Changes in synaptic inputs to sympathetic preganglionic neurons after spinal cord injury

Effect of spinal cord injury on the respiratory system: basic research and current clinical treatment options

Spinal cord injury (SCI) often leads to an impairment of the respiratory system. The more rostral the level of injury, the more likely the injury will affect ventilation. In fact, respiratory insufficiency is the number one cause of mortality and morbidity after SCI. This review highlights the progress that has been made in basic and clinical research, while noting the gaps in our knowledge. Basic research has focused on a hemisection injury model to examine methods aimed at improving respiratory function after SCI, but contusion injury models have also been used. Increasing synaptic plasticity, strengthening spared axonal pathways, and the disinhibition of phrenic motor neurons all result in the activation of a latent respiratory motor pathway that restores function to a previously paralyzed hemidiaphragm in animal models. Human clinical studies have revealed that respiratory function is negatively impacted by SCI. Respiratory muscle training regimens may improve inspiratory function after SCI, but more thorough and carefully designed studies are needed to adequately address this issue. Phrenic nerve and diaphragm pacing are options available to wean patients from standard mechanical ventilation. The techniques aimed at improving respiratory function in humans with SCI have both pros and cons, but having more options available to the clinician allows for more individualized treatment, resulting in better patient care. Despite significant progress in both basic and clinical research, there is still a significant gap in our understanding of the effect of SCI on the respiratory system.

VGLUT1 and VGLUT2 innervation in autonomic regions of intact and transected rat spinal cord

Fast excitatory neurotransmission to sympathetic and parasympathetic preganglionic neurons (SPN and PPN) is glutamatergic. To characterize this innervation in spinal autonomic regions, we localized immunoreactivity for vesicular glutamate transporters (VGLUTs) 1 and 2 in intact cords and after upper thoracic complete transections. Preganglionic neurons were retrogradely labeled by intraperitoneal Fluoro-Gold or with cholera toxin B (CTB) from superior cervical, celiac, or major pelvic ganglia or adrenal medulla. Glutamatergic somata were localized with in situ hybridization for VGLUT mRNA. In intact cords, all autonomic areas contained abundant VGLUT2-immunoreactive axons and synapses. CTB-immunoreactive SPN and PPN received many close appositions from VGLUT2-immunoreactive axons. VGLUT2-immunoreactive synapses occurred on Fluoro-Gold-labeled SPN. Somata with VGLUT2 mRNA occurred throughout the spinal gray matter. VGLUT2 immunoreactivity was not noticeably affected caudal to a transection. In contrast, in intact cords, VGLUT1-immunoreactive axons were sparse in the intermediolateral cell column (IML) and lumbosacral parasympathetic nucleus but moderately dense above the central canal. VGLUT1-immunoreactive close appositions were rare on SPN in the IML and the central autonomic area and on PPN. Transection reduced the density of VGLUT1-immunoreactive axons in sympathetic subnuclei but increased their density in the parasympathetic nucleus. Neuronal cell bodies with VGLUT1 mRNA occurred only in Clarke's column. These data indicate that SPN and PPN are densely innervated by VGLUT2-immunoreactive axons, some of which arise from spinal neurons. In contrast, the VGLUT1-immunoreactive innervation of spinal preganglionic neurons is sparse, and some may arise from supraspinal sources. Increased VGLUT1 immunoreactivity after transection may correlate with increased glutamatergic transmission to PPN.

Reorganization of sensory processing below the level of spinal cord injury as revealed by fMRI

The adult mammalian CNS undergoes plastic changes in response to injury. To investigate such changes in spinal cord, functional magnetic resonance imaging (fMRI) was applied in rats subjected to complete transection of the mid-thoracic spinal cord. Blood oxygenation level-dependent (BOLD) contrasts were recorded in the distal spinal cord different times after injury (3, 7, and 14 days, and 1, 3, and 6 months) in response to electrical hind limb stimulation. Functional MRI demonstrated a substantial increase of neuronal activation in the ipsilateral dorsal horn after injury. Notably, 0.5 mA, which did not evoke activation in the normal spinal cord and was considered a non-painful stimulus, induced significant BOLD responses in the dorsal horn after injury. Increased sensitivity was also seen in response to 1.0 mA stimulation. Our results suggest exaggerated responsiveness of spinal neurons after spinal cord injury. Reorganization in the injured spinal cord has been shown to involve the amplification of peripheral inputs and implicated as one underlying mechanism causing neuropathic pain and autonomic dysreflexia. Since BOLD signals can demonstrate such plastic changes in spinal cord parenchyma, we propose fMRI as a method to monitor functional reorganization in the spinal cord after injury. Combining brain and spinal cord fMRI allows the visualization of neuronal activities along the entire neuroaxis and thereby an evaluation of the different plastic responses to CNS injuries that occur in the brain and the spinal cord.

Recognition and effective management of autonomic dysreflexia in spinal cord injuries

Autonomic dysreflexia is a potentially life-threatening hypertensive medical emergency that occurs most often in spinal cord-injured individuals with spinal lesions at or above the mid-thoracic spinal cord level. It is a condition that remains poorly recognised outside of spinal cord injury centres, which may result in adverse outcomes including mortality from potentially delayed diagnosis and treatment. Acute autonomic dysreflexia is characterised by severe paroxysmal hypertension associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension and anxiety, which is sometimes accompanied by cognitive impairment. The key to effective management is prevention of the condition, by recognition and avoidance of factors that initiate the condition. When it occurs, immediate recognition and reversal of trigger factors along with prompt administration of pharmacological treatment is of paramount importance in order to prevent complications, which include intracranial and retinal haemorrhage, convulsions, cardiac irregularities and death. Promising data from recent animal studies may hold the key to future treatment options.

Multi-tasking in the spinal cord--do 'sympathetic' interneurones work harder than we give them credit for?

The role of interneurones in the control of sympathetic activity has been somewhat of a mystery since, for many years, it was difficult to target these cells for study. Recently scientists have started to unravel the action potential properties of these neurones, where they receive their inputs from and where they project to. This review looks at the information known to date about sympathetic interneurones. The locations of these neurones and their local axonal ramifications suggest that they play a more widespread function than previously thought. Therefore the data to support such a theory are also examined.

Targeting myelin to optimize plasticity of spared spinal axons

Functional re-innervation of target neurons following neurological damage such as spinal cord injury is an essential requirement of potential therapies. There are at least two avenues by which this can be achieved: (a) through the regeneration of injured axons and (b) through promoting plasticity of those spared by the initial insult. There are several reasons why the latter approach may be more feasible, not the least of which are the inhibitory character of the glial scar, the often long distances over which injured axons must regrow, and the fact that spared axons are often already in the vicinity of denervated targets. The challenge is to unveil the well-recognized intrinsic plasticity of spared axons in a way that avoids complications, such as pain or autonomic dysfunction. One approach that we as well as others have taken is to target growth-suppressing signaling pathways initiated in spared axons by myelin-derived proteins. This article reviews models used for the study of spinal axon plasticity and describes the anatomical and behavioral effects of interfering with myelinderived proteins, their receptors, and components of their intracellular signaling cascades.

Increased close appositions between corticospinal tract axons and spinal sympathetic neurons after spinal cord injury in rats

Treatments for spinal cord injury may promote new spinal cord synapses. However, the potential for new synapses between descending somatomotor and spinal sympathetic neurons has not been investigated. We studied rats with intact spinal cords and rats after a chronic, bilateral, dorsal spinal hemisection. We identified sympathetically related spinal neurons by transynaptic, retrograde transport of renally injected pseudorabies virus. We counted retrogradely labeled sympathetic preganglionic neurons (SPN) and putative sympathetic interneurons (IN) that, under light microscopy, appeared closely apposed by anterogradely labeled axons of the corticospinal tract (CST) and by axons descending from the well-established sympathetic regulatory region in the rostral ventrolateral medulla (RVLM). Spinal sympathetic neurons that were closely apposed by CST axons were significantly more numerous in lesioned rats than in unlesioned rats. CST axons closely apposed 5.4% of SPN and 10.3% of IN in rats with intact spinal cords, and 38.0% of SPN and 37.3% of IN in rats with chronically lesioned spinal cords. Further, CST appositions in SCI rats consisted of many more varicosities than those in uninjured rats. SPN and IN closely apposed by axons from the RVLM were not more numerous in lesioned rats. However, RVLM axons apposed many more SPN than IN in both control and lesioned rats. Therefore, RVLM sympathoexcitation may be mediated largely by direct synapses on SPN. Although we have not determined the functional significance of close appositions between the CST and spinal sympathetic neurons, we suggest that future studies of spinal cord repair and regeneration include an evaluation of potential, new, somatic-autonomic interactions.

Genetic manipulation of intraspinal plasticity after spinal cord injury alters the severity of autonomic dysreflexia

Severe spinal cord injuries above mid-thoracic levels can lead to a potentially life-threatening hypertensive condition termed autonomic dysreflexia, which is often triggered by painful distension of pelvic viscera (bladder or bowel) and consequent sensory fiber activation, including nociceptive C-fibers. Interruption of tonically active medullo-spinal pathways after injury causes disinhibition of thoracolumbar sympathetic preganglionic neurons, and intraspinal sprouting of nerve growth factor (NGF)-responsive primary afferent fibers is thought to contribute to their hyperactivity. We investigated spinal levels that are critical for eliciting autonomic dysreflexia using a model of noxious colorectal distension (CRD) after complete spinal transection at the fourth thoracic segment in rats. Post-traumatic sprouting of calcitonin gene-related peptide (CGRP)-immunoreactive primary afferent fibers was selectively altered at specific spinal levels caudal to the injury with bilateral microinjections of adenovirus encoding the growth-promoting NGF or growth-inhibitory semaphorin 3A (Sema3a) compared with control green fluorescent protein (GFP). Two weeks later, cardio-physiological responses to CRD were assessed among treatment groups before histological analysis of afferent fiber density at the injection sites. Dysreflexic hypertension was significantly higher with NGF overexpression in lumbosacral segments compared with GFP, whereas similar overexpression of Sema3a significantly reduced noxious CRD-evoked hypertension. Quantitative analysis of CGRP immunostaining in the spinal dorsal horns showed a significant correlation between the extent of fiber sprouting into the spinal segments injected and the severity of autonomic dysreflexia. These results demonstrate that site-directed genetic manipulation of axon guidance molecules after complete spinal cord injury can alter endogenous circuitry to modulate plasticity-induced autonomic pathophysiology.

Unstable baseline blood pressure in chronic tetraplegia

STUDY DESIGN

Case-control.

OBJECTIVE

Tetraplegic patients are subject to episodes of autonomic dysreflexia and postural hypotension. It is suggested that these patients sustain, in addition, unstable baseline blood pressure (BP) that is independent of symptoms and body position.

METHODS

BP monitoring was conducted in 10 tetraplegic patients, motor and sensory complete (American Spinal Injury Association (ASIA) A) (Group A), and five paraplegic at T8-T10 levels, ASIA A (Group B). A SpaceLabs automatically inflating pneumatic cuff recorded arm pressures at 10-30 min intervals in the daytime, sitting position and at 30 min intervals in the night-time, recumbent position. Group mean arterial pressure (MAP) and MAP standard deviation (MAP variation) for sitting and recumbent positions were compared.

RESULTS

Sitting the MAP for Group A was less than that of Group B; 87+/-9 versus 108+/-7 mmHg, P<0.01. However, MAP variability for Group A was greater than for Group B; 17+/-4 (20% of MAP) versus 13+/-2 mmHg (12% of MAP), P=0.04. In the recumbent position, the MAP for Group A was similar to that for Group B; 87+/-13 versus 97+/-7 mmHg, P=0.16. However, MAP variability for Group A remained higher than for Group B; 13+/-3 (20% of MAP) versus 8+/-2 mmHg (8% of MAP), P=0.02.

CONCLUSION

Tetraplegic patients demonstrate unstable BP in either the sitting or recumbent position compared with low thoracic paraplegic patients.

Effects of spinal cord injury on synaptic inputs to sympathetic preganglionic neurons

Spinal cord injuries often lead to disorders in the control of autonomic function, including problems with blood pressure regulation, voiding, defecation and reproduction. The root cause of all these problems is the destruction of brain pathways that control spinal autonomic neurons lying caudal to the lesion. Changes induced by spinal cord injuries have been most extensively studied in sympathetic preganglionic neurons, cholinergic autonomic neurons with cell bodies in the lateral horn of thoracic and upper lumbar spinal cord that are the sources of sympathetic outflow. After an injury, sympathetic preganglionic neurons in mid-thoracic cord show plastic changes in their morphology. There is also extensive loss of synaptic input from the brain, leaving these neurons profoundly denervated in the acute phase of injury. Our recent studies on sympathetic preganglionic neurons in lower thoracic and upper lumbar cord that regulate the pelvic viscera suggest that these neurons are not so severely affected by spinal cord injury. Spinal interneurons appear to contribute most of the synaptic input to these neurons so that injury does not result in extensive denervation. Since intraspinal circuitry remains intact after injury, drug treatments targeting these neurons should help to normalize sympathetically mediated pelvic visceral reflexes. Furthermore, sympathetic pelvic visceral control may be more easily restored after an injury because it is less dependent on the re-establishment of direct synaptic input from regrowing brain axons.

Segmental organization of spinal reflexes mediating autonomic dysreflexia after spinal cord injury

Spinal cord injuries above mid-thoracic levels can lead to a potentially life-threatening hypertensive condition termed autonomic dysreflexia that is often triggered by distension of pelvic viscera (bladder or bowel). This syndrome is characterized by episodic hypertension due to sudden, massive discharge of sympathetic preganglionic neurons in the thoracolumbar spinal cord. This hypertension is usually accompanied by bradycardia, particularly if the injury is caudal to the 2nd to 4th thoracic spinal segments. The development of autonomic dysreflexia is correlated with aberrant sprouting of peptidergic afferent fibers into the spinal cord below the injury. In particular, sprouting of nerve growth factor-responsive afferent fibers has been shown to have a major influence on dysreflexia, perhaps by amplifying the activation of disinhibited sympathetic neurons. Using a model of noxious bowel distension after complete thoracic spinal transection at the 4th thoracic segment in rats, we selectively altered C-fiber sprouting, at specified spinal levels caudal to the injury, with microinjections of adenovirus encoding the growth-promoting nerve growth factor or the growth-inhibitory semaphorin 3A. This was followed by assessment of physiological responses to colorectal distension and subsequent histology. Additionally, anterograde tract tracers were injected into the lumbosacral region to compare the extent of labeled propriospinal rostral projections in uninjured cords to those in cords after complete 4th thoracic transection. In summary, overexpression of chemorepulsive semaphorin 3A impeded C-fiber sprouting in lumbosacral segments and mitigated hypertensive autonomic dysreflexia, whereas the opposite results were obtained with nerve growth factor overexpression. Furthermore, compared to naïve rats, there were significantly more labeled lumbosacral propriospinal projections rostrally after thoracic injury. Collectively, our findings suggest that distension of pelvic viscera increases the excitation of expanded afferent terminals in the disinhibited lumbosacral spinal cord. This, in turn, triggers excitation and sprouting of local propriospinal neurons to relay visceral sensory stimuli and amplify the activation of sympathetic preganglionic neurons in the thoracolumbar cord, to enhance transmission in the spinal viscero-sympathetic reflex pathway. These responses are manifested as autonomic dysreflexia.

Autonomic dysreflexia after spinal cord injury: central mechanisms and strategies for prevention

Spinal reflexes dominate cardiovascular control after spinal cord injury (SCI). These reflexes are no longer restrained by descending control and they can be impacted by degenerative and plastic changes within the injured cord. Autonomic dysreflexia is a condition of episodic hypertension that stems from spinal reflexes initiated by sensory input entering the spinal cord caudal to the site of injury. This hypertension greatly detracts from the quality of life for people with cord injury and can be life-threatening. Changes in the spinal cord contribute substantially to the development of this condition. Rodent models are ideal for investigating these changes. Within the spinal cord, injury-induced plasticity leads to nerve growth factor (NGF)-dependent enlargement of the central arbor of a sub-population of sensory neurons. This enlarged arbor can provide increased afferent input to the spinal reflex, intensifying autonomic dysreflexia. Treatments such as antibodies against NGF can limit this afferent sprouting, and diminish the magnitude of dysreflexia. To assess treatments, a compression model of SCI that leads to progressive secondary damage, and also to some white matter sparing, is very useful. The types of spinal reflexes that likely mediate autonomic dysreflexia are highly susceptible to inhibitory influences of bulbospinal pathways traversing the white matter. Compression models of cord injury reveal that treatments that spare white matter axons also markedly reduce autonomic dysreflexia. One such treatment is an antibody to the integrin CD11d expressed by inflammatory leukocytes that enter the cord acutely after injury and cause significant secondary damage. This antibody blocks integrin-mediated leukocyte entry, resulting in greatly reduced white-matter damage and decreased autonomic dysreflexia after cord injury. Understanding the mechanisms for autonomic dysreflexia will provide us with strategies for treatments that, if given early after cord injury, can prevent this serious disorder from developing.

Enkephalin-immunoreactive interneurons extensively innervate sympathetic preganglionic neurons regulating the pelvic viscera

Enkephalin (ENK)-immunoreactive (IR) axons occur in regions containing spinal autonomic neurons and endogenous opiates contribute to spinal regulation of bladder function. To identify possible spinal sites of opiate action, we used immunocytochemistry for ENK with retrograde tracing from the major pelvic ganglion (MPG), a key location for postganglionic neurons controlling pelvic viscera, with cholera toxin B subunit (CTB) or CTB-horseradish peroxidase (CTB-HRP). We compared the relationship of ENK-IR axons with sympathetic preganglionic neurons (SPNs) projecting to the MPG between intact spinal cords and cords with 2- or 11-week complete transections between thoracic segments 4 and 5. By light microscopy, sections of intact cord showed dense networks of ENK-IR axons surrounding CTB-IR SPNs in the intermediolateral cell column (IML), intercalated nucleus, and central autonomic area of lower thoracic and upper lumbar cord. This staining pattern was similar in rats with 2- or 11-week transections. Ultrastructurally, ENK-IR axons formed synapses on SPNs in all three autonomic subnuclei of intact cord. In the IML, ENK-IR varicosities contributed 52% of the synapses on the somata of MPG-projecting SPNs. In 2-week transected cord, synapses from ENK-IR axons persisted on SPNs and the proportion of input to IML SPNs had increased to 67%, probably reflecting loss of supraspinal input. These results suggest that endogenous opioids could play a major role in controlling sympathetic outflow to the bladder through a direct action on SPNs. The persistence of the dense ENK innervation after complete cord transection indicates that the ENK-IR input to SPNs arises predominantly from intraspinal sources.

Comparison of effects of methylprednisolone and anti-CD11d antibody treatments on autonomic dysreflexia after spinal cord injury

Autonomic dysreflexia is a condition of episodic hypertension that develops after spinal cord injury (SCI). We previously showed that a two-day anti-inflammatory treatment with an anti-CD11d integrin monoclonal antibody (mAb), soon after SCI in rats, reduced the magnitude of dysreflexia for at least 6 weeks. Effects of methylprednisolone (MP), a commonly used neuroprotective treatment for SCI, on dysreflexia have never been examined. We compared the effects of a 2-day MP treatment and/or the anti-CD11d mAb on autonomic dysreflexia, elicited by colon distension, after clip-compression SCI at the 4th thoracic segment (T4) in rats. We assessed the effects of each treatment on the size of the calcitonin gene-related peptide (CGRP)-immunoreactive afferent arbour in the dorsal horn, as changes in this arbour can correlate with the development of dysreflexia. MP reduced autonomic dysreflexia by approximately 50% at 2 weeks after SCI, but this effect was lost by 6 weeks. At 2 weeks, the combined effects of MP and the mAb were not additive, reducing dysreflexia by approximately 50%. Neither MP nor the mAb treatment altered the area of CGRP-immunoreactive fibres in the lumbar cord, the crucial input region for dysreflexia initiated by colon distension. However, both treatments led to increased fibre areas in the T9 segment, correlated with greater tissue integrity and smaller lesions, delineated by inflammatory cells. In summary, MP only temporarily decreases autonomic dysreflexia after SCI. The early beneficial effects of both treatments on dysreflexia do not relate to changes in the CGRP-immunoreactive afferent arbour but may correlate with decreased lesion progression.

A soluble Nogo receptor differentially affects plasticity of spinally projecting axons

In the central nervous system, regeneration of injured axons and sprouting of intact axons are suppressed by myelin-derived molecules that bind to the Nogo receptor (NgR). We used a soluble form of the NgR (sNgR), constructed as an IgG of the human NgR extracellular domain, to manipulate plasticity of uninjured primary afferent and descending monoaminergic projections to the rat spinal cord following dorsal rhizotomy. Rats with quadruple dorsal rhizotomies were treated with intrathecal sNgR or saline, or were left untreated for 2 weeks. Rhizotomy alone resulted in sprouting of serotonergic axons and to a lesser extent, tyrosine-hydroxylase (TH)-expressing axons, while axons expressing dopamine-beta-hydroxylase (DbetaH) were unaffected. Human IgG immunohistochemistry revealed that sNgR infused into the intrathecal space penetrated approximately 300 microm into spinal white and grey matter. Separate axonal populations differed in their responses to intrathecal sNgR: TH-expressing and DbetaH-expressing axons responded most and least vigorously, respectively. Serotonergic axons were identified by serotonin (5-HT) or serotonin transporter (SERT) immunohistochemistry. Interestingly, a large increase in 5-HT compared to SERT-positive axons density in both saline and sNgR-treated rats indicated that serotonergic axons both sprouted and increased their transmitter content in response to rhizotomy and sNgR treatment. Calcitonin gene-related peptide-positive axons were largely depleted ipsilaterally by rhizotomy, and sNgR increased axon density only in deeper contralateral laminae (III-V). GAP-43 immunohistochemistry revealed a small increase in axon density following dorsal rhizotomy that was further augmented by sNgR treatment. These results reveal a differential effect of myelin antagonism on distinct populations of spinally projecting axons.

Setting the stage for functional repair of spinal cord injuries: a cast of thousands

Here we review mechanisms and molecules that necessitate protection and oppose axonal growth in the injured spinal cord, representing not only a cast of villains but also a company of therapeutic targets, many of which have yet to be fully exploited. We next discuss recent progress in the fields of bridging, overcoming conduction block and rehabilitation after spinal cord injury (SCI), where several treatments in each category have entered the spotlight, and some are being tested clinically. Finally, studies that combine treatments targeting different aspects of SCI are reviewed. Although experiments applying some treatments in combination have been completed, auditions for each part in the much-sought combination therapy are ongoing, and performers must demonstrate robust anatomical regeneration and/or significant return of function in animal models before being considered for a lead role.

Autonomic Dysreflexia, Induced by Noxious or Innocuous Stimulation, Does Not Depend on Changes in Dorsal Horn Substance P

After experimental spinal cord injury (SCI) in rats, autonomic dysreflexia is commonly induced by slightly noxious cutaneous or visceral stimuli. The presence of autonomic dysreflexia is associated with an increase in the afferent fiber arbor area labeled by cholera toxin B or with an anti-CGRP antibody. Our goal was to examine further the sensory afferent input contributing to exaggerated autonomic spinal reflexes and subsequent increases in blood pressure after SCI, typical of autonomic dysreflexia. We observed that changes in blood pressure and heart rate induced by slightly noxious stimuli (2.0-mL balloon colon distension, cutaneous pinch) were increased in magnitude with time after SCI. In contrast, cardiovascular responses induced by non-noxious stimuli (1.0-mL balloon colon distension, light stroking of hair) were relatively constant. We examined substance P-immunoreactive afferent fibers to identify type C, unmyelinated afferent fibers, and A delta lightly myelinated fibers in superficial and deeper laminae of the dorsal horn, respectively. The area of substance P-immunoreactive fibers was quantified in laminae I-V of the dorsal horn. Analysis revealed no difference in substance P afferent fiber area in laminae I-II, or laminae III-V, between sham-injured and SCI rats. These data suggest that noxious, or innocuous, stimulation induces autonomic dysreflexia without expansion of the central arbors of substance P-immunoreactive sensory neurons. Furthermore, autonomic dysreflexia induced by noxious stimulation increases with time after spinal cord injury.

Artificial autonomic reflexes: using functional electrical stimulation to mimic bladder reflexes after injury or disease

Autonomic reflexes controlling bladder storage (continence) and emptying (micturition) involve spinal and supraspinal nerve pathways, with complex mechanisms coordinating smooth muscle activity of the lower urinary tract with voluntary muscle activity of the external urethral sphincter (EUS). These reflexes can be severely disrupted by various diseases and by neurotrauma, particularly spinal cord injury (SCI). Functional electrical stimulation (FES) refers to a group of techniques that involve application of low levels of electrical current to artificially induce or modify nerve activation or muscle contraction, in order to restore function, improve health or rectify physiological dysfunction. Various types of FES have been developed specifically for improving bladder function and while successful for many urological patients, still require substantial refinement for use after spinal cord injury. Improved knowledge of the neural circuitry and physiology of human bladder reflexes, and the mechanisms by which various types of FES alter spinal outflow, is urgently required. Following spinal cord injury, physical and chemical changes occur within peripheral, spinal and supraspinal components of bladder reflex circuitry. Better understanding of this plasticity may determine the most suitable methods of FES at particular times after injury, or may lead to new FES approaches that exploit this remodeling or perhaps even influence the plasticity. Advances in studies of the neuroanatomy, neurophysiology and plasticity of lumbosacral nerve circuits will provide many further opportunities to improve FES approaches, and will provide "artificial autonomic reflexes" that much more closely resemble the original, healthy neuronal regulatory mechanisms.

Spinal shock revisited: a four-phase model

Spinal shock has been of interest to clinicians for over two centuries. Advances in our understanding of both the neurophysiology of the spinal cord and neuroplasticity following spinal cord injury have provided us with additional insight into the phenomena of spinal shock. In this review, we provide a historical background followed by a description of a novel four-phase model for understanding and describing spinal shock. Clinical implications of the model are discussed as well.

Activation and integration of bilateral GABA-mediated synaptic inputs in neonatal rat sympathetic preganglionic neurones in vitro

The role of GABA receptors in synaptic transmission to neonatal rat sympathetic preganglionic neurones (SPNs) was investigated utilizing whole-cell patch clamp recording techniques in longitudinal and transverse spinal cord slice preparations. In the presence of glutamate receptor antagonists (NBQX, 5 microm and D-APV, 10 microm), electrical stimulation of the ipsilateral or contralateral lateral funiculi (iLF and cLF, respectively) revealed monosynaptic inhibitory postsynaptic potentials (IPSPs) in 75% and 65% of SPNs, respectively. IPSPs were sensitive to bicuculline (10 microM) in all neurones tested and reversed polarity around -55 mV, the latter indicating mediation via chloride conductances. In three neurones IPSPs evoked by stimulation of the iLF (n = 1) or cLF (n = 2) were partly sensitive to strychnine (2 microM). The expression of postsynaptic GABA(A) and GABA(B) receptors were confirmed by the sensitivity of SPNs to agonists, GABA (2 mm), muscimol (10-100 microM) or baclofen (10-100 microM), in the presence of TTX, each of which produced membrane hyperpolarization in all SPNs tested. Muscimol-induced responses were sensitive to bicuculline (1-10 microM) and SR95531 (10 microM) and baclofen-induced responses were sensitive to 2-hydroxy-saclofen (100-200 microM) and CGP55845 (200 nM). The GABA(C) receptor agonist CACA (200 microM) was without significant effect on SPNs. These results suggest that SPNs possess postsynaptic GABA(A) and GABA(B) receptors and that subsets of SPNs receive bilateral GABAergic inputs which activate GABA(A) receptors, coupled to a chloride conductance. At resting or holding potentials close to threshold either single or bursts (10-100 Hz) of IPSPs gave rise to a rebound excitation and action potential firing at the termination of the burst. This effect was mimicked by injection of small (10-20 pA) rectangular-wave current pulses, which revealed a time-dependent, Cs(+)-sensitive inward rectification and rebound excitation at the termination of the response to current injection. Synaptic activation of a rebound excitation mediated by a time-dependent inward rectification expressed intrinsically by SPNs may provide a novel mechanism enabling SPNs to be entrained to rhythms driven from the brainstem or higher centres.

Tail arteries from chronically spinalized rats have potentiated responses to nerve stimulation in vitro

Patients with severe spinal cord lesions that damage descending autonomic pathways generally have low resting arterial pressure but bladder or colon distension or unheeded injuries may elicit a life-threatening hypertensive episode. Such episodes (known as autonomic dysreflexia) are thought to result from the loss of descending baroreflex inhibition and/or plasticity within the spinal cord. However, it is not clear whether changes in the periphery contribute to the exaggerated reflex vasoconstriction. The effects of spinal transection at T7-8 on nerve- and agonist-evoked contractions of the rat tail artery were investigated in vitro. Isometric contractions of arterial segments were recorded and responses of arteries from spinalized animals ('spinalized arteries') and age-matched and sham-operated controls were compared. Two and eight weeks after transection, nerve stimulation at 0.1-10 Hz produced contractions of greater force and duration in spinalized arteries. At both stages, the alpha-adrenoceptor antagonists prazosin (10 nm) and idazoxan (0.1 microm) produced less blockade of nerve-evoked contraction in spinalized arteries. Two weeks after transection, spinalized arteries were supersensitive to the alpha(1)-adrenoceptor agonist phenylephrine, and the alpha(2)-adrenoceptor agonist, clonidine, but 8 weeks after transection, spinalized arteries were supersensitive only to clonidine. Contractions of spinalized arteries elicited by 60 mm K(+) were larger and decayed more slowly at both stages. These findings demonstrate that spinal transection markedly increases nerve-evoked contractions and this can, in part, be accounted for by increased reactivity of the vascular smooth muscle to vasoconstrictor agents. This hyper-reactivity may contribute to the genesis of autonomic dysreflexia in patients.

Age-associated changes in the monoaminergic innervation of rat lumbosacral spinal cord

The effects of ageing on the innervation patterns of lumbosacral spinal nuclei involved in controlling lower urinary tract functions, including micturition, were studied using immunohistochemistry for serotonin (5-HT) and tyrosine hydroxylase (TH) in male Wistar rats of 3 and 24 months. Quantitative image analysis revealed significant age-associated declines in the innervation of most regions including the intermediolateral cell nucleus, sacral parasympathetic nucleus, dorsal grey commissure and in the ventral horn including the dorsolateral nucleus which in the rat is one of the component nuclei homologous to Onuf's nucleus in man. Notable exceptions to this generalised decline were observed in the 5-HT innervation of the sacral parasympathetic nucleus, which was maintained, and in the region of the dorsolateral motor nucleus where TH-like immunoreactivity did not significantly decline. These results suggest that the changes in micturition characteristics observed in aged rats may in part be a consequence of the alterations in, and decline of, aminergic inputs to both autonomic and somatic spinal nuclei associated with bladder function.

Glutamate and GABA content of calbindin-immunoreactive nerve terminals in the rat intermediolateral cell column

Immunoreactivity for calbindin-D28K (calbindin) occurs in some bulbospinal vasopressor neurons in the rostral ventrolateral medulla and calbindin-immunoreactive terminals form synapses in the intermediolateral cell column (IML), where the cell bodies of sympathetic preganglionic neurons are located. In this study, we used post-embedding immunogold labelling to determine whether calbindin terminals in the IML contained the excitatory amino acid neurotransmitter glutamate. We also assessed GABA immunoreactivity in semi-serial sections through the same terminals since this inhibitory amino acid transmitter is present in the inputs to sympathetic preganglionic neurons that lack glutamate. Analysis of 42 calbindin-positive terminals whose postsynaptic targets were not identified revealed two major groups on the basis of amino acid content. One group was immunoreactive for glutamate; and the other, for GABA. In addition, about 20% of the calbindin terminals were positive for both glutamate and GABA. Our anatomical methods cannot differentiate whether this third group is a subset of the GABAergic terminals or a separate population capable of co-releasing the two amino acids.

GABA in the control of sympathetic preganglionic neurons

1. Amino acid neurotransmitters are critical for controlling the activity of most central neurons, including sympathetic preganglionic neurons (SPN), the spinal cord neurons involved in controlling blood pressure and other autonomic functions. 2. In studies reviewed here, SPN were identified either by retrograde tracing from a peripheral target (superior cervical ganglion or adrenal medulla) or by detection of immunoreactivity for choline acetyltransferase (ChAT), the acetylcholine-synthesizing enzyme that is a marker for all SPN, in intact or completely transected rat spinal cord. 3. Postembedding immunogold labelling on ultrathin sections was then used to detect GABA and sometimes glutamate in nerve terminals on SPN or near them in the neuropil of the lateral horn. 4. In some cases, the terminals were prelabelled to show an anterograde tracer or immunoreactivity for ChAT or neuropeptide Y. 5. This anatomical work has provided information that is helpful in understanding how SPN are influenced by their GABAergic innervation. 6. Immunogold studies showed that the proportion of input provided by GABAergic terminals varies between different groups of SPN. For some groups, this input may be preferentially targeted to cell bodies. 7. Anterograde tracing demonstrated that supraspinal as well as intraspinal GABAergic neurons innervate SPN and investigations on completely transected cord suggested that supraspinal neurons may provide a surprisingly large proportion of the GABAergic terminals that contact SPN. 8. The double-labelling studies in which other amino acids, ChAT or neuropeptide Y were localized along with GABA indicate that GABAergic terminals contain other neurochemicals that could modulate the actions of GABA, depending on the complement of receptors that are present pre- and post-synaptically. 9. Taken together, these data indicate that GABAergic transmission to SPN may be much more complicated than suggested by the currently available electrophysiological studies.