Damien P. Kuffler

Immunosuppressants: Neuroprotection and promoting neurological recovery following peripheral nerve and spinal cord lesions

No clinical techniques induce restoration of neurological losses following spinal cord trauma. Peripheral nerve damage also leads to permanent neurological deficits, but neurological recovery can be relatively good, especially if the ends of a transected nerve are anastomosed soon after the injury. The time until recovery generally depends on the distance the axons must regenerate to their targets. Neurological recovery following the destruction of a length of a peripheral nerve requires a graft to bridge the gap that is permissive to, and promotes, axon regeneration. But neurological recovery is slow and limited, especially for gaps longer than 1.5 cm, even using autologous peripheral nerve grafts. Without a reliable means of bridging long nerve gaps, such injuries commonly result in amputations. Promoting extensive neurological recovery requires techniques that simultaneously provide protection to injured neurons and increase the numbers of neurons that extend axons, while inducing more rapid and extensive axon regeneration across long nerve gaps. Although conduits filled with various materials enhance axon regeneration across short nerve gaps, pure sensory nerve graft remains the gold standard for use across long nerve gaps, even though they lead to only limited neurological recovery. Consistent results demonstrate that several immunosuppressive agents enhance the number of axons and the rate at which they regenerate. This review examines the roles played by immunosuppressants, especially FK506, with primary focus on its role as a neuroprotectant and neurotrophic agent, and its potential clinical use to promote improved neurological recovery following peripheral nerve and spinal cord injuries.

Guidance of Regenerating Motor Axons In Vivo by Gradients of Diffusible Peripheral Nerve-Derived Factors

During development of the central nervous system, neurons rely on target-derived factors to guide their outgrowing processes. Several CNS target-derived chemoattractive and repellent factors have been isolated and characterized, and their mechanism of action determined. For the peripheral nervous system, the results from numerous experiments suggest that during regeneration axons also respond to concentration gradients of target-derived factors leading to an oriented outgrowth up the gradient to the denervated target in vivo. The results from in vitro experiments have shown that diffusible concentration gradients of factors released from a length of denervated peripheral nerve, composed predominantly of Schwann cells, direct the outgrowth of sensory and motor neuron growth cones over distances of several hundred microns. However, a conclusive demonstration of a chemoattractive influence of diffusible concentration gradients on regenerating adult motor axons in vivo has remained elusive. The present experiments show that concentration gradients of denervated peripheral nerve-released factors direct the regeneration of adult motor axons in vivo, and that these gradients are effective over distances of more than 6.5 mm. Nonconditioned medium exerted no influence on the regenerating axons. Thus, results from in vivo experiments parallel those from in vitro experiments and indicate that isolated peripheral nerve-released factors that are effective in vitro will play a similar role on sensory and motor axons in vivo. Finally, the results show that diffusible concentration gradients of target-derived factors direct axon outgrowth both during both development and regeneration, as well as in vivo and in vitro.

Promoting and directing axon outgrowth

Establishment of appropriate neuronal connections during development and regeneration requires the extension of processes that must then grow in the correct direction, find and recognize their targets, and make synapses with them. During development, embryonic neurons gradually establish central and peripheral connections in an evolving cellular environment in which neurotrophic factors are provided by supporting and target cells that promote neuronal survival, differentiation, and process outgrowth. Some cells also release neurotropic factors that direct the outgrowth of neuronal processes toward their targets. Following development the neurotrophic requirements of some adult neurons change so that, although they respond to neurotrophic factors, they no longer require exogenous neurotrophins to survive or to extend processes. Within the central nervous system (CNS), the ability of neurons to extend processes is eventually lost because of a change in their cellular environment from outgrowth permissive to inhibitory. Thus, neuronal connections that are lost in the adult CNS are rarely reestablished. In contrast, the environment of the adult peripheral nervous system fosters process outgrowth and synapse formation. This article discusses the neurotrophic requirements of embryonic and adult neurons, as well as the importance of neurotropic factors in directing the outgrowth of regenerating adult axons.

Neurological recovery across a 12-cm-long ulnar nerve gap repaired 3.25 years post trauma: case report.

BACKGROUND AND IMPORTANCE The standard clinical technique for repairing peripheral nerve gaps is the use of autologous sensory nerve grafts. The present study tested whether a collagen tube filled with autologous platelet-rich fibrin could induce sensory and motor recovery across a 12-cm nerve gap repaired 3.25 years post trauma, and reduce or eliminate neuropathic pain. CLINICAL PRESENTATION Two years postrepair, good ring and small finger motor function had developed that could generate 1 kg of force, and topographically correct 2-point discrimination and sensitivity to vibration in the small and ring finger and proximal but not distal wrist had developed. The patients excruciating neuropathic pain was reduced to tolerable, and he avoided the indicated extremity amputation. The 12-cm-long nerve gap was bridged with a collagen tube filled with autologous platelet-rich fibrin. CONCLUSION We demonstrate that a conduit filled with platelet-rich fibrin can induce limited, but appropriate, sensory and motor recovery across a 12-cm nerve gap repaired 3.25 years post trauma, without sacrificing a sensory nerve, can reduce existing excruciating neuropathic pain to tolerable, and allow avoidance of an indicated upper-extremity amputation. We believe the technique can be improved to induce more extensive and reliable neurological recovery.

Chemoattraction of sensory neuron growth cones by diffusible concentration gradients of acetylcholine

Axon guidance cues are critical for the development and repair of both the central and peripheral nervous systems. These cues serve to help select the pathways taken by axon growth cones, by attracting or repulsing them. During development and following injury to the adult peripheral nervous system, neurons must extend processes, often over long distances, through a variety of cellular environments composed of innervated and uninnervated cells, to find, recognize, and synapse on their appropriate targets. The responsibility for recognizing and responding to the extensive number of cues that are encountered as axons alongate falls on the growth cones at the tip of the elongating axons. Cajal (1928) proposed that denervated target cells release diffusible factors that assist in orienting the direction of outgrowth of peripheral axons. However, it is only relatively recently that experiments to identify the molecules responsible for serving this function, and the molecular mechanisms by which they function, have begun to bear fruit. Gradients of both substrate-bound and diffusible factors have now been shown to play critical roles in directing axon outgrowth. The present experiments were aimed at determining whether the neurotransmitter acetylcholine (ACh) can act as a chemoattractant for adult sensory neuron growth cones.

Growth cones turn up concentration gradients of diffusible peripheral target-derived factors

Severed peripheral nerve axons grow across a gap in their pathway to regenerate into the distal nerve stump. At the turn of the century this observation led to the proposal that concentration gradients of factors released from the cells of the distal nerve segment orient the growth of the regenerating axons. Recently, several central nervous system target-derived factors have been shown to direct process outgrowth via concentration gradients of the factors during development. The demonstration of target-derived tropic influences in the peripheral nervous system has however remained elusive. We have examined whether concentration gradients of diffusible factors released by the cells of a length of peripheral nerve influence the outgrowth of adult sensory neuron growth cones in vitro. We demonstrate that the growth cones turn and grow up the concentration gradients, providing evidence for the presence of diffusible peripheral target-derived neurotropic factors that can act in the peripheral nervous system.

Membrane-bound CSPG mediates growth cone outgrowth and substrate specificity by Schwann cell contact with the DRG neuron cell body and not via growth cone contact.

The central nervous system and peripheral nervous system (CNS/PNS) contain factors that inhibit axon regeneration, including myelin-associated glycoprotein (MAG), the Nogo protein, and chondroitin sulfate proteoglycan (CSPG). They also contain factors that promote axon regeneration, such as nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF). Axon regeneration into and within the CNS fails because the balance of factor favors inhibiting regeneration, while in the PNS, the balance of factor favors promoting regeneration. The balance of influences in the CNS can be shifted toward promoting axon regeneration by eliminating the regeneration-inhibiting factors, overwhelming them with regeneration-promoting factors, or making axon growth cones non-receptive to regeneration-inhibiting factors. The present in vitro experiments, using adult rat dorsal root ganglion (DRG) neurons, were designed to determine whether the regeneration-inhibiting influences of Schwann cell CSPG are mediated via Schwann cell membrane contact with the DRG neuron cell body or their growth cones. The average longest neurite of neurons in cell body contact with Schwann cells was 7.4-fold shorter than those of neurons without Schwann cell-neuron cell body contact (naked neurons), and the neurites showed substrate specificity, growing only on the Schwann cell membranes and not extending onto the laminin substrate. The neurites of naked neurons showed no substrate specificity and extended over the laminin substrate, as well as onto and off the Schwann cells. After digesting the Schwann cell CSPG with the enzyme C-ABC, neurons in cell body contact with Schwann cells extended neurites the same length as those of naked neurons, and their neurites showed no substrate selectivity. Further, the neurites of naked neurons were not longer than those of naked neurons not exposed to C-ABC. These data indicate that the extent of neurite outgrowth from adult rat DRG neurons and substrate specificity of their growth cone is mediated via contact between the Schwann cell membrane-bound CSPG and the DRG neuron cell body and not with their growth cones. Further, there was no apparent influence of diffusible or substrate-bound CSPG on neurite outgrowth. These results show that eliminating the CSPG of Schwann cells in contact with the cell body of DRG neurons eliminates the sensitivity of their growth cones to the CSPG-induced outgrowth inhibition. This may in turn allow the axons of these neurons to regenerate through the dorsal roots and into the spinal cord.

Isolation and long-term survival of adult human sensory neurons in vitro.

OBJECTIVE To determine whether adult human dorsal root ganglion neurons can be isolated and maintained in long-term tissue culture, where they would extend processes. METHODS Dorsal root ganglia were removed from adult human organ donors within 2 hours of clamping the aorta. They were then treated with enzymes for one hour, triturated to dissociate the neurons and their satellite cells, and the individual neurons were then plated in tissue culture dishes in medium containing serum. RESULTS Isolated adult human dorsal root ganglion neurons survive in vitro for more than 2 1/2 months, in the absence of exogenously supplied neurotrophins. where they remain electrically excitable and extend processes, CONCLUSIONS Isolated adult human dorsal root ganglion neurons survive in culture for more than 2 1/2 months, extend processes, and remain electrically excitable, without exogenous neurotrophins. These results suggest that, adult human sensory neurons do not require exogenous neurotrophins for survival and process outgrowth, or that sufficient factors were provided by the small number of satellite cells in the cultures. In addition, the neurons survive well in spite of an initial period of up to 14 hours of hypoxia, between the time the aorta was clamped and when the plated neurons were placed in an incubator with the appropriate O2/CO2 environment.

Platelet-Rich Plasma Promotes Axon Regeneration, Wound Healing, and Pain Reduction: Fact or Fiction

Platelet-rich plasma (PRP) has been tested in vitro, in animal models, and clinically for its efficacy in enhancing the rate of wound healing, reducing pain associated with injuries, and promoting axon regeneration. Although extensive data indicate that PRP-released factors induce these effects, the claims are often weakened because many studies were not rigorous or controlled, the data were limited, and other studies yielded contrary results. Critical to assessing whether PRP is effective are the large number of variables in these studies, including the method of PRP preparation, which influences the composition of PRP; type of application; type of wounds; target tissues; and diverse animal models and clinical studies. All these variables raise the question of whether one can anticipate consistent influences and raise the possibility that most of the results are correct under the circumstances where PRP was tested. This review examines evidence on the potential influences of PRP and whether PRP-released factors could induce the reported influences and concludes that the preponderance of evidence suggests that PRP has the capacity to induce all the claimed influences, although this position cannot be definitively argued. Well-defined and rigorously controlled studies of the potential influences of PRP are required in which PRP is isolated and applied using consistent techniques, protocols, and models. Finally, it is concluded that, because of the purported benefits of PRP administration and the lack of adverse events, further animal and clinical studies should be performed to explore the potential influences of PRP.

Platelet-Rich Plasma and the Elimination of Neuropathic Pain

Peripheral neuropathic pain typically results from trauma-induced nociceptive neuron hyperexcitability and their spontaneous ectopic activity. This pain persists until the trauma-induced cascade of events runs its full course, which results in complete tissue repair, including the nociceptive neurons recovering their normal biophysical properties, ceasing to be hyperexcitable, and stopping having spontaneous electrical activity. However, if a wound undergoes no, insufficient, or too much inflammation, or if a wound becomes stuck in an inflammatory state, chronic neuropathic pain persists. Although various drugs and techniques provide temporary relief from chronic neuropathic pain, many have serious side effects, are not effective, none promotes the completion of the wound healing process, and none provides permanent pain relief. This paper examines the hypothesis that chronic neuropathic pain can be permanently eliminated by applying platelet-rich plasma to the site at which the pain originates, thereby triggering the complete cascade of events involved in normal wound repair. Many published papers claim that the clinical application of platelet-rich plasma to painful sites, such as muscle injuries and joints, or to the ends of nerves evoking chronic neuropathic pain, a process often referred to as prolotherapy, eliminates pain initiated at such sites. However, there is no published explanation of a possible mechanism/s by which platelet-rich plasma may accomplish this effect. This paper discusses the normal physiological cascade of trauma-induced events that lead to chronic neuropathic pain and its eventual elimination, techniques being studied to reduce or eliminate neuropathic pain, and how the application of platelet-rich plasma may lead to the permanent elimination of neuropathic pain. It concludes that platelet-rich plasma eliminates neuropathic pain primarily by platelet- and stem cell-released factors initiating the complex cascade of wound healing events, starting with the induction of enhanced inflammation and its complete resolution, followed by all the subsequent steps of tissue remodeling, wound repair and axon regeneration that result in the elimination of neuropathic pain, and also by some of these same factors acting directly on neurons to promote axon regeneration thereby eliminating neuropathic pain.