Role of N-methyl-D-aspartate receptor in acute spinal cord injury

On the therapeutic targets and pharmacological treatments for pain relief following spinal cord injury: A mechanistic review

Spinal cord injury (SCI) is globally considered as one of the most debilitating disorders, which interferes with daily activities and life of the affected patients. Despite many developments in related recognizing and treating procedures, post-SCI neuropathic pain (NP) is still a clinical challenge for clinicians with no distinct treatments. Accordingly, a comprehensive search was conducted in PubMed, Medline, Scopus, Web of Science, and national database (SID and Irandoc). The relevant articles regarding signaling pathways, therapeutic targets and pharmacotherapy of post-SCI pain were also reviewed. Data were collected with no time limitation until November 2020. The present study provides the findings on molecular mechanisms and therapeutic targets, as well as developing the critical signaling pathways to introduce novel neuroprotective treatments of post-SCI pain. From the pathophysiological mechanistic point of view, post-SCI inflammation activates the innate immune system, in which the immune cells elicit secondary injuries. So, targeting the critical signaling pathways for pain management in the SCI population has significant importance in providing new treatments. Indeed, several receptors, ion channels, excitatory neurotransmitters, enzymes, and key signaling pathways could be used as therapeutic targets, with a pivotal role of n-methyl-D-aspartate, gamma-aminobutyric acid, and inflammatory mediators. The current review focuses on conventional therapies, as well as crucial signaling pathways and promising therapeutic targets for post-SCI pain to provide new insights into the clinical treatment of post-SCI pain. The need to develop innovative delivery systems to treat SCI is also considered.

Uric acid released from poly(ε-caprolactone) fibers as a treatment platform for spinal cord injury

Spinal cord injury (SCI) is characterized by a primary mechanical phase of injury, resulting in physical tissue damage, and a secondary pathological phase, characterized by biochemical processes contributing to inflammation, neuronal death, and axonal demyelination. Glutamate-induced excitotoxicity (GIE), in which excess glutamate is released into synapses and overstimulates glutamate receptors, is a major event in secondary SCI. GIE leads to mitochondrial damage and dysfunction, release of reactive oxygen species (ROS), DNA damage, and cell death. There is no clinical treatment that targets GIE after SCI, and there is a need for therapeutic targets for secondary damage in patients. Uric acid (UA) acts as an antioxidant and scavenges free radicals, upregulates glutamate transporters on astrocytes, and preserves neuronal viability in in vitro and in vivo SCI models, making it a promising therapeutic candidate. However, development of a drug release platform that delivers UA locally to the injured region in a controlled manner is crucial, as high systemic UA concentrations can be detrimental. Here, we used the electrospinning technique to synthesize UA-containing poly(ɛ-caprolactone) fiber mats that are biodegradable, biocompatible, and have a tunable degradation rate. We optimized delivery of UA as a burst within 20 min from uncoated fibers and sustained release over 2 h with poly(ethylene glycol) diacrylate coating. We found that both of these fibers protected neurons and decreased ROS generation from GIE in organotypic spinal cord slice culture. Thus, fiber mats represent a promising therapeutic for UA release to treat patients who have suffered a SCI.

Dental pulp stem cells and their potential roles in central nervous system regeneration and repair

Functional recovery from injuries to the brain or spinal cord represents a major clinical challenge. The transplantation of stem cells, traditionally isolated from embryonic tissue, may help to reduce damage following such events and promote regeneration and repair through both direct cell replacement and neurotrophic mechanisms. However, the therapeutic potential of using embryonic stem/progenitor cells is significantly restricted by the availability of embryonic tissues and associated ethical issues. Populations of stem cells reside within the dental pulp, representing an alternative source of cells that can be isolated with minimal invasiveness, and thus should illicit fewer moral objections, as a replacement for embryonic/fetal-derived stem cells. Here we discuss the similarities between dental pulp stem cells (DPSCs) and the endogenous stem cells of the central nervous system (CNS) and their ability to differentiate into neuronal cell types. We also consider in vitro and in vivo studies demonstrating the ability of DPSCs to help protect against and repair neuronal damage, suggesting that dental pulp may provide a viable alternative source of stem cells for replacement therapy following CNS damage.

Pathology dynamics predict spinal cord injury therapeutic success

Secondary injury, the complex cascade of cellular events following spinal cord injury (SCI), is a major source of post-insult neuron death. Experimental work has focused on the details of individual factors or mechanisms that contribute to secondary injury, but little is known about the interactions among factors leading to the overall pathology dynamics that underlie its propagation. Prior hypotheses suggest that the pathology is dominated by interactions, with therapeutic success lying in combinations of neuroprotective treatments. In this study, we provide the first comprehensive, system-level characterization of the entire secondary injury process using a novel relational model methodology that aggregates the findings of approximately 250 experimental studies. Our quantitative examination of the overall pathology dynamics suggests that, while the pathology is initially dominated by "fire-like", rate-dependent interactions, it quickly switches to a "flood-like", accumulation-dependent process with contributing factors being largely independent. Our evaluation of approximately 20,000 potential single and combinatorial treatments indicates this flood-like pathology results in few highly influential factors at clinically realistic treatment time frames, with multi-factor treatments being merely additive rather than synergistic in reducing neuron death. Our findings give new fundamental insight into the understanding of the secondary injury pathology as a whole, provide direction for alternative therapeutic strategies, and suggest that ultimate success in treating SCI lies in the pursuit of pathology dynamics in addition to individually involved factors.

Estrogen attenuates glutamate-induced cell death by inhibiting Ca2+ influx through L-type voltage-gated Ca2+ channels

Estrogen-mediated neuroprotection is observed in neurodegenerative disease and neurotrauma models; however, determining a mechanism for these effects has been difficult. We propose that estrogen may limit cell death in the nervous system tissue by inhibiting increases in intracellular free Ca(2+). Here, we present data using VSC 4.1 cell line, a ventral spinal motoneuron and neuroblastoma hybrid cell line. Treatment with 1 mM glutamate for 24 h induced apoptosis. When cells were pre-treated with 100 nM 17beta-estradiol (estrogen) for 1 h and then co-treated with glutamate, apoptotic death was significantly attenuated. Estrogen also prevented glutamate-mediated changes in resting membrane potential and membrane capacitance. Treatment with either 17 alpha-estradiol or cell impermeable estrogen did not mimic the findings seen with estrogen. Glutamate treatment significantly increased both intracellular free Ca(2+) and the activities of downstream proteases such as calpain and caspase-3. Estrogen attenuated both the increases in intracellular free Ca(2+) and protease activities. In order to determine the pathway responsible for estrogen-mediated inhibition of these increases in intracellular free Ca(2+), cells were treated with several Ca(2+) entry inhibitors, but only the L-type Ca(2+) channel blocker nifedipine demonstrated cytoprotective effects comparable to estrogen. To expand these findings, cells were treated with the L-type Ca(2+) channel agonist FPL 64176, which increased both cell death and intracellular free Ca(2+), and estrogen inhibited both effects. From these observations, we conclude that estrogen limits glutamate-induced cell death in VSC 4.1 cells through effects on L-type Ca(2+) channels, inhibiting Ca(2+) influx as well as activation of the pro-apoptotic proteases calpain and caspase-3.

Interleukin-1beta: a bridge between inflammation and excitotoxicity?

Interleukin-1 (IL-1) is a proinflammatory cytokine released by many cell types that acts in both an autocrine and/or paracrine fashion. While IL-1 is best described as an important mediator of the peripheral immune response during infection and inflammation, increasing evidence implicates IL-1 signaling in the pathogenesis of several neurological disorders. The biochemical pathway(s) by which this cytokine contributes to brain injury remain(s) largely unidentified. Herein, we review the evidence that demonstrates the contribution of IL-1beta to the pathogenesis of both acute and chronic neurological disorders. Further, we highlight data that leads us to propose IL-1beta as the missing mechanistic link between a potential beneficial inflammatory response and detrimental glutamate excitotoxicity.

Spatiotemporal patterns of postsynaptic density (PSD)-95 expression after rat spinal cord injury

AIMS

Postsynaptic density (PSD)-95 is a scaffolding protein linking the N-methyl-D-aspartate receptor with neuronal nitric oxide synthase (nNOS), which contributes to many physiological and pathological actions. We here investigated whether PSD-95 was involved in the secondary response following spinal cord injury (SCI).

METHODS

Spinal cord contusion (SCC) and spinal cord transection (SCT) models at thoracic (T) segment 9 (T(9)) were established in adults rats. Real-time polymerase chain reaction, Western blot, immunohistochemistry and immunofluorescence were used to detect the temporal profile and spatial distribution of PSD-95 after SCI. The association between PSD-95 and nNOS in the injured cords was also assessed by coimmmunoprecipation and double immunofluorescent staining.

RESULTS

The mRNA and protein for PSD-95 expression were significantly increased at 2 h or 8 h, and then gradually declined to the baseline level, ultimately up-regulated again from 5 days to 7 days for its mRNA level and at 7 days or 14 days for its protein level after either SCC or SCT. PSD-95 immunoreactivity was found in neurones, oligodendrocytes and synaptic puncta of spinal cord tissues within 5 mm from the lesion site. Importantly, injury-induced expression of PSD-95 was colabelled by active caspase-3 (apoptotic marker), Tau-1 (the marker for pathological oligodendrocytes) and nNOS.

CONCLUSIONS

Accompanied by the spatio-temporal changes for PSD-95 expression, the association between PSD-95 and nNOS undergoes substantial alteration after SCI. These two molecules are likely to form a complex on apoptotic neurones and pathological oligodendrocytes, which may in turn be involved in the secondary response after SCI.

Serum albumin improves recovery from spinal cord injury

A neuroprotective factor is shown to be present in mammalian serum. This factor is identified by Western blotting to be serum albumin. The serum factor and albumin both protected cultured spinal cord neurons against the toxicity of glutamate. The inability of K252a, a blocker of the high affinity tyrosine kinase receptor for members of the nerve growth factor family, to block the neuroprotective effect of the serum factor established that the serum factor is not a member of the nerve growth factor family. Post-injury injection of albumin intravenously or into the site of injury immediately after injury both improved significantly locomotor function according to Basso-Beattie-Bresnahan assessment and spontaneous locomotor activity recorded with a photobeam activity system. Albumin has multiple mechanisms whereby it may be neuroprotective, and it is a potentially useful agent for treating neurotraumas.

Role of Prostacyclin in the Development of Compression Trauma-Induced Spinal Cord Injury in Rats

We investigated the role of prostacyclin (PGI(2)) in the development of compression trauma-induced spinal cord injury (SCI) in rats. When measured after induction of SCI, tissue levels of 6-keto-PGF(1), a stable PGI(2) metabolite, thromboxane B(2) (TXB(2)), a stable metabolite of thromboxane A(2), myeloperoxidase (MPO) activity, and tumor necrosis factor (TNF) in the injured spinal cord segment were significantly increased, peaking at 2, 3, and 4 h after induction of SCI, respectively. Subcutaneous administration of indomethacin (IM), a non-selective cyclooxygenase (COX) inhibitor, completely inhibited increases in tissue levels of 6-keto-PGF(1) and TXB(2), while administration of NS-398, a selective inhibitor of COX-2, did not affect these increases. Although pretreatment with IM enhanced increases in tissue levels of MPO, TNF, and TNF mRNA and exacerbated both motor disturbances and histological damage in the spinal cord of animals subjected to SCI, pretreatment with NS-398 had no effect on any of these findings. Both iloprost, a stable analog of PGI(2), and leukocyte depletion significantly reversed changes in various variables and exacerbation of motor disturbances induced by IM pretreatment in animals subjected to SCI. These observations strongly suggested that compression trauma-induced increase in PGI(2) production in spinal cord tissue might be mainly mediated by COX-1 and PGI(2) might play a critical role in reduction of motor disturbances following SCI by inhibiting neutrophil accumulation through inhibition of TNF production.

Contributions of cyclooxygenase-2 to neuroplasticity and neuropathology of the central nervous system

Cyclooxygenase (COX) enzymes, or prostaglandin-endoperoxide synthases (PTGS), are heme-containing bis-oxygenases that catalyze the first committed reaction in metabolism of arachidonic acid (AA) to the potent lipid mediators, prostanoids and thromboxanes. Two isozymes of COX enzymes (COX-1 and COX-2) have been identified to date. This review will focus specifically on the neurobiological and neuropathological consequences of AA metabolism via the COX-2 pathway and discuss the potential therapeutic benefit of COX-2 inhibition in the setting of neurological disease. However, given the controversy surrounding the use of COX-2 selective inhibitors with respect to cardiovascular health, it will be important to move beyond COX to identify which down-stream effectors are responsible for the deleterious and/or potentially protective effects of COX-2 activation in the setting of neurological disease. Important advances toward this goal are highlighted herein. Identification of unique effectors in AA metabolism could direct the development of new therapeutics holding significant promise for the prevention and treatment of neurological disorders.

Preventive effect of erythropoietin on spinal cord cell apoptosis following acute traumatic injury in rats

STUDY DESIGN

Using a rat spinal cord injury (SCI) model, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL), anti-active caspase-3 antibody staining, histological examination, and histochemical studies were used to examine the antiapoptotic effect of erythropoietin.

OBJECTIVE

To evaluate in detail the antiapoptotic effect of erythropoietin following SCI.

SUMMARY OF BACKGROUND DATA

Although some investigators have reported antiapoptotic effects of erythropoietin using the TUNEL method, it has not been determined whether erythropoietin can prevent both acute neuronal death and secondary injury. Therefore, we examined the temporal and spatial effects of erythropoietin using TUNEL and active caspase-3 following SCI.

METHODS

An in vitro study used a cerebrocortical culture in which the antiapoptotic effect of erythropoietin was examined after N-methyl-D-aspartate treatment. Using an in vivo study, rats with SCI received erythropoietin intraperitoneally, and were examined histologically and immunohistochemically with TUNEL, active caspase-3, and cell markers between 6 hours and 7 days after injury.

RESULTS

Cerebrocortical culture confirmed an antiapoptotic effect of erythropoietin. Erythropoietin treatment significantly decreased TUNEL-positive apoptotic neurons and oligodendrocytes as early as 6 hours after SCI in rats. This antiapoptotic effect was observed until 7 days after injury. In addition, erythropoietin treatment significantly decreased the number of active caspase-3 immunoreactive cells within the SCI. In the in vitro study, cerebrocortical culture confirmed an antiapoptotic effect of erythropoietin.

CONCLUSIONS

These findings suggest that exogenous erythropoietin decreases the number of apoptotic cells observed between the very early and subchronic stages following traumatic SCI.

Magnesium sulfate treatment decreases caspase-3 activity after experimental spinal cord injury in rats

BACKGROUND

Apoptosis has increasingly been considered as an important factor in secondary injury after spinal cord injury (SCI). Manifestation of apoptotic cell death process involves activation of the caspase-3 apoptotic cascade. The aim of the study was to demonstrate the effect of magnesium sulfate on caspase-3 activity and to compare its effectiveness with methylprednisolone after acute SCI.

METHODS

The rats were randomly and blindly allocated into 5 groups of 8 rats each. Spinal cord contusion injury was produced by the weight drop method. The control group consisted of non-injured rats. In the trauma group, no treatment was given, whereas 1 mL saline, 600 mg/kg magnesium sulfate, and 30 mg/kg methylprednisolone sodium succinate (MPSS) were administered in the vehicle and both treatment groups immediately after injury. Twenty-four hours after trauma, spinal cord samples were obtained, and tissue caspase-3 activity levels were examined. A 1-way analysis of variance and the post hoc test were used for statistical analysis.

RESULTS

The results showed that caspase-3 activity increased to statistically significantly higher levels in spinal cord after contusion injury than in the control group. Caspase-3 enzyme activity levels were significantly reduced in animals treated either with magnesium sulfate or MPSS.

CONCLUSIONS

We have shown that magnesium sulfate decreases caspase-3 activity in rat spinal cord subjected to contusion injury. Magnesium sulfate may have potential therapeutic benefits by reducing apoptotic tissue damage after SCI.

Protective use of N-methyl-D-aspartate receptor antagonists as a spinoplegia against excitatory amino acid neurotoxicity

OBJECTIVE

Paraplegia remains a serious complication of thoracic and thoracoabdominal aortic operations. To avoid this dreadful complication, N-methyl-D-aspartate (NMDA) receptor antagonists have been examined in the ischemic or excitotoxic neuronal injury model. In the present study, we evaluated the protective efficacy of NMDA receptor antagonists that were infused segmentally after aortic clamping, as a spinoplegia, to reduce aspartate neurotoxicity in the spinal cord.

METHODS

Infrarenal aortic isolation was performed in New Zealand white rabbits. Group A animals (n = 7) were pretreated with the segmental infusion of MK-801, a noncompetitive NMDA receptor antagonist, followed by segmental aspartate (50 mmol) infusion for 10 minutes. Group B animals (n = 6) received pretreatment with CGS19755, a competitive NMDA receptor antagonist, followed by the same aspartate infusion as group A. Group C animals (n = 7) received vehicle only, followed by aspartate infusion as a control group. In addition, group D animals (n = 6) were pretreated with MK-801 that was administrated intravenously 1 hour before aspartate infusion. Neurologic status was assessed at 12, 24, and 48 hours after operation by using the Tarlov score. The spinal cords were procured at 48 hours for histopathologic analysis to determine the extent of excitotoxic neuronal injury.

RESULTS

Most of the animals in groups A and D revealed full recovery or mild motor disturbance. Group B and C animals exhibited paraplegia or paraparesis with marked neuronal necrosis. In the Tarlov score at 48 hours, group A animals represented better neurologic function than group C (P < .01) and similar motor function to group D animals. Severe histopathologic change was not observed in groups A and D. Animals in groups A and D showed a greater number of motor neurons than animals in groups B and C (P < .01). The difference could be due to chance between group A and D animals (P = .08).

CONCLUSIONS

These results showed that the segmental infusion of noncompetitive NMDA receptor antagonist as an intraoperative spinoplegia could have a protective effect on the spinal cord neurons against excitotoxic neuronal injury in vivo. On the other hand, efficacy of the use of competitive antagonist was suggested to be limited in this model, probably because of the insurmountable obstacle of the blood-brain barrier.

CLINICAL RELEVANCE

Paraplegia is a devastating complication during surgical repair of the thoracic and thoracoabdominal aortas. Excitatory amino acids neurotoxicity through the N-methyl-D-aspartate (NMDA) receptor is no doubt the pathologic hallmark of ischemic and postischemic spinal cord injury. Systemic administration of either a competitive or noncompetitive NMDA antagonist has been reported to have neuroprotective effect, in terms of preoperative treatment, with dose-related central sympathomimetic and sedative effects. Local administration, particularly of a noncompetitive NMDA antagonist, infused segmentally after aortic clamping could therefore be a potent intraoperative pharmacologic strategy to minimize the effective dose that retains NMDA antagonism without undesirable adverse effects. Our ability to reproduce this model could facilitate pharmacologic prevention or provide a new surgical technique as a spinoplegia for NMDA receptor-mediated neuronal injury.

The Role of Excitotoxicity in Secondary Mechanisms of Spinal Cord Injury: A Review with an Emphasis on the Implications for White Matter Degeneration

Following an initial impact after spinal cord injury (SCI), there is a cascade of downstream events termed 'secondary injury', which culminate in progressive degenerative events in the spinal cord. These secondary injury mechanisms include, but are not limited to, ischemia, inflammation, free radical-induced cell death, glutamate excitotoxicity, cytoskeletal degradation and induction of extrinsic and intrinsic apoptotic pathways. There is emerging evidence that glutamate excitotoxicity plays a key role not only in neuronal cell death but also in delayed posttraumatic spinal cord white matter degeneration. Importantly however, the differences in cellular composition and expression of specific types of glutamate receptors in grey versus white matter require a compartmentalized approach to understand the mechanisms of secondary injury after SCI. This review examines mechanisms of secondary white matter injury with particular emphasis on glutamate excitotoxicity and the potential link of this mechanism to apoptosis. Recent studies have provided new insights into the mechanisms of glutamate release and its potential targets, as well as the downstream pathways associated with glutamate receptor activation in specific types of cells. Evidence from molecular and functional expression of glutamatergic AMPA receptors in white matter glia (and possibly axons), the protective effects of AMPA/kainate antagonists in posttraumatic white matter axonal function, and the vulnerability of oligodendrocytes to excitotoxic cell death suggest that glutamate excitotoxicity is associated with oligodendrocyte apoptosis. The latter mechanism appears key to glutamatergic white matter degeneration after SCI and may represent an attractive therapeutic target.

NAD(P)H oxidase, superoxide dismutase, catalase, glutathione peroxidase and nitric oxide synthase expression in subacute spinal cord injury

Primary trauma to the spinal cord triggers a cascade of cellular and molecular events that promote continued tissue damage and expansion of the lesion for extended periods following the initial injury. Oxidative and nitrosative stresses play an important role in progression of spinal cord injury (SCI). In an attempt to explore the biochemical origin of oxidative/nitrosative stress associated with secondary SCI, we studied expression of the superoxide (O2*-)-generating enzyme, NAD(P)H oxidase, antioxidant enzymes [superoxide dismutase (CuZn SOD, Mn SOD), catalase, glutathione peroxidase (GPX)], nitric oxide synthases (NOS) and a byproduct of NO-O2*- interaction (nitrotyrosine) in the spinal cord tissues of rats 16 h and 14 days after surgical resections of a 5-mm segment of the cord below T8 or sham-operation. Immunodetectable NAD(P)H oxidase subunits (gp91phox and P67phox), Mn SOD, inducible NOS (iNOS), endothelial NOS (eNOS), and nitrotyrosine were elevated in the transected cords on day 1 and day 14. Neuronal NOS (nNOS) was unchanged on day 1 and significantly depressed on day 14. GPX was unchanged on day 1 and significantly elevated on day 14. Catalase was unchanged in the cord tissue surrounding the transection site at both points. Thus, concurrent upregulations of NAD(P)H oxidase, eNOS and iNOS (but not nNOS), work in concert to maintain oxidative and nitrosative stress in the injured cord tissue.

Neuroprotective effects of N-methyl-d-aspartate receptor antagonist on aspartate induced neurotoxicity in the spinal cord in vivo

OBJECTIVE

Much evidence has been gathered to show that neurotoxicity of excitatory amino acids is mainly activated through an N-methyl-D-aspartate (NMDA) receptor cascade. We evaluated the protective effects of NMDA receptor antagonists, MK-801 and CGS19755 on spinal cord neurons using the NMDA receptor mediated neurotoxicity model in vivo.

METHODS

New Zealand white rabbits underwent an infrarenal aortic isolation. Group A animals (n = 7) received segmental aspartate (50 mM) infusion for 10 minutes. Group B animals (n = 6) were pretreated with MK-801 (6mg/kg), a noncompetitive NMDA receptor antagonist, that was administrated intravenously for 3 hours beginning 1 hour before the segmental infusion of aspartate (50 mM) of 10 minutes. Group C animals (n = 6) received pretreatment with CGS19755 (30mg/kg), a competitive NMDA receptor antagonist, that was administrated in the same fashion as group B, followed by the segmental infusion of aspartate (50 mM). Neurologic status was scored at 12, 24, and 48 hours after operation using the Tarlov score. All the animals were sacrificed for histologic assessment at 48 hours.

RESULTS

Group A animals exhibited paraplegia or paraparesis with marked neuronal necrosis. Group B and C animals showed significantly better neurologic function compared with group A (p = 0.0013, A vs. B) (p = 0.0011, A vs. C). Pathohistological change was not observed in group B and C animals.

CONCLUSIONS

NMDA receptor antagonists can have protective effects on spinal cord neurons against aspartate induced neurotoxicity. This model may be useful in assaying protective agents in the spinal cord against neuronal injury mediated by NMDA receptors in vivo.

Estrogen as a neuroprotective agent in the treatment of spinal cord injury

The following review is a brief discussion about spinal cord injury and the possibility of using estrogen as a neuroprotective agent. There are several pathways by which secondary cell death can occur following spinal cord injury, including infiltration of inflammatory cells, generation of reactive oxygen species, decreases in spinal cord blood flow, and increases in intracellular Ca(2+) levels. This secondary damage leads to apoptotic cell death, and the neuroprotective effects of pharmacologic agents have been investigated using experimentally induced spinal cord injury in animals. Currently, only high-dose methylprednisolone is advocated for the treatment of patients following spinal cord injury. Estrogen has been shown to be neuroprotective in both in vitro and in vivo studies. There are several possible mechanisms of action by which estrogen may attenuate damage following spinal cord injury and improve functional outcome. Estrogen has been shown to have anti-inflammatory properties. Estrogen levels are correlated with an increase in post-traumatic blood flow to injured tissue. Estrogen may also upregulate protein levels of anti-apoptotic Bcl-2 and may attenuate the post-traumatic influx of Ca(2+).

Changes in nitric oxide and expression of nitric oxide synthase in spinal cord after acute traumatic injury in rats

The aim of this study was to observe the time course of NO production and NOS expression in the spinal cord following acute traumatic injury. Rat spinal cord was injured by extradural static weight-compression, which resulted in an incomplete transverse spinal cord lesion with paralysis of the lower extremities. Using this model, measurement of NO by microdialysis and Griess reaction and histological and immunohistochemical examinations using polyclonal antibodies to nNOS and iNOS were performed from immediately to 14 days after injury. In injured cord, the amount of NO markedly increased immediately after injury and gradually decreased between 1 and 12 h after injury. A second wave of increase in NO level was observed at 24 h and 3 days after injury. Histologically, hematomas and necrotic changes were observed after injury and demyelination of nerve fibers increased with time in the compressed segment. Immunohistochemically, the number of cells with expression of nNOS was increased immediately to 12 h after injury. Expression of iNOS was observed from 12 h to 3 days after injury. These findings suggested that the initial maximal increase of NO production might be caused mainly by nNOS and that the second wave of increase in NO might be due mainly to iNOS.

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.

Site of injury-directed induction of heme oxygenase-1 and -2 in experimental spinal cord injury: differential functions in neuronal defense mechanisms?

The heme oxygenase (HO) isozymes catalyze oxidation of the heme molecule to biliverdin and carbon monoxide (CO) with the release of chelated iron. Presently, we have defined, for the first time, propensity for site of injury-directed induction of isozymes--the stress-inducible isozyme, HO-1, responds distal (below) and the glucocorticoid (GC)-inducible HO-2 responds proximal (above) to the site of injury. We have also shown that reactive iron (Fe3+) and cGMP staining spatially resemble that of HO-1; which, in turn, colocalizes in motor neurons with transcription factors: Fas-associated protein containing death domain (FADD), tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) and p53. Spinal cord injury (SCI) was inflicted by clip compression for 30 min, and analyses were carried out after 4 h or 16 h. When compared with spinal cord segments proximal to the site of injury, northern blot analysis showed remarkably higher levels of HO-1 mRNA distal (below) to the site of injury at both time points. In contrast, HO-2 mRNA levels were elevated proximal (above) to the site of injury and more prominently at 16 h post SCI. Immunohistochemical analyses were carried out using 2 x 5 mm segments above and below the compression site. When compared with segments above the site of injury, the intensity of HO-1 immunostaining and the number of HO-1 positive neurons in the ventral horn motor neurons were prominently increased in segments below the injury. Western blot analysis confirmed the observations. HO-2 protein was mapped to the ventral horn motor neurons, oligodendrocytes, the Clarke's nucleus neurons and the ependymal cells. When compared with segments below the site of injury, neuronal HO-2 staining intensity was increased above the site of injury, and most notably at 16 h. These observations were also confirmed by western blotting and HO activity measurements. Tissue Fe3+ and cGMP staining were increased and prominently mapped below the site of injury, where cGMP colocalized with HO-1 in the nucleus of the motor neurons. Also, a site of injury-directed pattern of induction of FADD, TRAIL, and p53 immunoreactivity, and a widespread colocalization of the oncogenes with HO-1 protein, were found within motor neurons below the level of injury. We forward the hypothesis that HO-1 and HO-2 have different roles in the defense mechanisms of the injured nervous system. We hypothesize that HO-1 protects against further damage by contributing to controlled cell death through their intrinsic suicide program, while HO-2 is involved in suppression of inflammatory response by NO derived radicals.

Advances in secondary spinal cord injury: role of apoptosis

The outcome of spinal cord injury depends on the extent of secondary damage produced by a series of cellular and molecular events initiated by the primary trauma. This article reviews the evidence that secondary spinal cord injury involves the apoptotic as well as necrotic death of neurons and glial cells. Also discussed are the major factors that can contribute to cell death, such as glutamatergic excitotoxicity, free radical damage, cytokines, and inflammation. The development of innovative therapeutic strategies to reduce secondary spinal cord injury depends on an increased understanding of secondary injury mechanisms at the molecular and biochemical level. Such therapeutic interventions may include the use of antiapoptotic drugs, free radical scavengers, and anti-inflammatory agents. These could be targeted to block key reactions on cellular and molecular injury cascades, thus reducing secondary tissue damage, minimizing side effects, and improving functional recovery.

Apoptosis following spinal cord injury in rats and preventative effect of N-methyl-D-aspartate receptor antagonist

OBJECT

The aims of this study were to clarify the histological and histochemical changes associated with cell death in the spinal cord after acute traumatic injury and to examine the role of excitatory amino acid release mediated by N-methyl-D-aspartate (NMDA) receptors.

METHODS

Following laminectomy, the spinal cord in 70 rats was injured at the T-9 level by applying extradural static weight-compression, in which a cylindrical compressor was used to induce complete and irreversible transverse spinal cord injury (SCI) with paralysis of the lower extremities. The injured rats were killed between 30 minutes and 14 days after injury, and the injured cord was removed en bloc. Rats that received NMDA receptor antagonist (MK-801) were killed at the same time points as those that received saline. The specimens were stained with hematoxylin and eosin, Nissl, and Klüver-Barrera Luxol fast blue and subjected to in situ nick-end labeling, a specific in situ method used to allow visualization of apoptosis. Thirty minutes post-SCI, a large hematoma was observed at the compressed segment. Six hours after injury, large numbers of dead cells that were not stained by in situ nick-end labeling were observed. Between 12 hours and 14 days postinjury, nuclei stained by using the in situ nick-end labeling technique were observed not only at the injury site but also in adjoining segments that had not undergone mechanical compression, suggesting that the delayed cell death was due to apoptosis. The number of cells stained by in situ nick-end labeling was maximum at 3 days postinjury. The results of electron microscopic examination were also consistent with apoptosis. In the MK-801-treated rats, the number of cells stained by in situ nick-end labeling was smaller than in nontreated rats at both 24 hours and 7 days after injury.

CONCLUSIONS

These findings suggest that NMDA-receptor activation promotes delayed neuronal and glial cell death due to apoptosis.

Role of cyclooxygenase 2 in acute spinal cord injury

Cyclooxygenase, or prostaglandin G/H synthase, is the rate-limiting step in the production of prostaglandins. A new isoform, cyclooxygenase-2 (COX-2), has been cloned that is induced during inflammation in leukocytes and by synaptic activity in neurons. The objectives of this study are to determine the nature of COX-2 expression in normal and traumatized rat spinal cord, and to determine the effects of selective COX-2 inhibition on functional recovery following spinal cord injury. Using a weight-drop model of spinal cord injury, COX-2 mRNA expression was studied with in situ hybridization. COX-2 protein expression was examined by immunohistochemistry and Western analysis. Finally, using the highly selective COX-2 inhibitor, 1-[(4-methylsufonyl)phenyl]-3-tri-fluro-methyl-5-[(4-flur o)phenyl]prazole (SC58125), the effect of COX-2 inhibition on functional outcome following a spinal cord injury was determined. COX-2 was expressed in the normal adult rat spinal cord. COX-2 mRNA and protein production were increased following injury with increases in COX-2 mRNA production detectable at 2 h following injury. Increased levels of COX-2 protein were detectable for at least 48 h following traumatic spinal cord injury. Selective inhibition of COX-2 activity with SC58125 resulted in improved mean Basso, Beattie, and Bresnahan scores in animals with 12.5- and 25-g/cm spinal cord injuries; however, the effect was significant only for the 12.5g/cm injury group (p=0.0001 vs. p=0.0643 in the 25-g/cm group). These data demonstrate that COX-2 mRNA and protein expression are induced by spinal cord injury, and that selective inhibition of COX-2 improves functional outcome following experimental spinal cord injury.

Role of norepinephrine and excitatory amino acids in edema of the spinal cord after experimental compression injury in rats

The role of norepinephrine and excitatory amino acids in edema of the spinal cord after an acute experimental compression injury was studied in rats. Control rats received the compression injury only. Intraspinal norepinephrine was depleted in one rat group by injection of 6-hydroxydopamine (6-OHDA) into the subarachnoid space to selectively destroy catecholamine neurons and in a third group MK-801 was administered intravenously to block receptors for N-methyl-d-aspartate (NMDA), an excitatory amino acid. Recovery from motor paralysis and suppression of edema of the spinal cord were then compared in the three groups. Significant recovery from motor paralysis was found 12 h after injury in the 6-OHDA-treated rats, compared with the controls, and 24 h after injury in the MK-801-treated rats. Edema of the spinal cord was significantly suppressed for up to 24 h after injury in the 6-OHDA-treated rats. The MK-801-treated rats showed no significant suppression of the edema until 24 h after the spinal cord injury. It was concluded that norepinephrine is primarily involved in the formation of vasogenic edemas, which develop in the early stages after an injury, whereas excitatory amino acids affect the formation of cytotoxic edemas, which develop at a relatively later stage.

The effects of chronic alpha-tocopherol administration on lipid peroxidation in an experimental model of acute spinal cord injury

Most of the numerous experimental studies to research pathophysiological changes following acute spinal cord injury suggest a two-step mechanism of damage to the spinal cord in which the primary (direct) or mechanical injury caused by the trauma initiates secondary (indirect) or progressive autodestructive injury of the cord. During recent years, free oxygen radical generation and lipid peroxidation have been considered to be responsible for secondary autodestructive injury. Alpha tocopherol occupies an important and unique position in the overall antioxidant defense. Alpha tocopherol-depleted animals are generally more susceptible to the adverse effects of environmental agents than are supplemented animals. This study was planned to study the effectiveness in counteracting this autodestructive process by supplementing alpha-tocopherol in rats maintained on a nutritionally adequate diet, and also to evaluate whether it will provide additional protection or not. Eighty healthy Wistar rats (treatment and controls) were included. The treatment group received 100 mg/kg alpha tocopherol each day, intraperitoneally for seven days. Using a standard acute spinal cord trauma model in Wistar rats trauma was applied, an malondialdehyde (MDA) which is a lipid peroxidation product was measured in the traumatized spinal cord at various times following the trauma in order to indirectly evaluate the lipid peroxidation and generation of free oxygen radicals in a time sequence. Statistical analysis of the values demonstrated that malondialdehyde formation in the alpha-tocopherol administered group was significantly lower than in the control group. These findings indicate that longterm administration of alpha-tocopherol may be useful to decrease lipid peroxidation following acute spinal cord trauma.

Immuno-localization of kynurenine aminotransferase (KAT) in the rat medulla and spinal cord

In the mammalian brain, kynurenine aminotransferase (KAT) is pivotal to the synthesis of kynurenic acid, a preferential antagonist at the strychnine-insensitive NMDA-glycine site. As NMDA receptors are involved in autonomic function, we have examined the immunohistochemical localization of KAT in the medulla and spinal cord of the rat. KAT immunoreactivity (KAT-li) was found throughout these areas, in both glia and neurons. Unlike the mainly astrocytic localization in forebrain structures, KAT-li was predominantly neuronal, notably in areas important for blood pressure and heart rate regulation: ventral medulla, nucleus ambiguus, nucleus of the solitary tract and intramediolateral cell column of the spinal cord. The presence of KAT in these nuclei supports a neuromodulatory role for kynurenic acid in NMDA-mediated autonomic function.

Reduction of spinal cord injury by administration of iloprost, a stable prostacyclin analog

To investigate whether iloprost, a stable analog of prostacyclin, is useful for the prevention of posttraumatic spinal cord injury, we examined its effects on compression trauma-induced spinal cord injury in rats. Spinal cord injury was induced by applying a 20-g weight for 20 minutes to the spinal cord at the level of T-12, resulting in motor disturbances in the hindlimbs. These motor disturbances, evaluated using Tarlov's index, were markedly attenuated in rats with nitrogen mustard-induced leukocytopenia. Administration of iloprost also attenuated the motor deficits. Histological examination revealed that intramedullary hemorrhages observed 24 hours after trauma were significantly attenuated in leukocytopenic animals and in animals that received iloprost. The accumulation of leukocytes at the site of trauma, evaluated by measuring tissue myeloperoxidase activity, significantly increased with time following the trauma, peaking at 3 hours postinjury. Spinal cord myeloperoxidase activity in sham-operated animals did not increase postoperatively. Leukocyte depletion and administration of iloprost reduced the accumulation of leukocytes in the damaged spinal cord segment 3 hours posttrauma. These findings indicate that iloprost attenuates motor disturbances induced by spinal cord trauma and that its therapeutic efficacy can be partly explained by its inhibition of leukocyte accumulation at the traumatized site.

Comparative study of functional recovery for surgically explored and conservatively managed spinal cord missile injuries

OBJECTIVE

In a retrospective study, the extent of functional recovery and the merits of surgical exploration versus conservative management for spinal cord injuries were evaluated for 145 casualties from the front lines of the Iran-Iraq conflict.

METHODS

Eighty-seven patients who underwent surgical exploration and 58 patients who were conservatively treated were monitored for 6 to 140 months (average, 57 +/- 31 mo) for any changes from their baseline neurological status, using the Frankel Scoring System.

RESULTS

Twenty-two of 90 patients (24.4%) with complete injuries (Frankel score A) and 53 of 55 (96.4%) with incomplete injuries (Frankel scores B, C, and D) experienced changes in their neurological status as they recovered. Improvement was noted for 42 of 87 surgically treated patients (13 of 55 with complete injuries and 29 of 32 with incomplete injuries). Among conservatively treated patients, improvement was noted for 32 of 58 (55%), including 25.7% of those with complete injuries and 100% of those with incomplete injuries. Independent walking (Frankel scores D and E) was achieved by 10 of 90 patients with complete injuries and by 52 of 55 patients with incomplete injuries. Surgery did not affect the final outcome. Thirteen of 17 (76%) cerebrospinal fluid fistulas, 13 of 15 (87%) meningitides, and 4 of 6 (67%) local septic complications were encountered in the surgically treated group.

CONCLUSION

Surgery did not enhance functional recovery from spinal cord missile injuries but did correlate with an increased prevalence of complications (fistulas, meningitis, and local sepsis). With or without surgical exploration, patients with seemingly complete cauda equina injuries demonstrated better functional outcome than did those with spinal cord injuries.