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Mettyas T, Barton M, Sahar MSU, Lawrence F, Sanchez-Herrero A, Shah M, St John J, Bindra R. Negative Pressure Neurogenesis: A Novel Approach to Accelerate Nerve Regeneration after Complete Peripheral Nerve Transection. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3568. [PMID: 34881144 PMCID: PMC8647885 DOI: 10.1097/gox.0000000000003568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/18/2021] [Indexed: 11/30/2022]
Abstract
Various modalities to facilitate nerve regeneration have been described in the literature with limited success. We hypothesized that negative pressure applied to a sectioned peripheral nerve would enhance nerve regeneration by promoting angiogenesis and axonal lengthening. METHODS Wistar rats' sciatic nerves were cut (creating ~7 mm nerve gap) and placed into a silicone T-tube, to which negative pressure was applied. The rats were divided into 4 groups: control (no pressure), group A (low pressure: 10 mm Hg), group B (medium pressure: 20/30 mm Hg) and group C (high pressure: 50/70 mm Hg). The nerve segments were retrieved after 7 days for gross and histological analysis. RESULTS In total, 22 rats completed the study. The control group showed insignificant nerve growth, whereas the 3 negative pressure groups showed nerve growth and nerve gap reduction. The true nerve growth was highest in group A (median: 3.54 mm) compared to group B, C, and control (medians: 1.19 mm, 1.3 mm, and 0.35 mm); however, only group A was found to be significantly different to the control group (**P < 0.01). Similarly, angiogenesis was observed to be significantly greater in group A (**P < 0.01) in comparison to the control. CONCLUSIONS Negative pressure stimulated nerve lengthening and angiogenesis within an in vivo rat model. Low negative pressure (10 mm Hg) provided superior results over the higher negative pressure groups and the control, favoring axonal growth. Further studies are required with greater number of rats and longer recovery time to assess the functional outcome.
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Affiliation(s)
- Tamer Mettyas
- From the Department of Orthopaedics, Queen Elizabeth II Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, Griffith University, Australia
| | - Matthew Barton
- School of Nursing and Midwifery, Griffith University, Australia
- Menzies Health Institute Queensland, Griffith University, Australia
- Clem Jones Centre for Neurobiology and Stem Cell Research, Griffith University, Australia
| | - Muhammad Sana Ullah Sahar
- School of Engineering and Built Environment, Griffith University, Australia
- Department of Mechanical Engineering, Khwaja Fareed University of Engineering and information Technology, Rahim Yar Khan, Pakistan
| | - Felicity Lawrence
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Australia
| | | | - Megha Shah
- Menzies Health Institute Queensland, Griffith University, Australia
| | - James St John
- Menzies Health Institute Queensland, Griffith University, Australia
- Clem Jones Centre for Neurobiology and Stem Cell Research, Griffith University, Australia
- Griffith Institute for Drug Discovery, Griffith University, Australia
| | - Randy Bindra
- School of Medicine, Griffith University, Australia
- Department of Orthopaedics, Gold Coast University Hospital, Australia
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Lee JI, Hur JM, You J, Lee DH. Functional recovery with histomorphometric analysis of nerves and muscles after combination treatment with erythropoietin and dexamethasone in acute peripheral nerve injury. PLoS One 2020; 15:e0238208. [PMID: 32881928 PMCID: PMC7470391 DOI: 10.1371/journal.pone.0238208] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/11/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Peripheral nerve injury (PNI) often leads to significant functional loss in patients and poses a challenge to physicians since treatment options for improving functional outcomes are limited. Recent studies suggest that erythropoietin and glucocoticoids have beneficial effects as mediators of neuro-regenerative processes. We hypothesized that combination treatment with erythropoietin and glucocoticoids would have a synergistic effect on functional outcome after PNI. Materials and methods Sciatic nerve crush injury was simulated in ten-week-old male C57BL/6 mice. The mice were divided into four groups according to the type of drugs administered (control, erythropoietin, dexamethasone, and erythropoietin with dexamethasone). Motor functional recovery was monitored by walking track analysis at serial time points up to 28 days after injury. Morphological analysis of the nerve was performed by immunofluorescent staining for neurofilament (NF) heavy chain and myelin protein zero (P0) in cross-sectional and whole-mount nerve preparations. Additionally, morphological analysis of the muscle was performed by Hematoxylin and eosin staining. Results Combination treatment with erythropoietin and dexamethasone significantly improved the sciatic functional index at 3, 7, 14, and 28 days after injury. Fluorescence microscopy of cross sectional nerve revealed that the combination treatment increased the ratio of P0/NF-expressing axons. Furthermore, confocal microscopy of the whole-mount nerve revealed that the combination treatment increased the fluorescence intensity of P0 expression. The cross-sectional area and minimum Feret’s diameter of the muscle fibers were significantly larger in the mice which received combination treatment than those in the controls. Conclusion Our results demonstrated that combination treatment with erythropoietin and dexamethasone accelerates functional recovery and reduces neurogenic muscle atrophy caused by PNI in mice, which may be attributed to the preservation of myelin and Schwann cell re-myelination. These findings may provide practical therapeutic options for patients with acute PNI.
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Affiliation(s)
- Jung Il Lee
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, South Korea
- College of Medicine, Hanyang University, Seoul, South Korea
- * E-mail:
| | - Jeong Min Hur
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, South Korea
| | - Jooyoung You
- Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, South Korea
| | - Duk Hee Lee
- Department of Emergency Medicine, Ewha Women's University Mokdong Hospital, Seoul, South Korea
- College of Medicine, Ewha Women's University, Seoul, South Korea
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Modrak M, Sundem L, Gupta R, Zuscik MJ, Elfar J. Pharmacological Attenuation of Electrical Effects in a Model of Compression Neuropathy. J Bone Joint Surg Am 2019; 101:523-530. [PMID: 30893233 PMCID: PMC6738556 DOI: 10.2106/jbjs.18.00162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Peripheral nerve compression and entrapment can be debilitating. Using a validated animal model of peripheral nerve compression, we examined the utility of 2 drugs approved for other uses in humans, 4-aminopyridine (4-AP) and erythropoietin (EPO), as treatments for surgically induced ischemia and as adjuvants to surgical decompression. METHODS Peripheral nerve compression was induced in wild-type mice by placing an inert silicone sleeve around the sciatic nerve. Decompression surgery was performed at 6 weeks with mice receiving 4-AP, EPO, or saline solution either during and after compression or only after decompression. A nerve conduction study and morphometric analyses were performed to compare the extent of the injury and the efficacy of the therapies, and the findings were subjected to statistical analysis. RESULTS During peripheral nerve compression, there was a progressive decline in nerve conduction velocity compared with that in sham-treatment animals, in which nerve conduction velocity remained normal (∼55 m/s). Mice treated with 4-AP or EPO during the compression phase had significantly smaller declines in nerve conduction velocity and increased plateau nerve conduction velocities compared with untreated controls (animals that received saline solution). Histomorphometric analyses of newly decompressed nerves (i.e., nerves that underwent decompression on the day that the mouse was sacrificed) revealed that both treated groups had significantly greater proportions of large (>5-µm) axons than the untreated controls. Following surgical decompression, all animals recovered to a normal baseline nerve conduction velocity by day 15; however, treatment significantly accelerated improvement (in both the 4-AP and the EPO group), even when it was only started after decompression. Histomorphometric analyses at 7 and 15 days following surgical decompression revealed significantly increased myelin thickness and significantly greater proportions of large axons among the treated animals. CONCLUSIONS Both the 4-AP and the EPO-treated group demonstrated improvements in tissue architectural and electrodiagnostic measurements, both during and after peripheral nerve compression, compared with untreated mice. CLINICAL RELEVANCE Peripheral nerve decompression is one of the most commonly performed procedures in orthopaedic surgery. We believe that there is reason for some optimism about the translation of our findings to the clinical setting. Our findings in this murine model suggest that 4-AP and EPO may lessen the effects of nerve entrapment and that the use of these agents after decompression may speed and perhaps otherwise optimize recovery after surgery.
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Affiliation(s)
- Maxwell Modrak
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Leigh Sundem
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Ranjan Gupta
- Department of Orthopaedic Surgery, University of California at Irvine, Irvine, California
| | - Michael J. Zuscik
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York
| | - John Elfar
- Department of Orthopaedics and Rehabilitation, Center for Orthopaedic Research and Translational Science, The Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Modrak M, Sundem L, Elfar J. Erythropoietin enhanced recovery after peripheral nerve injury. Neural Regen Res 2017; 12:1268-1269. [PMID: 28966638 PMCID: PMC5607818 DOI: 10.4103/1673-5374.213544] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Max Modrak
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Leigh Sundem
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA; Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John Elfar
- Department of Orthopedic Surgery and Center for Orthopedic Research and Translational Science, Pennsylvania State University College of Medicine, Hershey, PA, USA
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Sundem L, Chris Tseng KC, Li H, Ketz J, Noble M, Elfar J. Erythropoietin Enhanced Recovery After Traumatic Nerve Injury: Myelination and Localized Effects. J Hand Surg Am 2016; 41:999-1010. [PMID: 27593486 PMCID: PMC5053901 DOI: 10.1016/j.jhsa.2016.08.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 06/08/2016] [Accepted: 08/06/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE We previously found that administration of erythropoietin (EPO) shortens the course of recovery after experimental crush injury to the mouse sciatic nerve. The course of recovery was more rapid than would be expected if EPO's effects were caused by axonal regeneration, which raised the question of whether recovery was instead the result of promoting remyelination and/or preserving myelin on injured neurons. This study tested the hypothesis that EPO has a direct and local effect on myelination in vivo and in vitro. METHODS Animals were treated with EPO after standard calibrated sciatic nerve crush injury; immunohistochemical analysis was performed to assay for myelinated axons. Combined in vitro neuron-Schwann cell co-cultures were performed to assess EPO-mediated effects directly on myelination and putative protective effects against oxidative stress. In vivo local administration of EPO in a fibrin glue carrier was used to demonstrate early local effects of EPO treatment well in advance of possible neuroregenerative effects. RESULTS Systemic Administration of EPO maintained more in vivo myelinated axons at the site of nerve crush injury. In vitro, EPO treatment promoted myelin formation and protected myelin from the effects of nitric oxide exposure in co-cultures of Schwann cells and dorsal root ganglion neurons. In a novel, surgically applicable local treatment using Food and Drug Administration-approved fibrin glue as a vehicle, EPO was as effective as systemic EPO administration at time points earlier than those explainable using standard models of neuroregeneration. CONCLUSIONS In nerve crush injury, EPO may be exerting a primary influence on myelin status to promote functional recovery. CLINICAL RELEVANCE Mixed injury to myelin and axons may allow the opportunity for the repurposing of EPO for use as a myeloprotective agent in which injuries spare a requisite number of axons to allow early functional recovery.
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Affiliation(s)
- Leigh Sundem
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY
| | | | - Haiyan Li
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY
| | - John Ketz
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Mark Noble
- Department of Biomedical Genetics, Institute for Stem Cell and Regenerative Medicine, University of Rochester Medical Center, Rochester, NY
| | - John Elfar
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY; Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY.
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Bernstein DT, Weiner BK, Tasciotti E, Mathis KB. Does the combination of erythropoietin and tapered oral corticosteroids improve recovery following iatrogenic nerve injury? Injury 2016; 47:1819-23. [PMID: 27287740 DOI: 10.1016/j.injury.2016.05.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/15/2016] [Accepted: 05/24/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The reported prognosis for recovery after peripheral nerve injury is remarkably poor. Deficits may persist for years, resulting in significant functional disability. Both corticosteroids and Erythropoietin have been investigated as neuroprotective agents; however, their efficacy in total hip and knee arthroplasty is not known. The purpose of this study was to evaluate the effect of systemically-administered Erythropoietin and tapered oral corticosteroids on the recovery of postoperative nerve palsies in the setting of total hip and knee arthroplasty. METHODS Eleven patients sustaining postoperative peripheral nerve injuries after total hip or knee arthroplasty were treated acutely with Erythropoietin and tapered oral steroids. Motor and sensory function was assessed clinically pre- and postoperatively until complete motor recovery or for a minimum of 1 year. RESULTS Motor loss was complete in seven (64%) patients and partial in four (36%). Seven (64%) patients' symptoms affected the common peroneal nerve distribution and four (36%) had concomitant tibial nerve involvement. Eight (73%) patients experienced full motor recovery at an average of 39 days (range: 3-133 days), and three (27%) had near-complete motor recovery. At final follow up, no patient required assistive devices for ambulation. CONCLUSIONS Administration of Erythropoietin coupled with oral tapered steroids for patients sustaining iatrogenic nerve injuries in total hip and knee arthroplasty demonstrated faster and more complete recovery of motor and sensory function compared to previous reports in the literature. This study highlights the importance of further investigation to define the role of each in the setting of acute postoperative nerve palsies. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Derek T Bernstein
- Houston Methodist Hospital, Department of Orthopaedic Surgery, 6550 Fannin Street, Smith Tower, Suite 2500, Houston, TX, 77030, United States.
| | - Bradley K Weiner
- Houston Methodist Hospital, Department of Orthopaedic Surgery, 6550 Fannin Street, Smith Tower, Suite 2500, Houston, TX, 77030, United States; The Methodist Hospital Research Institute, Department of Nanomedicine, 6670 Bertner Avenue, Houston, TX, 77030, United States
| | - Ennio Tasciotti
- The Methodist Hospital Research Institute, Department of Nanomedicine, 6670 Bertner Avenue, Houston, TX, 77030, United States
| | - Kenneth B Mathis
- Houston Methodist Hospital, Department of Orthopaedic Surgery, 6550 Fannin Street, Smith Tower, Suite 2500, Houston, TX, 77030, United States
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The incidence and risk factors for post-operative ileus after spinal fusion surgery: a multivariate analysis. INTERNATIONAL ORTHOPAEDICS 2016; 40:1067-74. [DOI: 10.1007/s00264-016-3148-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/24/2016] [Indexed: 12/20/2022]
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Localized and sustained delivery of erythropoietin from PLGA microspheres promotes functional recovery and nerve regeneration in peripheral nerve injury. BIOMED RESEARCH INTERNATIONAL 2015; 2015:478103. [PMID: 25821803 PMCID: PMC4363504 DOI: 10.1155/2015/478103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 02/09/2015] [Indexed: 12/14/2022]
Abstract
Erythropoietin (EPO) has been demonstrated to exert neuroprotective effects on peripheral nerve injury recovery. Though daily intraperitoneal injection of EPO during a long period of time was effective, it was a tedious procedure. In addition, only limited amount of EPO could reach the injury sites by general administration, and free EPO is easily degraded in vivo. In this study, we encapsulated EPO in poly(lactide-co-glycolide) (PLGA) microspheres. Both in vitro and in vivo release assays showed that the EPO-PLGA microspheres allowed sustained release of EPO within a period of two weeks. After administration of such EPO-PLGA microspheres, the peripheral nerve injured rats had significantly better recovery compared with those which received daily intraperitoneal injection of EPO, empty PLGA microspheres, or saline treatments. This was supported by the functional, electrophysiological, and histological evaluations of the recovery done at week 8 postoperatively. We conclude that sustained delivery of EPO could be achieved by using EPO-PLGA microspheres, and such delivery method could further enhance the recovery function of EPO in nerve injury recovery.
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Chan KM, Gordon T, Zochodne DW, Power HA. Improving peripheral nerve regeneration: from molecular mechanisms to potential therapeutic targets. Exp Neurol 2014; 261:826-35. [PMID: 25220611 DOI: 10.1016/j.expneurol.2014.09.006] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 08/29/2014] [Accepted: 09/05/2014] [Indexed: 11/19/2022]
Abstract
Peripheral nerve injury is common especially among young individuals. Although injured neurons have the ability to regenerate, the rate is slow and functional outcomes are often poor. Several potential therapeutic agents have shown considerable promise for improving the survival and regenerative capacity of injured neurons. These agents are reviewed within the context of their molecular mechanisms. The PI3K/Akt and Ras/ERK signaling cascades play a key role in neuronal survival. A number of agents that target these pathways, including erythropoietin, tacrolimus, acetyl-l-carnitine, n-acetylcysteine and geldanamycin have been shown to be effective. Trk receptor signaling events that up-regulate cAMP play an important role in enhancing the rate of axonal outgrowth. Agents that target this pathway including rolipram, testosterone, fasudil, ibuprofen and chondroitinase ABC hold considerable promise for human application. A tantalizing prospect is to combine different molecular targeting strategies in complementary pathways to optimize their therapeutic effects. Although further study is needed prior to human trials, these modalities could open a new horizon in the clinical arena that has so far been elusive.
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Affiliation(s)
- K Ming Chan
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Alberta, Canada; Centre for Neuroscience, University of Alberta, Canada.
| | - Tessa Gordon
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Alberta, Canada; Centre for Neuroscience, University of Alberta, Canada; Division of Plastic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Douglas W Zochodne
- Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
| | - Hollie A Power
- Division of Plastic Surgery, University of Alberta, Canada
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Lykissas MG, Aichmair A, Sama AA, Hughes AP, Lebl DR, Cammisa FP, Girardi FP. Nerve injury and recovery after lateral lumbar interbody fusion with and without bone morphogenetic protein-2 augmentation: a cohort-controlled study. Spine J 2014; 14:217-24. [PMID: 24269858 DOI: 10.1016/j.spinee.2013.06.109] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 06/29/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite common use of intraoperative electrophysiologic neuromonitoring, injuries to the lumbar plexus during lateral lumbar interbody fusion (LLIF) have been reported. Emerging data suggest that recombinant human bone morphogenetic protein-2 (rhBMP-2) use during an anterior or transforaminal lumbar interbody fusion may be associated with an increased risk of neurological deficit. Clinical data on the sequelae of rhBMP-2 implantation in close proximity to the lumbosacral plexus during LLIF remains to be understood. PURPOSE The purpose of this study was to compare the incidence of neurologic deficits and pain in patients undergoing LLIF with and without rhBMP-2. STUDY DESIGN/SETTING Retrospective outcome analysis in controlled cohorts undergoing the lateral exposure technique for LLIF with and without rhBMP-2. METHODS The electronic medical records of patients undergoing LLIF with and without supplemental posterior fusion for degenerative spinal conditions were retrospectively reviewed over a 6-year period. Patients with previous lumbar spine surgery or follow-up of less than 6 months were excluded. Patients were divided into 2 groups, Group 1 (rhBMP-2 use; n=72) and Group 2 (autograft/allograft use; n=72), and were matched according to the age at the time of surgery, gender, weight, body mass index, side of approach, total number of treated spinal segments, use of supplemental posterior fusion, and length of follow-up. RESULTS Immediately after surgery, a sensory deficit was recorded in 33 patients in Group 1 and 35 patients in Group 2 (odds ratio [OR] 0.895; 90% confidence interval [CI] 0.516-1.550; p=.739). At last follow-up, a persistent sensory deficit was identified in 29 patients whose LLIF procedure was supplemented by rhBMP-2 and 20 patients in whom autograft/allograft was used (OR 1.754; 90% CI 0.976-3.151; p=.115). A motor deficit was recorded in 37 patients immediately after the rhBMP-2 procedure and 28 patients treated with autograft/allograft (OR 1.661; 90% CI 0.953-2.895; p=.133). A persistent motor deficit was recorded in 35 and 17 patients in Groups 1 and 2, respectively, at last follow-up (OR 3.060; 90% CI 1.681-5.571; p=.002). During the first postoperative examination, 37 patients in Group 1 and 25 patients in Group 2 complained of anterior thigh or groin pain (OR 1.987; 90% CI 1.133-3.488; p=.045). At last follow-up, there was a significantly higher number of patients in Group 1 who complained of persistent anterior thigh or groin pain than Group 2 (8 vs. 0 patients) (OR 16.470; 90% CI 1.477-183.700; p=.006). CONCLUSIONS Our results provide evidence of an increased rate of postoperative neurologic deficit and anterior thigh/groin pain after LLIF using rhBMP-2, when compared with matched controls without rhBMP-2 exposure. This study suggests a potential direct deleterious effect of rhBMP-2 on the lumbosacral plexus.
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Affiliation(s)
- Marios G Lykissas
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E. 70th St, New York, NY 10021, USA.
| | - Alexander Aichmair
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E. 70th St, New York, NY 10021, USA
| | - Andrew A Sama
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E. 70th St, New York, NY 10021, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E. 70th St, New York, NY 10021, USA
| | - Darren R Lebl
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E. 70th St, New York, NY 10021, USA
| | - Frank P Cammisa
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E. 70th St, New York, NY 10021, USA
| | - Federico P Girardi
- Department of Orthopedic Surgery, Spine and Scoliosis Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 E. 70th St, New York, NY 10021, USA
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Ghoreishian M, Rezaei M, Beni BH, Javanmard SH, Attar BM, Zalzali H. Facial nerve repair with Gore-Tex tube and adipose-derived stem cells: an animal study in dogs. J Oral Maxillofac Surg 2012; 71:577-87. [PMID: 22868036 DOI: 10.1016/j.joms.2012.05.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 05/22/2012] [Accepted: 05/22/2012] [Indexed: 12/14/2022]
Abstract
PURPOSE Synthetic conduits have been considered a viable option in nerve reconstructive procedures. They address the goal of entubulization and eliminate the disadvantages of autografts. However, despite all successful reports, none has contained regeneration characteristics, such as growth factors or essential cells, for nerve repair. The authors evaluated the capability of adipose-derived stem cells in Gore-Tex tubes to enhance facial nerve repair. MATERIALS AND METHODS Undifferentiated mesenchymal stem cells were extracted from the autogenous adipose tissues of 7 mongrel dogs. The frontal branch of the facial nerve was transected. A gap size of 7 mm was repaired with an expanded polytetrafluoroethylene tube filled with undifferentiated adipose-derived stem cells encapsulated in alginate hydrogel. The control sides were repaired with the tube and alginate alone. The healing phase was 12 weeks. RESULTS Except in 2 control sides, an organized neural tissue was formed within the tubes. Compared with the normal nerve diameter, there was a decreased ratio of 29% and 39% in the experimental and control groups, respectively. Neurofilament-positive axon counts were 67% of normal values in the 2 groups. There was no significant difference between groups in histomorphometric parameters. Nerve conduction velocity in the experimental group (28.5 ± 3.5 m/s) was significantly greater than in the control group (16.2 ± 7 m/s). The experimental group also exhibited a greater maximal amplitude of action potential (1.86 ± 0.24 mV) than the control group (1.45 ± 0.49 mV). CONCLUSIONS Addition of stem cells in the Gore-Tex tube enhanced the neural repair from a functional standpoint. However, for better functional and histologic results, differentiated Schwann cells and other mediators may be warranted.
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Affiliation(s)
- Mehdi Ghoreishian
- Department of Oral and Maxillofacial Surgery and Torabinejad Dental Research Center, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
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Peripheral neuropathy response to erythropoietin in type 2 diabetic patients with mild to moderate renal failure. Clin Neurol Neurosurg 2012; 114:663-7. [DOI: 10.1016/j.clineuro.2012.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 01/05/2012] [Accepted: 01/07/2012] [Indexed: 01/29/2023]
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Kuffler DP. Combinatorial techniques for enhancing neuroprotection: hypothermia and alkalinization. Ann N Y Acad Sci 2010; 1199:164-74. [PMID: 20633122 DOI: 10.1111/j.1749-6632.2009.05353.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Brain and spinal cord (CNS) trauma typically kill a number of neurons, but even more neurons are killed by secondary causes triggered by the initial trauma. Thus, a minor insult may rapidly cause the death of a vastly larger number of neurons and complete paralysis. The best mechanism for reducing the extent of neurological deficits is to minimize the number of neurons killed by post-trauma sequelae. Neuroprotection techniques take many diverse forms with a breadth too great for a short review. Therefore, this review focuses on the neuroprotection provided by hypothermia and a number of other neuroprotective techniques, when administered singly or in combination, because it is generally found that combinations of applications lead to significantly better neuroprotection than is achieved by any one alone. The combinatorial approach to neuroprotection holds great promise for enhancing the degree of neuroprotection following trauma, leading to maximum maintenance of neurological function.
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Affiliation(s)
- Damien P Kuffler
- Institute of Neurobiology, Medical Sciences Campus, University of Puerto Rico, San Juan.
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Liao WC, Chen JR, Wang YJ, Tseng GF. The efficacy of end-to-end and end-to-side nerve repair (neurorrhaphy) in the rat brachial plexus. J Anat 2009; 215:506-21. [PMID: 19682138 PMCID: PMC2780569 DOI: 10.1111/j.1469-7580.2009.01135.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2009] [Indexed: 11/29/2022] Open
Abstract
Proximal nerve injury often requires nerve transfer to restore function. Here we evaluated the efficacy of end-to-end and end-to-side neurorrhaphy of rat musculocutaneous nerve, the recipient, to ulnar nerve, the donor. The donor was transected for end-to-end, while an epineurial window was exposed for end-to-side neurorrhaphy. Retrograde tracing showed that 70% donor motor and sensory neurons grew into the recipient 3 months following end-to-end neurorrhaphy compared to 40-50% at 6 months following end-to-side neurorrhaphy. In end-to-end neurorrhaphy, regenerating axons appeared as thick fibers which regained diameters comparable to those of controls in 3-4 months. However, end-to-side neurorrhaphy induced slow sprouting fibers of mostly thin collaterals that barely approached control diameters by 6 months. The motor end plates regained their control density at 4 months following end-to-end but remained low 6 months following end-to-side neurorrhaphy. The short-latency compound muscle action potential, typical of that of control, was readily restored following end-to-end neurorrhaphy. End-to-side neurorrhaphy had low amplitude and wide-ranging latency at 4 months and failed to regain control sizes by 6 months. Grooming test recovered successfully at 3 and 6 months following end-to-end and end-to-side neurorrhaphy, respectively, suggesting that powerful muscle was not required. In short, both neurorrhaphies resulted in functional recovery but end-to-end neurorrhaphy was quicker and better, albeit at the expense of donor function. End-to-side neurorrhaphy supplemented with factors to overcome the slow collateral sprouting and weak motor recovery may warrant further exploration.
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Affiliation(s)
- Wen-Chieh Liao
- Institute of Anatomy and Cell Biology, College of Medicine, National Taiwan UniversityTaipei, Taiwan
| | - Jeng-Rung Chen
- Department of Veterinary Medicine, College of Veterinary Medicine, National Chung-Hsing UniversityTaichung, Taiwan
| | - Yueh-Jan Wang
- Department of Anatomy, College of Medicine, Tzu Chi UniversityHualien, Taiwan
| | - Guo-Fang Tseng
- Department of Anatomy, College of Medicine, Tzu Chi UniversityHualien, Taiwan
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van Neck JW, de Kool BS, Hekking-Weijma JIM, Walbeehm ET, Visser GH, Blok JH. Histological validation of ultrasound-guided neurography in early nerve regeneration. Muscle Nerve 2009; 40:967-75. [DOI: 10.1002/mus.21405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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16
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Basics and Current Approaches to Tissue Engineering in Peripheral Nerve Reconstruction. ACTA ACUST UNITED AC 2009. [DOI: 10.1097/wnq.0b013e3181a361c6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Zhang W, Sun B, Yu Z, An J, Liu Q, Ren T. High dose erythropoietin promotes functional recovery of rats following facial nerve crush. J Clin Neurosci 2009; 16:554-6. [DOI: 10.1016/j.jocn.2008.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Revised: 05/24/2008] [Accepted: 06/25/2008] [Indexed: 01/04/2023]
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18
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The efficacy of erythropoietin on acute spinal cord injury. An experimental study on a rat model. Arch Orthop Trauma Surg 2009; 129:189-94. [PMID: 18309506 DOI: 10.1007/s00402-008-0594-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The accumulated knowledge of erythropoietin (EPO) interaction in neural injury has led to potentially novel therapeutic strategies. Previous experimental studies of recombinant human EPO (rhEPO) administration have shown favorable results after central and peripheral neural injury. In the present study we used the aneurysmal clip model to evaluate the efficacy of two different regimes of rhEPO administration on the functional outcome after severe acute spinal cord injury (ASCI). MATERIALS AND METHODS Thirty rats were operated on with posterior laminectomy at thoracic 10th vertebra. Spinal cord trauma produced by extradural placement of the aneurysm clip, for 1 min. Animals were divided into three groups; the first group received a low total EPO dose (EPO-L), (2 doses of 1,000 IU each s.c.). The second group was administered the high total EPO dose (EPO-H), (14 doses of 1,000 IU each s.c.), and the third was the Control group, which received normal saline in the same time fashion with EPO-H group. Follow-up was for 6 weeks. Estimation of the functional progress of each rat was calculated using the locomotor rating scale of Basso et al, with a range from 0 to 21. RESULTS After surgery the animals suffered paraplegia with urinary disturbances. Rats that received EPO demonstrated statistically significant functional improvement compared to the Control group, throughout study interval. On the last follow-up at 6 weeks the EPO-L rats achieved a mean score 17.3 +/- 1.15, the EPO-H 14.7 +/- 1.82, and the control group 8.2 +/- 0.78. Comparison between the two EPO groups reveals superior final outcome of the group treated with lower total dose. CONCLUSION Our study supports current knowledge, that EPO administration has a positive effect on functional recovery after experimental ASCI. These data reflect the positive impact of EPO on the pathophysiologic cascade of secondary neural damage. However, we observed a dose-related effect on functional recovery. Interestingly, large doses do not seem to favor the neurological recovery as lower doses do.
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Magnaghi V, Procacci P, Tata AM. Chapter 15 Novel Pharmacological Approaches to Schwann Cells as Neuroprotective Agents for Peripheral Nerve Regeneration. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2009; 87:295-315. [DOI: 10.1016/s0074-7742(09)87015-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Beris AE, Lykissas MG. Chapter 13 Experimental Results in End‐To‐Side Neurorrhaphy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2009; 87:269-79. [DOI: 10.1016/s0074-7742(09)87013-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Siemionow M, Brzezicki G. Chapter 8: Current techniques and concepts in peripheral nerve repair. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2009; 87:141-72. [PMID: 19682637 DOI: 10.1016/s0074-7742(09)87008-6] [Citation(s) in RCA: 277] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite the progress in understanding the pathophysiology of peripheral nervous system injury and regeneration, as well as advancements in microsurgical techniques, peripheral nerve injuries are still a major challenge for reconstructive surgeons. Thorough knowledge of anatomy, pathophysiology, and surgical reconstruction is a prerequisite of proper peripheral nerve injury management. This chapter reviews the currently available surgical treatment options for different types of nerve injuries in clinical conditions. In overview of direct nerve repair, various end-to-end coaptation techniques and the role of end-to-side repair for proximal nerve injuries is described. When primary repair cannot be performed without undue tension, nerve grafting or tubulization techniques are required. Current gold standard for bridging nerve gaps is nerve autografting. However, disadvantages of this approach, such as donor site morbidity and limited length of available graft material encouraged the search for alternative means of nerve gap reconstruction. Nerve allografting was introduced for repair of extensive nerve injuries. Tubulization techniques with natural or artificial conduits are applicable as an alternative for bridging short nerve defects without the morbidities associated with harvesting of autologous nerve grafts. Achieving better outcomes depends both on the advancements in microsurgical techniques and introduction of molecular biology discoveries into clinical practice. The field of peripheral nerve research is dynamically developing and concentrates on more sophisticated approaches tested at the basic science level. Future directions in peripheral nerve reconstruction including, tolerance induction and minimal immunosuppression for nerve allografting, cell based supportive therapies and bioengineering of nerve conduits are also reviewed in this chapter.
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Affiliation(s)
- Maria Siemionow
- Cleveland Clinic, Department of Plastic Surgery, Cleveland, Ohio 44195, USA
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Ichihara S, Inada Y, Nakamura T. Artificial nerve tubes and their application for repair of peripheral nerve injury: an update of current concepts. Injury 2008; 39 Suppl 4:29-39. [PMID: 18804584 DOI: 10.1016/j.injury.2008.08.029] [Citation(s) in RCA: 140] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Over the last 20 years, an increasing number of research articles have reported on the use of artificial nerve tubes to repair nerve defects. The development of an artificial nerve tube as an alternative to autogenous nerve grafting is currently a focus of interest for peripheral nerve repair. The clinical employment of tubes as an alternative to autogenous nerve grafts is mainly justified by the limited availability of donor tissue for nerve autografts and the related morbidity. Numerous studies indicate that short-distance defects in humans can be successfully treated by implantation of artificial nerve guides. This review provides a brief overview of various preclinical and clinical trials conducted to evaluate the utility of artificial nerve tubes for the regeneration of peripheral nerves. This review is also intended to help update hand surgeons on the rapid advances in tubulization techniques, and to provide them with indications of the various directions toward which future research can proceed. Future studies need to provide us with as much comparative information as possible on the effectiveness of different tubulization techniques, in order to guide the surgeon in choosing the best indications for their optimal clinical employment. Future progress in implant development can be expected from interdisciplinary approaches involving both materials and life sciences, leading to advances in neuro-tissue engineering that will be needed to effectively treat larger nerve defects.
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Affiliation(s)
- Satoshi Ichihara
- Department of Bioartificial Organs, Institute for Frontier Medical Sciences, Kyoto University, Kyoto, Japan
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Paschos N, Lykissas MG, Beris AE. The role of erythropoietin as an inhibitor of tissue ischemia. Int J Biol Sci 2008; 4:161-8. [PMID: 18566695 PMCID: PMC2430987 DOI: 10.7150/ijbs.4.161] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2008] [Accepted: 06/09/2008] [Indexed: 01/09/2023] Open
Abstract
Erythropoietin is a hypoxia-induced cytokine that stimulates erythropoiesis through the promotion of erythroid precursor cell proliferation and differentiation. Recent evidence supports that erythropoietin has a broad spectrum of tissue protecting actions affecting other systems than hemopoietic. Lately, research has focused on the nonhemopoietic effects of erythropoietin against tissue ischemia due to the unexpected observations of erythropoietin receptor expression by various cells, such as endothelial cells, neuronal cells, cardiac myocytes, and vascular smooth muscle cells. It has been shown that erythropoietin exerts its cardioprotective action during cardiac ischemic injury through reducing the infract size and enhancing new vessel formation over a longer time frame. Erythropoietin plays a crucial role in neuroprotection in many types of ischemic injury in the central and the peripheral nervous system. It is also strongly believed that erythropoietin exhibits a critical role in many other disorders that are pathogenetically related to acute tissue ischemia. This article reviews the proposed implications of erythropoietin in tissue ischemia and discusses the possible mechanisms for this action along with its potential therapeutic applications.
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Affiliation(s)
- Nikolaos Paschos
- Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina, P.O. Box 45110, Greece
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RETRACTED: Local erythropoietin signaling enhances regeneration in peripheral axons. Neuroscience 2008; 154:767-83. [DOI: 10.1016/j.neuroscience.2008.03.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 03/18/2008] [Accepted: 03/19/2008] [Indexed: 12/12/2022]
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Use of Erythropoietin as adjuvant therapy in nerve reconstruction. Langenbecks Arch Surg 2008; 393:317-23. [PMID: 18299885 DOI: 10.1007/s00423-008-0289-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2008] [Accepted: 01/17/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS Adjuvant therapies may improve the outcome after nerve reconstruction. We analyzed the influence of recombinant human Erythropoietin (rHuEpo), which has proven angiogenic and neuroprotective effects, on the quality of peripheral nerve regeneration. METHODS Thirty two female Lewis rats underwent nerve reconstruction by means of tubulization (groups I and II) or autologous sciatic nerve grafting (groups III and IV). Groups I and III received daily subcutaneous rHuEpo injections over 2 weeks (1,000 U/kg bw) with normal saline injections as controls (groups II and IV). Data on histology and muscle weight were collected after 7 weeks. Axon count and diameter were assessed by a new method based on digital segmentation. RESULTS Atrophy of the tibial muscle was less severe in the rHuEpo-treated group compared to controls resulting in significant higher muscle weight quotients (p = 0.006). The same trend was found in the gastrocnemius muscle, but without being statistically significant. No significant differences in axon count or axon diameter were detected in the presence of rHuEpo treatments. CONCLUSION Our findings give evidence for a positive effect of Erythropoietin on functional recovery after nerve grafting. Muscle recovery benefited from rHuEpo administration despite absence of improved neural morphology. Semi-automated axon detection facilitated accurate morphometrical assessment.
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Lykissas MG, Korompilias AV, Batistatou AK, Mitsionis GI, Beris AE. Can end-to-side neurorrhaphy bridge large defects? An experimental study in rats. Muscle Nerve 2008; 36:664-71. [PMID: 17661375 DOI: 10.1002/mus.20861] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This study was undertaken to evaluate collateral sprouting capability in an end-to-side repair model with long regenerative distance. Forty-five rats were used and divided into four groups, according to the reparative procedure following peroneal nerve division: (A) "double" end-to-side neurorrhaphy with a regenerative distance of 0.6 cm; (B) "double" end-to-side neurorrhaphy with a regenerative distance of 1.2 cm; (C) end-to-end neurorrhaphy; and (D) nerve stumps buried into neighboring muscles. In all animals the contralateral healthy side served as a control. Functional assessment of nerve regeneration was performed at intervals up to 5 months using the Peroneal Function Index (PFI). Evaluation 150 days after surgery included peroneal and tibial nerve histologic and morphometric examination and wet weights of the tibialis anterior muscle. Functional evaluation and axonal counting data demonstrated that there was no statistically significant difference between groups A and B, or between groups A and C. There was no functional or histologic evidence of donor nerve deterioration. In conclusion, the present study confirms that "double" end-to-side neurorrhaphy may be useful for the repair of divided human nerves with long gaps.
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Affiliation(s)
- Marios G Lykissas
- Department of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina, P.C. 45110, Greece.
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Lykissas MG, Korompilias AV, Vekris MD, Mitsionis GI, Sakellariou E, Beris AE. The role of erythropoietin in central and peripheral nerve injury. Clin Neurol Neurosurg 2007; 109:639-44. [PMID: 17624659 DOI: 10.1016/j.clineuro.2007.05.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2006] [Revised: 05/16/2007] [Accepted: 05/23/2007] [Indexed: 01/24/2023]
Abstract
Erythropoietin (Epo) is a cytokine which controls red cell production. Apart from the red cell surface, erythropoietin's receptor (Epo-R) is also expressed in a large variety of normal tissues. Erythropoietin, as well as its receptor, is present in the central and peripheral nervous system. As erythropoietin having direct and indirect effect on nerve cells, enhances antioxidotic enzyme production, antagonizes glutamate's cytotoxic action, metabolizes free radicals, normalizes cerebral blood flow, affects neurotransmitters release and stimulates neoangiogenesis. After injury of the central as well as the peripheral nervous system, Epo presents an anti-apoptotic action. In combination with its anti-apoptotic effect, Epo, by reducing the inflammatory response plays a crucial role in neuroprotection in many types of injury in the central and the peripheral nervous system. Epo's administration contributes to the recovery of mechanical allodynia and may be effective in peripheral nerve regeneration after neurorrhaphy.
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Affiliation(s)
- Marios G Lykissas
- Department of Orthopaedic Surgery, University of Ioannina School of Medicine, Ioannina, Greece.
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