciatic nerve transection, the responses were still much smaller than those before transection. Similar gradual development of responses to posterior tibial nerve stimulation was also seen in TA, suggesting that some regenerating fibers sent branches into both tibial and common peroneal nerves.
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Affiliation(s)
- Arthur W English
- Department of Cell Biology, Emory University School of Medicine, 615 Michael Street, Room 405P, Atlanta, GA 30322, USA.
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