Peripheral Nerve Injuries Treatment: a Systematic Review

Patients with peripheral nerve injuries, especially severe injury, often face poor nerve regeneration and incompletely functional recovery, even after surgical nerve repair. Current researches have extensively focused on the new approaches for the treatment of peripheral nerve injuries. This review summarizes treatments of peripheral nerve injures, from conventional suturing method, to conduit coaptation with stem cell and growth factor, and review the developments of research and clinical application of these therapies.     

Dead-ended autologous connective tissue chambers in peripheral nerve repair--early observations

The effects of the repair of nerve gap injuries are still unsatisfactory, despite the great progress in microsurgery. Until now, there is no effective method to induce the regeneration of the transected peripheral nerve when its distal stump is missing. The aim of this work was to examine whether the implantation of dead-ended connective tissue chambers can promote the outgrowth of injured peripheral neurites. This method differs from all previous nerve guides because it totally eliminates the distal part of the nerve and restricts the influence of surrounding tissues. We have also tried to establish whether some neurotrophic factors can be applied by means of these chambers. The results of this work show that dead-ended autologous connective tissue chambers can be a useful tool in peripheral nerve injuries treatment, even when the distal part of the nerve is missing.     

周围神经损伤中P2Y12受体-p38MAPK通路的研究进展

周围神经损伤是临床中常见的神经损伤之一,神经胶质细胞和信号通路转导在周围神经损伤和再生修复中发挥重要作用。小胶质细胞的活化与周围神经损伤导致的神经损伤及疼痛密切相关,小胶质细胞是周围神经损伤与修复的关键场所。脊髓背角的小胶质细胞可被嘌呤信号通路的P2Y_(12)受体活化,进而导致p38MAPK磷酸化,造成相关神经损伤及感觉功能障碍。以脊髓背角的小胶质细胞为靶点,从P2Y_(12)受体-p38MAPK通路的角度可揭示周围神经损伤的部分可能机制。探究从嘌呤信号通路与小胶质细胞活化的新角度,将神经损伤后的P2Y_(12)受体与p38MAPK的磷酸化表达联系为P2Y_(12)受体-p38MAPK通路,可为临床治疗周围神经损伤提供新的思路。本文就周围神经损伤中P2Y_(12)受体-p38MAPK通路的研究进展作一综述。     

A crucial role of IL-17 and IFN-γ during acute rejection of peripheral nerve xenotransplantation in mice

Nerve injuries causing segmental loss require nerve grafting. However, autografts and allografts have limitations for clinical use. Peripheral nerve xenotransplantation has become an area of great interest in clinical surgery research as an alternative graft strategy. However, xenotransplant rejection is severe with cellular immunity, and Th1 cells play an important role in the process. To better understand the process of rejection, we used peripheral nerve xenografts from rats to mice and found that mononuclear cells expressing IFN-γ and IL-17 infiltrated around the grafts, and IFN-γ and IL-17 producing CD4+ and CD8+ T cells increased during the process of acute rejection. The changes of IL-4 level had no significant difference between xenotransplanted group and sham control group. The rejection of xenograft was significantly prevented after the treatment of IL-17 and IFN-γ neutralizing antibodies. These data suggest that Th17 cells contribute to the acute rejection process of peripheral nerve xenotransplant in addition to Th1 cells.     

Direct transplantation of uncultured hair‐follicle pluripotent stem (hfPS) cells promotes the recovery of peripheral nerve injury

We previously showed that the stem cell marker nestin is expressed in hair follicle stem cells which suggested their pluripotency. We subsequently showed that the nestin‐expressing hair‐follicle pluripotent stem (hfPS) cells can differentiate in culture to neurons, glial cells, keratinocytes, and other cell types and can promote regeneration of peripheral nerve and spinal cord injuries upon injection to the injured nerve or spinal cord. The location of the hfPS cells has been termed the hfPS cell area (hfPSCA). Previously, hfPS cells were cultured for 1–2 months before transplantation to the injured nerve or spinal cord which would not be optimal for clinical application of these cells for nerve or spinal cord repair, since the patient should be treated soon after injury. In the present study, we addressed this issue by directly using the upper part of the hair follicle containing the hfPSCA, without culture, for injection into the severed sciatic nerve in mice. After injection of hfPSCA, the implanted hfPS cells grew and promoted joining of the severed nerve. The transplanted hfPS cells differentiated mostly to glial cells forming myelin sheaths, which promoted axonal growth and functional recovery of the severed nerve. These results suggest that the direct transplantation of the uncultured upper part of the hair follicle containing the hfPSA is an important method to promote the recovery of peripheral nerve injuries and has significant clinical potential. J. Cell. Biochem. 110: 272–277, 2010. © 2010 Wiley‐Liss, Inc.     

Sulindac derivatives inhibit cell growth and induce apoptosis in primary cells from malignant peripheral nerve sheath tumors of NF1-patients

Background  

Malignant peripheral nerve sheath tumors (MPNSTs) are neoplasms leading to death in most cases. Patients with Neurofibromatosis type 1 have an increased risk of developing this malignancy. The metabolites of the inactive prodrug Sulindac, Sulindac Sulfide and Sulindac Sulfone (Exisulind) are new chemopreventive agents that show promising results in the treatment of different cancer types. In this study we examined the antineoplastic effect of these compounds on primary cells derived from two MPNSTs of Neurofibromatosis type 1 patients.     

Augmenting peripheral nerve regeneration using stem cells: A review of current opinion

Outcomes following peripheral nerve injury remain frustratingly poor. The reasons for this are multifactorial, although maintaining a growth permissive environment in the distal nerve stump following repair is arguably the most important. The optimal environment for axonal regeneration relies on the synthesis and release of many biochemical mediators that are temporally and spatially regulated with a high level of incompletely understood complexity. The Schwann cell(SC) has emerged as a key player in this process. Prolonged periods of distal nerve stump denervation, characteristic of large gaps and proximal injuries, have been associated with a reduction in SC number and ability to support regenerating axons. Cell based therapy offers a potential therapy for the improvement of outcomes following peripheral nerve reconstruction. Stem cells have the potential to increase the number of SCs and prolong their ability to support regeneration. They may also have the ability to rescue and replenish populations of chromatolytic and apoptotic neurons following axotomy. Finally, they can be used in non-physiologic ways to preserve injured tissues such as denervated muscle while neuronal ingrowth has not yet occurred. Aside from stem cell type, careful consideration must be given to differentiation status, how stem cells are supported following transplantation and how they will be delivered to the site of injury. It is the aim of this article to review current opinions on the strategies of stem cell based therapy for the augmentation of peripheral nerve regeneration.     

Transplantation of adipose derived stem cells for peripheral nerve regeneration in sciatic nerve defects of the rat

Tissue engineering approaches for promoting the repair of peripheral nerve injuries have focused on cell-based therapies involving Adipose-derived stem cells (ASCs). The authors evaluated the effects of undifferentiated ASCs and of neurally differentiated ASCs on the regenerating abilities of peripheral nerves. We hope that this would demonstrate the feasibility of using adipose derived stem cells for peripheral nerve regeneration and provide clues regarding the use of adipose- derived stem cells. ASCs were isolated and cultured. Then the cells were cultured with neuronal induction agents for neural differentiation. ASCs and neurally differentiated ASCs were transplanted into sciatic nerve defects. After 12 weeks, the number and diameter of the myelinated fibers were measured and nerve conduction study was done. The extent of regeneration of myelinated fibers in the neurally differentiated ASCs transplanted group was greater than that in the ASCs transplanted group or the control group. However, thickness of myelin sheath and diameter of nerve fibers in the ASCs transplanted group were greater than those in the neutrally differentiated ASCs transplanted group or the control group. Nerve conduction study showed good recovery in the neurally differentiated ASCs transplanted groups. Muscles can atrophy and contract if denervation has started. It would be difficult to recover muscle function even if the nerve was reinnervated. Therefore, although neurally differentiated ASCs were found to have a greater functional effect than non-differentiated ASCs, time constraint is important when considering a method of ASCs transplantation.     

Current state of the development of mesenchymal stem cells into clinically applicable Schwann cell transplants

Schwann cells are critically important in recovery from injuries to the peripheral nervous system, and their absence from the central nervous system (CNS) may be a critical limiting factor in the CNS regeneration capacity. Various types of stem cells have been investigated for their potential to be induced to develop a Schwann cell phenotype, with mesenchymal stem cells (MSCs) being the most promising among them. The methods for inducing MSCs differentiation into Schwann cell-like cells are presented in detail in this review. The evidence related to successful differentiation of MSCs to Schwann cell-like cells is particularly discussed herein, which includes the changes in morphology, phenotype, function, and proteome. The possible explanations for the differentiation of MSCs to Schwann cell-like cells are also presented. Finally, we suggest future research aims which will need to be fulfilled to elucidate the biology of Schwann cell differentiation and MSC transdifferentiation, to enable clinical application of therapeutic differentiated MSC transplantation into nerve injury sites.     

成年大鼠雪旺细胞的快速扩增

采用接种雪旺细胞的可降解导管修复外周神经损伤是一种有望替代自体神经移植的方法。如何在短期内利用病人少量的神经碎片获得大量雪旺细胞是该方法用于临床的关键。以大鼠坐骨神经为模型,利用雪旺细胞增殖的内在机制,探索出一种快速增殖成年雪旺细胞的方法。采用预变性7d的坐骨神经,用酶消化分离出雪旺细胞,接种在层粘连蛋白包被的培养瓶中,经过7d的培养,获得纯度为96％、细胞密度为600个／mm^2的雪旺细胞,雪旺细胞的纯度和密度明显高于对照的新鲜神经。未使用霍乱毒素、毛喉素等促有丝分裂剂和抑制成纤维细胞的基因毒素,符合临床使用要求。结果表明,可以利用少量的损伤神经碎片在短期内获得大量可用于临床的雪旺细胞。     

电刺激联合干细胞修复周围神经损伤的研究进展

周围神经损伤在创伤中较为常见,易造成神经系统部分或全部损伤,从而导致功能丧失和其他神经性疾病．尽管周围神经损伤的治疗效果随着科技的发展有了明显提高,但距离真正的形态和功能重建还相差甚远,神经再生及功能恢复速度缓慢仍是临床治疗的难点．电刺激因使用方便、无创和副作用小等优点越来越受到研究者的青睐,与干细胞联合广泛用于周围神经损伤修复的体外研究．本文论述了电刺激联合干细胞在周围神经损伤修复方面的研究进展,并讨论了其可能的作用机理．特别分析了电刺激联合干细胞在周围神经损伤修复研究中的难点,展望了其发展前景．     

Allotransplanted neurons used to repair peripheral nerve injury do not elicit overt immunogenicity

A major problem hindering the development of autograft alternatives for repairing peripheral nerve injuries is immunogenicity. We have previously shown successful regeneration in transected rat sciatic nerves using conduits filled with allogeneic dorsal root ganglion (DRG) cells without any immunosuppression. In this study, we re-examined the immunogenicity of our DRG neuron implanted conduits as a potential strategy to overcome transplant rejection. A biodegradable NeuraGen® tube was infused with pure DRG neurons or Schwann cells cultured from a rat strain differing from the host rats and used to repair 8 mm gaps in the sciatic nerve. We observed enhanced regeneration with allogeneic cells compared to empty conduits 16 weeks post-surgery, but morphological analyses suggest recovery comparable to the healthy nerves was not achieved. The degree of regeneration was indistinguishable between DRG and Schwann cell allografts although immunogenicity assessments revealed substantially increased presence of Interferon gamma (IFN-γ) in Schwann cell allografts compared to the DRG allografts by two weeks post-surgery. Macrophage infiltration of the regenerated nerve graft in the DRG group 16 weeks post-surgery was below the level of the empty conduit (0.56 fold change from NG; p<0.05) while the Schwann cell group revealed significantly higher counts (1.29 fold change from NG; p<0.001). Major histocompatibility complex I (MHC I) molecules were present in significantly increased levels in the DRG and Schwann cell allograft groups compared to the hollow NG conduit and the Sham healthy nerve. Our results confirmed previous studies that have reported Schwann cells as being immunogenic, likely due to MHC I expression. Nerve gap injuries are difficult to repair; our data suggest that DRG neurons are superior medium to implant inside conduit tubes due to reduced immunogenicity and represent a potential treatment strategy that could be preferable to the current gold standard of autologous nerve transplant.     

干细胞治疗周围神经损伤研究进展

周围神经损伤是临床常见的疾病。损伤后神经的修复和再生是复杂又漫长的过程。严重的神经损伤其预后效果并不令人满意,相应支配区域的功能难以恢复,这给患者及家人带来了极大的痛苦。因此如何更好的对周围神经损伤进行治疗一直是医学界的难题。在神经修复机制的研究中,科学家发现施万细胞对周围神经的修复和再生起到了非常重要的作用,但获取和扩增的困难限制了其临床的应用。随着生物医学的发展,人们把目光投向了干细胞,经实验发现干细胞不仅具有旺盛的增殖能力,而且可以分化为神经系细胞,还能分泌相关的神经营养因子促进神经的修复和再生,这为周围神经损伤后的治疗带来了新的希望。本文就近些年来应用于修复周围神经的干细胞及促进修复机制的研究做以综述。     

Pulsing electromagnetic field therapy in nerve regeneration: an experimental study in the cat

A multidisciplinary approach to the study of peripheral nerve regeneration in the cat has been presented. The purpose of this work has been to determine if pulsing electromagnetic field (PEMF) therapy can enhance peripheral nerve regeneration after injury. In equal groups of animals, two types of pulsing electromagnetic field treatment were compared with untreated controls. All animals underwent quantitative electrophysiologic and morphologic assessment at the area of injury. In addition, muscle fiber sizing in the periphery and retrograde labeling of anterior horn motoneurons with horseradish peroxidase were studied. Results have shown no statistical differences between the groups in electrophysiologic or morphologic parameters. However, in animals treated with a pulse-burst electromagnetic field there was a statistically significant improvement in the labeling and localization of anterior horn cells in the central nervous system. These results indicate that pulse-burst electromagnetic radiation can increase the numbers of motor neurons that reestablish appropriate connections to the periphery after nerve injury. It remains to be seen if this improved spinal cord organization can translate to improved peripheral functional return.     

Magnetic Resonance Neurography for Evaluation of Peripheral Nerves

Peripheral nerve injuries (PNIs) continue to present both diagnostic and treatment challenges. While nerve transections are typically a straightforward diagnosis, other types of PNIs, such as chronic or traumatic nerve compression, may be more difficult to evaluate due to their varied presentation and limitations of current diagnostic tools. As a result, diagnosis may be delayed, and these patients may go on to develop progressive symptoms, impeding normal activity. In the past, PNIs were diagnosed by history and clinical examination alone or techniques that raised concerns regarding accuracy, invasiveness, or operator dependency. Magnetic resonance neurography (MRN) has been increasingly utilized in clinical settings due to its ability to visualize complex nerve structures along their entire pathway and distinguish nerves from surrounding vasculature and tissue in a noninvasive manner. In this review, we discuss the clinical applications of MRN in the diagnosis, as well as pre- and postsurgical assessments of patients with peripheral neuropathies.     

New era of optogenetics: from the central to peripheral nervous system

Abstract

Optogenetics has recently gained recognition as a biological technique to control the activity of cells using light stimulation. Many studies have applied optogenetics to cell lines in the central nervous system because it has the potential to elucidate neural circuits, treat neurological diseases and promote nerve regeneration. There have been fewer studies on the application of optogenetics in the peripheral nervous system. This review introduces the basic principles and approaches of optogenetics and summarizes the physiology and mechanism of opsins and how the technology enables bidirectional control of unique cell lines with superior spatial and temporal accuracy. Further, this review explores and discusses the therapeutic potential for the development of optogenetics and its capacity to revolutionize treatment for refractory epilepsy, depression, pain, and other nervous system disorders, with a focus on neural regeneration, especially in the peripheral nervous system. Additionally, this review synthesizes the latest preclinical research on optogenetic stimulation, including studies on non-human primates, summarizes the challenges, and highlights future perspectives. The potential of optogenetic stimulation to optimize therapy for peripheral nerve injuries (PNIs) is also highlighted. Optogenetic technology has already generated exciting, preliminary evidence, supporting its role in applications to several neurological diseases, including PNIs.     

Functional evaluation of complete sciatic, peroneal, and posterior tibial nerve lesions in the rat

Quantification of peripheral nerve regeneration in animal studies of nerve injury and repair by histologic, morphologic, and electrophysiologic parameters has been controversial because such studies may not necessarily correlate with actual nerve function. This study modifies the previously described sciatic functional index (SFI), tibial functional index (TFI), and peroneal functional index (PFI) based on multiple linear regression analysis of factors derived from measurements of walking tracks in rats with defined nerve injuries. The factors that contributed to these formulas were print-length factor (PLF), toe-spread factor (TSF), and intermediary toe-spread factor (ITF). It was shown that animals with selective nerve injuries gave walking tracks that were consistent, predictable, and based on known neuromuscular deficits. The new formula for sciatic functional index was compared with previously described indices. The sciatic functional index, tibial functional index, and peroneal functional index offer the peripheral nerve investigator a noninvasive quantitative assessment of hindlimb motor function in the rat with selective hindlimb nerve injury.     

PAF antagonism modifies neuroprotective action of histone deacetylase and calcineurin phosphatase inhibitors in mice

To evaluate the hypothesis that platelet activating factor (PAF) antagonism may affect the functional recovery following the nerve injuries and also to evaluate the effect of PAF receptor antagonism on the neuroprotective effect of tacrolimus and sodium valproate, effect of PAF receptor antagonist, WEB2086 was evaluated in animal models of sciatic nerve crush and endothelin-1 induced focal cerebral ischemia. WEB2086, per se, while attenuating spontaneous sensory motor recovery after sciatic nerve crush, enhanced functional recovery after focal cerebral ischemia. WEB2086 also attenuated the neuroprotective effect of tacrolimus and sodium valproate subsequent to peripheral nerve injury, while it significantly improved the neuroprotective action of tacrolimus and sodium valproate following cerebral ischemia reperfusion injury. These results suggest that PAF receptor antagonists alone and in combination with tacrolimus/sodium valproate could be used in the treatment of cerebral ischemia reperfusion injuries however, their use following peripheral nerve injuries could be detrimental.     

Prosaposin Facilitates Sciatic Nerve Regeneration In Vivo

Abstract: Prosaposin, a multifunctional protein, is the precursor of saposins, which activate sphingolipid hydrolases. In addition to acting as a precursor for saposins, prosaposin has been shown to rescue hippocampal CA1 neurons from lethal ischemic damage in vivo and to promote neurite extension of neuroblastoma cells in vitro. Here we show that prosaposin, when added to a collagen-filled nerve guide after sciatic nerve transection in guinea pigs, increased dramatically the number of regenerating nerve fibers within the guide. To identify the target neurons of prosaposin during peripheral nerve regeneration, we determined the degree of atrophy and chromatolysis of neurons in the spinal anterior horn and dorsal root ganglia on the prosaposin-treated and untreated side. The effect of prosaposin on large spinal neurons and small neurons of the dorsal root ganglion was more conspicuous. Subsequent immunohistochemistry demonstrated that the atrophy of cholinergic large neurons in the anterior horn is prevented to significant extent by prosaposin treatment. These findings suggest that prosaposin promotes peripheral nerve regeneration by acting on α-motor neurons in the anterior horn and on small sensory neurons in the dorsal root ganglion. The present study raises the possibility of using prosaposin as a tool for the treatment of peripheral nerve injuries.     

A Silk Fibroin/Collagen Nerve Scaffold Seeded with a Co-Culture of Schwann Cells and Adipose-Derived Stem Cells for Sciatic Nerve Regeneration

As a promising alternative to autologous nerve grafts, tissue-engineered nerve grafts have been extensively studied as a way to bridge peripheral nerve defects and guide nerve regeneration. The main difference between autogenous nerve grafts and tissue-engineered nerve grafts is the regenerative microenvironment formed by the grafts. If an appropriate regenerative microenvironment is provided, the repair of a peripheral nerve is feasible. In this study, to mimic the body’s natural regenerative microenvironment closely, we co-cultured Schwann cells (SCs) and adipose-derived stem cells (ADSCs) as seed cells and introduced them into a silk fibroin (SF)/collagen scaffold to construct a tissue-engineered nerve conduit (TENC). Twelve weeks after the three different grafts (plain SF/collagen scaffold, TENC, and autograft) were transplanted to bridge 1-cm long sciatic nerve defects in rats, a series of electrophysiological examinations and morphological analyses were performed to evaluate the effect of the tissue-engineered nerve grafts on peripheral nerve regeneration. The regenerative outcomes showed that the effect of treatment with TENCs was similar to that with autologous nerve grafts but superior to that with plain SF/collagen scaffolds. Meanwhile, no experimental animals had inflammation around the grafts. Based on this evidence, our findings suggest that the TENC we developed could improve the regenerative microenvironment and accelerate nerve regeneration compared to plain SF/collagen and may serve as a promising strategy for peripheral nerve repair.