Contributions of pathway and neuron to preferential motor reinnervation

Repair and regeneration of peripheral nerve injuries that ablate branch points

The peripheral nervous system has an extensive branching organization, and peripheral nerve injuries that ablate branch points present a complex challenge for clinical repair. Ablations of linear segments of the PNS have been extensively studied and routinely treated with autografts, acellular nerve allografts, conduits, wraps, and nerve transfers. In contrast, segmental-loss peripheral nerve injuries, in which one or more branch points are ablated so that there are three or more nerve endings, present additional complications that have not been rigorously studied or documented. This review discusses: (1) the branched anatomy of the peripheral nervous system, (2) case reports describing how peripheral nerve injuries with branched ablations have been surgically managed, (3) factors known to influence regeneration through branched nerve structures, (4) techniques and models of branched peripheral nerve injuries in animal models, and (5) conclusions regarding outcome measures and studies needed to improve understanding of regeneration through ablated branched structures of the peripheral nervous system.

Sensory and motor fibroblasts have different protein expression patterns and exert different growth promoting effects on sensory and motor neurons

Functional reconstruction after peripheral nerve injury depends on the ability of the regenerated sensory and motor axons to re-innervate the suitable target organs. Therefore, it is essential to explore the cellular mechanisms of peripheral nerve-specific regeneration. In a previous study, we found that sensory and motor fibroblasts can guide Schwann cells to migrate towards the same phenotype. In the present paper, we analyzed the different effects of sensory and motor fibroblasts on sensory or motor neurons. The fibroblasts and neurons co-culture assay showed that compared with motor fibroblasts, sensory fibroblasts promote the neurite outgrowth of sensory neurons on a larger scale, and vice versa. Furthermore, a higher proportion of sensory or motor fibroblasts migrated towards their respective (sensory or motor) neurons. Meanwhile, a comparative proteomic approach was applied to obtain the protein expression profiles of sensory and motor fibroblasts. Among a total of 2597 overlapping proteins identified, we counted 148 differentially expressed items, of those 116 had a significantly higher expression in sensory fibroblasts, and 32 had a significantly greater expression in motor fibroblasts. Functional categorization revealed that differentially expressed proteins were involved in regeneration, axon guidance and cytoskeleton organization, all of which might play a critical role in peripheral nerve-specific regeneration. After nerve crush injury, ITB1 protein expression decreased significantly in motor nerves and increased in sensory nerves. In vitro, ITB1 significantly promoted axonal regeneration of sensory neurons, but had no significant effect on motor neurons. Overall, sensory and motor fibroblasts express different proteins and exert different growth promoting effects on sensory and motor neurons. This comparative proteomic database of sensory and motor fibroblasts could provide future directions for in-depth research on peripheral nerve-specific regeneration. Data are available via ProteomeXchange with identifier PXD034827.

The effects of graft source and orientation on outcomes after ablation of a branched peripheral nerve

Segmental peripheral nerve injuries (PNI) are the most common cause of enduring nervous system dysfunction. The peripheral nervous system (PNS) has an extensive and highly branching organization. While much is known about the factors that affect regeneration through sharp bisections and linear ablations of peripheral nerves, very little has been investigated or documented about PNIs that ablate branch points. Such injuries present additional complexity compared to linear segmental defects. This study compared outcomes following ablation of a branch point with branched grafts, specifically examining how graft source and orientation of the branched graft contributed to regeneration. The model system was Lewis rats that underwent a 2.5 cm ablation that started in the sciatic nerve trunk and included the peroneal/tibial branch point. Rats received grafts that were rat sciatic autograft, inbred sciatic allograft, and inbred femoral allograft, each of which was a branched graft of 2.5 cm. Allografts were obtained from Lewis rats, which is an inbred strain. Both branches of the sciatic grafts were mixed motor and sensory while the femoral grafts were smaller in diameter than sciatic grafts and one branch of the femoral graft is sensory and the other motor. All branched grafts were sutured into the defect in two orientations dictated by which branch in the graft was sutured to the tibial vs peroneal stumps in recipients. Outcome measures include compound muscle action potentials (CMAPs) and CatWalk gait analysis throughout the recovery period, with toluidine blue for intrinsic nerve morphometry and retrograde labeling conducted at the 36-week experimental end point. Results indicate that graft source and orientation does play a significant role earlier in the regenerative process but by 36 weeks all groups showed very similar indications of regeneration across multiple outcomes.

Preferential regeneration and collateral dynamics of motor and sensory neurons after nerve injury in mice

Specificity in regeneration after peripheral nerve injuries is a major determinant of functional recovery. Unfortunately, regenerating motor and sensory axons rarely find their original pathways to reinnervate appropriate target organs. Although a preference of motor axons to regenerate towards the muscle has been described, little is known about the specificity of the heterogeneous sensory populations. Here, we propose the comparative study of regeneration in different neuron subtypes. Using female and male reporter mice, we assessed the regenerative preference of motoneurons (ChAT-Cre/Ai9), proprioceptors (PV-Cre/Ai9), and cutaneous mechanoreceptors (Npy2r-Cre/Ai9). The femoral nerve of these animals was transected above the bifurcation and repaired with fibrin glue. Regeneration was assessed by applying retrograde tracers in the distal branches of the nerve 1 or 8 weeks after the lesion and counting the retrotraced somas and the axons in the branches. We found that cutaneous mechanoreceptors regenerated faster than other populations, followed by motoneurons and, lastly, proprioceptors. All neuron types had an early preference to regenerate into the cutaneous branch whereas, at long term, all neurons regenerated more through their original branch. Finally, we found that myelinated neurons extend more regenerative sprouts in the cutaneous than in the muscle branch of the femoral nerve and, particularly, that motoneurons have more collaterals than proprioceptors. Our findings reveal novel differences in regeneration dynamics and specificity, which indicate distinct regenerative mechanisms between neuron subtypes that can be potentially modulated to improve functional recovery after nerve injury.

Treatment With Nimodipine or FK506 After Facial Nerve Repair Neither Improves Accuracy of Reinnervation Nor Recovery of Mimetic Function in Rats

Purpose

Nimodipine and FK506 (Tacrolimus) are drugs that have been reported to accelerate peripheral nerve regeneration. We therefore tested these substances aiming to improve the final functional outcome of motoric reinnervation after facial nerve injury.

Methods

In 18 female rats, the transected facial nerve was repaired by an artificial nerve conduit. The rats were then treated with either placebo, nimodipine, or FK506, for 56 days. Facial motoneurons were pre-operatively double-labeled by Fluoro-Gold and again 56 days post-operation by Fast-Blue to measure the cytological accuracy of reinnervation. The whisking motion of the vibrissae was analyzed to assess the quality of functional recovery.

Results

On the non-operated side, 93–97% of those facial nerve motoneurons innervating the vibrissae were double-labeled. On the operated side, double-labeling only amounted to 38% (placebo), 40% (nimodipine), and 39% (FK506), indicating severe misdirection of reinnervation. Regardless of post-operative drug or placebo therapy, the whisking frequency reached 83–100% of the normal value (6.0 Hz), but whisking amplitude was reduced to 33–48% while whisking velocity reached 39–66% of the normal values. Compared to placebo, statistically neither nimodipine nor FK506 improved accuracy of reinnervation and function recovery.

Conclusion

Despite previous, positive data on the speed and quantity of axonal regeneration, nimodipine and FK506 do not improve the final functional outcome of motoric reinnervation in rats.

Approach to management of nerve gaps in peripheral nerve injuries

Peripheral nerve injuries (PNI) are a major clinical problem. In general, PNI results from motor vehicle accidents, lacerations with sharp objects, penetrating trauma (gunshot wounds) and stretching or crushing trauma and fractures. They can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Currently, the standard surgical technique for complete nerve transection is end-to-end neurorrhaphy. Unfortunately, there is segmental loss of the nerve trunk in some cases where nerve mobilization may permit end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. But in light of limited availability and concerned donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers and end-to-side neurorrhaphy. This review intends to present an overview of the literature on the applications of these techniques in repair of peripheral nerve injuries. This article also focuses on preoperative assessment, surgical timing, available options and future perspectives.

A novel dual mode-of-action anti-hyperalgesic compound in rats which is neuroprotective and promotes neuroregeneration

Chronic neuropathic pain (CNP) can result from surgery or traumatic injury, but also from peripheral neuropathies caused by diseases, viral infections, or toxic treatments. Opioids, although very effective for acute pain, do not prevent the development of CNP, and are considered as insufficient treatment. Therefore, there is high need for effective and safe non-opioid options to treat, prevent and eventually reverse CNP. A more effective approach to alleviating CNP would constitute a treatment that acts concurrently on various mechanisms involved in relieving pain symptoms and preventing or reversing chronification by enhancing both neuroprotection and neuroregeneration. We have identified and characterized GRT-X (N-[(3-fluorophenyl)-methyl]-1-(2-methoxyethyl)-4-methyl-2-oxo-(7-trifluoromethyl)-1H-quinoline-3-caboxylic acid amide), a novel drug which is able to activate both voltage-gated potassium channels of the Kv7 family and the mitochondrial translocator protein 18 kDa (TSPO). The dual mode-of-action (MoA) of GRT-X was indicated in in vitro studies and in vivo in a rat model of diabetic neuropathy. In this model, mechanical hyperalgesia was dose-dependently inhibited. After severe crush lesion of cervical spinal nerves in rats, GRT-X promoted survival, speeded up regrowth of sensory and motor neurons, and accelerated recovery of behavioral and neuronal responses to heat, cold, mechanical and electrical stimuli. These properties may reduce the likelihood of chronification of acute pain, and even potentially relieve established CNP. The absence of a conditioned place preference in rats suggests lack of abuse potential. In conclusion, GRT-X offers a promising preclinical profile with a novel dual MoA.

Application of Extradural Nerve Root Transfer in the Restoration of Lower Limb Function in Spinal Cord Injury: Hypothesis and a Cadaver Feasibility Study

STUDY DESIGN

Two fresh-frozen and six formalin-fixed cadavers were included in the study.

OBJECTIVE

To ascertain whether transferring T9 or T11 ventral root (VR) to L2 VR and T10 or T12 VR to L3 VR in restoring lower limb function after spinal cord injury is anatomically feasible.

SUMMARY OF BACKGROUND DATA

Lower limb paralysis impairs the quality of the life and places burden on the whole society. However, no significant improvement in this area was achieved during recent years.

METHODS

In the present study, two fresh-frozen and six formalin-fixed cadavers were dissected to confirm the anatomical feasibility. A limited laminectomy was performed to expose the T9-L3 extradural nerve roots. T9 and T10 VR were anastomosed to L2 and L3 VR respectively, or T11 and T12 VR were anastomosed to L2 and L3 VR respectively. The pertinent distances between the donor and recipient nerves were measured and H&E staining was used to detect the axon number and cross-section area of each VR.

RESULTS

The limited incision was performed to expose the T9-L3 nerve root. According to the anatomic landmark of dorsal root ganglion, each VR could be isolated from each extradural nerve root. The T9 or T11 VR needs sural nerve graft to be transferred to L2 VR, and T10 or T12 VR also needs a nerve bridge to connect to L3 VR. The nerve numbers of T9, T10, T11, T12, L2, and L3 VRs and the sural nerves were measured respectively. The cross-section areas of T9, T10, T11, T12, L2, and L3 VRs and sural nerves were measured respectively.

CONCLUSION

Our study suggested that application of transferring T9 or T11 VR to L2 VR and T10 or T12 VR to L3 VR in restoring lower limb function is anatomically feasible.Level of Evidence: 5.

Three-Dimensional Engineered Peripheral Nerve: Toward a New Era of Patient-Specific Nerve Repair Solutions

Reconstruction of peripheral nerve injuries (PNIs) with substance loss remains challenging because of limited treatment solutions and unsatisfactory patient outcomes. Currently, nerve autografting is the first-line management choice for bridging critical-sized nerve defects. The procedure, however, is often complicated by donor site morbidity and paucity of nerve tissue, raising a quest for better alternatives. The application of other treatment surrogates, such as nerve guides, remains questionable, and it is inefficient in irreducible nerve gaps. More importantly, these strategies lack customization for personalized patient therapy, which is a significant drawback of these nerve repair options. This negatively impacts the fascicle-to-fascicle regeneration process, critical to restoring the physiological axonal pathway of the disrupted nerve. Recently, the use of additive manufacturing (AM) technologies has offered major advancements to the bioengineering solutions for PNI therapy. These techniques aim at reinstating the native nerve fascicle pathway using biomimetic approaches, thereby augmenting end-organ innervation. AM-based approaches, such as three-dimensional (3D) bioprinting, are capable of biofabricating 3D-engineered nerve graft scaffolds in a patient-specific manner with high precision. Moreover, realistic in vitro models of peripheral nerve tissues that represent the physiologically and functionally relevant environment of human organs could also be developed. However, the technology is still nascent and faces major translational hurdles. In this review, we spotlighted the clinical burden of PNIs and most up-to-date treatment to address nerve gaps. Next, a summarized illustration of the nerve ultrastructure that guides research solutions is discussed. This is followed by a contrast of the existing bioengineering strategies used to repair peripheral nerve discontinuities. In addition, we elaborated on the most recent advances in 3D printing and biofabrication applications in peripheral nerve modeling and engineering. Finally, the major challenges that limit the evolution of the field along with their possible solutions are also critically analyzed.

Schwann Cell Role in Selectivity of Nerve Regeneration

Peripheral nerve injuries result in the loss of the motor, sensory and autonomic functions of the denervated segments of the body. Neurons can regenerate after peripheral axotomy, but inaccuracy in reinnervation causes a permanent loss of function that impairs complete recovery. Thus, understanding how regenerating axons respond to their environment and direct their growth is essential to improve the functional outcome of patients with nerve lesions. Schwann cells (SCs) play a crucial role in the regeneration process, but little is known about their contribution to specific reinnervation. Here, we review the mechanisms by which SCs can differentially influence the regeneration of motor and sensory axons. Mature SCs express modality-specific phenotypes that have been associated with the promotion of selective regeneration. These include molecular markers, such as L2/HNK-1 carbohydrate, which is differentially expressed in motor and sensory SCs, or the neurotrophic profile after denervation, which differs remarkably between SC modalities. Other important factors include several molecules implicated in axon-SC interaction. This cell–cell communication through adhesion (e.g., polysialic acid) and inhibitory molecules (e.g., MAG) contributes to guiding growing axons to their targets. As many of these factors can be modulated, further research will allow the design of new strategies to improve functional recovery after peripheral nerve injuries.

Extradural Contralateral C7 Nerve Root Transfer in a Cervical Posterior Approach for Treating Spastic Limb Paralysis: A Cadaver Feasibility Study

STUDY DESIGN

Anatomic study in nine fresh-frozen cadavers.

OBJECTIVE

To confirm the anatomical feasibility of transferring the extradural ventral roots (VRs) and dorsal roots (DRs) of contralateral C7 nerves to those of the ipsilateral C7 nerves respectively through a cervical posterior approach.

SUMMARY OF BACKGROUND DATA

The contralateral C7 nerve root transfer technique makes breakthrough for treating spastic limb paralysis. However, its limitations include large surgical trauma and limited indications.

METHODS

Nine fresh-frozen cadavers (four females and five males) were placed prone, and the feasibility of exposing the bilateral extradural C7 nerve roots, separation of the extradural C7 VR and DR, and transfer of the VR and DR of the contralateral C7 to those of the ipsilateral C7 on the dural mater were assessed. The pertinent distances and the myelography results of each specimen were analyzed. The acetylcholinesterase (AChE) and antineurofilament 200 (NF200) double immunofluorescent staining were preformed to determine the nerve fiber properties.

RESULTS

A cervical posterior midline approach was made and the laminectomy was performed to expose the bilateral extradural C7 nerve roots. After the extradural C7 VR and DR are separated, the VR and DR of the contralateral C7 have sufficient lengths to be transferred to those of the ipsilateral C7 on the dural mater. The myelography results showed that the spinal cord is not compressed after the nerve anastomosis. The AChE and NF200 double immunofluorescent staining showed the distal ends of the contralateral C7 VRs were mostly motor nerve fibers, and the distal ends of the contralateral C7 DRs were mostly sensory nerve fibers.

CONCLUSION

Extradural contralateral C7 nerve root transfer in a cervical posterior approach for treating spastic limb paralysis is anatomically feasible.

LEVEL OF EVIDENCE

5.

The course of recovery of locomotor function over a 10-week observation period in a rat model of femoral nerve resection and autograft repair

BACKGROUND

A great extent of knowledge on peripheral nerve regeneration has been gathered using the rat sciatic nerve model. The femoral nerve model of the rat offers an interesting alternative, as it lacks disadvantageous features such as automutilation. For the analysis of locomotor behavior in rats after sciatic nerve injury, the CatWalk^™ XT Gait Analysis System is often used. However, lesions of the femoral nerve in the rat have yet remained unstudied with this method.

MATERIAL AND METHODS

Ten male Sprague Dawley rats were evaluated with the CatWalk XT to study their gait after a 6-mm resection of the right femoral nerve and reconstruction with an autologous nerve graft. Animals were observed for 10 weeks after surgery.

RESULTS

Print Area, Print Length, Swing Speed, and Duty Cycle decreased to a minimum of 40% of baseline 2 weeks after surgery. Swing Time was elevated more than twofold at this time point. However, all these parameters recovered back to >90% of baseline values at 10 weeks after surgery. This degree of functional recovery has not been reported after sciatic nerve resection and autograft repair. Base of support varied minimally postoperatively in contrast to a strong decrement after sciatic nerve resection and repair.

CONCLUSION

We hereby provide a comprehensive in-depth analysis of how to study functional recovery after injury of the femoral nerve in the rat via the CatWalk XT. We place special emphasis on highlighting the differences between the femoral nerve and sciatic nerve injury model in this context.

An update on the management of nerve gaps

No abstract required

Restoration of Neurological Function Following Peripheral Nerve Trauma

Following peripheral nerve trauma that damages a length of the nerve, recovery of function is generally limited. This is because no material tested for bridging nerve gaps promotes good axon regeneration across the gap under conditions associated with common nerve traumas. While many materials have been tested, sensory nerve grafts remain the clinical “gold standard” technique. This is despite the significant limitations in the conditions under which they restore function. Thus, they induce reliable and good recovery only for patients < 25 years old, when gaps are <2 cm in length, and when repairs are performed <2–3 months post trauma. Repairs performed when these values are larger result in a precipitous decrease in neurological recovery. Further, when patients have more than one parameter larger than these values, there is normally no functional recovery. Clinically, there has been little progress in developing new techniques that increase the level of functional recovery following peripheral nerve injury. This paper examines the efficacies and limitations of sensory nerve grafts and various other techniques used to induce functional neurological recovery, and how these might be improved to induce more extensive functional recovery. It also discusses preliminary data from the clinical application of a novel technique that restores neurological function across long nerve gaps, when repairs are performed at long times post-trauma, and in older patients, even under all three of these conditions. Thus, it appears that function can be restored under conditions where sensory nerve grafts are not effective.

Neuromuscular Activity Induces Paracrine Signaling and Triggers Axonal Regrowth after Injury in Microfluidic Lab-On-Chip Devices

Peripheral nerve injuries, including motor neuron axonal injury, often lead to functional impairments. Current therapies are mostly limited to surgical intervention after lesion, yet these interventions have limited success in restoring functionality. Current activity-based therapies after axonal injuries are based on trial-error approaches in which the details of the underlying cellular and molecular processes are largely unknown. Here we show the effects of the modulation of both neuronal and muscular activity with optogenetic approaches to assess the regenerative capacity of cultured motor neuron (MN) after lesion in a compartmentalized microfluidic-assisted axotomy device. With increased neuronal activity, we observed an increase in the ratio of regrowing axons after injury in our peripheral-injury model. Moreover, increasing muscular activity induces the liberation of leukemia inhibitory factor and glial cell line-derived neurotrophic factor in a paracrine fashion that in turn triggers axonal regrowth of lesioned MN in our 3D hydrogel cultures. The relevance of our findings as well as the novel approaches used in this study could be useful not only after axotomy events but also in diseases affecting MN survival.

Contemporary Concepts of Primary Dynamic Facial Nerve Reconstruction in the Oncologic Patient

Transection of the facial nerve and its branches during extensive ablative procedures in the oncologic patient causes loss of control of facial mimetic muscles with severe functional and aesthetic sequelae. In such patients with advanced tumorous disease, copious comorbidities, and poor prognosis, rehabilitation of the facial nerve has long been considered of secondary priority. However, recent advances in primary facial nerve reconstruction after extensive resection demonstrated encouraging results focusing on rapid and reliable restoration of facial functions. The authors summarize 3 innovative approaches of primary dynamic facial nerve reconstruction by using vascularized nerve grafts, dual innervation concepts, and intra-facial nerve transfers.

Muscle-Derived Extracellular Vesicles Influence Motor Neuron Regeneration Accuracy

Extracellular vesicles are lipid bilayer-enclosed extracellular structures. Although the term extracellular vesicles is quite inclusive, it generally refers to exosomes (<200 nm), and microvesicles (~100-1000 nm). Such vesicles are resistant to degradation and can contain proteins, lipids, and nucleic acids. Although it was previously thought that the primary purpose of such vesicles was to rid cells of unwanted components, it is now becoming increasingly clear that they can function as intercellular messengers, sometimes operating over long distances. As such, there is now intense interest in extracellular vesicles in fields as diverse as immunology, cell biology, cancer, and more recently, neuroscience. The influence that such extracellular vesicles might exert on peripheral nerve regeneration is just beginning to be investigated. In the current studies we show that muscle-derived extracellular vesicles significantly influence the anatomical accuracy of motor neuron regeneration in the rat femoral nerve. These findings suggest a basic cellular mechanism by which target end-organs could guide their own reinnervation following nerve injury.

The Surgical Management of Nerve Gaps: Present and Future

Peripheral nerve injuries can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Nowadays, the gold standard for the treatment of nerve section is end-to-end neurorrhaphy. Unfortunately, in some cases, there is segmental loss of the nerve trunk. Nerve mobilization allows primary repair of the sectioned nerve by end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. To overcome the limited availability and the donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers, and end-to-side neurorrhaphy. The purpose of this review is to present an overview of the literature on the applications of these techniques in peripheral nerve repair. Furthermore, preoperative evaluation, timing of repair, and future perspectives are also discussed.

Effect of surgically guided axonal regrowth into a 3-way-conduit (isogeneic trifurcated aorta) on functional recovery after facial-nerve reconstruction: Experimental study in rats

BACKGROUND

The "post-paralytic syndrome" after facial nerve reconstruction has been attributed to (i) malfunctioning axonal guidance at the fascicular (branches) level, (ii) collateral branching of the transected axons at the lesion site, and (iii) intensive intramuscular terminal sprouting of regenerating axons which causes poly-innervation of the neuromuscular junctions (NMJ).

OBJECTIVE

The first two reasons were approached by an innovative technique which should provide the re-growing axons optimal conditions to elongate and selectively re-innervate their original muscle groups.

METHODS

The transected facial nerve trunk was inserted into a 3-way-conduit (from isogeneic rat abdominal aorta) which should "guide" the re-growing facial axons to the three main branches of the facial nerve (zygomatic, buccal and marginal mandibular). The effect of this method was tested also on hypoglossal axons after hypoglossal-facial anastomosis (HFA). Coaptational (classic) FFA (facial-facial anastomosis) and HFA served as controls.

RESULTS

When compared to their coaptation (classic) alternatives, both types of 3-way-conduit operations (FFA and HFA) promoted a trend for reduction in the collateral axonal branching (the proportion of double- or triple-labelled perikarya after retrograde tracing was slightly reduced). In contrast, poly-innervation of NMJ in the levator labii superioris muscle was increased and vibrissal (whisking) function was worsened.

CONCLUSIONS

The use of 3-way-conduit provides no advantages to classic coaptation. Should the latter be impossible (too large interstump defects requiring too long interpositional nerve grafts), this type of reconstruction may be applied. (230 words).

Evaluation of the host immune response and functional recovery in peripheral nerve autografts and allografts

Allogeneic peripheral nerve (PN) transplants are an effective bridge for stimulating regeneration of segmental PN defects, but there are currently no detailed studies about the timeline and scope of the immunological response for PN allografting. In this study, the cellular immune response in PN allografts and autograft was studied during the acute and chronic phases of a 1.0 cm critical size defect in the rat sciatic nerve at 3, 7, 14, 28 and 98 days after grafting autologous or allogeneic nerves without any immunosuppressive treatment. The assessment was based on functional, histomorphometrical and immunohistochemical criteria. Results showed modestly better functional outcomes for autografts with coordinate and adaptive immune response represented by the presence of CD11c, CD3, CD4, NKp46 and CD8 cells at 3 days, CD45R positive cells and CD25 positive cells at seven and CD45R positive cells at 14 days which seems an adaptive immune response. In contrast, allograft in the early time points showed innate immune response instead of adaptive immune response until day 14, when there was some increase in cell-mediated immunity. In conclusion, in PN autografts the immune system is synchronic initiating with a more robust early innate response that more rapidly transitions to adaptive while for PN allografts the infiltration of immune cells is slower and more gradually progresses to a moderate adaptive response.

Optogenetically enhanced axon regeneration: motor versus sensory neuron-specific stimulation

Brief neuronal activation in injured peripheral nerves is both necessary and sufficient to enhance motor axon regeneration, and this effect is specific to the activated motoneurons. It is less clear whether sensory neurons respond in a similar manner to neuronal activation following peripheral axotomy. Further, it is unknown to what extent enhancement of axon regeneration with increased neuronal activity relies on a reflexive interaction within the spinal circuitry. We used mouse genetics and optical tools to evaluate the precision and selectivity of system-specific neuronal activation to enhance axon regeneration in a mixed nerve. We evaluated sensory and motor axon regeneration in two different mouse models expressing the light-sensitive cation channel, channelrhodopsin (ChR2). We selectively activated either sensory or motor axons using light stimulation combined with transection and repair of the sciatic nerve. Regardless of genotype, the number of ChR2-positive neurons whose axons had regenerated successfully was greater following system-specific optical treatment, with no effect on the number of ChR2-negative neurons (whether motor or sensory neurons). We conclude that acute system-specific neuronal activation is sufficient to enhance both motor and sensory axon regeneration. This regeneration-enhancing effect is likely cell autonomous.

Segregation of motor and sensory axons regenerating through bicompartmental tubes by combining extracellular matrix components with neurotrophic factors

Segregation of regenerating motor and sensory axons may be a good strategy to improve selective functionality of regenerative interfaces to provide closed-loop commands. Provided that extracellular matrix components and neurotrophic factors exert guidance effects on different neuronal populations, we assessed in vivo the potential of separating sensory and motor axons regenerating in a bicompartmental Y-type tube, with each branch prefilled with an adequate combination of extracellular matrix and neurotrophic factors. The severed rat sciatic nerve was repaired using a bicompartmental tube filled with a collagen matrix enriched with fibronectin (FN) and brain-derived neurotrophic factor (BDNF) encapsulated in poly-lactic co-glycolic acid microspheres (FN + MP.BDNF) in one compartment to preferentially attract motor axons and collagen enriched with laminin (LM) and nerve growth factor (NGF) and neurotrophin-3 (NT-3) in microspheres (LM + MP.NGF/NT-3) in the other compartment for promoting sensory axons regeneration. Control animals were implanted with the same Y-tube with a collagen matrix with microspheres (MP) containing PBS (Col + MP.PBS). By using retrotracer labelling, we found that LM + MP.NGF/NT-3 did not attract higher number of regenerated sensory axons compared with controls, and no differences were observed in sensory functional recovery. However, FN + MP.BDNF guided a higher number of regenerating motor axons compared with controls, improving also motor recovery. A small proportion of sensory axons with large soma size, likely proprioceptive neurons, was also attracted to the FN + MP.BDNF compartment. These results demonstrate that muscular axonal guidance can be modulated in vivo by the addition of fibronectin and BDNF.

Surgical repair in humans after traumatic nerve injury provides limited functional neural regeneration in adults

Traumatic nerve injuries result in devastating loss of neurologic function with unpredictable functional recovery despite optimal medical management. After traumatic nerve injury and denervation, regenerating axons must traverse a complex environment in which they encounter numerous barriers on the way to reinnervation of their target muscle. Outcomes of surgical intervention alone have unfortunately reached a plateau, resulting in often unsatisfactory functional recovery. Over the past few decades, many improvements were developed to supplement and boost the results of surgical repair. Biological optimization of Schwann cells, macrophages, and degradation enzymes have been studied due to the key roles of these components in axonal development, maintenance and response to injury. Moreover, surgical techniques such as nerve grafting, conduits, and growth factor supplementation are also employed to enhance the microenvironment and nerve regeneration. Yet, most of the roadblocks to recovery after nerve injury remain unsolved. These roadblocks include, but are not limited to: slow regeneration rates and specificity of target innervation, the presence of a segmental nerve defect, and degeneration of the target end-organ after prolonged periods of denervation. A recognition of these limitations is necessary so as to develop new strategies to improve functional regeneration for these life changing injuries.

End-to-side neurorrhaphy repairs peripheral nerve injury: sensory nerve induces motor nerve regeneration

End-to-side neurorrhaphy is an option in the treatment of the long segment defects of a nerve. It involves suturing the distal stump of the disconnected nerve (recipient nerve) to the side of the intimate adjacent nerve (donor nerve). However, the motor-sensory specificity after end-to-side neurorrhaphy remains unclear. This study sought to evaluate whether cutaneous sensory nerve regeneration induces motor nerves after end-to-side neurorrhaphy. Thirty rats were randomized into three groups: (1) end-to-side neurorrhaphy using the ulnar nerve (mixed sensory and motor) as the donor nerve and the cutaneous antebrachii medialis nerve as the recipient nerve; (2) the sham group: ulnar nerve and cutaneous antebrachii medialis nerve were just exposed; and (3) the transected nerve group: cutaneous antebrachii medialis nerve was transected and the stumps were turned over and tied. At 5 months, acetylcholinesterase staining results showed that 34% ± 16% of the myelinated axons were stained in the end-to-side group, and none of the myelinated axons were stained in either the sham or transected nerve groups. Retrograde fluorescent tracing of spinal motor neurons and dorsal root ganglion showed the proportion of motor neurons from the cutaneous antebrachii medialis nerve of the end-to-side group was 21% ± 5%. In contrast, no motor neurons from the cutaneous antebrachii medialis nerve of the sham group and transected nerve group were found in the spinal cord segment. These results confirmed that motor neuron regeneration occurred after cutaneous nerve end-to-side neurorrhaphy.

Combined use of Y-tube conduits with human umbilical cord stem cells for repairing nerve bifurcation defects

Given the anatomic complexity at the bifurcation point of a nerve trunk, enforced suturing between stumps can lead to misdirection of nerve axons, thereby resulting in adverse consequences. We assumed that Y-tube conduits injected with human umbilical cord stem cells could be an effective method to solve such problems, but studies focused on the best type of Y-tube conduit remain controversial. Therefore, the present study evaluated the applicability and efficacy of various types of Y-tube conduits containing human umbilical cord stem cells for treating rat femoral nerve defects on their bifurcation points. At 12 weeks after the bridging surgery that included treatment with different types of Y-tube conduits, there were no differences in quadriceps femoris muscle weight or femoral nerve ultrastructure. However, the Y-tube conduit group with longer branches and a short trunk resulted in a better outcome according to retrograde labeling and electrophysiological analysis. It can be concluded from the study that repairing a mixed nerve defect at its bifurcation point with Y-tube conduits, in particular those with long branches and a short trunk, is effective and results in good outcomes.

Polyethylene glycol fusion repair prevents reinnervation accuracy in rat peripheral nerve

Functional recovery following a peripheral nerve injury is made easier when regenerating axons correctly reinnervate their original targets. Polyethylene glycol (PEG) has recently been used in attempts to fuse severed peripheral axons during suture-based repair, but an analysis of target selectivity following such repair has not been undertaken. The rat femoral nerve (in which muscle and cutaneous pathways comingle proximally but segregate distally into separate terminal nerve branches) is a convenient in vivo model for assessing motor neuron regeneration accuracy. The present study uses retrograde labeling of motor neurons to compare reinnervation accuracy after suture-based nerve repair with and without PEG fusion. The results show that adding PEG to the suture repair site blocked the preference of motor neurons to reinnervate correctly the distal terminal nerve branch to muscle that was seen with suture repair. Retrograde transport and diffusion studies also determined that PEG fusion allowed passage of probes across the repair site, as has previously been seen, but did not result in motor neuron labeling in the spinal cord. The results suggest that PEG fusion disrupts the beneficial trophic influence of muscle on motor neuron reinnervation accuracy normally seen after suture repair and that such fusion-based approaches may be best suited to nerve injuries in which accurate target reinnervation at the terminal nerve branch level is not a priority. © 2016 Wiley Periodicals, Inc.

Effect of new neuronal growth factor on healing of sciatic nerve in rats

OBJECTIVE

The study aimed to investigate the effect of a new peptide new nerve growth factor (NNGF) on the healing of divided sciatic nerves in rats.

MATERIAL AND METHODS

Twenty Sprague-Dawley rats of 250-300g were divided into two groups (group 1 - study group and group 2 - control group). Under ketamine intramuscular anesthesia sciatic nerves were exposed, divided and repaired using 10/0 dexon. Study animals had 10mg/kg body weight of NNGF added to the repair. Electromyographic studies of the hind libs were carried out after 8weeks. The average stimulation was 50mA for 200μS and four twitches (T) were recorded. The animals were euthanized and the sciatic nerves were removed for histological analysis.

RESULTS

There were no deaths in either of the groups. Electromyographic study showed that in the control group the average T1-T4 was 0.587±0.17% and in the study group the average was 87.89±5.02% (p value of 0.001). Histologically the control group showed regenerated axons sprouting from the proximal segment of cut nerve with empty endoneurial channels, while in the study group whole nerve trunks were seen within endoneurial channels.

CONCLUSION

This study shows that the NNGF has a positive influence on the experimental healing of sciatic nerves in animals.

Management of Isolated Musculocutaneous Injury: Comparing Double Fascicular Nerve Transfer With Conventional Nerve Grafting

PURPOSE

To compare the functional outcomes of nerve grafts and nerve transfers in the management of isolated musculocutaneous nerve (MCN) injuries.

METHODS

We performed a retrospective case-control study of isolated MCN injury managed at a tertiary care center. The study group was composed of 12 patients managed with double nerve transfer whereas the 8 patients in the grafted group constituted the control group.

RESULTS

In the study group, stab and missile injuries constituted most cases with a denervation period ranging between 3 and 9 months. Eleven patients in this group experienced a full range of active elbow flexion whereas one had antigravity flexion of 120°. Electromyography revealed the first sign of reinnervation of biceps at 10 ± 2 weeks, compared with 20 ± 2 weeks in the grafted group. The overall trend was for patients in the study group to have earlier return of active elbow flexion and better restoration of elbow flexion strength and range of (presumably active) elbow motion than those treated with grafting, although none of these measures reached statistical significance.

CONCLUSIONS

We found that distal nerve transfer was a superior method of managing isolated MCN injury compared with conventional nerve grafting.

Past, Present, and Future of Nerve Conduits in the Treatment of Peripheral Nerve Injury

With significant advances in the research and application of nerve conduits, they have been used to repair peripheral nerve injury for several decades. Nerve conduits range from biological tubes to synthetic tubes, and from nondegradable tubes to biodegradable tubes. Researchers have explored hollow tubes, tubes filled with scaffolds containing neurotrophic factors, and those seeded with Schwann cells or stem cells. The therapeutic effect of nerve conduits is improving with increasing choice of conduit material, new construction of conduits, and the inclusion of neurotrophic factors and support cells in the conduits. Improvements in functional outcomes are expected when these are optimized for use in clinical practice.

N-Propionylmannosamine stimulates axonal elongation in a murine model of sciatic nerve injury

Increasing evidence indicates that sialic acid plays an important role during nerve regeneration. Sialic acids can be modified in vitro as well as in vivo using metabolic oligosaccharide engineering of the N-acyl side chain. N-Propionylmannosamine (ManNProp) increases neurite outgrowth and accelerates the reestablishment of functional synapses in vitro. We investigated the influence of systemic ManNProp application using a specific in vivo mouse model. Using mice expressing axonal fluorescent proteins, we quantified the extension of regenerating axons, the number of regenerating axons, the number of arborising axons and the number of branches per axon 5 days after injury. Sciatic nerves from non-expressing mice were grafted into those expressing yellow fluorescent protein. We began a twice-daily intraperitoneal application of either peracetylated ManNProp (200 mg/kg) or saline solution 5 days before injury, and continued it until nerve harvest (5 days after transection). ManNProp significantly increased the mean distance of axonal regeneration (2.49 mm vs. 1.53 mm; P < 0.005) and the number of arborizing axons (21% vs. 16%; P = 0.008) 5 days after sciatic nerve grafting. ManNProp did not affect the number of regenerating axons or the number of branches per arborizing axon. The biochemical glycoengineering of the N-acyl side chain of sialic acid might be a promising approach for improving peripheral nerve regeneration.

Minced nerve tissue in vein grafts used as conduits in rat tibial nerves

INTRODUCTION

Peripheral nerve injuries are encountered frequently in clinical practice. In nerve repair, an end-to-end suture is the preferable choice of treatment. However, where primary closure is not possible, the defect is to be repaired with a nerve graft.

METHODS

A total of 21 female Wistar rats weighing 230 to 290 g were used in the study. They were classified into the following 3 groups: (I) nerve graft, (II) vein graft, and (III) minced nerve graft. In group I, after exposure of the tibial nerve, a 1-cm-long nerve gap was created on the tibial nerve, and the defect was repaired epineurally by using the autogenous nerve. In group II, the 1-cm tibial nerve defect was repaired by using an autogenous vein graft. In group III, a 1-cm nerve graft was divided to 3 equal parts, with one of the nerve parts being minced with microscissors and placed in the vein graft lumen. Thereafter, a 1-cm tibial nerve defect was repaired by the vein graft filled with minced nerve tissue. The tibial function indices (TFIs) were calculated for functional assessment using the Bain-Mackinnon-Hunter formula. Light and electron microscopic evaluations were performed for morphometric assessment. In addition, the myelinated fibers were counted in all groups.

RESULTS

The TFIs of group II were found to be the lowest among all the groups after the sixth week, whereas the TFI of group I was found to be better than the other groups after the sixth week. There was no difference in TFIs between group I and group III. On the basis of the number of myelinated fibers, there was no statistically significant difference between group I and group III, whereas the difference was significant (P<0.05) between groups I/III and group II. Presence of peripheral nerves in light microscopic evaluation revealed normal characteristics of myelinated fibers in all groups. The myelinated axon profile was near normal in the nerve graft group in electron microscopic evaluation. However, there were more degenerated axons with disturbed contours and vacuolizations in the vein graft group compared to the minced nerve graft group.

CONCLUSIONS

We can conclude that using minced nerve tissue in vein grafts as a conduit increases the regeneration of nerves (almost like the nerve graft group) and it may not be caused by donor-site morbidity. It can be used in the repair of nerve defects instead of autogenous nerve grafts after further experimental evidence and clinical trials.

In vivo stimulation of early peripheral axon regeneration by N-propionylmannosamine in the presence of polysialyltransferase ST8SIA2

The key enzyme of sialic acid (Sia) biosynthesis is the bifunctional UDP-N-acetylglucosamine 2-epimerase/ManNAc kinase (GNE/MNK). It metabolizes the physiological precursor ManNAc and N-acyl modified analogues such as N-propionylmannosamine (ManNProp) to the respective modified sialic acid. Polysialic acid (polySia) is a crucial compound for several functions in the nervous system and is synthesized by the polysialyltransferases ST8SIA2 and ST8SIA4. PolySia can be modified in vitro and in vivo by metabolic glycoengineering of the N-acyl side chain of Sia. In vitro studies show that the application of ManNProp increases neurite outgrowth and accelerates the re-establishment of functional synapses. In this study, we investigate in vivo how ManNProp application might benefit peripheral nerve regeneration. In mice expressing axonal fluorescent proteins (thy-1-YFP), we transected the sciatic nerve and then replaced part of it with a sciatic nerve graft from non-expressing mice (wild-type mice or St8sia2(-/-) mice). Analyses conducted 5 days after grafting showed that systemic application of ManNProp (200 mg/kg, twice a day, i.p.), but not of physiological ManNAc (1 g/kg, twice a day, i.p.), significantly increased the extent of axonal elongation, the number of arborizing axons and the number of branches per regenerating axon within the grafts from wild-type mice, but not in those from St8sia2(-/-) mice. The results demonstrate that the application of ManNProp has beneficial effects on early peripheral nerve regeneration and indicate that the stimulation of axon growth depends on ST8SIA2 activity in the nerve graft.

Pathways regulating modality-specific axonal regeneration in peripheral nerve

Following peripheral nerve injury, the distal nerve is primed for regenerating axons by generating a permissive environment replete with glial cells, cytokines, and neurotrophic factors to encourage axonal growth. However, increasing evidence demonstrates that regenerating axons within peripheral nerves still encounter axonal-growth inhibitors, such as chondroitin sulfate proteoglycans. Given the generally poor clinical outcomes following peripheral nerve injury and reconstruction, the use of pharmacological therapies to augment axonal regeneration and overcome inhibitory signals has gained considerable interest. Joshi et al. (2014) have provided evidence for preferential or modality-specific (motor versus sensory) axonal growth and regeneration due to inhibitory signaling from Rho-associated kinase (ROCK) pathway regulation. By providing inhibition to the ROCK signaling pathway through Y-27632, they demonstrate that motor neurons regenerating their axons are impacted to a greater extent compared to sensory neurons. In light of this evidence, we briefly review the literature regarding modality-specific axonal regeneration to provide context to their findings. We also describe potential and novel barriers, such as senescent Schwann cells, which provide additional axonal-growth inhibitory factors for future consideration following peripheral nerve injury.

GDNF preconditioning can overcome Schwann cell phenotypic memory

While it is known that Schwann cells (SCs) provide cues to enhance regeneration following peripheral nerve injury, the effect of SC phenotypic memory (muscle or cutaneous nerve-derived) on enhancing axonal regeneration and functional recovery has been unclear in the literature. In particular, differences between muscle and cutaneous nerve-derived SC may encourage specific motor or sensory axonal guidance in cell/tissue transplantation therapies. Thus, the goal of this study was to determine whether phenotypically matched combinations of neurons and SCs stimulate greater axonal extension compared to mismatched combinations (i.e. motor neurons/muscle nerve-derived SCs vs. motor neurons/cutaneous nerve-derived SCs). Additionally, the effect of glial cell line-derived neurotrophic factor (GDNF) treatment on SC-neuron interaction was also evaluated. In order to examine these interactions, microfluidic devices were used to assess the effects of soluble factors secreted from SCs on neurons. Unlike traditional co-culture methods, the devices allow for easier quantification of single neurite extension over long periods of time, as well as easy cell and media sampling of pure populations for biochemical analyses. Results demonstrated longer neurite growth when neurons are cultured with phenotype matched SCs, suggesting that SCs are capable of retaining phenotypic memory despite a prolonged absence of axonal contact. Furthermore, the negative effect of mismatched cultures can be overcome when mismatched SCs are preconditioned with GDNF. These results suggest that treatment of SCs with GDNF could enhance their ability to promote regeneration through mismatched grafts frequently used in clinical settings.

Accuracy of regenerating motor neurons: influence of diffusion in denervated nerve

Following injury to a peripheral nerve the denervated distal nerve segment undergoes remarkable changes including loss of the blood-nerve barrier, Schwann cell proliferation, macrophage invasion, and the production of many cytokines and neurotrophic factors. The aggregate consequence of such changes is that the denervated nerve becomes a permissive and even preferred target for regenerating axons from the proximal nerve segment. The possible role that an original end-organ target (e.g. muscle) may play in this phenomenon during the regeneration period is largely unexplored. We used the rat femoral nerve as an in vivo model to begin to address this question. We also examined the effects of disrupting communication with muscle in terms of accuracy of regenerating motor neurons as judged by their ability to correctly project to their original terminal nerve branch. Our results demonstrate that the accuracy of regenerating motor neurons is dependent upon the denervated nerve segment remaining in uninterrupted continuity with muscle. We hypothesized that this influence of muscle on the denervated nerve might be via diffusion-driven movement of biomolecules or the active axonal transport that continues in severed axons for several days in the rat, so we devised experiments to separate these two possibilities. Our data show that disrupting ongoing diffusion-driven movement in a denervated nerve significantly reduces the accuracy of regenerating motor neurons.

Stimulation of denervated muscle promotes selective reinnervation, prevents synkinesis, and restores function

OBJECTIVES/HYPOTHESIS

Previously, electrical stimulation of denervated canine laryngeal muscle was shown to promote reinnervation by native over foreign motoneurons. The goal of this study was to assess the effect of different stimulus paradigms on reinnervation quality and functional recovery.

STUDY DESIGN

A prospective study of six canines over 8 to 20 months.

METHODS

A clinical model of laryngeal paralysis was used, where recurrent laryngeal nerves of the animals were sectioned and ventilation compromised. The abductor, posterior cricoarytenoid (PCA) muscles were implanted bilaterally with electrodes from an implantable pulse generator. Animals were randomly assigned to three groups to assess the effect of different stimulus paradigms: 1) 40 pulses per second (pps) train, 2) 10 pps train, 3) no stimulation. Spontaneous vocal fold movement was measured endoscopically during hypercapnia. Exercise tolerance was measured on a treadmill using pulse oximetry. In the terminal session, electromyography (EMG) potentials were recorded during superior laryngeal nerve stimulation to index foreign reinnervation of the PCA by reflex glottic closure (RGC) motoneurons.

RESULTS

After reinnervation started, nonstimulated and stimulated 40 pps animals displayed paradoxical closure of the glottis during hypercapnia and severely decreased exercise tolerance due to faulty reinnervation. In contrast, stimulated 10 pps animals displayed minimal paradoxical closure and normal exercise tolerance (12 minutes up to 8 mph). EMG findings in this group demonstrated significantly less PCA reinnervation by foreign RGC motoneurons.

CONCLUSION

PCA stimulation with low frequency reduced synkinetic reinnervation by foreign RGC motoneurons. Paradoxical closure of the glottis with inspiration was reduced and exercise tolerance restored to normal.

Adult motor axons preferentially reinnervate predegenerated muscle nerve

Preferential motor reinnervation (PMR) is the tendency for motor axons regenerating after repair of mixed nerve to reinnervate muscle nerve and/or muscle rather than cutaneous nerve or skin. PMR may occur in response to the peripheral nerve pathway alone in juvenile rats (Brushart, 1993; Redett et al., 2005), yet the ability to identify and respond to specific pathway markers is reportedly lost in adults (Uschold et al., 2007). The experiments reported here evaluate the relative roles of pathway and end organ in the genesis of PMR in adult rats. Fresh and 2-week predegenerated femoral nerve grafts were transferred in correct or reversed alignment to replace the femoral nerves of previously unoperated Lewis rats. After 8 weeks of regeneration the motoneurons projecting through the grafts to recipient femoral cutaneous and muscle branches and their adjacent end organs were identified by retrograde labeling. Motoneuron counts were subjected to Poisson regression analysis to determine the relative roles of pathway and end organ identity in generating PMR. Transfer of fresh grafts did not result in PMR, whereas substantial PMR was observed when predegenerated grafts were used. Similarly, the pathway through which motoneurons reached the muscle had a significant impact on PMR when grafts were predegenerated, but not when they were fresh. Comparison of the relative roles of pathway and end organ in generating PMR revealed that neither could be shown to be more important than the other. These experiments demonstrate unequivocally that adult muscle nerve and cutaneous nerve differ in qualities that can be detected by regenerating adult motoneurons and that can modify their subsequent behavior. They also reveal that two weeks of Wallerian degeneration modify the environment in the graft from one that provides no modality-specific cues for motor neurons to one that actively promotes PMR.

Major peripheral nerve injuries

Major peripheral nerve injuries in the upper extremities can result in significant morbidity. Understanding the pathophysiology of these injuries aids in the assessment and planning of appropriate treatment. With limited nerve mobilization, tension-free repairs can often be performed using sutures, fibrin glue, or nerve connectors. Acellular allograft and autograft reconstruction are better for bridging any gaps greater than a few millimeters. Adherence to proper principles of nerve repair improves the chances of achieving a favorable result, although in general these injuries portend a guarded prognosis.

Nerve physiology: mechanisms of injury and recovery

Peripheral nerve injuries are common conditions, with broad-ranging groups of symptoms depending on the severity and nerves involved. Although much knowledge exists on the mechanisms of injury and regeneration, reliable treatments that ensure full functional recovery are scarce. This review aims to summarize various ways these injuries are classified in light of decades of research on peripheral nerve injury and regeneration.

Delayed repair of facial nerve trauma: an experimental study in guinea pigs

CONCLUSION

The curative effect in the group where facial-facial anastomosis (FFA) was delayed for 7 days was similar to that in the immediate FFA group and had a better repair within 60 days.

OBJECTIVE

Due to the uncertainty about optimal timing of delayed facial nerve repair, we designed an experimental study in guinea pigs to find out the cut-off duration for delayed nerve repair.

METHODS

In this study, 64 male guinea pigs were randomly divided into 8 groups: normal, immediate FFA, and delayed FFA for 7, 14, 21, 30, 60, and 90 days (n = 6). Two months after suture of the nerves, the passing rate of myelinated fibers growing from the proximal to the distal stumps was calculated.

RESULTS

The passing rates of myelinated fibers in the groups with immediate FFA and FFA delayed for 7 days were significantly higher than those in other delayed FFA groups and the difference was statistically significant (p < 0.05), whereas the passing rates of the groups where FFA was delayed for 60 and 90 days were apparently lower than those of the immediate FFA and other delayed FFA groups. Under the electron microscope, regenerated fibers of the groups with immediate FFA and FFA delayed for 7 days were very similar to the normal myelinated fibers.

Advances in experimental and clinical studies of chemotaxis

The theory of chemotaxis has been widely accepted, but its mechanisms are disputed. Chemotactic growth of peripheral nerves may be tissue, topographic and end-organ specific. Recent studies indicated that peripheral nerve regeneration lacks topographic specificity, but whether it has end-organ specificity is disputed. Chemotaxis in nerve regeneration is affected by the distance between stumps, volume, and neurotrophic support, as well as the structure of distal nerve stumps. It can be applied to achieve precise repair of nerves and complete recovery of end organ function. Small gap sleeve bridging technique, which is based on this theory shows promising effects but it is still challenging to find the perfect combination of nerve conduits, cells and neurotrophic factors to put it intoits best use. In this paper, we made a comprehensive review of mechanisms, effect factors and applications of chemotaxis.

Polysialic acid expression is not necessary for motor neuron target selectivity

INTRODUCTION

Recovery after peripheral nerve lesions depends on guiding axons back to their targets. Polysialic acid upregulation by regrowing axons has been proposed recently as necessary for this target selectivity.

METHODS

We reexamined this proposition using a cross-reinnervation model whereby axons from obturator motor neurons that do not upregulate polysialic acid regenerated into the distal femoral nerve. Our aim was to assess their target selectivity between pathways to muscle and skin.

RESULTS

After simple cross-repair, obturator motor neurons showed no pathway preference, but the same repair with a shortened skin pathway resulted in selective targeting of these motor neurons to muscle by a polysialic acid-independent mechanism.

CONCLUSION

The intrinsic molecular differences between motor neuron pools can be overcome by manipulation of their access to different peripheral nerve pathways such that obturator motor neurons preferentially project to a terminal nerve branch to muscle despite not upregulating the expression of polysialic acid.

Advanced imaging and arthroscopic management of shoulder contracture after birth palsy

Modern imaging techniques applied to the pediatric glenohumeral joint have advanced understanding of the anatomic changes that occur secondary to muscular imbalance after brachial plexus birth palsy. A better understanding of the progression and timing of glenohumeral dysplasia has also increased awareness and vigilance of this problem. Early detection of glenohumeral joint subluxation is now possible, allowing for prompt treatment with closed, arthroscopic, or open joint reduction with and without tendon transfers. Dynamic ultrasound imaging, Botox, and arthroscopic techniques have expanded treatment options, providing minimally invasive methods to successfully manage glenohumeral joint dysplasia.

Brief transvertebral electrical stimulation of the spinal cord improves the specificity of femoral nerve reinnervation

BACKGROUND

Functional outcomes are generally poor following peripheral nerve injury (PNI). The reason is multifactorial but includes the misdirection of regenerating axons to inappropriate end organs. It has been shown that brief electrical stimulation (Estim) of nerves has the potential to improve the accuracy and rate of peripheral axon regeneration.

OBJECTIVE

The present study explores a novel percutaneous transvertebral approach to Estim, which was tested in the mouse femoral nerve model.

METHODS

Inspired by the protocol of Gordon and colleagues (ie, 20 Hz, for 1 hour), we applied Estim to the cervicothoracic spinal cord (SC-Estim) to remotely activate lumbar motor neurons following transection and repair of the femoral nerve. Fluorescent dyes were applied to the distal nerve to label reinnervating cells. Sections of nerve were taken to quantify the numbers of reinnervating axons as well as to stain for a known femoral axon guidance molecule-polysialylated neural cell adhesion molecule (PSA-NCAM).

RESULTS

In comparison to sham treatment, SC-Estim led to significantly greater expression of PSA-NCAM as well as improved the specificity of motor reinnervation. Interestingly, although SC-Estim did not alter the number of early reinnervating (ie, pioneer) axons, there was a reduction in the number of retrogradely labeled neurons at 2 weeks postrepair. However, by 6 weeks postrepair, there was no difference in the number of neurons that had reinnervated the femoral nerve.

CONCLUSIONS

The present findings support the development of SC-Estim as a novel approach to enhance the specificity of reinnervation and potentially improve functional outcomes following PNI.

The brain-derived neurotrophic factor, nerve growth factor, neurotrophin-3, and induced nitric oxide synthase expressions after low-level laser therapy in an axonotmesis experimental model

BACKGROUND DATA

A robust body of evidence has shown that low-level laser therapy (LLLT) improves peripheral nerve regeneration. However, the biochemical background triggered in this process is not yet fully understood.

OBJECTIVE

The purpose of this study was to evaluate the mRNA expression of neurotrophic factors (brain-derived neurotrophic factor [BDNF], nerve growth factor [NGF], and neurotrophin-3, [NT-3]) and also an inflammatory marker (induced nitric oxide synthase [iNOS]) in an axonotmesis experimental model after low-level laser therapy.

METHODS

Thirty-six adult male Wistar rats (250-350 g) were subjected to right sciatic nerve crush injury, and 24 h later, the animals in the three different experimental groups (n=18) were irradiated on a daily basis with helium-neon laser (collimated HeNe laser, continuous emission, wavelength: 632.8 nm, power density: 0.5 mW/cm(2), irradiation time: 20 sec, energy density: 10 J/cm(2)) during 7, 14, and 21 consecutive days, respectively. The control group (n=18) underwent the same procedures, but with the equipment turned off. At the end of the experiments, animals were killed with an overdose of anesthesia to remove samples from the sciatic nerve lesion epicenter to determine the mRNA expression of BDNF, NGF, NT-3 and iNOS enzyme.

RESULTS

Comparisons between groups showed that HeNe laser increased the mRNA expression of both BDNF and NGF factors after 14 days of LLLT, with peak expression at the 21st day. Increase in NT-3 mRNA expression was not observed. In addition, HeNe laser produced iNOS expression reduction, which played an important role in the inflammatory process.

CONCLUSIONS

The reported data could have a relevant practical value because LLLT is a noninvasive procedure, and have revealed significant increase in neurotrophic factor expressions and inflammatory process reduction, opening the possibility of using LLLT as an important aid to nerve regeneration process.

Axonal regeneration and motor neuron survival after microsurgical nerve reconstruction

Rodent models are used extensively for studying nerve regeneration, but little is known about how sprouting and pruning influence peripheral nerve fiber counts and motor neuron pools. The purpose of this study was to identify fluctuations in nerve regeneration and neuronal survival over time. One hundred and forty-four Lewis rats were randomized to end-to-end repair or nerve grafting (1.5 cm graft) after sciatic nerve transection. Quantitative histomorphometry and retrograde labeling of motor neurons were performed at 1, 3, 6, 9, 12, and 24 months and supplemented by electron microscopy. Fiber counts and motor neuron counts increased between 1 and 3 months, followed by plateau. End-to-end repair resulted in persistently higher fiber counts compared to the grafting for all time points (P < 0.05). Percent neural tissue and myelin width increased with time while fibrin debris dissipated. In conclusion, these data detail the natural history of regeneration and demonstrate that overall fiber counts may remain stable despite pruning.

Specificity of peripheral nerve regeneration: interactions at the axon level

Peripheral nerves injuries result in paralysis, anesthesia and lack of autonomic control of the affected body areas. After injury, axons distal to the lesion are disconnected from the neuronal body and degenerate, leading to denervation of the peripheral organs. Wallerian degeneration creates a microenvironment distal to the injury site that supports axonal regrowth, while the neuron body changes in phenotype to promote axonal regeneration. The significance of axonal regeneration is to replace the degenerated distal nerve segment, and achieve reinnervation of target organs and restitution of their functions. However, axonal regeneration does not always allows for adequate functional recovery, so that after a peripheral nerve injury, patients do not recover normal motor control and fine sensibility. The lack of specificity of nerve regeneration, in terms of motor and sensory axons regrowth, pathfinding and target reinnervation, is one the main shortcomings for recovery. Key factors for successful axonal regeneration include the intrinsic changes that neurons suffer to switch their transmitter state to a pro-regenerative state and the environment that the axons find distal to the lesion site. The molecular mechanisms implicated in axonal regeneration and pathfinding after injury are complex, and take into account the cross-talk between axons and glial cells, neurotrophic factors, extracellular matrix molecules and their receptors. The aim of this review is to look at those interactions, trying to understand if some of these molecular factors are specific for motor and sensory neuron growth, and provide the basic knowledge for potential strategies to enhance and guide axonal regeneration and reinnervation of adequate target organs.