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D. Alvites R, V. Branquinho M, Sousa AC, Zen F, Maurina M, Raimondo S, Mendonça C, Atayde L, Geuna S, Varejão AS, Maurício AC. Establishment of a Sheep Model for Hind Limb Peripheral Nerve Injury: Common Peroneal Nerve. Int J Mol Sci 2021; 22:ijms22031401. [PMID: 33573310 PMCID: PMC7866789 DOI: 10.3390/ijms22031401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 02/07/2023] Open
Abstract
Thousands of people worldwide suffer from peripheral nerve injuries and must deal daily with the resulting physiological and functional deficits. Recent advances in this field are still insufficient to guarantee adequate outcomes, and the development of new and compelling therapeutic options require the use of valid preclinical models that effectively replicate the characteristics and challenges associated with these injuries in humans. In this study, we established a sheep model for common peroneal nerve injuries that can be applied in preclinical research with the advantages associated with the use of large animal models. The anatomy of the common peroneal nerve and topographically related nerves, the functional consequences of its injury and a neurological examination directed at this nerve have been described. Furthermore, the surgical protocol for accessing the common peroneal nerve, the induction of different types of nerve damage and the application of possible therapeutic options were described. Finally, a preliminary morphological and stereological study was carried out to establish control values for the healthy common peroneal nerves regarding this animal model and to identify preliminary differences between therapeutic methods. This study allowed to define the described lateral incision as the best to access the common peroneal nerve, besides establishing 12 and 24 weeks as the minimum periods to study lesions of axonotmesis and neurotmesis, respectively, in this specie. The post-mortem evaluation of the harvested nerves allowed to register stereological values for healthy common peroneal nerves to be used as controls in future studies, and to establish preliminary values associated with the therapeutic performance of the different applied options, although limited by a small sample size, thus requiring further validation studies. Finally, this study demonstrated that the sheep is a valid model of peripheral nerve injury to be used in pre-clinical and translational works and to evaluate the efficacy and safety of nerve injury therapeutic options before its clinical application in humans and veterinary patients.
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Affiliation(s)
- Rui D. Alvites
- Departamento de Clínicas Veterinárias, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP), Rua de Jorge Viterbo Ferreira, nº 228, 4050-313 Porto, Portugal; (R.D.A.); (M.V.B.); (A.C.S.); (C.M.); (L.A.)
- Centro de Estudos de Ciência Animal (CECA), Instituto de Ciências, Tecnologias e Agroambiente da Universidade do Porto (ICETA), Rua D. Manuel II, Apartado 55142, 4051-401 Porto, Portugal
| | - Mariana V. Branquinho
- Departamento de Clínicas Veterinárias, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP), Rua de Jorge Viterbo Ferreira, nº 228, 4050-313 Porto, Portugal; (R.D.A.); (M.V.B.); (A.C.S.); (C.M.); (L.A.)
- Centro de Estudos de Ciência Animal (CECA), Instituto de Ciências, Tecnologias e Agroambiente da Universidade do Porto (ICETA), Rua D. Manuel II, Apartado 55142, 4051-401 Porto, Portugal
| | - Ana C. Sousa
- Departamento de Clínicas Veterinárias, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP), Rua de Jorge Viterbo Ferreira, nº 228, 4050-313 Porto, Portugal; (R.D.A.); (M.V.B.); (A.C.S.); (C.M.); (L.A.)
- Centro de Estudos de Ciência Animal (CECA), Instituto de Ciências, Tecnologias e Agroambiente da Universidade do Porto (ICETA), Rua D. Manuel II, Apartado 55142, 4051-401 Porto, Portugal
| | - Federica Zen
- Department of Clinical and Biological Sciences, Cavalieri Ottolenghi Neuroscience Institute, University of Turin, Regione Gonzole 10, 10043 Orbassano, TO, Italy; (F.Z.); (M.M.); (S.R.); (S.G.)
| | - Monica Maurina
- Department of Clinical and Biological Sciences, Cavalieri Ottolenghi Neuroscience Institute, University of Turin, Regione Gonzole 10, 10043 Orbassano, TO, Italy; (F.Z.); (M.M.); (S.R.); (S.G.)
| | - Stefania Raimondo
- Department of Clinical and Biological Sciences, Cavalieri Ottolenghi Neuroscience Institute, University of Turin, Regione Gonzole 10, 10043 Orbassano, TO, Italy; (F.Z.); (M.M.); (S.R.); (S.G.)
| | - Carla Mendonça
- Departamento de Clínicas Veterinárias, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP), Rua de Jorge Viterbo Ferreira, nº 228, 4050-313 Porto, Portugal; (R.D.A.); (M.V.B.); (A.C.S.); (C.M.); (L.A.)
- Centro de Estudos de Ciência Animal (CECA), Instituto de Ciências, Tecnologias e Agroambiente da Universidade do Porto (ICETA), Rua D. Manuel II, Apartado 55142, 4051-401 Porto, Portugal
| | - Luís Atayde
- Departamento de Clínicas Veterinárias, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP), Rua de Jorge Viterbo Ferreira, nº 228, 4050-313 Porto, Portugal; (R.D.A.); (M.V.B.); (A.C.S.); (C.M.); (L.A.)
- Centro de Estudos de Ciência Animal (CECA), Instituto de Ciências, Tecnologias e Agroambiente da Universidade do Porto (ICETA), Rua D. Manuel II, Apartado 55142, 4051-401 Porto, Portugal
| | - Stefano Geuna
- Department of Clinical and Biological Sciences, Cavalieri Ottolenghi Neuroscience Institute, University of Turin, Regione Gonzole 10, 10043 Orbassano, TO, Italy; (F.Z.); (M.M.); (S.R.); (S.G.)
| | - Artur S.P. Varejão
- CECAV, Centro de Ciência Animal e Veterinária, Universidade de Trás-os-Montes e Alto Douro (UTAD), Quinta de Prados, 5001-801 Vila Real, Portugal;
- Departamento de Ciências Veterinárias, Universidade de Trás-os-Montes e Alto Douro (UTAD), Quinta de Prados, 5001-801 Vila Real, Portugal
| | - Ana C. Maurício
- Departamento de Clínicas Veterinárias, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto (UP), Rua de Jorge Viterbo Ferreira, nº 228, 4050-313 Porto, Portugal; (R.D.A.); (M.V.B.); (A.C.S.); (C.M.); (L.A.)
- Centro de Estudos de Ciência Animal (CECA), Instituto de Ciências, Tecnologias e Agroambiente da Universidade do Porto (ICETA), Rua D. Manuel II, Apartado 55142, 4051-401 Porto, Portugal
- Correspondence: or
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Burrell JC, Browne KD, Dutton JL, Laimo FA, Das S, Brown DP, Roberts S, Petrov D, Ali Z, Ledebur HC, Rosen JM, Kaplan HM, Wolf JA, Smith DH, Chen HI, Cullen DK. A Porcine Model of Peripheral Nerve Injury Enabling Ultra-Long Regenerative Distances: Surgical Approach, Recovery Kinetics, and Clinical Relevance. Neurosurgery 2021; 87:833-846. [PMID: 32392341 DOI: 10.1093/neuros/nyaa106] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/11/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Millions of Americans experience residual deficits from traumatic peripheral nerve injury (PNI). Despite advancements in surgical technique, repair typically results in poor functional outcomes due to prolonged periods of denervation resulting from long regenerative distances coupled with slow rates of axonal regeneration. Novel surgical solutions require valid preclinical models that adequately replicate the key challenges of clinical PNI. OBJECTIVE To develop a preclinical model of PNI in swine that addresses 2 challenging, clinically relevant PNI scenarios: long segmental defects (≥5 cm) and ultra-long regenerative distances (20-27 cm). Thus, we aim to demonstrate that a porcine model of major PNI is suitable as a potential framework to evaluate novel regenerative strategies prior to clinical deployment. METHODS A 5-cm-long common peroneal nerve or deep peroneal nerve injury was repaired using a saphenous nerve or sural nerve autograft, respectively. Histological and electrophysiological assessments were performed at 9 to 12 mo post repair to evaluate nerve regeneration and functional recovery. Relevant anatomy, surgical approach, and functional/histological outcomes were characterized for both repair techniques. RESULTS Axons regenerated across the repair zone and were identified in the distal stump. Electrophysiological recordings confirmed these findings and suggested regenerating axons reinnervated target muscles. CONCLUSION The models presented herein provide opportunities to investigate peripheral nerve regeneration using different nerves tailored for specific mechanisms of interest, such as nerve modality (motor, sensory, and mixed fiber composition), injury length (short/long gap), and total regenerative distance (proximal/distal injury).
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Affiliation(s)
- Justin C Burrell
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin D Browne
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - John L Dutton
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Franco A Laimo
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Suradip Das
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Daniel P Brown
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Sanford Roberts
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Dmitriy Petrov
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Zarina Ali
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Joseph M Rosen
- Division of Plastic Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, New Hampshire
| | - Hilton M Kaplan
- New Jersey Center for Biomaterials, Rutgers University, New Brunswick, New Jersey
| | - John A Wolf
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Douglas H Smith
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Axonova Medical, Philadelphia, Pennsylvania
| | - H Isaac Chen
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - D Kacy Cullen
- Center for Brain Injury and Repair, Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Neurotrauma, Neurodegeneration & Restoration, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania.,Department of Bioengineering, School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, Pennsylvania.,Axonova Medical, Philadelphia, Pennsylvania
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Nerve grafting for peripheral nerve injuries with extended defect sizes. Wien Med Wochenschr 2018; 169:240-251. [PMID: 30547373 PMCID: PMC6538587 DOI: 10.1007/s10354-018-0675-6] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 11/21/2018] [Indexed: 12/25/2022]
Abstract
Artificial and non-artificial nerve grafts are the gold standard in peripheral nerve reconstruction in cases with extensive loss of nerve tissue, particularly where a direct end-to-end suture or an autologous nerve graft is inauspicious. Different materials are marketed and approved by the US Food and Drug Administration (FDA) for peripheral nerve graft reconstruction. The most frequently used materials are collagen and poly(DL-lactide-ε-caprolactone). Only one human nerve allograft is listed for peripheral nerve reconstruction by the FDA. All marketed nerve grafts are able to demonstrate sufficient nerve regeneration over small distances not exceeding 3.0 cm. A key question in the field is whether nerve reconstruction on large defect lengths extending 4.0 cm or more is possible. This review gives a summary of current clinical and experimental approaches in peripheral nerve surgery using artificial and non-artificial nerve grafts in short and long distance nerve defects. Strategies to extend nerve graft lengths for long nerve defects, such as enhancing axonal regeneration, include the additional application of Schwann cells, mesenchymal stem cells or supporting co-factors like growth factors on defect sizes between 4.0 and 8.0 cm.
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Nerve Allograft Transplantation Model. Plast Reconstr Surg 2015. [DOI: 10.1007/978-1-4471-6335-0_67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sönmez E, Siemionow MZ. Nerve Allograft Transplantation. Plast Reconstr Surg 2015. [DOI: 10.1007/978-1-4471-6335-0_68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Page EK, Dar WA, Knechtle SJ. Tolerogenic therapies in transplantation. Front Immunol 2012; 3:198. [PMID: 22826708 PMCID: PMC3399382 DOI: 10.3389/fimmu.2012.00198] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 06/22/2012] [Indexed: 01/08/2023] Open
Abstract
Since the concept of immunologic tolerance was discovered in the 1940s, the pursuit of tolerance induction in human transplantation has led to a rapid development of pharmacologic and biologic agents. Short-term graft survival remains an all-time high, but successful withdrawal of immunosuppression to achieve operational tolerance rarely occurs outside of liver transplantation. Collaborative efforts through the NIH sponsored Immune Tolerance Network and the European Commission sponsored Reprogramming the Immune System for Establishment of Tolerance consortia have afforded researchers opportunity to evaluate the safety and efficacy of tolerogenic strategies, investigate mechanisms of tolerance, and identify molecular and genetic markers that distinguish the tolerance phenotype. In this article, we review traditional and novel approaches to inducing tolerance for organ transplantation, with an emphasis on their translation into clinical trials.
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Moore AM, Borschel GH, Santosa KB, Flagg ER, Tong AY, Kasukurthi R, Newton P, Yan Y, Hunter DA, Johnson PJ, Mackinnon SE. A transgenic rat expressing green fluorescent protein (GFP) in peripheral nerves provides a new hindlimb model for the study of nerve injury and regeneration. J Neurosci Methods 2012; 204:19-27. [DOI: 10.1016/j.jneumeth.2011.10.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 10/12/2011] [Accepted: 10/13/2011] [Indexed: 12/29/2022]
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Forden J, Xu QG, Khu KJ, Midha R. A Long Peripheral Nerve Autograft Model in the Sheep Forelimb. Neurosurgery 2011; 68:1354-62; discussion 1362. [DOI: 10.1227/neu.0b013e31820c08de] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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9
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Whitlock EL, Myckatyn TM, Tong AY, Yee A, Yan Y, Magill CK, Johnson PJ, Mackinnon SE. Dynamic quantification of host Schwann cell migration into peripheral nerve allografts. Exp Neurol 2010; 225:310-9. [PMID: 20633557 DOI: 10.1016/j.expneurol.2010.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 06/24/2010] [Accepted: 07/07/2010] [Indexed: 12/21/2022]
Abstract
Host Schwann cell (SC) migration into nerve allografts is the limiting factor in the duration of immunosuppression following peripheral nerve allotransplantation, and may be affected by different immunosuppressive regimens. Our objective was to compare SC migration patterns between clinical and experimental immunosuppression regimens both over time and at the harvest endpoint. Eighty mice that express GFP under the control of the Schwann cell specific S100 promoter were engrafted with allogeneic, nonfluorescent sciatic nerve grafts. Mice received immunosuppression with either tacrolimus (FK506), or experimental T-cell triple costimulation blockade (CSB), consisting of CTLA4-immunoglobulin fusion protein, anti-CD40 monoclonal antibody, and anti-inducible costimulator monoclonal antibody. Migration of GFP-expressing host SCs into wild-type allografts was assessed in vivo every 3 weeks until 15 weeks postoperatively, and explanted allografts were evaluated for immunohistochemical staining patterns to differentiate graft from host SCs. Immunosuppression with tacrolimus exhibited a plateau of SC migration, characterized by significant early migration (< 3 weeks) followed by a constant level of host SCs in the graft (15 weeks). At the endpoint, graft fluorescence was decreased relative to surrounding host nerve, and donor SCs persisted within the graft. CSB-treated mice displayed gradually increasing migration of host SCs into the graft, without the plateau noted in tacrolimus-treated mice, and also maintained a population of donor SCs at the 15-week endpoint. SC migration patterns are affected by immunosuppressant choice, particularly in the immediate postoperative period, and the use of a single treatment of CSB may allow for gradual population of nerve allografts with host SCs.
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Affiliation(s)
- Elizabeth L Whitlock
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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Abstract
BACKGROUND In the nerve allograft model, costimulation blockade has permitted good regeneration but is still inferior to the nerve isograft. We hypothesize that a short course of multiple costimulatory pathway blockade will be more effective in inhibiting the redundancy of the immune response and improve nerve regeneration through the nerve allograft. METHODS The murine sciatic nerve allograft model was used to reconstruct a 1 cm sciatic nerve gap. Treatment consisted of the inhibition of the CD40, CD28/B7 and ICOS pathways and was compared with only single or double costimulation blockade. Assessment methods included quantitative histomorphometry and ELISPOT assay to quantify the host immune response after 3 weeks post-operatively. RESULTS Triple costimulation blockade permitted regeneration through the nerve allograft that was equivalent to the nerve isograft. A short course of three doses was more effective than a single dose for all combinations tested. ELISPOT assay demonstrated minimal in vitro immune response with a short course of double or triple pathway-blocking agents. CONCLUSION Costimulation blockade, especially with the simultaneous inhibition of multiple pathways, remains a promising strategy to promote regeneration through the peripheral nerve allograft, and may be uniquely suited to the temporary immunosuppressive requirements of the peripheral nerve allograft.
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Affiliation(s)
- Chau Y. Tai
- Division of Plastics and Orthopedics, Kern Medical Center, CA, USA
| | - Renata V. Weber
- Plastic and Reconstructive Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, NY, USA
| | - Susan E. Mackinnon
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Thomas H. Tung
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, MO, USA
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Kasukurthi R, Brenner MJ, Moore AM, Moradzadeh A, Ray WZ, Santosa KB, Mackinnon SE, Hunter DA. Transcardial perfusion versus immersion fixation for assessment of peripheral nerve regeneration. J Neurosci Methods 2009; 184:303-9. [DOI: 10.1016/j.jneumeth.2009.08.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 08/22/2009] [Accepted: 08/24/2009] [Indexed: 10/20/2022]
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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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Brenner MJ, Moradzadeh A, Myckatyn TM, Tung THH, Mendez AB, Hunter DA, Mackinnon SE. Role of timing in assessment of nerve regeneration. Microsurgery 2008; 28:265-72. [PMID: 18381659 DOI: 10.1002/micr.20483] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Small animal models are indispensable for research on nerve injury and reconstruction, but their superlative regenerative potential may confound experimental interpretation. This study investigated time-dependent neuroregenerative phenomena in rodents. Forty-six Lewis rats were randomized to three nerve allograft groups treated with 2 mg/(kg day) tacrolimus; 5 mg/(kg day) Cyclosporine A; or placebo injection. Nerves were subjected to histomorphometric and walking track analysis at serial time points. Tacrolimus increased fiber density, percent neural tissue, and nerve fiber count and accelerated functional recovery at 40 days, but these differences were undetectable by 70 days. Serial walking track analysis showed a similar pattern of recovery. A "blow-through" effect is observed in rodents whereby an advancing nerve front overcomes an experimental defect given sufficient time, rendering experimental groups indistinguishable at late time points. Selection of validated time points and corroboration in higher animal models are essential prerequisites for the clinical application of basic research on nerve regeneration.
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Affiliation(s)
- Michael J Brenner
- Department of Otolaryngology-Head & Neck Surgery, Washington University School of Medicine, Saint Louis, MO, USA
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15
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Abstract
Nerve allograft transplantation should be used for the repair of devastating peripheral nerve injuries that cannot be reconstructed through traditional means such as autologous nerve grafting or nerve transfer procedures. The risks of required systemic immunosuppression, although only temporary for nerve allograft recipients, preclude widespread use of this treatment modality. Translational research has led to several advancements in this field including the use of preoperative allograft cold preservation in University of Wisconsin organ preservation solution and inclusion of tacrolimus as part of the immunosuppressive regimen. Investigation of how to further diminish nerve allograft immunogenicity, speed neuroregeneration by use of agents such as tacrolimus, and promote preferential motor regeneration will further advance this field with the goal of restoring optimal function while minimizing patient morbidity.
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Affiliation(s)
- Ida K Fox
- Division of Plastic Surgery, Washington University School of Medicine, Saint Louis, Missouri
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16
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Hontanilla B, Aubá C, Arcocha J, Gorría O. Nerve Regeneration through Nerve Autografts and Cold Preserved Allografts using Tacrolimus (FK506) in a Facial Paralysis Model: A Topographical and Neurophysiological Study in Monkeys. Neurosurgery 2006; 58:768-79; discussion 768-79. [PMID: 16575341 DOI: 10.1227/01.neu.0000204319.37546.5f] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Nerve regeneration through cold preserved nerve allografts is demonstrated, and treatment of nerve allografts with FK506 induces better regeneration than other immunosuppressants. We study nerve regeneration through cold preserved nerve allografts temporarily treated with FK506 and compare it with the regeneration obtained using classic nerve autografts in a facial paralysis model in monkeys. METHODS A trunk of the facial nerve on both sides was transected in eight monkeys and immediately repaired with a 3 to 4 cm nerve autograft or allograft. FK506 was administered to the animals of the allograft group for 2 months, and nerve allografts were cold preserved for 3 weeks. At periods of 3, 5, and 8 months after surgery, quantitative electrophysiological assessment and video recordings were performed. At the end of the study, quantitative analysis of neurons in the facial nucleus was carried out, and axons were stereologically counted. RESULTS After the regenerative period, neuronal density was higher in the autograft group. However, distal axonal counts were similar in both groups. Serial electrophysiological recordings and histology of nerve allografts showed that the grafts were partially rejected after cessation of the immunosuppressant. CONCLUSION The regeneration through nerve allografts temporarily treated with FK506 does not achieve the electrophysiological results and neuronal counts achieved with nerve autografts, but axonal collateralization in the allografts induces a similar activation of mimic muscles.
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Affiliation(s)
- Bernardo Hontanilla
- Department of Plastic and Reconstructive Surgery, Clínica Universitaria, University of Navarra, Pamplona, Spain.
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Scharpf J, Strome M, Siemionow M. Immunomodulation with anti-αβ T-cell receptor monoclonal antibodies in combination with cyclosporine a improves regeneration in nerve allografts. Microsurgery 2006; 26:599-607. [PMID: 17066409 DOI: 10.1002/micr.20294] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To investigate the use of nerve allografts in animals treated with a short-term combined protocol of anti-alpha/beta T-cell receptor monoclonal antibodies and Cyclosporine A (CsA) to induce tolerance and allow for nerve regeneration. STUDY DESIGN An established rat sciatic nerve model was used. A total of 76 rats were used in this experiment (Lew RT1L n=44, Lewis-Brown-Norway (LBN RT1L+N, n=22), Brown-Norway (BN RT1N, n=10). Sciatic nerve (1.5 cm) deficits were created in the Lewis rats and the animals were randomized to seven treatment groups to allow for repair with isograft controls (LEW-LEW) and with both semiallogeneic (LBN-LEW) and full major histocompatability (MHC) mismatched (BN-Lew) allografts. METHODS Nerve regeneration was evaluated at 6 and 12 weeks by somatosensory evoked potentials (SSEP) and standardized pin-prick and toe-spread tests. Nerve samples were harvested at 12 weeks and stained with toluidine blue to assess the total number of myelinated axons, axon area, and myelin sheath thickness. Muscle denervation atrophy was evaluated by gastrocnemius weights. Immunocompetence was investigated through skin grafting and fluorescent activated cell sorting (FACS) analysis. RESULTS Improved functional, electrophysiologic, and histomorphometric outcomes were observed in animals treated with anti-alpha/betaTCR mAbs and CsA after nerve allograft transplantation when compared to animals receiving no treatment and CsA alone. CONCLUSIONS The immunomodulating protocol of combination anti-alpha/beta TCR mAbs and CsA for a 5 week period altered the rejection process, affording nerve regeneration. It may provide for an expanded source of nerve tissue to alleviate the morbidity of harvesting peripheral nerves from multiple sites for those afflicted with extensive peripheral nerve injuries.
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Affiliation(s)
- Joseph Scharpf
- Head and Neck Institute, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Gordon CR, Nazzal J, Lozano-Calderan SA, Lee SGP, Lee WPA, Siemionow M, Matthews MS, Hewitt CW. From experimental rat hindlimb to clinical face composite tissue allotransplantation: Historical background and current status. Microsurgery 2006; 26:566-72. [PMID: 17091477 DOI: 10.1002/micr.20296] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The purpose of this article is to review the historical background and clinical status of composite tissue allotransplantation and to discuss the scientific evolution of clinical face transplantation. Composite tissue allotransplantation (CTA) rapidly progressed in the 1980s with the discovery of cyclosporine. Although the most success has been achieved with hand transplantation, others have made progress with allografts of trachea, peripheral nerve, flexor tendon apparatus, vascularized knee, larynx, abdominal wall, and most recently, partial face. The world's first partial face allotransplantation occurred in November 2005 in France. In April of 2006, there was a second performed in China. As of today, there are now multiple institutions with plans to attempt the world's first full facial/scalp transplant. Complete facial/scalp allotransplantation offers a viable alternative for unfortunate individuals suffering severe facial disfigurement and is a product of many decades of experimental research, beginning with rat hindlimb allografts.
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Affiliation(s)
- Chad R Gordon
- Department of Surgery, Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey 08103, USA.
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Sosa I, Reyes O, Kuffler DP. Immunosuppressants: neuroprotection and promoting neurological recovery following peripheral nerve and spinal cord lesions. Exp Neurol 2005; 195:7-15. [PMID: 15935348 DOI: 10.1016/j.expneurol.2005.04.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2005] [Accepted: 04/28/2005] [Indexed: 12/17/2022]
Abstract
No clinical techniques induce restoration of neurological losses following spinal cord trauma. Peripheral nerve damage also leads to permanent neurological deficits, but neurological recovery can be relatively good, especially if the ends of a transected nerve are anastomosed soon after the injury. The time until recovery generally depends on the distance the axons must regenerate to their targets. Neurological recovery following the destruction of a length of a peripheral nerve requires a graft to bridge the gap that is permissive to, and promotes, axon regeneration. But neurological recovery is slow and limited, especially for gaps longer than 1.5 cm, even using autologous peripheral nerve grafts. Without a reliable means of bridging long nerve gaps, such injuries commonly result in amputations. Promoting extensive neurological recovery requires techniques that simultaneously provide protection to injured neurons and increase the numbers of neurons that extend axons, while inducing more rapid and extensive axon regeneration across long nerve gaps. Although conduits filled with various materials enhance axon regeneration across short nerve gaps, pure sensory nerve graft remains the gold standard for use across long nerve gaps, even though they lead to only limited neurological recovery. Consistent results demonstrate that several immunosuppressive agents enhance the number of axons and the rate at which they regenerate. This review examines the roles played by immunosuppressants, especially FK506, with primary focus on its role as a neuroprotectant and neurotrophic agent, and its potential clinical use to promote improved neurological recovery following peripheral nerve and spinal cord injuries.
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Affiliation(s)
- I Sosa
- Section of Neurosurgery, Medical Sciences Campus, UPR, 201 Boulevard del Valle, San Juan 00901, Puerto Rico
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