The protective effects of small gap sleeve in bridging peripheral nerve mutilation

The effect of a gap concept on peripheral nerve recovery in modified epineurial neurorrhaphy: An experimental study in rats

BACKGROUND

Several factors such as surgical approach that only consider topographic anatomy; inadequate fascicular alignment, extraepineurial sprouting in the repair zone; contact of axons with the suture area are the disadvantages of epineurial neurorrhaphy. Accordingly, axonal mismatch, neuroma, and unfavorable nerve recovery become inevitable. Neurotropism is the theory clarifying appropriate matching of the nerve fibers independently without needing surgical approach. The studies comparing the primary nerve repair with the nerve defects bridged in different ways demonstrated better outcomes of nerve recovery in the groups with a nerve gap. In this study, we aimed to demonstrate the effects of the gap concept in primary nerve repair bridged by own epineurium. We hypothesized that this technique will provide better results in terms of peripheral nerve recovery and will significantly eliminate the occurrence of a neuroma, which is quite possible in epineurial neurorrhaphy.

MATERIALS AND METHODS

A total of 35 Wistar female rats weighing 200 ~ 250 g were randomly divided into five groups each with seven rats. Sham controls constituted Group 1, while the rats with epineural neurorrhaphy were included in Group 2. The remaining three groups were the study groups. In Group 3, after the sciatic nerve transection, epineurium of the distal segment was sleeved and preserved. A 2-mm axonal segment was removed from the epineurium free distal ending and no any procedure was applied to the proximal ending of the transected sciatic nerve. Epineuriums of the both sides were approximated and repaired. In Group 4, a 2-mm axonal segment was removed from the proximal ending of the sciatic nerve after preservation of epineurium and no any procedure was applied to the distal part of sciatic nerve. Epineuriums of the both sides were approximated and repaired. In addition, in Group 5, after epineuriums were sleeved in the both distal and proximal stumps, a 1-mm nerve segment was removed from both endings and epineuriums were repaired in the middle bridging a 2-mm axonal gap again. After a 3 months follow-up period Sciatic Functional Index (SFI) was measured by walking track analysis; the area under the evoked compound muscle action potential (CMAP) and latency periods were calculated via electromyographic (EMG) analysis; and histopathological evaluation were performed to compare the parameters of edema, fibrosis, inflammation, vascularization, axonal degeneration, axonal density, myelination, disorganization, and neuroma occurrence. Vascular structures and nerve fibers were counted at ×200 magnification: +1, +2, and +3 indicated the presence of 0-15, 16-30, and >30 structures, respectively. For uncountable parameters (edema, disorganization, myelination, fibrosis, and inflammation): +1 indicated mild, +2 indicated moderate, and +3 indicated severe.

RESULTS

The differences between the groups with axonal gap repair and epineural neurorrhaphy were not significant regarding to SFI. The areas under CMAP were as follows: 27.9 ± 5.9 (Δ = 12.1%) in Group 1; 16.5 ± 5.5 (Δ = 6.3%) in Group 2; 14.1 ± 6.2 (Δ = 4.8%) in group 3; 13.8 ± 2.3 (Δ = 9.2%) in Group 4, and 22.5 ± 18.3 (Δ = 2.2%) in Group 5. Group 5 (1 mm gap in the distal +1 mm gap in the proximal segments) had a significantly better result in terms of the area under CMAP with the value of 22.5 ± 18.3 m/Mv (p = .031). Axonal density was 0.9 ± 0.6 (Δ = 2.2%) in Group 2, 2.4 ± 0.3 (Δ = 5.1%) in Group 3, 2.8 ± 0.1 (Δ = 7.7%) in Group 4, and 2.8 ± 0.2 (Δ = 4.8%) in Group 5. Myelination was 1.1 ± 0.5 (Δ = 3.4%) in group 2, 2.2 ± 0.2 (Δ = 6.7%) in group 3, 2.4 ± 0.4 (Δ = 6.0%) in Group 4, and 2.7 ± 0.3 (Δ = 4.6%) in Group 5. Disorganization was 2.3 ± 0.4 (Δ = 4.1%) in Group 2, 1.2 ± 0.2 (Δ = 7.7%) in Group 3, 1.3 ± 0.2 (Δ = 6.5%) in Group 4, and 1 ± 0.3 (Δ = 5.9%) in Group 5. And, neuroma occurrence was found 2.2 ± 0.6 (Δ = 2.8%) in Group 2 and 0.3 ± 0.2 (Δ = 0.1%) in Group 4 while neuroma was not encountered in Group 3 and Group 5. Comparison between the epineurial neurorrhaphy group and the groups with axonal defect revealed the statistically significant results in the factors of axonal density (p = .001), myelination (p = .028), disorganization (p = .016) and neuroma (p = .001).

CONCLUSIONS

Creating axonal gap bridged by own epineurium showed favorable results comparing with epineurial neurorrhaphy. Resection of a 1 mm axonal segment from the proximal and distal stumps following the epineurial sleeve procedure and performing the epineurium- only repair can facilitate the nerve regeneration. The feasibility of the described technique has been demonstrated in a small rat model and must be further validated in larger animals before clinical testing.

Enhanced Nerve Regeneration by Bionic Conductive Nerve Scaffold Under Electrical Stimulation

Repair of peripheral nerve defect (PND) with a poor prognosis is hard to deal with. Neural conduit applied to nerve defect at present could not achieve the effect of autologous nerve transplantation. We prepared bionic conductive neural scaffolds to provide a new strategy for the treatment of PNDs. The highly aligned poly (L-lactic acid) (PLLA) fiber mats and the multi-microchannel conductive scaffolds were combined into bionic conductive nerve scaffolds, which were implanted into rats with sciatic nerve defects. The experimental animals were divided into the scaffold group (S), scaffold with electrical stimulation (ES) group (S&E), and autologous nerve transplantation group (AT). The regenerative effect of bionic conductive nerve scaffolds was analyzed. Compared with aligned PLLA fiber mats (APFMs), highly aligned fiber mats had a higher fiber orientation and did not change the tensile strength, Young’s modulus, degradation rate, elongation at break of the fiber membrane, and biocompatibility. The bionic conductive nerve scaffolds were well matched with the rat sciatic nerve. The evaluations of the sciatic nerve in Group S&E were close to those in Group AT and better than those in Group S. Immunohistochemical results showed that the expression levels of neurofilament heavy polypeptide (NF-H) and protein S100-B (S100-β) in Group S&E were higher than those in Group S, and the expression levels of low-density lipoprotein receptor-related protein 4 (LRP4), mitogen-activated protein kinase (MAPK) p38, extracellular signal-regulated kinase (ERK), and mitogen-activated protein kinase kinase (MEK) in Group AT were higher than those in Group S. Bionic conductive nerve scaffolds combined with ES could enhance peripheral nerve regeneration and achieve satisfactory nerve regeneration close to autologous nerve grafts. ERK, p38 MAPK, MEK, and LRP4 may be involved in peripheral nerve regeneration under ES.

Small-Molecule SB216763-Loaded Microspheres Repair Peripheral Nerve Injury in Small Gap Tubulization

Peripheral nerve injury has yet to be fully resolved because of its complicated pathological process. SB216763 is a small molecular compound that can enhance the remyelination of peripheral nerves by inhibiting glycogen synthase kinase-3β (GSK3β). GSK-3β inhibitor stimulates myelin gene expression and restores the myelin structure. Herein, we presented the effect of integrating small gap tubulization with SB216763-loaded microspheres by using a chitosan conduit. In vitro, SB216763 could promote neurite growth of dorsal root ganglia. In vivo studies showed that SB216763 increased the number of myelinated axons and the thickness of myelin sheaths. Electrophysiological examination and sciatic functional index results also indirectly indicated the role of SB216763 in repairing peripheral nerve injury. SB216763 promoted the recovery of muscle function. Therefore, combining SB216763-loaded PLGA microspheres with conduit small gap tubulization shows potential for applications in repairing peripheral nerve injury.

Phenotypic changes of Schwann cells on the proximal stump of injured peripheral nerve during repair using small gap conduit tube

Dedifferentiation of Schwann cells is an important feature of the response to peripheral nerve injury and specific negative myelination regulators are considered to have a major role in this process. However, most experiments have focused on the distal nerve stump, where the Notch signaling pathway is strongly associated with Schwann cell dedifferentiation and repair of the nerve. We observed the phenotypic changes of Schwann cells and changes of active Notch signaling on the proximal stump during peripheral nerve repair using small gap conduit tubulization. Eighty rats, with right sciatic nerve section of 4 mm, were randomly assigned to conduit bridging group and control group (epineurium suture). Glial fibrillary acidic protein expression, in myelinating Schwann cells on the proximal stump, began to up-regulate at 1 day after injury and was still evident at 5 days. Compared with the control group, Notch1 mRNA was expressed at a higher level in the conduit bridging group during the first week on the proximal stump. Hes1 mRNA levels in the conduit bridging group significantly increased compared with the control group at 3, 5, 7 and 14 days post-surgery. The change of the Notch intracellular domain shared a similar trend as Hes1 mRNA expression. Our results confirmed that phenotypic changes of Schwann cells occurred in the proximal stump. The differences in these changes between the conduit tubulization and epineurium suture groups correlate with changes in Notch signaling. This suggests that active Notch signaling might be a key mechanism during the early stage of neural regeneration in the proximal nerve stump.

Biological conduit small gap sleeve bridging method for peripheral nerve injury: regeneration law of nerve fibers in the conduit

The clinical effects of 2-mm small gap sleeve bridging of the biological conduit to repair peripheral nerve injury are better than in the traditional epineurium suture, so it is possible to replace the epineurium suture in the treatment of peripheral nerve injury. This study sought to identify the regeneration law of nerve fibers in the biological conduit. A nerve regeneration chamber was constructed in models of sciatic nerve injury using 2-mm small gap sleeve bridging of a biodegradable biological conduit. The results showed that the biological conduit had good histocompatibility. Tissue and cell apoptosis in the conduit apparently lessened, and regenerating nerve fibers were common. The degeneration regeneration law of Schwann cells and axons in the conduit was quite different from that in traditional epineurium suture. During the prime period for nerve fiber regeneration (2-8 weeks), the number of Schwann cells and nerve fibers was higher in both proximal and distal ends, and the effects of the small gap sleeve bridging method were better than those of the traditional epineurium suture. The above results provide an objective and reliable theoretical basis for the clinical application of the biological conduit small gap sleeve bridging method to repair peripheral nerve injury.

Small gap sleeve bridging can improve the accuracy of peripheral nerve selective regeneration

The pure motor peripheral nerves animal model, obtained by ablating the dorsal root ganglions (DRGs), was used to investigate the accuracy of peripheral nerve selective regeneration using small gap sleeve bridging compared to epineurium neurorrhaphy. The results showed that the number of improperly regenerated motor axons in the distal stump and the misrouting ratio were significantly lower when the nerve transection was treated by small gap sleeve bridging. This suggests that more accurate reinnervation may be achieved by small gap sleeve bridging than by traditional epineurium neurorrhaphy.

Biodegradable conduit small gap tubulization for peripheral nerve mutilation: a substitute for traditional epineurial neurorrhaphy

Nerve regeneration and re-innervation are usually difficult after peripheral nerve injury. Epineurium neurorrhaphy to recover the nerve continuity is the traditional choice of peripheral nerve mutilation without nerve defects, whereas the functional recovery remains quite unsatisfactory. Based on previous research in SD rats and Rhesus Monkeys, a multiple centers clinical trial about biodegradable conduit small gap tubulization for peripheral nerve mutilation to substitute traditional epineurial neurorrhaphy was carried out. Herein, the authors reviewed the literature that focused on peripheral nerve injury and possible clinical application, and confirmed the clinical possibilities of biodegradable conduit small gap tubulization to substitute traditional epineurial neurorrhaphy for peripheral nerve mutilation. The biodegradable conduit small gap tubulization to substitute traditional epineurial neurorrhaphy for peripheral nerve mutilation may be a revolutionary innovation in peripheral nerve injury and repair field.

The experimental research of nerve fibers compensation amplification innervation of ulnar nerve and musculocutaneous nerve in rhesus monkeys

This experiment intended to authenticate the compensation and amplification effect of regenerated nerve fibers after nerve injury in primate. The Rhesus Monkeys right ulnar nerves and musculocutaneous nerves were chosed. The proximal impaired ulnar nerve as the proximal end and the distal impaired ulnar nerve musculocutaneous nerve as the distal ends. The ulnar nerve proximal stump fibers can grow into both the ulnar nerve distal stump and the musculocutaneus nerve at the same time and established two different electrophysiological conduction passageway. There exist nerve fibers compensation amplification effect after peripheral nerve injury on Rhesus Monkeys.