Stimulation of corticospinal tract regeneration in the chronically injured spinal cord

Therapeutic repair for spinal cord injury: combinatory approaches to address a multifaceted problem

The recent years saw the advent of promising preclinical strategies that combat the devastating effects of a spinal cord injury (SCI) that are progressing towards clinical trials. However, individually, these treatments produce only modest levels of recovery in animal models of SCI that could hamper their implementation into therapeutic strategies in spinal cord injured humans. Combinational strategies have demonstrated greater beneficial outcomes than their individual components alone by addressing multiple aspects of SCI pathology. Clinical trial designs in the future will eventually also need to align with this notion. The scenario will become increasingly complex as this happens and conversations between basic researchers and clinicians are required to ensure accurate study designs and functional readouts.

Combinatorial Therapies After Spinal Cord Injury: How Can Biomaterials Help?

Traumatic spinal cord injury (SCI) results in an immediate loss of motor and sensory function below the injury site and is associated with a poor prognosis. The inhibitory environment that develops in response to the injury is mainly due to local expression of inhibitory factors, scarring and the formation of cystic cavitations, all of which limit the regenerative capacity of endogenous or transplanted cells. Strategies that demonstrate promising results induce a change in the microenvironment at- and around the lesion site to promote endogenous cell repair, including axonal regeneration or the integration of transplanted cells. To date, many of these strategies target only a single aspect of SCI; however, the multifaceted nature of SCI suggests that combinatorial strategies will likely be more effective. Biomaterials are a key component of combinatorial strategies, as they have the potential to deliver drugs locally over a prolonged period of time and aid in cell survival, integration and differentiation. Here we summarize the advantages and limitations of widely used strategies to promote recovery after injury and highlight recent research where biomaterials aided combinatorial strategies to overcome some of the barriers of spinal cord regeneration.

Small Molecule Agonists of Cell Adhesion Molecule L1 Mimic L1 Functions In Vivo

Lack of permissive mechanisms and abundance of inhibitory molecules in the lesioned central nervous system of adult mammals contribute to the failure of functional recovery after injury, leading to severe disabilities in motor functions and pain. Peripheral nerve injury impairs motor, sensory, and autonomic functions, particularly in cases where nerve gaps are large and chronic nerve injury ensues. Previous studies have indicated that the neural cell adhesion molecule L1 constitutes a viable target to promote regeneration after acute injury. We screened libraries of known drugs for small molecule agonists of L1 and evaluated the effect of hit compounds in cell-based assays in vitro and in mice after femoral nerve and spinal cord injuries in vivo. We identified eight small molecule L1 agonists and showed in cell-based assays that they stimulate neuronal survival, neuronal migration, and neurite outgrowth and enhance Schwann cell proliferation and migration and myelination of neurons in an L1-dependent manner. In a femoral nerve injury mouse model, enhanced functional regeneration and remyelination after application of the L1 agonists were observed. In a spinal cord injury mouse model, L1 agonists improved recovery of motor functions, being paralleled by enhanced remyelination, neuronal survival, and monoaminergic innervation, reduced astrogliosis, and activation of microglia. Together, these findings suggest that application of small organic compounds that bind to L1 and stimulate the beneficial homophilic L1 functions may prove to be a valuable addition to treatments of nervous system injuries.

A Fab fragment directed against the neural cell adhesion molecule L1 enhances functional recovery after injury of the adult mouse spinal cord

A recombinant monovalent Fab fragment recognizing a functional epitope within the third fibronectin type III domain of murine cell adhesion molecule L1 induces neurite outgrowth and neuronal survival in vitro and enhances functional recovery after spinal cord injury in mice.

Neurotrophin treatment to promote regeneration after traumatic CNS injury

Neurotrophins are a family of growth factors that have been found to be central for the development and functional maintenance of the nervous system, participating in neurogenesis, neuronal survival, axonal growth, synaptogenesis and activity-dependent forms of synaptic plasticity. Trauma in the adult nervous system can disrupt the functional circuitry of neurons and result in severe functional deficits. The limitation of intrinsic growth capacity of adult nervous system and the presence of an inhospitable environment are the major hurdles for axonal regeneration of lesioned adult neurons. Neurotrophic factors have been shown to be excellent candidates in mediating neuronal repair and establishing functional circuitry via activating several growth signaling mechanisms including neuron-intrinsic regenerative programs. Here, we will review the effects of various neurotrophins in mediating recovery after injury to the adult spinal cord.

Dissociated predegenerated peripheral nerve transplants for spinal cord injury repair: a comprehensive assessment of their effects on regeneration and functional recovery compared to Schwann cell transplants

Several recent studies suggest that predegenerated nerves (PDNs) or dissociated PDNs (dPDNs) can improve behavioral and histological outcomes following transplantation into the injured rat spinal cord. In the current study we tested the efficacy of dPDN transplantation by grafting cells isolated from the sciatic nerve 7 days after crush. We did not replicate one study, but rather assessed what appeared, based on five published reports, to be a reported robust effect of dPDN grafts on corticospinal tract (CST) regeneration and locomotor recovery. Using a standardized rodent spinal cord injury model (200 kD IH contusion) and transplantation procedure (injection of GFP⁺ cells 7 days post-SCI), we demonstrate that dPDN grafts survive within the injured spinal cord and promote the ingrowth of axons to a similar extent as purified Schwann cell (SC) grafts. We also demonstrate for the first time that while both dPDN and SC grafts promote the ingrowth of CGRP axons, neither graft results in mechanical or thermal hyperalgesia. Unlike previous studies, dPDN grafts did not promote long-distance axonal growth of CST axons, brainstem spinal axons, or ascending dorsal column sensory axons. Moreover, using a battery of locomotor tests (Basso Beattie Bresnahan [BBB] score, BBB subscore, inked footprint, Catwalk, and ladderwalk), we failed to detect any beneficial effects of dPDN transplantation on the recovery of locomotor function after SCI. We conclude that dPDN transplants are not sufficient to promote CST regeneration or locomotor recovery after SCI.

Fibronectin supports neurite outgrowth and axonal regeneration of adult brain neurons in vitro

The molecular basis of axonal regeneration of central nervous system (CNS) neurons remains to be fully elucidated. In part, this is due to the difficulty in maintaining CNS neurons in vitro. Here, we show that dissociated neurons from the cerebral cortex and hippocampus of adult mice may be maintained in culture for up to 9 days in defined medium without added growth factors. Outgrowth of neurites including axons was observed from both CNS sources and was significantly greater on plasma fibronectin than on other substrata such as laminin and merosin. Neurite outgrowth on fibronectin appears to be mediated by α5β1 integrin since a recombinant fibronectin fragment containing binding sites for this receptor was as effective as intact fibronectin in supporting neurite outgrowth. Conversely, function-blocking antibodies to α5 and β1 integrin sub-units inhibited neurite outgrowth on intact fibronectin. These results suggest that the axonal regeneration seen in in vivo studies using fibronectin-based matrices is due to the molecule itself and not a consequence of secondary events such as cellular infiltration. They also indicate the domains of fibronectin that may be responsible for eliciting this response.

Mesenchymal stem cells for treatment of CNS injury

Brain and spinal cord injuries present significant therapeutic challenges. The treatments available for these conditions are largely ineffective, partly due to limitations in directly targeting the therapeutic agents to sites of pathology within the central nervous system (CNS). The use of stem cells to treat these conditions presents a novel therapeutic strategy. A variety of stem cell treatments have been examined in animal models of CNS trauma. Many of these studies have used stem cells as a cell-replacement strategy. These investigations have also highlighted the significant limitations of this approach. Another potential strategy for stem cell therapy utilises stem cells as a delivery mechanism for therapeutic molecules. This review surveys the literature relevant to the potential of mesenchymal stem cells for delivery of therapeutic agents in CNS trauma in humans.

Cellular and paracellular transplants for spinal cord injury: a review of the literature

BACKGROUND

Experimental approaches to limit the spinal cord injury and to promote neurite outgrowth and improved function from a spinal cord injury have exploded in recent decades. Due to the cavitation resulting after a spinal cord injury, newer important treatment strategies have consisted of implanting scaffolds with or without cellular transplants. There are various scaffolds, as well as various different cellular transplants including stem cells at different levels of differentiation, Schwann cells and peripheral nerve implants, that have been reviewed. Also, attention has been given to different re-implantation techniques in avulsion injuries.

METHODS

Using standard search engines, this literature is reviewed.

CONCLUSION

Cellular and paracellular transplantation for application to spinal cord injury offers promising results for those patients with spinal cord pathology.

Cocultures of rat sensorimotor cortex and spinal cord slices to investigate corticospinal tract sprouting

STUDY DESIGN

Experimental study of corticospinal axonal sprouting in an organotypic slice culture model.

OBJECTIVE

To develop an in vitro model that simplifies the study of various factors regulating neuronal regeneration.

SUMMARY OF BACKGROUND DATA

Spinal cord injury leads to permanent neurologic damage, mainly due to the inability of the adult central nervous system to regenerate. Much attention has been focused on promoting axonal regeneration and sprouting, either by exogenous administration of various neurotrophic factors or by the antagonization of factors inhibiting regeneration.

METHODS

An in vitro system that allows coculture of slices from rat sensorimotor cortex and spinal cord (p4) was established. Two groups of cultures were investigated: In the first group, intact spinal cord slices were cultured adjacent to sensorimotor cortex slices, while in the second group the spinal cord slices were sagittally cut into halves, with the sectioned interface placed directly adjacent to the sensorimotor cortex, to prevent the spinal white matter from interference. Each group was further divided into 2 subgroups: The neurotrophin-3 (NT-3) group, where the culture medium contained 50 ng/mL NT-3 and the control group treated with normal culture medium. Sensorimotor cortex pyramidal neurons were anterogradely labeled with Mini-Ruby, a 10 kD biotinylated dextran amine.

RESULTS

Cocultures of cortical and spinal cord tissue were propagated in vitro, and axonal sprouting occurred. The group of cocultures treated with NT-3 showed an improved cortical cytoarchitecture, and sprouting axons were more frequently observed. In NT-3-treated cocultures where spinal cord gray matter was directly opposed to cortical slices sprouting axons entered the adjacent spinal cord tissue. This phenomenon was not observed if spinal cord pia mater and white matter were opposed to the cortical slices, or if NT-3 was absent.

CONCLUSION

Our data suggest that the absence of repellent factors such as white matter and the presence of neurotrophic factors promote axonal sprouting. Cocultures of sensorimotor cortex and spinal cord slices combined with anterograde axonal labeling could provide a valuable in vitro model for the simplified screening of factors influencing corticospinal tract regeneration.

Contuse lesion of the rat spinal cord of moderate intensity leads to a higher time-dependent secondary neurodegeneration than severe one. An open-window for experimental neuroprotective interventions

Secondary neurodegeneration takes place in the surrounding tissue of spinal cord trauma and modifies substantially the prognosis, considering the small diameter of its transversal axis. We analyzed neuronal and glial responses in rat spinal cord after different degree of contusion promoted by the NYU Impactor. Rats were submitted to vertebrae laminectomy and received moderate or severe contusions. Control animals were sham operated. After 7 and 30 days post surgery, stereological analysis of Nissl staining cellular profiles showed a time progression of the lesion volume after moderate injury, but not after severe injury. The number of neurons was not altered cranial to injury. However, same degree of diminution was seen in the caudal cord 30 days after both severe and moderate injuries. Microdensitometric image analysis demonstrated a microglial reaction in the white matter 30 days after a moderate contusion and showed a widespread astroglial reaction in the white and gray matters 7 days after both severities. Astroglial activation lasted close to lesion and in areas related to Wallerian degeneration. Data showed a more protracted secondary degeneration in rat spinal cord after mild contusion, which offered an opportunity for neuroprotective approaches. Temporal and regional glial responses corroborated to diverse glial cell function in lesioned spinal cord.

Use of engineered peripheral nerve autografts for spinal cord repair

We developed a clinically compatible protocol for the production of engineered tissue for grafting into the injured spinal cord. We used autologous tissue derived from pre-ligated peripheral nerves, which avoids supply, immunocompatibility and ethical hinderances, combined with non-viral transfection, which is a versatile and non-immunogenic gene transfer method. In-vitro transfection of glial cells or primary tissue from pre-ligated rat peripheral nerve with the neurotrophic gene brain-derived neurotrophic factor significantly enhanced its expression, when quantified or labelled by immunofluorescence. Engineered tissue expressed brain-derived neurotrophic factor after being grafted into the spinal cord of rats that had received spinal contusion injury 3 weeks before. Anatomical and functional assays of repair, conducted on a small cohort, showed that the treatment may promote axonal regeneration and improve motor performance.

Regeneration of descending axon tracts after spinal cord injury

Axons within the adult mammalian central nervous system do not regenerate spontaneously after injury. Upon injury, the balance between growth promoting and growth inhibitory factors in the central nervous system dramatically changes resulting in the absence of regeneration. Axonal responses to injury vary considerably. In central nervous system regeneration studies, the spinal cord has received a lot of attention because of its relatively easy accessibility and its clinical relevance. The present review discusses the axon-tract-specific requirements for regeneration in the rat. This knowledge is very important for the development and optimalization of therapies to repair the injured spinal cord.

Synapse elimination in the corticospinal projection during the early postnatal period

In corticospinal synapses reconstructed in vitro by slice co-culture, we previously showed that the synapses were distributed across the gray matter at 6-7 days in vitro (DIV). Thereafter, they began to be eliminated from the ventral side, and dorsal-dominant distribution was nearly complete at 11-12 DIV. The synapse elimination is associated with retraction of the corticospinal (CS) terminals. We studied whether this specific type of synapse elimination is a physiological phenomenon rather than in vitro artifact. The rat corticospinal tract was stimulated at the medullary pyramid, and field potentials were recorded at the cervical cord along an 200-microm interval lattice on the axial plane. Clearly defined negative field potential were identified as field excitatory postsynaptic potentials (fEPSPs) generated by corticospinal synapses. They were recorded from the entire spinal gray matter at postnatal day 7 (P7). These negative fEPSPs reversed to positive in the most ventrolateral part at P8. Reversal extended to the more mediodorsal area at P10, indicative of progressive synapse elimination in the ventrolateral area. To verify that regression of the axons in vivo paralleled the changes in spatial distribution of fEPSPs as observed in vitro, corticospinal axons were anterogradely labeled. Redistribution of the labeled terminals closely paralleled the fEPSP distribution, being present in the ventrolateral spinal cord at P7, decreased at P8, further deceased at P10, but unchanged at P11. Furthermore, double immunostaining for labeled terminals and synaptophysin observed under a confocal microscope suggests that corticospinal fibers at P7 possess presynaptic structures in the ventrolateral area as well as the dorsomedial area. These findings suggest that corticospinal synapses are widely formed in the spinal gray matter at P7, are rapidly eliminated from the ventrolateral side from P8 to P10, a time-course very similar to that observed in vitro, and are associated with axonal regression.

Treatment of spinal cord injury with co-grafts of genetically modified Schwann cells and fetal spinal cord cell suspension in the rat

Fetal spinal cord cells, Schwann cells and neurotrophins all have the capacity to promote repair of injured spinal cord in animal models. To explore the possibility of using these approaches to treat clinical patients, we have examined whether a combination of these protocols produces functional and anatomical improvement. The spinal cords of adult rats (n=16) were injured with a modified New York University (NYU) device (10 gram.5cm). One week after injury, the injured cords were injected with Dulbecco-modified Eagles Medium (DMEM, control group), or fetal spinal cord cell suspension (FSCS) plus nerve growth factor (NGF) gene-modified Schwann cells (SC) and brain-derived neurotrophic factor (BDNF) gene-modified SC (treatment group). The rats were subjected to BBB (Basso, Beattie, Bresnahan, Exp. Neurol. 139:244, 1996) behavioral tests. Anterograde tracing of corticospinal tract was performed before sacrifice 3 months after the treatment. The results showed that the combination treatment elicited a robust growth of corticospinal axons within and beyond the injury site. A dramatic functional recovery in the treatment group was observed compared with the control group. We conclude that the combination of FSCS with genetically modified Schwann cells over-expressing NGF and BDNF was an effective protocol for the treatment of severe spinal cord injury.

Spontaneous and induced aberrant sprouting at the site of injury is irrelevant to motor function outcome in rats with spinal cord injury

In the absence of effective regeneration following spinal cord (SC) injury, sprouting from undamaged axons has been regarded as an underlying factor for functional improvement after incomplete SC injury. The influence of spontaneous and induced axonal sprouting at the injury site on motor function was tested using rats subjected to moderate SC contusion at T9 level, using megadoses of methylprednisolone (MP) and intralesion implantation of cells from sciatic nerve (PNI). Groups using MP and PNI combined, implant vehicle, and injury with no treatment were also included. Amount of sprouting at the injury sites was significantly different depending on treatment. It was abundant in PNI-treated rats, moderate in rats treated with vehicle or nontreated, and limited in rats given MP with or without PNI (chi2, p=0.0084). This sprouting showed an aberrant course and was located in proliferating tissue at the site of injury, characterized by the presence of ependymal cells, macrophages, and myelinating and nonmyelinating Schwann cells. Functional scores and amount of spared white matter were not significantly different among groups. Correlation of the amount of sprouting vs. functional outcome or vs. amount of spared tissue was not significant, while correlation of functional outcome vs. amount of spared tissue was significant (p<0.0001). In conclusion, PNI increase aberrant sprouting at the injury site, while MP limits such sprouting, in either case without impact on motor function outcome. Missing guiding channels for sprouting axons could explain the absence of any functional improvement.

Motor Recovery and Anatomical Evidence of Axonal Regrowth in Spinal Cord-Repaired Adult Rats

Behavioral assessments of hindlimb motor recovery and anatomical assessments of extended axons of long spinal tracts were conducted in adult rats following complete spinal cord transection. Rats were randomly divided into 3 groups: 1) sham control group (laminectomy only; n = 12); 2) transection-only group, spinal cord transection at T8 (n = 20); and 3) experimental treatment group, spinal cord transection at T8, with peripheral nerve grafts (PNG) and application of acidic fibroblast growth factor (aFGF) (n = 14). The locomotor behavior and stepping of all rats were analyzed over a 6-month survival time using the Basso, Beattie, Bresnahan (BBB) open field locomotor test and the contact placing test. Immunohistochemistry for serotonin (5-HT), anterograde tracing with biotinylated dextran amine (BDA), and retrograde tracing with fluoro-gold were used to evaluate the presence of axons below the damage site following treatment. When compared with the transection-only group, the nerve graft with the aFGF group showed 1) significant improvement in hindlimb locomotion and stepping, 2) the presence of 5-HT-labeled axons below the lesion site at lumbar cord level (these were interpreted as regenerated axons from the raphe nuclei), 3) the presence of anterograde BDA labeling of corticospinal tract axons at the graft site and below, and 4) fluoro-gold retrograde labeling of neuron populations in motor cortex and in red nucleus, reticulospinal nuclei, raphe nuclei, and vestibular nuclei. We conclude that peripheral nerve grafts and aFGF treatments facilitate the regrowth of the spinal axons and improve hindlimb function in a T-8 spinal cord-transected rat model.

Use of gene therapy in central nervous system repair

Recent advances have increased our molecular understanding of the central nervous system (CNS), in both health and disease. In order to realize the clinical benefits of these findings, new molecular-based therapies need to be developed, such as CNS gene therapy. Although the field has suffered setbacks, it remains an attractive technology for providing new therapies in the post-genomic world. The development of new vectors, and their extensive application in animal models of CNS disease, provides evidence suggesting that gene therapy will eventually become an accepted clinical option. In fact, the first gene therapy clinical trial for Parkinson's disease has recently begun. This review discusses how gene therapy has been applied in animal models, and how it may be used to repair the damage caused by CNS diseases and trauma in human beings. Furthermore, it explores how such treatments may be combined with, and augment, more conventional therapeutic approaches.

Experimental models of partial lesion of rat spinal cord to investigate neurodegeneration, glial activation, and behavior impairments

The article demonstrates two experimental models of spinal cord partial injury in rats: a contuse model promoted by the NYU impactor system and a partial hemitransection model achieved by a stereotaxic-positioned adjustable wire knife. By means of a defined impact weight (10 g) and a digital optical potentiometer linked to a computer, the impactor transferred and registered a moderate or a severe contusion to the rat spinal cord at a low thoracic level after dropping the weight from distances of 25 mm and 50 mm, respectively, to the dorsal surface of the exposed dura spinal cord. Impact curve was calculated and the parameters of the trauma, like impact velocity, cord compression distance and cord compression rates were obtained in order to demonstrate trauma severity. To promote partial hemitransection, rats were positioned in a spinal cord unit of a stereotaxic apparatus and lesion was made with the adjustable wire knife spatially oriented. By means of a computerized infrared motion sensor-home cage activity monitor and a noncomputerized evaluation of motor behavior using the inclined plane and the motor score of Tarlov tests, behavior was analyzed in an acute period postlesion. Rats were sacrificed and spinal cords were processed for routine staining to show neurons and for GFAP and OX42 immunohistochemistry to demonstrate glial cells. The tissue labelings were quantified using computer assisted stereology by means of an optical disector and microdensitometric image analysis by means of quantification of gray values of discriminated profiles. While partial hemitransection model favored a more accurate control of the lesion location, the contuse model allowed us to perform different degrees of lesion severity. A close correlation between behavioral impairment and severity of trauma was seen in the rats submitted to spinal cord contusion. The stereologic lesion index showed a correlation between severity of trauma and tissue damage by 7 days and demonstrated a time-dependent secondary degeneration after moderate but not after severe spinal cord contusion from 7 to 30 days after injury. Long-lasting activations of astrocytes and microglia seen by persisted increases in the specific mean gray values of immunoreactivities were also found in all levels of the white and gray matters of the partial hemitransected spinal cord until 3 months postinjury which can be related to wound/repair events and paracrine trophic support to spinal cord remaining neurons. The results showed that controlled partial lesions may provide an important toll to study trophism and plasticity in the spinal cord.

Comparison of wheat germ agglutinin-horseradish peroxidase and biotinylated dextran for anterograde tracing of corticospinal tract following spinal cord injury

Established methods for monitoring regeneration of the corticospinal tract involve anterograde labelling of the cortical motor neuron. While wheat germ agglutinin-horseradish peroxidase conjugate has been used to anterogradely label these neurons, we demonstrate that this technique may not completely label the whole axon and fine terminal processes when this tracer is administered in dried form. An alternative method is described for anterograde labelling of cortical motor neurons using biotinylated dextran. This tracer may be applied by either microinjection of 10% biotinylated dextran or implanting small globules of the dried tracer into the motor cortex. While more laborious, microinjection results in better anterograde labelling than implantation of dried biotinylated dextran. A procedure is also described for preparing serial coronal sections through the entire spinal cord and thaw-mounted on a minimum number of slides. The labelled nerve processes in these tissue sections can be visualised in the spinal cord under a fluorescent microscope following incubation with cy3-streptavidin complex. Permanent labelling of the biotinylated nerve processes is achieved by incubation of tissue sections with streptavidin-horseradish peroxidase conjugate followed by stringent washes and staining with tetramethylbenzidine. Use of tetramethylbenzidine allows resolution of a greater number of finer labelled processes than diaminobenzindine and allows clear visualisation of individual regenerating corticospinal tract processes. Using these procedures, we demonstrate that the corticospinal tract is completely lesioned by a standardised contusion spinal cord injury produced by the New York University weight-drop device.