Nerve regeneration through artificial tubular implants

Nerve Capping Techniques for Neuroma Management: A Comprehensive Literature Review

BACKGROUND/AIM OF THE STUDY

Nerve capping is a method of neuroma treatment or prevention that consists of the transplantation of a proximal nerve stump into an autograft or other material cap, after surgical removal of the neuroma or transection of the nerve. The aim was to reduce neuroma formation and symptoms by preventing neuronal adhesions and scar tissue. In this narrative literature review, we summarize the studies that have investigated the effectiveness of nerve capping for neuroma management to provide clarity and update the clinician's knowledge on the topic.

METHODS

A systematic electronic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria was performed in the PubMed database combining "neuroma," "nerve," "capping," "conduit," "treatment," "management," "wrap," "tube," and "surgery" as search terms. English-language clinical studies on humans and animals that described nerve capping as a treatment/prevention technique for neuromas were then selected based on a full-text article review. The data from the included studies were compiled based on the technique and material used for nerve capping, and technique and outcomes were reviewed.

RESULTS

We found 10 applicable human studies from our literature search. Several capping materials were described: epineurium, nerve, muscle, collagen nerve conduit, Neurocap (synthetic copolymer of lactide and caprolactone, which is biocompatible and resorbable), silicone rubber, and collagen. Overall, 146 patients were treated in the clinical studies. After surgery, many patients were completely pain-free or had considerable improvement in pain scores, whereas some patients did not have improvement or were not satisfied after the procedure. Nerve capping was used in 18 preclinical animal studies, using a variety of capping materials including autologous tissues, silicone, and synthetic nanofibers. Preclinical studies demonstrated successful reduction in rates of neuroma formation.

CONCLUSIONS

Nerve capping has undergone major advancements since its beginnings and is now a useful option for the treatment or prevention of neuromas. As knowledge of peripheral nerve injuries and neuroma prevention grows, the criterion standard neuroprotective material for enhancement of nerve regeneration can be identified and applied to produce reliable surgical outcomes.

Magnetothermal spider silk-based scaffolds for cartilage regeneration

Developing biocompatible, magnetically controlled polymers is a multifunctional solution to many surgical complications. By combining nanoparticle technology with the latest advancements in polymer materials science, we created a multicomponent hybrid system comprised of a robust native spider silk-based matrix; a Mn0.9Zn0.1Fe2O4 nanoparticles coating to provide a controlled thermal trigger for drug release; and liposomes, which act as drug carriers. Fluorescent microscope images show that the dye loaded into the liposomes is released when the system is exposed to an alternating magnetic field due to heating of ferromagnetic nanoparticles, which had a low Curie temperature (40-46°С). The silk matrix also demonstrated outstanding biocompatibility, creating a favorable environment for human postnatal fibroblast cell adhesion, and paving the way for their directed growth. This paper describes a complex approach to cartilage regeneration by developing a spider silk-based scaffold with anatomical mechanical properties for controlled drug delivery in a multifunctional autologous matrix-induced chondrogenesis.

Three-Dimensional Microfilament Printing of a Decellularized Extracellular Matrix (dECM) Bioink Using a Microgel Printing Bath for Nerve Graft Fabrication and the Effectiveness of dECM Graft Combined with a Polycaprolactone Conduit

Various synthetic and decellularized materials are being used to reconstruct peripheral nerve defects and replace autologous nerve grafts. In this study, we developed a microgel printing bath to three-dimensionally (3D) print a peripheral nervous system decellularized extracellular matrix nerve graft reinforced by a polycaprolactone (PCL) conduit. The straightforward fabrication method of an alginate microgel-supplemented printing bath allows a 30 μm filament resolution of a low viscous decellularized extracellular matrix hydrogel with neutral pH. When applied to a sciatic nerve defect model of rats, the total number of regenerated axons and relative gastrocnemius muscle weight ratio were comparable to those of the autologous nerve graft group. Meanwhile, the results were superior to those of the porcine decellularized nerve graft group or the 3D printed decellularized extracellular matrix graft group. This study will be the first step demonstrating that the 3D printed decellularized extracellular matrix (dECM) graft with a PCL conduit is an effective and reliable choice to replace an autologous nerve graft in the near future.

Effects of Adipose-Derived Mesenchymal Stem Cells and Human Amniotic Membrane on Sciatic Nerve Repair in Rats

Background: Peripheral nerve injuries remain a great challenge for microsurgery despite the significant progress in recent decades. The current gold standard is autogenous nerve grafting with a success rate as low as 50% in long gaps. Current studies have focused on finding alternative methods for bridging nerve defects. Previous data have demonstrated the role of human amniotic membrane in stimulating neural regeneration. On the other hand, adipose-derived mesenchymal stem cells can differentiate into all three germ layers and could support nerve repair. The purpose of this study was to compare the role of the human amniotic membrane with and without adipose tissue stem cells in sciatic nerve injury with gap in rats. Objectives: We aimed to evaluate the effectiveness of the human amniotic membrane with and without adipose-derived mesenchymal stem cells in sciatic nerve injury with gap in rats. Methods: Twenty-four male Wistar rats in four random groups were used in our study. In the first group, the nerve gap was repaired using the inverse resected nerve segment (Control group), the second group was repaired with a human amniotic membrane (AM group), the third group was repaired with an amnion sheet with seeded adipose-derived mesenchymal stem cells (AM/ADMSCs group), and the last group was not repaired, and both stumps were sutured to muscles. Results: All the animals underwent the procedures and survived without complication. The sciatic function index and hot plate test results were significantly improved in the AM and AM/ADMSCs groups compared to the Control group (as a gold standard of care) (P>0.05). Based on histopathology findings, regenerative nerve fibers were seen in the implanted area of both AM and AM/ADMSCs groups; however, nerve fibers were surrounded by significant fibrosis (scar formation) in the AM/ADMSCs group. The axon count in the Control group was significantly higher than both experimental groups (P < 0.01). Conclusions: Our study showed the role of amniotic membrane in the promotion of nerve regeneration in sciatic nerve injury with a gap, but adding adipose-derived mesenchymal stem cells not only has no extra benefits, but also causes more tissue scar.

TNF-mimetic peptide mixed with fibrin glue improves peripheral nerve regeneration

Surgical intervention is necessary following nerve trauma. Tubular prostheses can guide growing axons and inserting substances within these prostheses can be positive for the regeneration, making it an alternative for the current standard tools for nerve repair. Our aim was to investigate the effects of fibrin glue BthTL when combined with a synthetic TNF mimetic-action peptide on nerve regeneration. Male Wistar rats suffered left sciatic nerve transection. For repairing, we used empty silicon tubes (n = 10), tubes filled with fibrin glue BthTL (Tube + Glue group, n = 10) or tubes filled with fibrin glue BThTL mixed with TNF mimetic peptide (Tube + Glue + Pep group, n = 10). Animals were euthanized after 45 days. We collected nerves to perform immunostaining (neurofilament, GAP43, S100-β, NGFRp75 and Iba-1), light and transmission electron microscopy (for counting myelinated, unmyelinated and degenerated fibers; and for the evaluation of morphometric aspects of regenerated fibers) and collagen staining. All procedures were approved by local ethics committee (protocol 063/17). Tube + Glue + Pep group showed intense inflammatory infiltrate, higher Iba-1 expression, increased immunostaining for NGFRp75 receptor (which characterizes Schwann cell regenerative phenotype), higher myelin thickness and fiber diameter and more type III collagen deposition. Tube + Glue group showed intermediate results between empty tube and Tube + Glue + Pep groups for anti-NGFRp75 immunostaining, inflammation and collagen; on fiber counts, this group showed more degenerate fibers and fewer unmyelinated axons than others. Empty tube group showed superiority only in GAP43 immunostaining. A combination of BthTL glue and TNF mimetic peptide induced greater axonal regrowth and remyelination.

[Research progress of peripheral nerve mismatch regeneration]

Objective

To review the research progress of peripheral nerve mismatch regeneration, and to provide reference for its related basic research and clinical treatment.

Methods

The pathophysiology of peripheral nerve after injury, several main factors affecting the mismatch regeneration of peripheral nerve, and the fate of axon after mismatch regeneration were summarized by referring to the relevant literature at home and abroad in recent years.

Results

Distal pathways and target organs can selectively affect the mismatch regeneration of peripheral nerves; different phenotypes of Schwann cells have different effects on the mismatch regeneration of peripheral nerves; studying the mechanism of action of exosomes from different Schwann cells on different types of axons can provide a new direction for solving the mismatch regeneration of peripheral nerves.

Conclusion

Peripheral nerve mismatch regeneration is affected by various factors. However, the specific mechanism and characteristics of these factors remain to be further studied.

Influence of aging on the peripheral nerve repair process using an artificial nerve conduit

The influence of aging on the induction of nerve regeneration in artificial nerve conduits has yet to be clarified. In the present study, artificial nerve conduit transplantation and histological analysis using the sciatic nerve of young and elderly mice were performed. Using 20 male C57BL/6 mice, an artificial nerve conduit was transplanted to the sciatic nerve at 8 weeks (Young group) or 70 weeks of age (Aged group), and the sciatic nerve was evaluated histologically at 1, 4 and 12 weeks after surgery. Using hematoxylin and eosin staining, the state of induction of nerve regeneration in the artificial nerve conduit was evaluated. Additionally, immunohistochemical staining was used to investigate an angiogenic marker [vascular endothelial growth factor A (VEGFA)], Schwann cell markers [sex determining region Y-box 10 (SOX10) and S100 calcium-binding protein β (S100β)] and a nerve damage marker [nerve growth factor (NGF)]. The results revealed that the induction of nerve regeneration was significantly higher in the Young group than in the Aged group. In addition, VEGFA and SOX10 expression at 1 week, SOX10 expression at 4 weeks and SOX10, S100β and NGF expression at 12 weeks in the proximal stump were significantly higher in the Young group than in the Aged group. At the center of the artificial nerve conduit, S100β and NGF expression at 4 weeks, and VEGFA, SOX10, S100β and NGF expression at 12 weeks were significantly higher in the Young group than in the Aged group. In the distal stump, no significant difference was noted in immunostaining at any week between the two groups. The present study suggested that the nerve regeneration-inducing functions decrease due to aging.

Bacterial cellulose tubes as a nerve conduit for repairing complete facial nerve transection in a rat model

PURPOSE

Functionality of the facial nerve is cosmetically important. While many techniques have been investigated, early and effective treatment for traumatic facial nerve paralysis remains challenging. Here, we aim to examine bacterial cellulose (BC) as a new tubularization material for improving facial nerve regeneration.

METHODS

Our study was performed on 40 female Sprague Dawley rats. Rats were randomly divided into four groups, with 10 rats per group. In all rats, the main trunk of the facial nerve was completely cut 8 mm before the branching point. For repairing the facial nerve, in group 1, the nerve was left to recover spontaneously (control group); in group 2, it was repaired by primary suturing (8.0 Ethilon sutures, Ethicon); in group 3, BC tubes alone were used to aid nerve repair; and in group 4, both BC tubes and primary sutures (8.0 Ethilon sutures) were used. After 10 weeks, the facial nerve regeneration was evaluated by the whisker movement test and electrophysiologically (nerve stimulation threshold and compound muscle action potential). Nerve regeneration was assessed by calculating the number of myelinated nerve fibers, and by microscopically evaluating the amount of regeneration and fibrosis.

RESULTS

No significant difference was observed among the groups in terms of whisker movement and electrophysiological parameters (P > 0.05). We found that the numbers of regenerating myelinated fibers were significantly increased (P < 0.05) when BC tubes were used as a nerve conduit.

CONCLUSIONS

BC can be easily shaped into a hollow tube that guides nerve axons, resulting in better nerve regeneration after transection.

Axonotmesis-evoked plantar vasodilatation as a novel assessment of C-fiber afferent function after sciatic nerve injury in rats

Quantitative assessment of the recovery of nerve function, especially sensory and autonomic nerve function, remains a challenge in the field of nerve regeneration research. We previously found that neural control of vasomotor activity could be potentially harnessed to evaluate nerve function. In the present study, five different models of left sciatic nerve injury in rats were established: nerve crush injury, nerve transection/suturing, nerve defect/autografting, nerve defect/conduit repair, and nerve defect/non-regeneration. Laser Doppler perfusion imaging was used to analyze blood perfusion of the hind feet. The toe pinch test and walking track analysis were used to assess sensory and motor functions of the rat hind limb, respectively. Transmission electron microscopy was used to observe the density of unmyelinated axons in the injured sciatic nerve. Our results showed that axonotmesis-evoked vasodilatation in the foot 6 months after nerve injury/repair recovered to normal levels in the nerve crush injury group and partially in the other three repair groups; whereas the nerve defect/non-regeneration group exhibited no recovery in vasodilatation. Furthermore, the recovery index of axonotmesis-evoked vasodilatation was positively correlated with toe pinch reflex scores and the density of unmyelinated nerve fibers in the regenerated nerve. As C-fiber afferents are predominantly responsible for dilatation of the superficial vasculature in the glabrous skin in rats, the present findings indicate that axonotmesis-evoked vasodilatation can be used as a novel way to assess C-afferent function recovery after peripheral nerve injury. This study was approved by the Ethics Committee for Laboratory Animals of Nantong University of China (approval No. 20130410-006) on April 10, 2013.

The amnion muscle combined graft (AMCG) conduits in nerves repair: an anatomical and experimental study on a rat model

The amnion muscle combined graft (AMCG) conduits showed good clinical results in peripheral nerves gap repair. It combines the human amniotic membrane with autologous skeletal muscle fibres. These results seem attributable to the biological characteristics of human amniotic membrane: Pluripotency, anti-inflammatory and low immunogenicity.We here evaluate the final outcome of nerve regeneration morphologically and functionally, across the AMCG compared to nerve autograft. Fourteen Wistar rats were divided into two groups: In Group A, including 6 rats, the left forelimb was treated performing a 1.5 cm length gap on median nerve that was then reconstructed with a reverse autograft. In Group B, including 8 rats, the gap was reconstructed with AMCG. Functional results were evaluated at 30, 60 and 90 days performing grasping tests. Morphological and stereological analyses were performed at T90 using high-resolution light microscopy and design-based stereology. The AMCG conduits revealed nerve fibres regeneration and functional recovery. Functional recovery was observed in both groups with AMCG conduits group showing lower values and a regeneration of median nerves with more myelinated fibres with the same axon size, but thinner myelin than the autograft group. Though the autograft remains the gold standard to restore wide nerve gaps, the AMCG conduit has proved to be effective in enabling nerve regeneration through a critical rat's nerve gap of 15 mm. These findings empirically support the great clinical results obtained using AMCG conduit to restore traumatic nerve's gap from 3 to 6 cm of mixed forearm nerves.

Tubulation repair mitigates misdirection of regenerating motor axons across a sciatic nerve gap in rats

The repair of peripheral nerve laceration injury to obtain optimal function recovery remains a big challenge in the clinic. Misdirection of regenerating axons to inappropriate target, as a result of forced mismatch of endoneurial sheaths in the case of end-to-end nerve anastomosis or nerve autografting, represents one major drawback that limits nerve function recovery. Here we tested whether tubulation repair of a nerve defect could be beneficial in terms of nerve regeneration accuracy and nerve function. We employed sequential retrograde neuronal tracing to assess the accuracy of motor axon regeneration into the tibial nerve after sciatic nerve laceration and entubulation in adult Sprague-Dawley rats. In a separate cohort of rats with the same sciatic nerve injury/repair protocols, we evaluated nerve function recovery behaviorally and electrophysiologically. The results showed that tubulation repair of the lacerated sciatic nerve using a 3-6-mm-long bioabsorbable guidance conduit significantly reduced the misdirection of motor axons into the tibial nerve as compared to nerve autografting. In addition, tubulation repair ameliorated chronic flexion contracture. This study suggests that tubulation repair of a nerve laceration injury by utilizing a bioresorbable nerve guidance conduit represents a potential substitute for end-to-end epineurial suturing and nerve autografting.

Hydrogel composition and laser micropatterning to regulate sciatic nerve regeneration

Treatment of peripheral nerve injuries has evolved over the past several decades to include the use of sophisticated new materials endowed with trophic and topographical cues that are essential for in vivo nerve fibre regeneration. In this research, we explored the use of an advanced design strategy for peripheral nerve repair, using biological and semi-synthetic hydrogels that enable controlled environmental stimuli to regenerate neurons and glial cells in a rat sciatic nerve resection model. The provisional nerve growth conduits were composed of either natural fibrin or adducts of synthetic polyethylene glycol and fibrinogen or gelatin. A photo-patterning technique was further applied to these 3D hydrogel biomaterials, in the form of laser-ablated microchannels, to provide contact guidance for unidirectional growth following sciatic nerve injury. We tested the regeneration capacity of subcritical nerve gap injuries in rats treated with photo-patterned materials and compared these with injuries treated with unpatterned hydrogels, either stiff or compliant. Among the factors tested were shear modulus, biological composition, and micropatterning of the materials. The microchannel guidance patterns, combined with appropriately matched degradation and stiffness properties of the material, proved most essential for the uniform tissue propagation during the nerve regeneration process.

Stimulating effect of thyroid hormones in peripheral nerve regeneration: research history and future direction toward clinical therapy

Injury to peripheral nerves is often observed in the clinic and severe injuries may cause loss of motor and sensory functions. Despite extensive investigation, testing various surgical repair techniques and neurotrophic molecules, at present, a satisfactory method to ensuring successful recovery does not exist. For successful molecular therapy in nerve regeneration, it is essential to improve the intrinsic ability of neurons to survive and to increase the speed of axonal outgrowth. Also to induce Schwann cell phenotypical changes to prepare the local environment favorable for axonal regeneration and myelination. Therefore, any molecule that regulates gene expression of both neurons and Schwann cells could play a crucial role in peripheral nerve regeneration. Clinical and experimental studies have reported that thyroid hormones are essential for the normal development and function of the nervous system, so they could be candidates for nervous system regeneration. This review provides an overview of studies devoted to testing the effect of thyroid hormones on peripheral nerve regeneration. Also it emphasizes the importance of combining biodegradable tubes with local administration of triiodothyronine for future clinical therapy of human severe injured nerves. We highlight that the local and single administration of triiodothyronine within biodegradable nerve guide improves significantly the regeneration of severed peripheral nerves, and accelerates functional recovering. This technique provides a serious step towards future clinical application of triiodothyronine in human severe injured nerves. The possible regulatory mechanism by which triiodothyronine stimulates peripheral nerve regeneration is a rapid action on both axotomized neurons and Schwann cells.

Peripheral Nerve Defects: Overviews of Practice in Europe

Many surgical techniques are available for the repair of peripheral nerve defects. Autologous nerve grafts are the gold standard for most clinical conditions. In selected cases, alternative types of reconstructions are performed to fill the nerve gap. Non-nervous autologous tissue-based conduits or synthetic ones are alternatives to nerve autografts. Allografts represent another new field of interest. Decision making in the treatment of nerve defects is based on timing of referral, level of the injury, type of lesion, and size of any gap. This review focuses on current clinical practice, influenced by the numerous new experimental researches.

A Novel Use of Genipin-Fixed Gelatin as Extracellular Matrix for Peripheral Nerve Regeneration

Application of combining herbal medicine and biomedical material science to nerve regeneration is a new approach. In this study, we describe a novel use of purified genipin, which can be extracted from Gardenia jasminoides Ellis, fixing the gelatin to be an extracellular matrix for peripheral nerve regeneration. A 10-mm gap of rat sciatic nerve was created between the proximal and distal nerve stumps, which were sutured into silicone rubber tubes filled with either the genipin-fixed gelatin or collagen gel. Silicone rubber tubes filled with saline were used as controls. Six weeks after implantation, regeneration across the nerve gaps occurred in 80 and 90% of the animals from the groups of genipin-fixed gelatin and collagen, respectively, whereas only 30% in the control group. Large numbers of myelinated axons were also seen in the genipin-fixed gelatin (5104±3278) and the collagen groups (8063±1807). These findings indicated that the genipin-fixed gelatin could be an acceptable extracellular matrix for nerve regeneration.

Retinoic acid regulates Schwann cell migration via NEDD9 induction by transcriptional and post-translational mechanisms

Schwann cell migration is essential during the regenerative response to nerve injury, however, the factors that regulate this phenomenon are not yet clear. Here we describe that retinoic acid (RA), whose production and signaling activity are greatly enhanced during nerve regeneration, increases Schwann cell migration. This is accompanied by the up-regulation of NEDD9, a member of the CAS family of scaffold proteins previously implicated in migratory and invasive behavior in gliomas, melanomas and the neural crest cells from which Schwann cells derive. This RA-induced NEDD9 accumulation is due to augmented mRNA levels, as well as an increase of NEDD9 protein stability. Although all NEDD9 phospho-isoforms present in Schwann cells are induced by the retinoid, the hormone also changes its phosphorylation status, thus altering the ratio between the different isoforms. Silencing NEDD9 in Schwann cells had no effect on basal migratory ability, but completely abrogated RA-induced enhanced migration. Collectively, our results indicate that RA could be a major regulator of Schwann cell migration after nerve injury, thus offering a new insight into peripheral nerve repair.

Evaluation of biodegradable electric conductive tube-guides and mesenchymal stem cells

AIM: To study the therapeutic effect of three tube-guides with electrical conductivity associated to mesenchymal stem cells (MSCs) on neuro-muscular regeneration after neurotmesis.

METHODS: Rats with 10-mm gap nerve injury were tested using polyvinyl alcohol (PVA), PVA-carbon nanotubes (CNTs) and MSCs, and PVA-polypyrrole (PPy). The regenerated nerves and tibialis anterior muscles were processed for stereological studies after 20 wk. The functional recovery was assessed serially for gait biomechanical analysis, by extensor postural thrust, sciatic functional index and static sciatic functional index (SSI), and by withdrawal reflex latency (WRL). In vitro studies included cytocompatibility, flow cytometry, reverse transcriptase polymerase chain reaction and karyotype analysis of the MSCs. Histopathology of lung, liver, kidneys, and regional lymph nodes ensured the biomaterials biocompatibility.

RESULTS: SSI remained negative throughout and independently from treatment. Differences between treted groups in the severity of changes in WRL existed, showing a faster regeneration for PVA-CNTs-MSCs (P < 0.05). At toe-off, less acute ankle joint angles were seen for PVA-CNTs-MSCs group (P = 0.051) suggesting improved ankle muscles function during the push off phase of the gait cycle. In PVA-PPy and PVA-CNTs groups, there was a 25% and 42% increase of average fiber area and a 13% and 21% increase of the “minimal Feret’s diameter” respectively. Stereological analysis disclosed a significantly (P < 0.05) increased myelin thickness (M), ratio myelin thickness/axon diameter (M/d) and ratio axon diameter/fiber diameter (d/D; g-ratio) in PVA-CNT-MSCs group (P < 0.05).

CONCLUSION: Results revealed that treatment with MSCs and PVA-CNTs tube-guides induced better nerve fiber regeneration. Functional and kinematics analysis revealed positive synergistic effects brought by MSCs and PVA-CNTs. The PVA-CNTs and PVA-PPy are promising scaffolds with electric conductive properties, bio- and cytocompatible that might prevent the secondary neurogenic muscular atrophy by improving the reestablishment of the neuro-muscular junction.

Peripheral nerve regeneration with conduits: use of vein tubes

Treatment of peripheral nerve injuries remains a challenge to modern medicine due to the complexity of the neurobiological nerve regenerating process. There is a greater challenge when the transected nerve ends are not amenable to primary end-to-end tensionless neurorraphy. When facing a segmental nerve defect, great effort has been made to develop an alternative to the autologous nerve graft in order to circumvent morbidity at donor site, such as neuroma formation, scarring and permanent loss of function. Tubolization techniques have been developed to bridge nerve gaps and have been extensively studied in numerous experimental and clinical trials. The use of a conduit intends to act as a vehicle for moderation and modulation of the cellular and molecular ambience for nerve regeneration. Among several conduits, vein tubes were validated for clinical application with improving outcomes over the years. This article aims to address the investigation and treatment of segmental nerve injury and draw the current panorama on the use of vein tubes as an autogenous nerve conduit.

Toward intelligent synthetic neural circuits: directing and accelerating neuron cell growth by self-rolled-up silicon nitride microtube array

In neural interface platforms, cultures are often carried out on a flat, open, rigid, and opaque substrate, posing challenges to reflecting the native microenvironment of the brain and precise engagement with neurons. Here we present a neuron cell culturing platform that consists of arrays of ordered microtubes (2.7-4.4 μm in diameter), formed by strain-induced self-rolled-up nanomembrane (s-RUM) technology using ultrathin (<40 nm) silicon nitride (SiNx) film on transparent substrates. These microtubes demonstrated robust physical confinement and unprecedented guidance effect toward outgrowth of primary cortical neurons, with a coaxially confined configuration resembling that of myelin sheaths. The dynamic neural growth inside the microtube, evaluated with continuous live-cell imaging, showed a marked increase (20×) of the growth rate inside the microtube compared to regions outside the microtubes. We attribute the dramatic accelerating effect and precise guiding of the microtube array to three-dimensional (3D) adhesion and electrostatic interaction with the SiNx microtubes, respectively. This work has clear implications toward building intelligent synthetic neural circuits by arranging the size, site, and patterns of the microtube array, for potential treatment of neurological disorders.

Rat sciatic nerve reconstruction across a 30 mm defect bridged by an oriented porous PHBV tube with Schwann cell as artificial nerve graft

An oriented poly(3-hydroxybutyrate-co-3-hydroxyvalerate) nerve conduit has been used to evaluate its efficiency based on the promotion of peripheral nerve regeneration in rats. The oriented porous micropatterned artificial nerve conduit was designed onto the micropatterned silicon wafers, and then their surfaces were modified with oxygen plasma to increase cell adhesion. The designed conduits were investigated by cell culture analyses with Schwann cells (SCs). The conduits were implanted into a 30 mm gap in sciatic nerves of rats. Four months after surgery, the regenerated nerves were monitored and evaluated by macroscopic assessments and histology and behavioral analyses. Results of cellular analyses showed suitable properties of designed conduit for nerve regeneration. The results demonstrated that in the polymeric graft with SCs, the rat sciatic nerve trunk had been reconstructed with restoration of nerve continuity and formatted nerve fibers with myelination. Histological results demonstrated the presence of Schwann and glial cells in regenerated nerves. Functional recovery such as walking, swimming, and recovery of nociceptive function was illustrated for all the grafts especially conduits with SCs. This study proves the feasibility of the artificial nerve graft filled with SCs for peripheral nerve regeneration by bridging a longer defect in an animal model.

The amnion muscle combined graft (AMCG) conduits: a new alternative in the repair of wide substance loss of peripheral nerves

The use of autologous sural nerve grafts is still the current gold standard for the repair of peripheral nerve injuries with wide substance losses, but with a poor rate of functional recovery after repair of mixed and motor nerves, a limited donor nerve supply, and morbidity of donor site. At present, tubulization through the muscle vein combined graft, is a viable alternative to the nerve autografts and certainly is a matter of tissue engineering still open to continuous development, although this technique is currently limited to a critical gap of 3 cm with less favorable results for motor function recovery. In this report, we present a completely new tubulization method, the amnion muscle combined graft (AMCG) technique, that consists in the combination of the human amniotic membrane hollow conduit with autologous skeletal muscle fragments for repairing the substance loss of peripheral nerves and recover both sensory and motor functions. In a series of five patients with loss of substance of the median nerve ranging 3-5 cm at the wrist, excellent results graded as S4 in two cases, S3+ in two cases, and S3 in one case; M4 in four cases and M3 in one case were achieved. No iatrogenic damage due to withdrawal of a healthy nerve from donor site was observed. This technique allows to repair extensive loss of substance up to 5 cm with a good sensory and motor recovery. The AMCG thus may be considered a reasonable alternative to traditional nerve autograft in selected clinical conditions.

Biocompatibility and Efficacy of Five-Channel and Eight-Channel Crosslinked Urethane-Doped Polyester Elastomers (CUPEs) as Nerve Guidance Conduit for Reconstruction of Segmental Peripheral Nerve Defect Using Rat Model

Introduction: Peripheral nerve injury is common in clinical practice. Nerve defect is a challenging scenario. The current gold standard of managing a nerve defect is autologous nerve graft. However, due to the selection of nerve graft and donor site morbidity, artificial nerve conduits are gaining popularity. However, there are drawbacks of single hollow conduit such as lack of internal support to prevent conduit collapse and inability so as to recreate the proper native spatial arrangement of cells and extracellular matrix within the conduit. In this study, the biocompatibility and efficacy of five-channel and eight-channel Crosslinked Urethane-doped Polyester Elastomers (CUPEs) as nerve guidance conduit will be evaluated through a rat model with reconstruction of segmental peripheral nerve defect. Material and Method: Eighteen adult Sprague-Dawley rats were used. They were randomly allocated to three groups: autograft group, five-channel conduit group and eight-channel conduit group with each consisted of six rats. A 10mm nerve defects were created at the right sciatic nerve. They were bridged with reverse autograft, 5-channel conduit and 8-channel conduit. After eight weeks the rats were euthanized and the reconstructed nerves were harvested for histomorphometric analysis. Result: All conduits showed regenerated nerve tissue inside. There was no collapse of the conduits. There were no severe tissue reaction or scarring near the reconstructed nerve. No neuroma was formed. Histomorphometric analysis showed nerve regeneration was enhanced with increasing number of channels inside conduit. There was overall drop in fiber density between proximal and distal segment among all groups. Conclusion: CUPE nerve guidance conduit is biocompatible and shows good nerve regeneration in reconstructing nerve defect.

Spider silk as guiding biomaterial for human model neurons

Over the last years, a number of therapeutic strategies have emerged to promote axonal regeneration. An attractive strategy is the implantation of biodegradable and nonimmunogenic artificial scaffolds into injured peripheral nerves. In previous studies, transplantation of decellularized veins filled with spider silk for bridging critical size nerve defects resulted in axonal regeneration and remyelination by invading endogenous Schwann cells. Detailed interaction of elongating neurons and the spider silk as guidance material is unknown. To visualize direct cellular interactions between spider silk and neurons in vitro, we developed an in vitro crossed silk fiber array. Here, we describe in detail for the first time that human (NT2) model neurons attach to silk scaffolds. Extending neurites can bridge gaps between single silk fibers and elongate afterwards on the neighboring fiber. Culturing human neurons on the silk arrays led to an increasing migration and adhesion of neuronal cell bodies to the spider silk fibers. Within three to four weeks, clustered somata and extending neurites formed ganglion-like cell structures. Microscopic imaging of human neurons on the crossed fiber arrays in vitro will allow for a more efficient development of methods to maximize cell adhesion and neurite growth on spider silk prior to transplantation studies.

Update on nerve repair by biological tubulization

Many surgical techniques are available for bridging peripheral nerve defects. Autologous nerve grafts are the current gold standard for most clinical conditions. In selected cases, alternative types of conduits can be used. Although most efforts are today directed towards the development of artificial synthetic nerve guides, the use of non-nervous autologous tissue-based conduits (biological tubulization) can still be considered a valuable alternative to nerve autografts. In this paper we will overview the advancements in biological tubulization of nerve defects, with either mono-component or multiple-component autotransplants, with a special focus on the use of a vein segment filled with skeletal muscle fibers, a technique that has been widely investigated in our laboratory and that has already been successfully introduced in the clinical practice.

Study of tibial nerve regeneration in Wistar rats in primary neurorrhaphy with and without gap, wrapped in vein segments

Objective

This study compared nerve regeneration in Wistar rats, using epineural neurorrhaphy with a gap of 1.0 mm and without a gap, both wrapped with jugular vein tubes. Motor neurons in the spinal cord between L3 and S1 were used for the count, marked by exposure of the tibial nerve to Fluoro-Gold (FG).

Method

The tibial nerves on both sides were cut and sutured, with a gap on one side and no gap in the other. The sutures were wrapped with a jugular vein. Four months after surgery the tibial nerves were exposed to Fluoro-Gold and the motor neuron count performed in the spinal cord.

Results

The results were statistically analyzed by the paired Wilcoxon test. There was a statistical difference between the groups with and without gap in relation to the motor neuron count (p=0.013).

Conclusion

The epineural neurorraphy without gap wrapped with jugular vein showed better results for nerve regeneration than the same procedure with gap. Level of Evidence: Experimental Study.

Collagen conduit versus microsurgical neurorrhaphy: 2-year follow-up of a prospective, blinded clinical and electrophysiological multicenter randomized, controlled trial

PURPOSE

To compare repair of acute lacerations of mixed sensory-motor nerves in humans using a collagen tube versus conventional repair.

METHODS

In a prospective randomized trial, we repaired the ulnar or the median nerve with a collagen nerve conduit or with conventional microsurgical techniques. We enrolled 43 patients with 44 nerve lacerations. We performed electrophysiological tests and hand function using a standardized clinical evaluation instrument, the Rosen scoring system, after 12 and 24 months.

RESULTS

Operation time using the collagen conduit was significantly shorter than for conventional neurorrhaphy. There were no complications in terms of infection, extrusion of the conduit, or other local adverse reaction. Thirty-one patients with 32 nerve lesions, repaired with collagen conduits or direct suture, attended the 24-month follow-up. There was no difference between sensory function, discomfort, or total Rosen scores. Motor scores were significantly better for the direct suture group after 12 months, but after 24 months, there were no differences between the treatment groups. There was a general further recovery of both motor and sensory conduction parameters at 24 months compared with 12 months. There were no statistically significant differences in amplitudes, latencies, or conduction velocities between the groups.

CONCLUSIONS

Use of a collagen conduit produced recovery of sensory and motor functions that were equivalent to direct suture 24 months after repair when the nerve gap inside the tube was 6 mm or less, and the collagen conduit proved to be safe for these nerve lacerations in the forearm.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Custom prefabrication of silicone tubes from urinary catheters for experimental peripheral nerve surgery

The entubulation principle represents a neurobiological approach to nerve surgery in which the role of the surgeon is limited and intrinsic healing capabilities of the nerve play the primary role. Herein, a technique for fabricating custom-made silicone tubes from a silicone urinary catheter is described. Silicone tubes with varying size and dimensions can be tailored depending on the diameter of the silicone urinary catheter (14 F to 18 F). Tubes crafted from silicone urinary catheters were used either as a nerve conduit to facilitate regeneration or as compressive nerve banding to simulate compressive neuropathy in the rat sciatic nerve. Custom-made silicone tubes have similar pros and cons to the commercially available silicone tubes regarding the capsule and foreign body reaction. It can be concluded that these cost effective tubes can be easily cut and used in experimental peripheral nerve surgery in developing countries where the cost of such materials becomes an important issue for the researchers.

Efficacy of nanofibrous conduits in repair of long-segment sciatic nerve defects

Our previous studies have histomorphologically confirmed that nanofibrous poly(3-hydroxybutyrate-co-3-hydroxyvalerate) conduit can be used to repair 30-mm-long sciatic nerve defects. However, the repair effects on rat behaviors remain poorly understood. In this study, we used nanofibrous poly(3-hydroxybutyrate-co-3-hydroxyvalerate) conduit and autologous sciatic nerve to bridge 30-mm-long rat sciatic nerve gaps. Within 4 months after surgery, rat sciatic nerve functional recovery was evaluated per month by behavioral analyses, including toe out angle, toe spread analysis, walking track analysis, extensor postural thrust, swimming test, open-field analysis and nociceptive function. Results showed that rat sciatic nerve functional recovery was similar after nanofibrous poly(3-hydroxybutyrate-co-3-hydroxyvalerate) conduit and autologous nerve grafting. These findings suggest that nanofibrous poly(3-hydroxybutyrate-co-3-hydroxyvalerate) conduit is suitable in use for repair of long-segment sciatic nerve defects.

Role of extracellular matrix components in facial nerve regeneration: an experimental study

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.

Bridging peripheral nerve defects with muscle–vein combined guides

Various tubulization techniques can be used to bridge peripheral nerve lesions with substance loss. Among the different materials that have been used so far in alternative to traditional fresh nerve autografts, fresh muscle-vein combined conduits (made by a vein segment filled with fresh skeletal muscle) proved to be particularly effective. In this study, nerve repair of 10-mm long nerve defects by means of muscle-vein combined tubes was compared with repair by means of traditional nerve autografts in the rat sciatic nerve experimental model. Results did not reveal any significant difference between the two groups of regenerated nerves with respect to the total number, mean density and mean size of myelinated nerve fibers. In addition, we also report the results of an experimental study in the rabbit sciatic nerve model, which showed that fresh skeletal muscle enrichment of the vein segment made it possible to bridge 55-mm long nerve gaps. These results provide further evidence of the effectiveness of fresh muscle-vein combined grafts and support the view that this type of conduit can be used also for repairing long nerve gaps.

Enhanced peripheral nerve regeneration by the combination of a polycaprolactone tubular prosthesis and a scaffold of collagen with supramolecular organization

The purpose of this study was to investigate the influence of implanting collagen with a supramolecular organization on peripheral nerve regeneration, using the sciatic nerve tubulization technique. For this purpose, adult female Sprague Dawley rats were divided into five groups: (1) TP - sciatic nerve repaired with empty polyethylene tubular prothesis (n = 10), (2) TPCL - nerve repair with empty polycaprolactone (PCL) tubing (n = 8), (3) TPCLF - repair with PCL tubing filled with an implant of collagen with a supramolecular organization (n = 10), (4) AG - animals that received a peripheral nerve autograft (n = 8), and (5) Normal nerves (n = 8). The results were assessed by quantification of the regenerated fibers, nerve morphometry, and transmission electron microscopy, 60 days after surgery. Immunohistochemistry and polarization microscopy were also used to analyze the regenerated nerve structure and cellular elements. The results showed that the AG group presented a larger number of regenerated axons. However, the TPCL and TPCLF groups presented more compact regenerated fibers with a morphometric profile closer to normal, both at the tube midpoint and 2 mm distal to the prosthesis. These findings were reinforced by polarization microscopy, which indicated a better collagen/axons suprastructural organization in the TPCLF derived samples. In addition, the immunohistochemical results obtained using the antibody anti-p75NTR as a Schwann cell reactivity marker demonstrated that the Schwann cells were more reactive during the regenerative process in the TPCLF group as compared to the TPCL group and the normal sciatic nerve. Altogether, the results of this study indicated that the implant of collagen with a supramolecular organization positively influenced and stimulated the regeneration process through the nerve gap, resulting in the formation of a better morphologically arranged tissue.

Sensory recovery 1 year after bridging digital nerve defects with collagen tubes

PURPOSE

To investigate digital nerve regeneration following implantation of collagen tubes in a prospective study.

METHODS

Forty-five digital nerve defects (≤ 2.6 cm) in the hand were reconstructed in 35 patients (6 female, 29 male; mean age, 47 y). Nerve regeneration was evaluated at 3, 6, and 12 months after surgery by applying a sum score comprising static 2-point discrimination, sensory threshold with Semmes-Weinstein monofilament mechanical stimuli, warm/cold sensation, vibration sense, sharp/dull recognition, recognition of numbers, and subjective estimation of the patient. Electroneurography and ultrasound were also performed.

RESULTS

In the distribution of 60% of the operated nerves, very good or good recovery was found. In contrast to basic sensory function, the more complex static 2-point discrimination was more frequently impaired after 1 year. After 6 months, the sum score correlated with electroneurography. The type of injury altered the final sensory nerve function. Circular saw and iatrogenic injuries showed a negative correlation with final sensory nerve function. Complications (infection) were observed in 2 patients.

CONCLUSIONS

Owing to the good functional outcome in the majority of cases, the use of collagen tubes is useful to span digital nerve defects up to 2.6 cm.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

GELATIN-TRICALCIUM PHOSPHATE MEMBRANE MODIFIED WITH NGF AND CULTURED SCHWANN CELLS FOR PERIPHERAL NERVE REPAIR: A TISSUE ENGINEERING APPROACH

This study attempted to enhance the efficacy of peripheral nerve regeneration using our previously developed gelatin-tricalcium phosphate (GTG) conduits by incorporating them with nerve growth factors and cultured Schwann cells. The nerve growth factors were covalently immobilized onto the GTG conduits (GEN) using carbodiimide. Schwann cells were harvested from neonatal Lewis rats, cultured for seven days and injected into the GEN conduits. The experiment was performed in three groups: GTG conduits, GEN conduits and GEN conduits with Schwann cells injected (GEN+Sc). The effects of different conduits (GTG, GEN and GEN with Schwann cells) on the peripheral nerve regeneration were evaluated in rat sciatic nerve repair model. 24 weeks after implantation of conduits, degradation of the conduits in all groups was illustrated by the fragmentation of the conduits. All conduits were well tolerated by the host tissue. Under microscopic evaluations, regenerated nerve tissue with myelinated and unmyelinated axons presented in all groups. Histomorphometrically, the total nerve area of GEN+Sc group was significantly higher than GTG group. Conversely, the autotomy score evaluated 12 weeks after nerve repair showed better results for GTG group. Besides, GEN+Sc group had the highest average recovery index of compound muscle action potential, but the difference among each group did not reach statistical significance. Although the electrophysiological recovery of nerve was not significantly improved with GEN+Sc conduit, nerve repair using tissue engineered conduits still provided better histological results. However, it should be noticed that autotomy may be the price paid for enhanced peripheral nerve.

Standardized criterion to analyze and directly compare various materials and models for peripheral nerve regeneration

Progress in understanding conditions for optimal peripheral nerve regeneration has been stunted due to lack of standardization of experimental conditions and assays. In this paper we review the large database that has been generated using the Lundborg nerve chamber model and compare various theories for their ability to explain the experimental data. Data were normalized based on systematic use of the critical axon elongation, the gap length at which the probability of axon reconnection between the stumps is just 50%. Use of this criterion has led to a rank-ordering of devices or treatments and has led, in turn, to conclusions about the conditions that facilitate regeneration. Experimental configurations that have maximized facilitation of peripheral nerve regeneration are those in which the tube wall comprised degradable polymers, including collagen and certain synthetic biodegradable polymers, and was cell-permeable rather than protein-permeable. Tube fillings that showed very high regenerative activity were suspensions of Schwann cells, a solution either of acidic or basic fibroblast growth factor, insoluble ECM substrates rather than solutions or gels, polyamide filaments oriented along the tube axis and highly porous, insoluble analogs of the ECM with specific structure and controlled degradation rate. It is suggested that the data are best explained by postulating that the quality of regeneration depends on two critical processes. The first is compression of stumps and regenerating nerve by a thick myofibroblast layer that surrounds these tissues and blocks synthesis of a nerve of large diameter (pressure cuff theory). The second is synthesis of linear columns of Schwann cells that serve as tracks for axon elongation (basement membrane microtube theory). It is concluded that experimental configurations that show high regenerative activity suppress the first process while facilitating the second.

EXPERIMENTAL NERVE GRAFTING — TOWARDS FUTURE SOLUTIONS OF A CLINICAL PROBLEM

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