Effect of naloxone on posttraumatic ischemia in experimental spinal contusion

Established and Emerging Therapies in Acute Spinal Cord Injury

Acute spinal cord injury (SCI) is devastating for patients and their caretakers and has an annual incidence of 20–50 per million people. Following initial assessment with appropriate physical examination and imaging, patients who are deemed surgical candidates should undergo decompression with stabilization. Earlier intervention can improve neurological recovery in the post-operative period while allowing earlier mobilization. Optimized medical management is paramount to improve outcomes. Emerging strategies for managing SCI in the acute period stem from an evolving understanding of the pathophysiology of the injury. General areas of focus include ischemia prevention, reduction of secondary injury due to inflammation, modulation of the cytotoxic and immune response, and promotion of cellular regeneration. In this article, we review established, emerging, and novel experimental therapies. Continued translational research on these methods will improve the feasibility of bench-to-bedside innovations in treating patients with acute SCI.

Acute spinal cord injury: Pathophysiology and pharmacological intervention (Review)

Spinal cord injury (SCI) is one of the most debilitating of all the traumatic conditions that afflict individuals. For a number of years, extensive studies have been conducted to clarify the molecular mechanisms of SCI. Experimental and clinical studies have indicated that two phases, primary damage and secondary damage, are involved in SCI. The initial mechanical damage is caused by local impairment of the spinal cord. In addition, the fundamental mechanisms are associated with hyperflexion, hyperextension, axial loading and rotation. By contrast, secondary injury mechanisms are led by systemic and cellular factors, which may also be initiated by the primary injury. Although significant advances in supportive care have improved clinical outcomes in recent years, a number of studies continue to explore specific pharmacological therapies to minimize SCI. The present review summarized some important pathophysiologic mechanisms that are involved in SCI and focused on several pharmacological and non‑pharmacological therapies, which have either been previously investigated or have a potential in the management of this debilitating injury in the near future.

Extent of Spinal Cord Decompression in Motor Complete (American Spinal Injury Association Impairment Scale Grades A and B) Traumatic Spinal Cord Injury Patients: Post-Operative Magnetic Resonance Imaging Analysis of Standard Operative Approaches

Although decompressive surgery following traumatic spinal cord injury (TSCI) is recommended, adequate surgical decompression is rarely verified via imaging. We utilized magnetic resonance imaging (MRI) to analyze the rate of spinal cord decompression after surgery. Pre-operative (within 8 h of injury) and post-operative (within 48 h of injury) MRI images of 184 motor complete patients (American Spinal Injury Association Impairment Scale [AIS] grade A = 119, AIS grade B = 65) were reviewed to verify spinal cord decompression. Decompression was defined as the presence of a patent subarachnoid space around a swollen spinal cord. Of the 184 patients, 100 (54.3%) underwent anterior cervical discectomy and fusion (ACDF), and 53 of them also underwent laminectomy. Of the 184 patients, 55 (29.9%) underwent anterior cervical corpectomy and fusion (ACCF), with (26 patients) or without (29 patients) laminectomy. Twenty-nine patients (16%) underwent stand-alone laminectomy. Decompression was verified in 121 patients (66%). The rates of decompression in patients who underwent ACDF and ACCF without laminectomy were 46.8% and 58.6%, respectively. Among these patients, performing a laminectomy increased the rate of decompression (72% and 73.1% of patients, respectively). Twenty-five of 29 (86.2%) patients who underwent a stand-alone laminectomy were found to be successfully decompressed. The rates of decompression among patients who underwent laminectomy at one, two, three, four, or five levels were 58.3%, 68%, 78%, 80%, and 100%, respectively (p < 0.001). In multi-variate logistic regression analysis, only laminectomy was significantly associated with successful decompression (odds ratio 4.85; 95% confidence interval 2.2-10.6; p < 0.001). In motor complete TSCI patients, performing a laminectomy significantly increased the rate of successful spinal cord decompression, independent of whether anterior surgery was performed.

Naloxone exacerbates memory impairments and depressive-like behavior after mild traumatic brain injury (mTBI) in mice with upregulated opioid system activity

The neuroprotective role of the endogenous opioid system in the pathophysiological sequelae of brain injury remains largely ambiguous. Noteworthy, almost no data is available on how its genetically determined activity influences the outcome of mild traumatic brain injury. Thus, the aim of our study was to examine the effect of opioid receptor blockage on cognitive impairments produced by mild traumatic brain injury in mice selectively bred for high (HA) and low (LA) swim-stress induced analgesia that show innate divergence in opioid system activity. Mild traumatic brain injury was induced with a weight-drop device on anaesthetized mice. Naloxone (5mg/kg) was intraperitoneally delivered twice a day for 7days to non-selectively block opioid receptors. Spatial memory performance and manifestations of depressive-like behavior were assessed using the Morris Water Maze and tail suspension tests, respectively. Mild traumatic brain injury resulted in a significant deterioration of spatial memory performance and severity of depressive-like behavior in the LA mouse line as opposed to HA mice. Opioid receptor blockage with naloxone unmasked cognitive deficits in HA mice but was without effect in the LA line. The results suggest a protective role of genetically predetermined enhanced opioid system activity in suppression of mild brain trauma-induced cognitive impairments. Mice selected for high and low swim stress-induced analgesia might therefore be a useful model to study the involvement of the opioid system in the pathophysiology and neurological outcome of traumatic brain injury.

ADVANCES IN THE USE OF STEM CELLS IN ORTHOPEDICS

Primordial cells or stem cells are multipotent undifferentiated cells with the capacity to originate any type of cell in the organism. They may have their origins in the blastocyst and thus are classified as embryonic, or tissues developed in fetuses, newborns or adults and thus are known as somatic stem cells. Bone marrow is one of the main locations for isolating primordial cells, and there are two lineages: hematopoietic and mesenchymal progenitor cells. There are several uses for these undifferentiated cells in orthopedics, going from cartilaginous lesions in osteoarthrosis, osteochondritis dissecans and patellar chondromalacia, to bone lesions like in pseudarthrosis or bone losses, or nerve lesions like in spinal cord trauma. Studying stem cells is probably the most promising field of study of all within medicine, and this is shortly going to revolutionize all medical specialties (both clinical and surgical) and thus provide solutions for diseases that today are difficult to deal with.

Naloxone added to bupivacaine or bupivacaine-fentanyl prolongs motor and sensory block during supraclavicular brachial plexus blockade: a randomized clinical trial

BACKGROUND

In this study, the effect of naloxone on duration of supraclavicular brachial plexus block was evaluated. It was hypothesized that naloxone can increase the duration of neural blockade.

METHODS

Sixty-eight patients scheduled for surgery under supraclavicular brachial plexus block were randomly assigned to receive 30 ml bupivacaine (Group C); 30 ml bupivacaine with 100 μg of fentanyl (Group F); 30 ml bupivacaine with 100 ng naloxone (Group N); or 30 ml bupivacaine with 100 μg of fentanyl and 100 ng naloxone (Group N + F). Sensory and motor blockade were recorded at 5, 15, and 30 min following the block, and every 10 min following the end of surgery. Duration of sensory and motor block was considered to be the time interval between the complete block and the first postoperative pain and complete recovery of motor functions.

RESULTS

Sensory and motor onset times were the same in all groups. The duration of sensory and motor block in Group C (11.3 ± 1.7 h and 4.56 ± 1.0 h) and Group F (12.8 ± 3.3 h and 5.1 ± 2.0 h) were less than in the other groups (18.1 ± 2.2 h and 6.18 ± 1.0 h in Group N, and 15.8 ± 2.9 h and 6.53 ± 1.1 h in Group N + F, P < 0.0001).

CONCLUSION

Addition of naloxone to bupivacaine in supraclavicular brachial plexus block prolonged the duration of the neural blockade.

Perfusion imaging of spinal cord contusion: injury-induced blockade and partial reversal by β2-agonist treatment in rats

OBJECT

Traumatic injury to the spinal cord results in considerable delayed tissue loss. The authors investigated the extent to which ischemia occurs following contusion-induced spinal cord injury and whether ischemia exacerbates tissue damage that leads to the loss of locomotor function. They also determined if ischemia is reversed with β2-adrenoceptor agonist treatment, which has been established to be neuroprotective following contusion injury.

METHODS

The extent and role of circulation loss in spinal cord injury was determined in an established experimental model of contusion injury. The spinal cord dura mater of Wistar rats was exposed by performing a laminectomy at T-8 to T-11. Laser Doppler perfusion imaging was then used to measure microcirculation in the exposed spinal cord. After imaging, a moderately severe contusion injury was produced using a weight-drop device unto the exposed dura at T-10. Perfusion imaging was again performed, scans were quantitated, and integrated intensities were compared.

RESULTS

Postinjury imaging revealed an 18%-27% reduction in perfusion in regions rostral and caudal to the injury site, and a 68% reduction was observed at the contusion epicenter. These perfusion losses persisted for at least 48 hours. At 24 hours after injury, some rats were intraperitoneally injected with 2 mg/kg of the β2-adrenoceptor agonist clenbuterol, which has been shown to promote the partial recovery of locomotor function and spare spinal cord tissue when administered within 2 days after contusion injury. Clenbuterol injection caused a gradual increase in perfusion, which was detectable at 30 minutes postinjection and continued over time, resulting in an 127% overall increase in perfusion at the epicenter 24 hours after treatment.

CONCLUSIONS

These results suggest that the occurrence of chronic perfusion loss after contusion contributes to delayed damage and tissue loss. In contrast, β2-adrenoceptor agonist treatment may exert neuroprotection by restoring perfusion, thereby preventing ischemic neurodegeneration. The ability of laser Doppler imaging to measure the loss of perfusion and its restoration upon treatment suggests that it may have clinical utility in the assessment and treatment of spinal cord injury.

From basics to clinical: a comprehensive review on spinal cord injury

Spinal cord injury (SCI) is a devastating neurological disorder that affects thousands of individuals each year. Over the past decades an enormous progress has been made in our understanding of the molecular and cellular events generated by SCI, providing insights into crucial mechanisms that contribute to tissue damage and regenerative failure of injured neurons. Current treatment options for SCI include the use of high dose methylprednisolone, surgical interventions to stabilize and decompress the spinal cord, and rehabilitative care. Nonetheless, SCI is still a harmful condition for which there is yet no cure. Cellular, molecular, rehabilitative training and combinatorial therapies have shown promising results in animal models. Nevertheless, work remains to be done to ascertain whether any of these therapies can safely improve patient's condition after human SCI. This review provides an extensive overview of SCI research, as well as its clinical component. It starts covering areas from physiology and anatomy of the spinal cord, neuropathology of the SCI, current clinical options, neuronal plasticity after SCI, animal models and techniques to assess recovery, focusing the subsequent discussion on a variety of promising neuroprotective, cell-based and combinatorial therapeutic approaches that have recently moved, or are close, to clinical testing.

Advances in the management of spinal cord and spinal column injuries

Spinal cord injury (SCI) is a significant public problem, with recent data suggesting that over 1 million people in the U.S.A. alone are affected by paralysis resulting from SCI. Recent advances in prehospital care have improved survival as well as reduced incidence and severity of SCI following spine trauma. Furthermore, increased understanding of the secondary mechanisms of injury following SCI has provided improvements in critical care and acute management in patients suffering from SCI, thus limiting morbidity following injury. In addition, improved technology and biomechanical understanding of the mechanisms of spine trauma have allowed further advances in available techniques for spinal decompression and stabilization. In this chapter we review the most recent data and salient literature regarding SCI and address current controversies, including the use of pharmacological adjuncts in the setting of acute SCI. We will also attempt to provide a reader with basic understanding of the classifications of SCI and spinal column injury. Finally, we review advances in spinal column stabilization including improvements in instrumented fusion and minimally invasive surgery.

Kinin receptor antagonists as potential neuroprotective agents in central nervous system injury

Injury to the central nervous system initiates complex physiological, cellular and molecular processes that can result in neuronal cell death. Of interest to this review is the activation of the kinin family of neuropeptides, in particular bradykinin and substance P. These neuropeptides are known to have a potent pro-inflammatory role and can initiate neurogenic inflammation resulting in vasodilation, plasma extravasation and the subsequent development of edema. As inflammation and edema play an integral role in the progressive secondary injury that causes neurological deficits, this review critically examines kinin receptor antagonists as a potential neuroprotective intervention for acute brain injury, and more specifically, traumatic brain and spinal cord injury and stroke.

Effects of methylprednisolone and ganglioside GM-1 on a spinal lesion: a functional analysis

OBJECTIVES

The pharmacological effects of methylprednisolone (MP) and ganglioside GM-1 on spinal injuries have been thoroughly investigated, but only a few studies have evaluated the interaction between these two drugs.

METHODS

Twenty-four Wistar rats were subjected to contusive injury of the spinal cord produced by the NYU system. These animals were divided into four groups: group I was injected with MP; group II was injected with GM-1; group III was injected with MP together with GM-1; and group control received physiological serum. The animals were evaluated with regard to their recovery of locomotive function by means of the BBB test on the second, seventh and fourteenth days after receiving the contusive injury to the spinal cord. They were sacrificed on the fourteenth day.

RESULTS

This study demonstrated that the MP and GM-1 groups presented functional results that were better than those of the control group, although the enhanced recovery of group II (GM-1) relative to the control group was not statistically significant (p>0.05). The most notable recovery of locomotive function was observed in the group that received MP alone (p<0.05). The group that received MP together with GM-1 presented results that were better than those of the control group (p<0.05).

CONCLUSION

Administration of methylprednisolone alone or with GM-1 was shown to be effective for recovery of locomotive function. Combined administration of these drugs resulted in better outcomes than administration of methylprednisolone alone.

[Prehospital management of spinal cord injuries]

In both the United States and Europe about 10,000 patients suffer from spinal cord injury (SCI) each year and 20% die before being admitted to hospital. Prehospital management of SCI is very important since 25% of SCI damage may occur after the initial event. Emergency treatment includes examination of the patient, spinal immobilization, careful airway management, cardiovascular stabilization (maintenance of mean arterial blood pressure above 90 mmHg) and glucose levels within the normal range. From an evidence-based point of view, it is still not known whether additional specific therapy is useful and studies have not convincingly demonstrated that methylprednisolone (MPS) or other substances have clinically important benefits. Recently published statements from the US do not support the therapeutic use of MPS in patients suffering from SCI in the prehospital setting. Moreover, it is not known whether hypothermia or any other pharmacological interventions have beneficial effects. Networks for clinical studies in SCI patients should be established as a basic requirement for further improvement in outcome in these patients.

Damage control surgery for spine trauma

The concept of "damage control" surgery was originally developed for massive abdominal trauma and also successfully applied to the management of lone bone injuries. More recently this has been extended to severely injured patients with spine injuries. This paper provided an overview of how damage control principles can be applied to multitrauma patients with spine injuries, to patients with isolated spine injuries and to spine injuries with and without neurology. The role of neuroimaging in acute spine trauma and controversies in the pharmaceutical approach to spine injuries are discussed. Additional prospective controlled trials are required to delineate the role and timing of damage control surgery in acute spine injury. With improved neuroimaging early spinal damage control surgery will be formally established in the management of spine trauma.

Evaluation of time-dependent spread of tissue damage in experimental spinal cord injury by killed-end evoked potential: effect of high-dose methylprednisolone

OBJECT

Histopathological studies on spinal cord injury (SCI) have demonstrated time-dependent spread of tissue damage during the initial several hours postinjury. When the long tract within the spinal cord is stimulated, a large monophasic positivity occurs at the injury site. This type of potential, termed the killed-end evoked potential (KEEP), indicates that a nerve impulse approaches but does not pass beyond the injury site. The authors tested the hypothesis that the damage spread can be evaluated as a progressive shift of the KEEP on a real-time basis. The effect of high-dose methylprednisolone sodium succinate (MPSS) on the spread of tissue damage was also examined by this methodology.

METHODS

The KEEP was recorded using an electrode array placed on the spinal cord at the T-10 level in cats. This electrode array consisted of multiple 0.2-mm-diameter electrodes, each separated by 0.5 mm. Spinal cord injury was induced using a vascular clip (65 g pinching pressure for 30 seconds). The midline posterior surface of the spinal cord was stimulated bipolarly at the C-7 level by applying a single pulse at supramaximal intensity. During the initial period of 6 hours postinjury, the localization of the largest KEEP shifted progressively up to 2.5 mm rostral from the injury site. The amplitude of the KEEP recorded at the injury site decreased to 55 to 70% and became slightly shortened in latency as the localization of the largest KEEP shifted rostrally. These findings imply that the injury site KEEP represents the volume-conducted potential of the largest KEEP at the site of the conduction block. It moved away from the injury site in association with the damage spread, and this was confirmed histopathologically. A decrease in amplitude of KEEP at the injury site appeared to be the most sensitive measure of the damage spread, because the amplitude of the volume-conducted KEEP is inversely proportional to the square of the distance between the recording site and site of conduction block. Administered immediately after SCI, MPSS clearly inhibited these events, especially within 30 minutes postinjury.

CONCLUSIONS

The KEEP enables sequential evaluation to be made of the time-dependent spread of tissue damage in SCI in the same animal. It is, therefore, useful for detecting the effect of therapeutic interventions and for determining the therapeutic time window. The efficiency of MPSS to inhibit the spread of damaged tissue appeared to be maximized when it was administered within the initial 30-minute period postinjury.

Spinal cord contusion models

Most human spinal cord injuries involve contusions of the spinal cord. Many investigators have long used weight-drop contusion animal models to study the pathophysiology and genetic responses of spinal cord injury. All spinal cord injury therapies tested to date in clinical trial were validated in such models. In recent years, the trend has been towards use of rats for spinal cord injury studies. The MASCIS Impactor is a well-standardized rat spinal cord contusion model that produces very consistent graded spinal cord damage that linearly predicts 24-h lesion volumes, 6-week white matter sparing, and locomotor recovery in rats. All aspects of the model, including anesthesia for male and female rats, age rather than body weight criteria, and arterial blood gases were empirically selected to enhance the consistency of injury.

Current developments in spinal cord injury research

BACKGROUND CONTEXT

Recent advances in neuroscience have opened the door for hope toward prevention and cure of the devastating effects of spinal cord injury (SCI).

PURPOSE

To highlight the current understanding of traumatic SCI mechanisms, provide information regarding state-of-the-art care for the acute spinal cord-injured patient, and explore future treatments aimed at neural preservation and reconstruction.

STUDY DESIGN/SETTING

A selective overview of the literature pertaining to the neuropathophysiology of traumatic SCI is provided with an emphasis on pharmacotherapies and posttraumatic experimental strategies aimed at improved neuropreservation and late neuroregenerative repair.

METHODS

One hundred fifty-four peer-reviewed basic science and clinical articles pertaining to SCI were reviewed. Articles cited were chosen based on the relative merits and contribution to the current understanding of SCI neuropathophysiology, neuroregeneration, and clinical SCI treatment patterns.

RESULTS

A better understanding of the pathophysiology and early treatment for the spinal cord-injured patient has led to a continued decrease in mortality, decreased acute hospitalization and complication rates, and more rapid rehabilitation and re-entry into society. Progressive neural injury results from a combination of secondary injury mechanisms, including ischemia, biochemical alterations, apoptosis, excitotoxicity, calpain proteases, neurotransmitter accumulation, lipid peroxidation/free radical injury, and inflammatory responses. Experimental studies suggest that the final posttraumatic neurologic deficit is not only a result of the initial impaction forces but rather a combination of these forces and secondary time-dependent events that follow shortly after the initial impact.

CONCLUSIONS

Experimental studies continue to provide a better understanding of the complex interaction of pathophysiologic events after traumatic SCI. Future approaches will involve strategies aimed at blocking the multiple mechanisms of progressive central nervous system injury and promoting neuroregeneration.

Evidence that nitric oxide- and opioid-containing interneurons innervate vessels in the dorsal horn of the spinal cord of rats

In the dorsal horn of the spinal cord, activation of small fibre nociceptive afferents leads to the release of nitric oxide and enkephalins by interneurons. In this work we encountered unexpected relationships among local spinal cord dorsal horn blood flow, specific forms of afferent input, nitric oxide and intrinsic opioids. Selective rises in rat lumbar dorsal cord blood flow using laser Doppler flowmetry and microelectrode hydrogen clearance polarography were generated by ipsilateral, 'nociceptive' low (3 Hz) frequency stimulation of sciatic afferents. Inhibitors of nitric oxide synthase (NOS) prevented rises in flow during stimulation without influencing baseline flow. Ipsilateral hindpaw intradermal injection of capsaicin, a nociceptive activator, also generated large rises in flow sensitive to NOS inhibition. During NOS blockade or morphine administration there were unexpected acute declines in the dorsal cord blood flow strictly confined to low frequency stimulation epochs. This acute vasoconstrictive effect was prevented by administration of an opioid receptor antagonist. Using immunohistochemistry, terminals apparently innervating dorsal spinal cord blood vessels were labelled with antibodies against neuronal NOS and met-enkephalin. We conclude that local nitric oxide and opioids, probably from interneurons, have competitive actions on dorsal horn microvessels once interneurons are activated during a nociceptive barrage. Collateral innervation of blood vessels may explain this property.

Vascular Events After Spinal Cord Injury: Contribution to Secondary Pathogenesis

Traumatic spinal cord injury results in the disruption of neural and vascular structures (primary injury) and is characterized by an evolution of secondary pathogenic events that collectively define the extent of functional recovery. This article reviews the vascular responses to spinal cord injury, focusing on both early and delayed events, including intraparenchymal hemorrhage, inflammation, disruption of the blood-spinal cord barrier, and angiogenesis. These vascular-related events not only influence the evolution of secondary tissue damage but also define an environment that fosters neural plasticity in the chronically injured spinal cord.

Promising pharmacological agents in the management of acute spinal cord injury

The search for a pharmacologic treatment of acute spinal cord injury (SCI) dates back to the 1960s. It was not until 1990 that the pharmacologic agent methylprednisolone demonstrated improved outcomes in humans. Methylprednisolone has shown superiority to placebo in humans in two large, multicenter trials, and is the standard of care thus far. Other potentially useful agents include tirilazad, ganglioside (GM-1), and naloxone. Additional studies are needed for these agents to determine the optimal dose and timing of administration.

Pathogenesis and pharmacological strategies for mitigating secondary damage in acute spinal cord injury

OBJECTIVE

Experimental models and clinical observations of acute spinal cord injury (SCI) support the concepts of primary and secondary injury, in which the initial mechanical insult is succeeded by a series of deleterious events that promote progressive tissue damage and ischemia. Whereas the primary injury is fated by the circumstances of the trauma, the outcome of the secondary injury may be amenable to therapeutic modulation. This article reviews the pathogenetic determinants of these two phases of injury and summarizes the pharmacological manipulations that may restore neurological function after SCI.

METHODS

Experimental models of SCI and their inherent limitations in simulating human SCI are surveyed. The pathogenesis of primary and secondary injury, as well as the theoretical bases of neurological recovery, are examined in detail. The effects of glucocorticoids, lazeroids, gangliosides, opiate antagonists, calcium channel blockers, glutamate receptor antagonists, antioxidants, free radical scavengers, and other pharmacological agents in both animal models and human trials are summarized. Practical limitations to inducing neural regeneration are also addressed.

RESULTS

The molecular events that mediate the pathogenesis of SCI are logical targets for pharmacological manipulation and include glutamate accumulation, aberrant calcium fluxes, free radical formation, lipid peroxidation, and generation of arachidonic acid metabolites. Enhancement of neural regeneration and plasticity comprise other possible strategies.

CONCLUSION

Pharmacological agents must be given within a narrow window of opportunity to be effective. Although many therapeutic agents show potential promise in animal models, only methylprednisolone has been shown in large, randomized, double-blinded human studies to enhance the functional recovery of neural elements after acute SCI. Future therapy is likely to involve various combinations of these agents.

Inhibitory mechanisms of naloxone on human platelets

1. In the present study, naloxone was tested for its antiplatelet activities in human platelet-rich plasma (PRP). In human PRP, naloxone (0.1-0.5 mmol/L) inhibited aggregation stimulated by a variety of agonists (i.e. collagen, adenosine diphosphate (ADP), U46619 and adrenaline). 2. Naloxone (0.1-0.5 mmol/L) did not significantly affect cyclic adenosine monophosphate and cGMP levels in human washed platelets, whereas naloxone (0.5 mmol/L) significantly inhibited thromboxane B2 formation stimulated by collagen (5 micrograms/mL) in human washed platelets. 3. Naloxone (0.5 mmol/L) significantly inhibited [3H]-inositol monophosphate formation of [3H]-myoinositol-loaded platelets stimulated by collagen and U46619. Moreover, naloxone did not influence the binding of 125I-triflavin to platelet membranes. Triflavin is an Arg-Gly-Asp-containing specific fibrinogen receptor antagonist. 4. Addition of naloxone (0.5 mmol/L) to platelet preparations tagged with diphenylhexatriene (DPH) resulted in a considerable decrease in relative fluorescence intensity. 5. It is suggested that the anti-platelet effects of naloxone may be caused, at least partly, by the induction of conformational changes in the platelet membrane initially, followed by the inhibition of thromboxane A2 formation and phosphoinositide breakdown of platelets stimulated by agonists.

Anoxic injury in the rat spinal cord: pharmacological evidence for multiple steps in Ca(2+)-dependent injury of the dorsal columns

To examine anoxic injury in spinal cord white matter, we studied axonal conduction in the dorsal columns during and following a standard 60 min anoxic insult at 36 degrees C. Perfusion of the spinal cord in 0-Ca2+ Ringer solution resulted in significantly improved recovery of the compound action potential. Similarly, removal of Na+ from the perfusate resulted in significantly improved recovery of conduction in dorsal column axons. Exposure of the anoxic spinal cord to the Na+ channel blocker tetrodotoxin (TTX), the Na-Ca exchange blockers benzamil and bepridil, Na(+)-H+ exchange blockers amiloride and harmaline, and perfusion in Ringer solution with pH adjusted to 6.4, all resulted in improved recovery. The tertiary anesthetics procaine and lidocaine, as well as phenytoin and carbamazepine, also resulted in improved recovery of compound action potential amplitude after 60 min of anoxia. These results demonstrate that a significant component of irreversible loss of conduction, following anoxic injury of the dorsal columns, is Ca(2+)-dependent. Moreover, these results demonstrate that TTX-inhibitable Na+ channels participate in the pathophysiology of anoxic injury in spinal cord white matter, and indicate that reverse Na-Ca exchange provides a route for at least part of the damaging influx of Ca2+ into an intracellular compartment in anoxic spinal cord white matter. Our results also suggest that extracellular acidosis may have a protective effect on anoxic spinal cord white matter, and support the hypothesis that anoxic injury of spinal cord white matter may involve the Na(+)-H+ exchanger.

Superoxide radicals play important roles in the pathogenesis of spinal cord injury

To investigated a possible role of superoxide dismutase (SOD) in the pathogenesis of spinal cord injury (SCI), the change in the circulatory status in an experimental SCI model of rats was examined. The blood pressure (BP) of the SCI group decreased markedly by compression or head-up-tilt (60 degrees). The extent of the BP decrease was diminished by the administration of along acting SOD (SM-SOD) prior to injury. Compression, tilting and the administration of SM-SOD increased the sensitivity of resistant arteries to acetylcholine. SM-SOD treated rats had a significantly lower mortality than was found in untreated rats. These findings indicate that superoxide radicals may contribute to the pathogenesis of spinal cord injury and orthostatic hypotension caused by SCI.

Effects of GABAergic drugs on the recovery of reflex potentials after spinal cord ischemia in cats

Effects of GABAergic drugs on the recovery of reflex potentials after spinal cord ischemia were examined in anesthethized spinal cats. Monosynaptic reflex (MSR) and polysynaptic reflex (PSR) potentials, elicited by electrical stimulation of the tibial nerve in spinal cats, were recorded from the lumbo-sacral ventral root. The spinal reflex potentials were immediately depressed by occlusion of the thoracic aorta and the bilateral mammary arteries for 10 min. The potentials recovered gradually to the control level within 90 min after reperfusion. Pretreatment with bicuculline (0.3 mg/kg, i.v.), a GABA antagonist, or semicarbazide (200 mg/kg, i.v.), an inhibitor of GABA synthesis, accelerated the recovery of PSR potentials after the removal of the arterial occlusion. In contrast, pretreatment with aminooxyacetic acid (10 mg/kg, i.v.), an inhibitor of GABA degradation, retarded the recovery of PSR potentials, and this effect was overcome by the addition of the opioid antagonist naloxone (10 mg/kg, i.v.). These results suggest that the GABAergic system retards the recovery of PSR potentials after a brief spinal cord ischemia, which can be antagonized by naloxone.

Effects of naloxone on sodium- and potassium-activated and magnesium-dependent adenosine-5'-triphosphatase activity and lipid peroxidation and early ultrastructural findings after experimental spinal cord injury

Endorphins have been implicated in the pathophysiology of spinal cord injury. The effect of naloxone on the sodium- and potassium-activated and magnesium-dependent adenosine-5'-triphosphatase (Na(+)-K+/Mg+2 ATPase, EC.3.6.1.3.) activity, lipid peroxidation, and early ultrastructural findings were studied in rats at the early stage of spinal cord injury, produced with an aneurysm clip on the T2-T7 segments. The rats were divided into four groups. The 10 rats in Group I, which had no injury and received no medication, were used for determining Na(+)-K+/Mg+2 ATPase activity, the extent of lipid peroxidation (by measuring the level of thiobarbituric acid-reactive substances as malondialdehyde), and normal ultrastructural findings. On the 15 rats in Group II, without spinal cord injury, only laminectomy was performed to determine the effect of surgery on the biochemical indices and findings. In the 15 rats in Group III, physiological saline was administered intraperitoneally in an amount equivalent to that of the naloxone administered immediately after spinal cord injury. In the 15 rats in Group IV, 0.5 mg of naloxone was administered intraperitoneally as a single dose immediately after injury and again 60 minutes after injury. The Na(+)-K+/Mg+2 ATPase activity was promptly reduced after spinal cord injury and remained in a lower level than the levels of Groups I and II during 120 minutes after injury. Naloxone treatment, immediately after trauma, attenuated the inactivation of Na(+)-K+/Mg+2 ATPase. On the other hand, there was a significant difference in the malondialdehyde content between animals in Groups I and III. Naloxone treatment reduced the malondialdehyde content in Group IV.(ABSTRACT TRUNCATED AT 250 WORDS)

Opiate antagonists for the treatment of schizophrenia

Numerous studies suggest that opiate antagonists may have antipsychotic properties. A review of the literature describing the use of naloxone to treat schizophrenic patients has shown mixed results. The three studies on naltrexone have found no benefit in controlling auditory hallucinations. We present a synopsis of these studies.

Modulation of substance P-ergic system in the rat spinal cord by an opioid antagonist

Substance P- and opioid peptide-immunoreactive nerve terminals functionally interact in the spinal cord as two opposing systems in the regulation of the nociceptive pathway. In order to determine how SP-ergic system adapts to chronic opioid receptor blockade, the effects of naltrexone on SP level, SP receptor and the second messenger system coupled to the SP receptor were examined in the rat spinal cord. Male Sprague-Dawley rats were treated with naltrexone or vehicle for seven days by constant minipump infusion. Animals were sacrificed on day 8, spinal cords rapidly removed, segmentally sectioned and used to determine SP and inositol 1,4,5-trisphosphate [ins(1,4,5)P3] tissue contents, and to examine the regulation of their respective receptors in in vitro receptor binding assays. Following chronic naltrexone treatment, SP content in the lumbosacral segment of the spinal cord was increased by 53% over matched control values. The binding capacity (Bmax) of SP receptors, determined using [125I]BHSP, in lumbosacral synaptosomal membranes was significantly increased by 92%, but the binding affinity (Kd) remained unchanged. In addition, the concentration of [Sar9, Met(O2)11]SP, an NK-1 receptor-specific agonist, required to inhibit half of [125I]BHSP binding (IC50) in lumbosacral synaptosomal membranes was significantly decreased, but the IC50s for SP, the endogenous ligand for the SP receptor, and [Pro7]NK B, an NK-3 receptor-specific agonist, were unaltered by chronic blockade of opioid receptors. The data suggest that although naltrexone does not directly interact with tachykinin receptors, it acts indirectly on SP-ergic neurons to cause a change in the apparent affinity of NK-1 receptor (as reflected by a change in IC50 value). Formation of cellular ins(1,4,5)P3 in the lumbosacral cord, quantified by a highly sensitive and selective radioreceptor assay, was significantly increased by 34% relative to matched controls. A time course study indicated that increases in ins(1,4,5)P3 contents over the time studied corresponded qualitatively with increases in SP level in the lumbosacral cord. With [3H]ins(1,4,5)P3 as a ligand, Scatchard analyses of the concentration dependent saturation curves showed that the density of intracellular ins(1,4,5)P3 receptors was also increased by 119%, with no change in binding affinity. The data suggest that ins(1,4,5)P3 formation, possibly coupled to functional SP receptor activation, and ins(1,4,5)P3 receptors, which mediate ins(1,4,5)P3-induced alterations in intracellular Ca2+ flux, are increased in the lumbosacral cord by chronic blockade of opioid receptors. Taken together, the data support the concept of a role for endogenous opioids in the regulation of SP receptor activity in the spinal cord.

Effects of timing of methylprednisolone or naloxone administration on recovery of segmental and long-tract neurological function in NASCIS 2

Previous analyses of the National Acute Spinal Cord Injury Study (NASCIS) have not distinguished recovery of segmental function at the injury level from recovery of the long spinal tracts. Recovery at the injury level could be of considerable clinical significance, but long-tract recovery is the ultimate therapeutic goal. This analysis demonstrates that the greatest proportion of all neurological recovery and of recovery due to treatment with very high doses of methylprednisolone within 8 hours of injury occurs below the lesion. Methylprednisolone treatment administered early following injury has been found to improve recovery below the lesion in patients initially diagnosed as having complete or incomplete injuries; it also leads to greater (but still relatively small) improvement in the injury level. The analysis indicates that delayed treatment with methylprednisolone is associated with decreased neurological recovery. Naloxone administration also improved neurological function below the lesion in patients with incomplete injuries; these results support further experimental work with this drug. This observation of differential neurological response within a narrow treatment window has important implications for both experimental studies and clinical management. Early clinical management with high-dose methylprednisolone is supported by this analysis.

Spinal cord blood flow and evoked potential responses after treatment with nimodipine or methylprednisolone in spinal cord-injured rats

This study examined the effect of nimodipine or methylprednisolone on spinal cord blood flow (SCBF) and electrophysiological function after spinal cord injury in rats. Three groups of male rats (n = 10 per group) were injured by compression of the cord at T1 for 1 minute with a 52-g clip. The hydrogen clearance technique was used to measure SCBF at the T1 segment. Motor and somatosensory evoked potentials were recorded. SCBF and evoked potentials were measured before injury and again at approximately 1 and 2.5 hours after injury. The methylprednisolone group received a bolus of methylprednisolone (30 mg/kg) at 5 minutes after injury and then at 15 minutes after injury, the group received an infusion of methylprednisolone at 5.4 mg/kg per hour. The nimodipine group received placebo at 5 minutes and then received an infusion of nimodipine at 0.02 mg/kg per hour at 15 minutes. The placebo group received placebo at both times. Physiological parameters were closely monitored and maintained within the normal range. Albumin was administered after injury to maintain mean arterial blood pressure at or above 80 mm Hg. The infusions were continued for approximately 3 hours after spinal cord injury. SCBF was not significantly different between the experimental groups at either 1 or 2.5 hours postinjury (P = 0.16 and 0.71, respectively), and evoked potential responses did not return in any rat at any time after injury. Thus, this experiment failed to demonstrate an improvement in SCBF or electrophysiological function with either drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Antagonists of excitatory amino acids and endogenous opioid peptides in the treatment of experimental central nervous system injury

Trauma to the central nervous system can lead to primary injuries occurring at the time of impact as well as secondary or delayed injury processes that can result from cellular hypoxia, oligemia/ischemia, edema and swelling, and intracranial hypertension that are manifested over a period of hours to weeks after the initial event. Although the mechanisms underlying delayed tissue injury are poorly understood, they appear to be associated with endogenous neurochemical changes resulting from traumatic nervous system injury. These neurochemical changes may include excessive neurotransmitter release, deregulation of ion homeostasis, and the synthesis, release, or activation of various "autodestructive" neurochemical factors. Experimental studies over the past decade indicate that these alterations mediate important components of the neurochemical cascade leading to central nervous system injury. Furthermore, pharmacologic manipulations of these neurochemical changes have been reported to attenuate secondary central nervous system damage, ameliorate neuronal death, and promote functional recovery after central nervous system injury. This article focuses on the role of excitatory amino acid neurotransmitters, endogenous opioid peptides, and magnesium in the pathophysiology of central nervous system injury and on the therapeutic manipulation of these systems to improve functional outcome after central nervous system injury.

Molecular dissection of the myelinated axon

The membrane of the myelinated axon expresses a rich repertoire of physiologically active molecules: (1) Voltage-sensitive NA+ channels are clustered at high density (approximately 1,000/microns 2) in the nodal axon membrane and are present at lower density (< 25/microns 2) in the internodal axon membrane under the myelin. Na+ channels are also present within Schwann cell processes (in peripheral nerve) and perinodal astrocyte processes (in the central nervous system) which contact the Na+ channel-rich axon membrane at the node. In some demyelinated fibers, the bared (formerly internodal) axon membrane reorganizes and expresses a higher-than-normal Na+ channel density, providing a basis for restoration of conduction. The presence of glial cell processes, adjacent to foci of Na+ channels in immature and demyelinated axons, suggests that glial cells participate in the clustering of Na+ channels in the axon membrane. (2) "Fast" K+ channels, sensitive to 4-aminopyridine, are present in the paranodal or internodal axon membrane under the myelin; these channels may function to prevent reexcitation following action potentials, or participate in the generation of an internodal resting potential. (3) "Slow" K+ channels, sensitive to tetraethylammonium, are present in the nodal axon membrane and, in lower densities, in the internodal axon membrane; their activation produces a hyperpolarizing afterpotential which modulates repetitive firing. (4) The "inward rectifier" is activated by hyperpolarization. This channel is permeable to both Na+ and K+ ions and may modulate axonal excitability or participate in ionic reuptake following activity. (5) Na+/K(+)-ATPase and (6) Ca(2+)-ATPase are also present in the axon membrane and function to maintain transmembrane gradients of Na+, K+, and Ca2+. (7) A specialized antiporter molecule, the Na+/Ca2+ exchanger, is present in myelinated axons within central nervous system white matter. Following anoxia, the Na+/Ca2+ exchanger mediates an influx of Ca2+ which damages the axon. The molecular organization of the myelinated axon has important pathophysiological implications. Blockade of fast K+ channels and Na+/K(+)-ATPase improves action potential conduction in some demyelinated axons, and block of the Na+/Ca2+ exchanger protects white matter axons from anoxic injury. Modification of ion channels, pumps, and exchangers in myelinated fibers may thus provide an important therapeutic approach for a number of neurological disorders.

Early assessment of neurologic deficits in the fluid percussion model of brain injury

This study was designed to quantify the early neurologic effects of brain injury elicited by fluid percussion to the dura of cats. Propofol was used for surgical anesthesia because recovery in normal animals from an intravenous infusion was found to be nearly complete within 2 h of cessation and absolutely complete by 4 h. In addition, a cat coma scale (CCS) was developed that reflects normal (CCS, 14) to moribund (CCS, 3) behavior. The CCS values at 6 h were compared with the force of injury expressed in atmospheres (atm), maximum blood pressure change, and gross neuropathology to ascertain which parameter might best account for the behavior observed after brain injury. The results showed that decreasing neurologic scores correlated well with increasing atmospheres of injury (Pearson's r 0.71, p < 0.001) but not with the rise in systolic blood pressure caused by the trauma (n = 29). Coma scores did correlate with the cross sectional area of ponto-mesencephalic lesions (Pearson's r = 0.51, p < 0.01) and proved to be significantly different in animals grouped according to lesion size of less or more than 3 mm in length (t test, p < 0.01). Thus the CCS and the pharmacologic properties of propofol permit an early analysis of the neurologic status in the feline fluid percussion model of brain injury. These procedures could facilitate the evaluation of early biochemical changes that affect behavior and of therapies designed to ameliorate the deleterious effects of head injury.

Beneficial effect of the nonselective opiate antagonist naloxone hydrochloride and the thyrotropin-releasing hormone (TRH) analog YM-14673 on long-term neurobehavioral outcome following experimental brain injury in the rat

Neurobehavioral dysfunction following traumatic brain injury results, in part, from delayed biochemical changes initiated by the traumatic insult. Endogenous opioid peptides have been implicated as one type of neurochemical factor involved in the delayed pathological sequelae of central nervous system (CNS) injury, including brain trauma. Both opiate antagonists and thyrotropin-releasing hormone (TRH) and its analogs, which antagonize the physiologic effects of endogenous opioids, have been shown to improve cardiovascular, cerebrovascular, metabolic, and neurologic status following both traumatic and ischemic CNS injury. The present study evaluated the ability of the opiate antagonist naloxone hydrochloride to improve posttraumatic neurologic motor function following experimental fluid-percussion brain injury in the rat, and compared the therapeutic effectiveness of naloxone to the long-acting, centrally active TRH analog YM-14673. Thirty minutes following fluid-percussion brain injury of moderate severity, animals received an intravenous bolus of either naloxone (2.0 mg/kg with constant infusion of 1.7 mg/kg/h, n = 8), YM-14673 (1.0 mg/kg, n = 8), or saline (n = 8). Although naloxone caused a modest and nonsignificant increase in mean arterial blood pressure (MAP); YM-14673 significantly increased MAP within 5 min of administration (p < 0.05), an effect that continued up to 4 h postinjury. Postinjury administration of both naloxone and YM-14673 caused a significant improvement in neurobehavioral outcome which persisted up to 4 weeks postinjury. These results suggest that endogenous opioid peptides may be involved in the pathologic response to traumatic CNS injury and that pharmacotherapies directed at antagonizing opioid peptides may enhance neurobehavioral recovery after brain injury.

Novel pharmacologic therapies in the treatment of experimental traumatic brain injury: a review

Delayed or secondary neuronal damage following traumatic injury to the central nervous system (CNS) may result from pathologic changes in the brain's endogenous neurochemical systems. Although the precise mechanisms mediating secondary damage are poorly understood, posttraumatic neurochemical changes may include overactivation of neurotransmitter release or re-uptake, changes in presynaptic or postsynaptic receptor binding, or the pathologic release or synthesis of endogenous "autodestructive" factors. The identification and characterization of these factors and the timing of the neurochemical cascade after CNS injury provides a window of opportunity for treatment with pharmacologic agents that modify synthesis, release, receptor binding, or physiologic activity with subsequent attenuation of neuronal damage and improvement in outcome. Over the past decade, a number of studies have suggested that modification of postinjury events through pharmacologic intervention can promote functional recovery in both a variety of animal models and clinical CNS injury. This article summarizes recent work suggesting that pharmacologic manipulation of endogenous systems by such diverse pharmacologic agents as anticholinergics, excitatory amino acid antagonists, endogenous opioid antagonists, catecholamines, serotonin antagonists, modulators of arachidonic acid, antioxidants and free radical scavengers, steroid and lipid peroxidation inhibitors, platelet activating factor antagonists, anion exchange inhibitors, magnesium, gangliosides, and calcium channel antagonists may improve functional outcome after brain injury.

Histopathology of experimental spinal cord trauma. Comparison of treatment with TRH, naloxone, and dexamethasone

The results of treatment with thyrotropin-releasing hormone (TRH), naloxone and dexamethasone treatments albino rats with experimental spinal cord injury were compared. All the animals were made paraplegic by the application clip method of Rivlin and Tator. Treatment was administered i.p. as bolus injections in two doses, at 45 and 120 min after the injury. Animals were allocated randomly to four experimental groups: (1) TRH (0.6 mg per dose), (2) naloxone (0.8 mg per dose), (3) dexamethasone (0.6 mg per dose), and (4) control (saline). TRH-treated rats showed significantly better histopathological scores than either naloxone or dexamethasone-treated ones (Kruskal Wallis: 24.058 P less than 0.001).

Effects of naloxone and levallorphan on the spinal cord reflex potentials under the spinal ischemic condition in cats

The spinal reflex potentials elicited by electrical stimulation of the tibial nerve were recorded from the lumbo-sacral ventral root in spinal cats. When the thoracic aorta and the bilateral internal mammary arteries were occluded for 10 min, the potentials were completely depressed. Reappearance of these potentials could be observed at about 10 min after removal of the occlusion and they gradually recovered. Intravenous injection of naloxone (1 or 10 mg/kg) or levallorphan (0.1 mg/kg) together with removal of occlusion significantly promoted the recovery of the polysynaptic reflex potential. Morphine (5 mg/kg) showed no particular effect on the recovery of potentials. Furthermore, pretreatment with morphine (5 mg/kg) did not influence the effects of these opioid antagonists. These results suggest that naloxone and levallorphan may preserve or potentiate the interneuronal activities of the lumbo-sacral spinal cord under the ischemic condition and that the effects may not be mediated through morphine-like opioid receptors.

N-methyl-D-aspartate (NMDA) and opioid receptors mediate dynorphin-induced spinal cord injury: behavioral and histological studies

Both N-methyl-D-aspartate (NMDA) and opioid receptors have been implicated in the pathophysiology of traumatic spinal cord injury and dynorphin-induced paralysis. The present studies compared the effects of the non-competitive NMDA antagonist dextrorphan (Dex) and the kappa-selective opioid antagonist nor-binaltorphimine (nor-BNI) on the acute motor deficits and chronic neuropathological alterations caused by intrathecally administered dynorphin A-(1-17) (Dyn A). Infusion of Dyn A into the rat lower thoracic spinal subarachnoid space produced acute, reversible hindlimb paresis. Histological evaluations of spinal cord sections from these animals at 2 weeks post-infusion revealed ventral grey matter necrosis, neuronal loss and gliosis as well as axonal loss in adjacent white matter; however, there was minimal alteration in serotonin immunocytochemistry caudal to the injury zone. Dex or non-BNI pretreatment each significantly (P less than 0.05) reduced, and to a similar degree, the acute motor deficits and certain histological changes associated with Dyn A administration. These findings further support the hypothesis that dynorphin-induced spinal cord injury involves both NMDA receptors and opioid receptors.

Changes of neuropeptides and their receptors in experimental stroke gerbil brains

Eight kinds of neuropeptides and four kinds of neuropeptide receptors were examined in the right and left hemispheres of mongolian gerbils after unilateral carotid ligation-induced stroke and in normal controls. Five hours after ligation of the right common carotid artery, beta-endorphin concentration in the right hemisphere (ischemic side) of the stroke group was significantly increased compared with that in the contralateral hemisphere (non-ischemic side), but there were no differences between sides in other neuropeptides either with or without stroke. Furthermore, although there were no differences in [3H]naloxone binding, [3H]thyrotropin-releasing hormone binding or 125I-vasoactive intestinal polypeptide binding in the brain in this model of stroke, [3H]enkephalin binding was significantly lower on the ischemic side than on the non-ischemic side in the stroke group. These results suggest that increased activity in the beta-endorphinergic system in the brain might be partly caused by ischemic brain failure.