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Gordon T. Brief Electrical Stimulation Promotes Recovery after Surgical Repair of Injured Peripheral Nerves. Int J Mol Sci 2024; 25:665. [PMID: 38203836 PMCID: PMC10779324 DOI: 10.3390/ijms25010665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024] Open
Abstract
Injured peripheral nerves regenerate their axons in contrast to those in the central nervous system. Yet, functional recovery after surgical repair is often disappointing. The basis for poor recovery is progressive deterioration with time and distance of the growth capacity of the neurons that lose their contact with targets (chronic axotomy) and the growth support of the chronically denervated Schwann cells (SC) in the distal nerve stumps. Nonetheless, chronically denervated atrophic muscle retains the capacity for reinnervation. Declining electrical activity of motoneurons accompanies the progressive fall in axotomized neuronal and denervated SC expression of regeneration-associated-genes and declining regenerative success. Reduced motoneuronal activity is due to the withdrawal of synaptic contacts from the soma. Exogenous neurotrophic factors that promote nerve regeneration can replace the endogenous factors whose expression declines with time. But the profuse axonal outgrowth they provoke and the difficulties in their delivery hinder their efficacy. Brief (1 h) low-frequency (20 Hz) electrical stimulation (ES) proximal to the injury site promotes the expression of endogenous growth factors and, in turn, dramatically accelerates axon outgrowth and target reinnervation. The latter ES effect has been demonstrated in both rats and humans. A conditioning ES of intact nerve days prior to nerve injury increases axonal outgrowth and regeneration rate. Thereby, this form of ES is amenable for nerve transfer surgeries and end-to-side neurorrhaphies. However, additional surgery for applying the required electrodes may be a hurdle. ES is applicable in all surgeries with excellent outcomes.
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Affiliation(s)
- Tessa Gordon
- Division of Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON M4G 1X8, Canada
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Gordon T. Peripheral Nerve Regeneration and Muscle Reinnervation. Int J Mol Sci 2020; 21:ijms21228652. [PMID: 33212795 PMCID: PMC7697710 DOI: 10.3390/ijms21228652] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/24/2022] Open
Abstract
Injured peripheral nerves but not central nerves have the capacity to regenerate and reinnervate their target organs. After the two most severe peripheral nerve injuries of six types, crush and transection injuries, nerve fibers distal to the injury site undergo Wallerian degeneration. The denervated Schwann cells (SCs) proliferate, elongate and line the endoneurial tubes to guide and support regenerating axons. The axons emerge from the stump of the viable nerve attached to the neuronal soma. The SCs downregulate myelin-associated genes and concurrently, upregulate growth-associated genes that include neurotrophic factors as do the injured neurons. However, the gene expression is transient and progressively fails to support axon regeneration within the SC-containing endoneurial tubes. Moreover, despite some preference of regenerating motor and sensory axons to “find” their appropriate pathways, the axons fail to enter their original endoneurial tubes and to reinnervate original target organs, obstacles to functional recovery that confront nerve surgeons. Several surgical manipulations in clinical use, including nerve and tendon transfers, the potential for brief low-frequency electrical stimulation proximal to nerve repair, and local FK506 application to accelerate axon outgrowth, are encouraging as is the continuing research to elucidate the molecular basis of nerve regeneration.
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Affiliation(s)
- Tessa Gordon
- Department of Surgery, University of Toronto, Division of Plastic Reconstructive Surgery, 06.9706 Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
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[Delayed decompression for cauda equina syndrome secondary to lumbar disc herniation: long-term follow-up results]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2017; 37. [PMID: 28951353 PMCID: PMC6765480 DOI: 10.3969/j.issn.1673-4254.2017.09.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To assess the impact of delayed decompression on long-term neurological and bladder function recovery in patients with cauda equina syndrome (CES) secondary to lumbar disc herniation (LDH). METHODS The clinical data of 35 patients receiving delayed decompression surgery for CES secondary to LDH were reviewed. The bladder empty function, bowel control, sexual ability and neurological functions of the lower limbs were evaluated after the operation, and the urodynamic changes were assessed in 6 patients with urodynamic data before and after the operation. RESULTS Surgical decompression was performed at 4.1±3.9 weeks in 12 patients with complete CES and at 5.5±7.6 weeks in 23 patients with incomplete CES after the onset of symptoms. The patients were followed up for a mean of 43.0±28.9 months (3-110 months). In the 23 patients with incomplete CES, 19 obtained full recovery, 4 had slight sensory alterations in the saddle area or the lower limbs. In the 12 patients with complete CES, 2 had full recovery, 4 reported slight sensory alterations in the saddle area or the lower limbs (including 2 with occasional constipation); 6 still had sense deficit in the saddle area and difficulties in bladder or bowl emptying, but they all reported significant improvements compared to the condition before operation. Urodynamic analysis in the 6 patients with pre-and postoperative urodynamic data showed increased abdominal pressure when voiding with significantly reduced residual urine in all the 6 patients; 4 patients with abnormal first desire volume before operation reported recovery after the operation. CONCLUSION Patients with LDH-induced CES who missed the chance of early decompression can still expect favorable functional recovery in the long term. The improvement of bladder function following decompression is probably a result of recovery of bladder sensation and the compensation by increased intra-abdominal pressure. The key strategy to promote bladder function recovery in these patients is to promote the detrusor recovery.
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Mackenzie SJ, Yi JL, Singla A, Russell TM, Osterhout DJ, Calancie B. Cauda equina repair in the rat: Part 3. Axonal regeneration across Schwann cell-Seeded collagen foam. Muscle Nerve 2017; 57:E78-E84. [PMID: 28746726 DOI: 10.1002/mus.25751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 07/12/2017] [Accepted: 07/23/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Treatments for patients with cauda equina injury are limited. METHODS In this study, we first used retrograde labeling to determine the relative contributions of cauda equina motor neurons to intrinsic and extrinsic rat tail muscles. Next, we transected cauda equina ventral roots and proceeded to bridge the proximal and distal stumps with either a type I collagen scaffold coated in laminin (CL) or a collagen-laminin scaffold that was also seeded with Schwann cells (CLSC). Regeneration was assessed by way of serial retrograde labeling. RESULTS After accounting for the axonal contributions to intrinsic vs. extrinsic tail muscles, we noted a higher degree of double labeling in the CLSC group (58.0 ± 39.6%) as compared with the CL group (27.8 ± 16.0%; P = 0.02), but not the control group (33.5 ± 18.2%; P = 0.10). DISCUSSION Our findings demonstrate the feasibility of using CLSCs in cauda equina injury repair. Muscle Nerve 57: E78-E84, 2018.
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Affiliation(s)
- Samuel J Mackenzie
- Department of Neuroscience, Upstate Medical University, Syracuse, New York, USA
| | - Juneyoung L Yi
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Amit Singla
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Thomas M Russell
- Department of Cell and Developmental Biology, Upstate Medical University, Syracuse, New York, USA
| | - Donna J Osterhout
- Department of Cell and Developmental Biology, Upstate Medical University, Syracuse, New York, USA
| | - Blair Calancie
- Department of Neurosurgery, Upstate Medical University, IHP 1213, 750 East Adams Street, Syracuse, New York, 13210, USA
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DeLong WB, Polissar NL, Neradilek MB, Laam LA. A Letter to the Editor regarding, "Time to Surgery and Outcomes in Cauda Equina Syndrome: An Analysis of 45 Cases." Critique of Bydon et al. World Neurosurg 2016; 93:479-82. [PMID: 27637700 DOI: 10.1016/j.wneu.2016.02.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Affiliation(s)
- W Bradford DeLong
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA.
| | | | | | - Leslie A Laam
- Health Services Research and Policy, University of Rochester Medical Center, Rochester, New York, USA
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Gordon T. Nerve Regeneration: Understanding Biology and Its Influence on Return of Function After Nerve Transfers. Hand Clin 2016; 32:103-17. [PMID: 27094884 DOI: 10.1016/j.hcl.2015.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Poor functional outcomes are frequent after peripheral nerve injuries despite the regenerative support of Schwann cells. Motoneurons and, to a lesser extent, sensory neurons survive the injuries but outgrowth of axons across the injury site is slow. The neuronal regenerative capacity and the support of regenerating axons by the chronically denervated Schwann cells progressively declines with time and distance of the injury from the denervated targets. Strategies, including brief low-frequency electrical stimulation that accelerates target reinnervation and functional recovery, and the insertion of cross-bridges between a donor nerve and a recipient denervated nerve stump, are effective in promoting functional outcomes after complete and incomplete injuries.
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Affiliation(s)
- Tessa Gordon
- Division of Plastic Reconstructive Surgery, Department of Surgery, 06.9706 Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M5G 0A4, Canada.
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Todd NV. Neurological deterioration in cauda equina syndrome is probably progressive and continuous. Implications for clinical management. Br J Neurosurg 2015; 29:630-4. [PMID: 26401618 DOI: 10.3109/02688697.2015.1054364] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Fifty-six human and animal studies of cauda equina syndrome (CES) were reviewed. The evidence from human studies was poor (level IV). Evidence from animal studies and limited evidence from human studies suggest that structural and functional neurological losses are a progressive, continuous process. The longer the cauda equina nerve roots are compressed the greater the harm and the poorer the extent of recovery. This should prompt diagnosis and surgery for all CES patients as soon as practicably possible.
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Gordon T, English AW. Strategies to promote peripheral nerve regeneration: electrical stimulation and/or exercise. Eur J Neurosci 2015; 43:336-50. [PMID: 26121368 DOI: 10.1111/ejn.13005] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 06/19/2015] [Accepted: 06/23/2015] [Indexed: 12/14/2022]
Abstract
Enhancing the regeneration of axons is often considered to be a therapeutic target for improving functional recovery after peripheral nerve injury. In this review, the evidence for the efficacy of electrical stimulation (ES), daily exercise and their combination in promoting nerve regeneration after peripheral nerve injuries in both animal models and in human patients is explored. The rationale, effectiveness and molecular basis of ES and exercise in accelerating axon outgrowth are reviewed. In comparing the effects of ES and exercise in enhancing axon regeneration, increased neural activity, neurotrophins and androgens are considered to be common requirements. Similarly, there are sex-specific requirements for exercise to enhance axon regeneration in the periphery and for sustaining synaptic inputs onto injured motoneurons. ES promotes nerve regeneration after delayed nerve repair in humans and rats. The effectiveness of exercise is less clear. Although ES, but not exercise, results in a significant misdirection of regenerating motor axons to reinnervate different muscle targets, the loss of neuromuscular specificity encountered has only a very small impact on resulting functional recovery. Both ES and exercise are promising experimental treatments for peripheral nerve injury that seem to be ready to be translated to clinical use.
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Affiliation(s)
- Tessa Gordon
- Division of Plastic Reconstructive Surgery, Department of Surgery, 06.9706 Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, M4G 1X8, Canada
| | - Arthur W English
- Department of Cell Biology, Emory University School of Medicine, Atlanta, GA, USA
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MacKenzie SJ, Yi JL, Singla A, Russell TM, Calancie B. Innervation and function of rat tail muscles for modeling cauda equina injury and repair. Muscle Nerve 2015; 52:94-102. [PMID: 25346299 DOI: 10.1002/mus.24498] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 09/26/2014] [Accepted: 10/17/2014] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The rat tail exhibits functional impairment after cauda equina injury. Our goal was to better understand the innervation and roles of muscles that control the tail. METHODS Adult rats received either: (1) ventral root injury; (2) caudales nerve injury; or (3) mapping of sacrococcygeal myotomes. Activation of small muscles within the tail itself (intrinsics) was compared with that of larger lumbosacral muscles acting on the tail (extrinsics). Behavioral testing of tail movement was done 1 week later. RESULTS Rats that received ventral root injury exhibited multiple behavioral deficits, whereas rats with injury to caudales nerves maintained more fully preserved tail movement. Mapping studies revealed much broader overlap of myotomes for extrinsic muscles. CONCLUSIONS Extrinsic tail muscles play a greater role in tail movement in the rat than their intrinsic counterparts and are innervated by multiple neurological segments. These findings have major implications for future research on cauda equina injury.
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Affiliation(s)
- Samuel J MacKenzie
- Department of Neuroscience, Upstate Medical University, Syracuse, New York, USA
| | - Juneyoung L Yi
- Department of Neurosurgery, Institute for Human Performance, Upstate Medical University, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Amit Singla
- Department of Neurosurgery, Institute for Human Performance, Upstate Medical University, 750 East Adams Street, Syracuse, New York, 13210, USA
| | - Thomas M Russell
- Department of Neuroscience, Upstate Medical University, Syracuse, New York, USA
| | - Blair Calancie
- Department of Neurosurgery, Institute for Human Performance, Upstate Medical University, 750 East Adams Street, Syracuse, New York, 13210, USA
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Chen WT, Zhang PX, Xue F, Yin XF, Qi CY, Ma J, Chen B, Yu YL, Deng JX, Jiang BG. Large animal models of human cauda equina injury and repair: evaluation of a novel goat model. Neural Regen Res 2015; 10:60-4. [PMID: 25788921 PMCID: PMC4357118 DOI: 10.4103/1673-5374.150707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2014] [Indexed: 11/04/2022] Open
Abstract
Previous animal studies of cauda equina injury have primarily used rat models, which display significant differences from humans. Furthermore, most studies have focused on electrophysiological examination. To better mimic the outcome after surgical repair of cauda equina injury, a novel animal model was established in the goat. Electrophysiological, histological and magnetic resonance imaging methods were used to evaluate the morphological and functional outcome after cauda equina injury and end-to-end suture. Our results demonstrate successful establishment of the goat experimental model of cauda equina injury. This novel model can provide detailed information on the nerve regenerative process following surgical repair of cauda equina injury.
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Affiliation(s)
- Wen-Tao Chen
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
| | - Pei-Xun Zhang
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
| | - Feng Xue
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
| | - Xiao-Feng Yin
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
| | - Cao-Yuan Qi
- Department of Radiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Jun Ma
- Department of Radiology, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Bo Chen
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
| | - You-Lai Yu
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
| | - Jiu-Xu Deng
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
| | - Bao-Guo Jiang
- Department of Trauma and Orthopedics, Peking University People's Hospital, Beijing, China
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Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurg 2013; 81:640-50. [PMID: 24240024 DOI: 10.1016/j.wneu.2013.11.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/01/2013] [Accepted: 11/06/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Cauda equina syndrome (CES) is a rare but important neurosurgical emergency. Despite being a recognized clinical entity since 1934, there remains significant uncertainty in the literature regarding the urgency for surgical intervention. The past decade has seen the emergence of the much-referred-to 48-hour limit as a possible window of safety. The ramifications of this time point are significant for early patients who may subsequently have urgent treatment delayed, and for litigation cases, after which adverse decisions are more likely to occur. METHODS A systematic principally qualitative review of the animal and human clinical literature is presented, examining the evidence for urgent surgical decompression in CES and the much-quoted 48-hour rule. RESULTS There is significant discordance in the literature regarding whether emergency surgery improves outcomes; however, a growing consensus is the acknowledgment that biologic systems deteriorate in a continuous rather than stepwise manner. Level of neurological dysfunction at surgery (incomplete CES vs. CES with retention) is probably the most significant determinant of prognosis. Onset and duration of symptoms also are likely to have an impact, if not on overall outcome then at least on duration of neurological recovery. CONCLUSIONS There is no strong basis to support 48 hours as a blanket safe time point to delay surgery. Both early and delayed surgery may result in improved neurological outcomes. However, it is likely that the earlier the surgical intervention, the more beneficial the effects for compressed nerves, especially with acute neurological compromise.
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