Thomas Carlstedt

Return of function after spinal cord implantation of avulsed spinal nerve roots

Avulsion of nerve roots from the spinal cord is widely regarded as an untreatable injury. However, a series of experiments in animals has shown that, if continuity is restored between spinal cord and ventral roots, axons from spinal motor neurons can regrow into the peripheral nerves with recovery of motor function. These observations were applied in the treatment of a man with avulsion of the 6th cervical (C6) to 1st thoracic roots due to brachial plexus injury. Two ventral roots were implanted into the spinal cord through slits in the pia mater, C6 directly and C7 via sural nerve grafts. Voluntary activity in proximal arm muscles was detected electromyographically after nine months and clinically after one year. After three years the patient had voluntary activity (with some co-contraction) in the deltoid, biceps, and triceps muscles. To determine whether the improvement was due to spontaneous recovery from C5, the C5 root was blocked pharmacologically, and the results indicated that the repaired roots were contributing substantially to motor function. Repair of spinal nerve roots deserves further exploration in management of brachial plexus injury.

Regenerating axons form nerve terminals at astrocytes

In adult rats ventral root (cholinergic axons) or hypogastric nerve (catecholaminergic axons) has been coapted to ganglionectomized dorsal root. The cholinergic and catecholaminergic fibers elongate as far as the peripheral-central nervous border. At this point some fibres were observed to have made synaptoid nerve terminals among astrocytes. The nerve endings accumulated transmitter substance even though they made no neuronal synapses.

Motoneurons reinnervate skeletal muscle after ventral root implantation into the spinal cord of the cat

By use of intracellular recording and staining with horseradish peroxidase it was found that alpha and probably also gamma motoneurons were able to reinnervate ventral root implants after an avulsion of ventral roots at the spinal cord surface in the cat. The reinnervation of the implant was achieved after an initial growth of new axons in central nervous system tissue. Reinnervating neurons could be excited or inhibited by segmental reflex activity and their axons could conduct nerve impulses. The character of muscle twitch responses elicited by electrical stimulation of implanted roots strongly indicated that denervated muscles were reinnervated by new motor axons via the implant.

Interaction of transplanted olfactory-ensheathing cells and host astrocytic processes provides a bridge for axons to regenerate across the dorsal root entry zone

A single fourth lumbar dorsal rootlet was transected at the entry point into the spinal cord. The nerve fibres were labelled with biotin dextran injected into the rootlet. An endogenous matrix containing olfactory-ensheathing cells (OECs) labelled with green fluorescent protein was applied to the opposing cut surfaces of the rootlet and the spinal cord, which were then brought into apposition and held in place by fibrin glue. Two weeks later, a ladderlike bridging structure has been formed by astrocytic processes growing out for about 200-300 microm from the spinal cord. The transplanted cells remained largely confined to this area. They were elongated along the nerve axis but did not enter the spinal cord itself. Labelled dorsal root axons crossed the repaired dorsal root entry zone in alignment with the bridging astrocytic processes and the transplanted cells and then proceeded beyond the transplant to enter the grey matter of the dorsal horn and send axons both rostrally and caudally for at least 10 mm in the white matter of the ascending dorsal columns.

Fetal mesencephalic neurons survive and extend long axons across peripheral nervous system grafts inserted into the adult rat striatum

In adult rats whose nigrostriatal dopamine (DA) pathway had been chemically damaged we implanted a fetal mesencephalic graft over the superior colliculus and joined it to the denervated striatum by means of an approximately 2 cm long segment of heterologous sciatic nerve. Monoaminergic neurons within the implant extended axons along the entire length of the nerve bridges and of these fibers extended into the striatum, which is the normal target of nigral projections. Thus, combinations of fetal neuronal and peripheral nervous system grafts can be used in vivo to provide both a source and a substrate for lengthy axonal growth.

Regrowth of lesioned dorsal root nerve fibers into the spinal cord of neonatal rats

In postnatal rat pups the L4 and L5 dorsal roots were lesioned. After 3-6 months the spinal cord of the rats was subjected to tracing studies of regenerated dorsal root axons with transganglionically transported horseradish peroxidase (HRP) and immunohistochemistry with antibodies to calcitonin gene-related peptide (CGRP). In rats operated at birth (0-2 days old) HRP-filled profiles as well as CGRP staining were found in the outer lamina of the spinal cord dorsal horn. Signs of dorsal root nerve fiber regrowth in the spinal cord could not be found in rats which had been operated at the end of the first postnatal week or later.

Co-treatment with riluzole and GDNF is necessary for functional recovery after ventral root avulsion injury.

Unilateral avulsion of lumbar ventral roots kills approximately 50% of injured motoneurons within 2 weeks of surgery. Immediate treatment involving surgical reimplantation of the ventral root (VRI) or intrathecal glial cell line-derived neurotrophic factor (GDNF) delivery or intraperitoneal injection of riluzole for 2 weeks ameliorates motoneuron death to 80% of control but combining the different treatment paradigms did not further enhance survival except when GDNF was combined with VRI. At 3 months, all combined treatments provided a neuroprotective effect compared to avulsion only, but the neuroprotective effect of surgical reimplantation alone was not maintained unless combined with riluzole and GDNF treatment. Analysis of regenerating motoneurons using retrograde labelling techniques showed that riluzole, but not GDNF, increased the number of dendrites per labelled motoneuron. However, when functional motor recovery was assessed using the BBB locomotor score and rotarod tests, only VRI animals treated with riluzole and GDNF application showed significantly improved locomotor function in both tests. Our results show that functional recovery appears related to a combination of enhanced dendrite formation, increased motoneuron survival and the neurotrophic actions of GDNF. Thus, combination treatment may offer a new therapeutic strategy for treating patients with avulsion injury.

Pain phenomena and sensory recovery following brachial plexus avulsion injury and surgical repairs.

Seventy-six patients with severe brachial plexus avulsion injuries were studied using pain questionnaires and quantitative sensory testing. There was significant correlation between pain intensity and the number of roots avulsed prior to surgery (P = 0.0004) and surgical repairs were associated with pain relief. Sensory recovery to thermal stimuli was observed, mainly in the C5 dermatome. Allodynia to mechanical and thermal stimuli was observed in the border zone of affected and unaffected dermatomes in 18% of patients assessed early (<6 months) and 37% patients at later stages. Pain and sensations referred to the original source of afferents occurred at a later stage (>6 months) in 12% of patients and were related to nerve regeneration. By contrast, “wrong-way” referred sensations (e.g. down the affected arm while shaving or drinking cold fluids) were reported by 44% of patients and often occurred early, suggesting CNS plasticity. Understanding sensory mechanisms will help develop new treatments for severe brachial plexus injuries.

Spinal cord implantation of avulsed ventral roots in primates; correlation between restored motor function and morphology

Abstractu2002Functional restitution following spinal cord implantation of avulsed ventral roots was assessed electromyographically and correlated with the morphology of the regenerated neural structures in primates. The C5–C8 ventral roots were avulsed from the spinal cord in seven Macaca fascicularis monkeys. In three animals the roots were immediately reimplanted into the ventrolateral part of the spinal cord. In two monkeys the avulsed roots were reimplanted with a delay of 2 months and in two control animals the roots were not reimplanted. There was substantial recovery of function after both immediate and delayed spinal cord implantation of the avulsed ventral roots. The population of neurons that had regenerated was larger than on the control side, indicating a rescue of cells after an immediate root implantation. Different functional types of neurons had been attracted to regrow axons to the implanted root as judged by their position in the ventral horn. Thus, neurons normally supplying antagonistic muscles, such as the triceps muscle, participated in the innervation of the biceps muscle. Functionally this deficient directional specificity was correlated to both spasticity and co-contractions among agonistic and antagonistic muscles. Occasional electromyographic signs of function occurred also in control animals where the avulsed roots had not been implanted. This recovery was found to depend on regrowth from the site of avulsion, within the pia mater among the leptomeningeal cells and to the avulsed roots. The acceptable functional dexterity regained due to corrective surgery is discussed in terms of neurotrophism and plasticity.

Regrowth of motor axons following spinal cord lesions: Distribution of laminin and collagen in the CNS scar tissue

In previous studies we have demonstrated that spinal motoneurons in the adult cat can regenerate CNS-type axons through CNS scar tissue into denervated ventral roots. This scar tissue, which appears to support and sustain the growth of injured CNS axons, has been shown to have a persistent defect in the blood-brain barrier (BBB). In the present study, the binding of antibodies to nerve growth factor receptor (NGFr), laminin, collagen, and a microtubule associated protein (MAP5) was assessed with indirect immunohistochemical methods 4 days-20 weeks after a lesion in the ventral funiculus of the spinal cord. An increase in content of collagen-, laminin-, and NGFr-like immunoreactivity was observed in the scar tissue during the first 3 weeks. Although type I collagen dominated in superficial areas of the scar, type IV collagen and laminin-like immunoreactivity was observed in expanded perivascular spaces all over the lesion zone. Type IV collagen- and laminin-immunoreactive structures sometimes appeared to form strands which interconnected the ventral horn and the ventral root. Regenerating axons, as revealed by staining with MAP5 or NGFr antibodies, were observed in close association to these paths. It has been suggested that a breakdown of the BBB may play a vital role in certain types of CNS regeneration by increasing the access of blood-borne trophic factors to the lesion area. The demonstration of extracellular matrix proteins like laminin provides further evidence for the notion that the observed regenerative growth takes place in an environment that is markedly different from the normal CNS.