Nerve regeneration along bioengineered scaffolds

Evaluation methods as quality control in the generation of decellularized peripheral nerve allografts

Nowadays, the high incidence of peripheral nerve injuries and the low success ratio of surgical treatments are driving research to the generation of novel alternatives to repair critical nerve defects. In this sense, tissue engineering has emerged as a possible alternative with special attention to decellularization techniques. Tissue decellularization offers the possibility to obtain a cell-free, natural extracellular matrix (ECM), characterized by an adequate 3D organization and proper molecular composition to repair different tissues or organs, including peripheral nerves. One major problem, however, is that there are no standard quality control methods to evaluate decellularized tissues. Therefore, in this review, a brief description of current strategies for peripheral nerve repair is given, followed by an overview of different decellularization methods used for peripheral nerves. Furthermore, we extensively discuss the available and currently used methods to demonstrate the success of tissue decellularization in terms of the cell removal, preservation of essential ECM molecules and maintenance or modification of biomechanical properties. Finally, orientative guidelines for the evaluation of decellularized peripheral nerve allografts are proposed.

The Median Nerve Injury Model in Pre-clinical Research - A Critical Review on Benefits and Limitations

The successful introduction of innovative treatment strategies into clinical practise strongly depends on the availability of effective experimental models and their reliable pre-clinical assessment. Considering pre-clinical research for peripheral nerve repair and reconstruction, the far most used nerve regeneration model in the last decades is the sciatic nerve injury and repair model. More recently, the use of the median nerve injury and repair model has gained increasing attention due to some significant advantages it provides compared to sciatic nerve injury. Outstanding advantages are the availability of reliable behavioural tests for assessing posttraumatic voluntary motor recovery and a much lower impact on the animal wellbeing. In this article, the potential application of the median nerve injury and repair model in pre-clinical research is reviewed. In addition, we provide a synthetic overview of a variety of methods that can be applied in this model for nerve regeneration assessment. This article is aimed at helping researchers in adequately adopting this in vivo model for pre-clinical evaluation of peripheral nerve reconstruction as well as for interpreting the results in a translational perspective.

A New Preparation Method for Anisotropic Silk Fibroin Nerve Guidance Conduits and Its Evaluation In Vitro and in a Rat Sciatic Nerve Defect Model

Over the past decade, silk fibroin (SF) has been emergently used in peripheral nerve tissue engineering. Current approaches aiming at producing SF-based nerve guidance conduits (SF-NGCs) used dissolved silk based on either aqueous solutions or organic solvents. In this study, we describe a novel procedure to produce SF-NGCs: A braided tubular structure of raw Bombyx mori silk is subsequently processed with the ternary solvent CaCl2/H2O/ethanol, formic acid, and methanol to improve its mechanical and topographical characteristics. Topographically, the combination of the treatments results in a fusion of the outer single silk fibers to a closed layer with a thickness ranging from about 40 to 75 μm. In contrast to the outer wall, the inner lumen (not treated with processing solvents) still represents the braided structure of single fibers. Mechanical stability, elasticity, and kink characteristics were evaluated with a custom-made test system. The modification procedure described here drastically improved the elastic properties of our tubular raw scaffold, favoring its use as a NGC. A cell migration assay with NIH/3T3-fibroblasts revealed the impermeability of the SF-NGC wall for possible invading and scar-forming cells. Moreover, the potential of the SF-NGC to serve as a substratum for Schwann cells has been demonstrated by cytotoxicity tests and live-dead stainings of Schwann cells grown on the inner surface of the SF-NGC. In vivo, the SF-NGC was tested in a rat sciatic nerve injury model. In short-term in vivo studies, it was proved that SF-NGCs are not triggering host inflammatory reactions. After 12 weeks, we could demonstrate morphological and functional reinnervation of the distal targets. Filled with collagen, a higher number of axons could be found in the distal to the graft (1678±303), compared with the empty SF-NGC (1274±146). The novel SF-NGC presented here shows promising results for the treatment of peripheral nerve injuries. The modification of braided structures to adapt their mechanical and topographical characteristics may support the translation of SF-based scaffolds into the clinical setting. However, further improvements and the use of extracellular matrix molecules and Schwann cells are suggested to enable silk tube based conduits to bridge long-distance nerve gaps.

Triggering protein adsorption on tailored cationic cellulose surfaces

The equipment of cellulose ultrathin films with BSA (bovine serum albumin) via cationization of the surface by tailor-made cationic celluloses is described. In this way, matrices for controlled protein deposition are created, whereas the extent of protein affinity to these surfaces is controlled by the charge density and solubility of the tailored cationic cellulose derivative. In order to understand the impact of the cationic cellulose derivatives on the protein affinity, their interaction capacity with fluorescently labeled BSA is investigated at different concentrations and pH values. The amount of deposited material is quantified using QCM-D (quartz crystal microbalance with dissipation monitoring, wet mass) and MP-SPR (multi-parameter surface plasmon resonance, dry mass), and the mass of coupled water is evaluated by combination of QCM-D and SPR data. It turns out that adsorption can be tuned over a wide range (0.6-3.9 mg dry mass m(-2)) depending on the used conditions for adsorption and the type of employed cationic cellulose. After evaluation of protein adsorption, patterned cellulose thin films have been prepared and the cationic celluloses were adsorbed in a similar fashion as in the QCM-D and SPR experiments. Onto these cationic surfaces, fluorescently labeled BSA in different concentrations is deposited by an automatized spotting apparatus and a correlation between the amount of the deposited protein and the fluorescence intensity is established.

Update on nerve repair by biological tubulization

Many surgical techniques are available for bridging peripheral nerve defects. Autologous nerve grafts are the current gold standard for most clinical conditions. In selected cases, alternative types of conduits can be used. Although most efforts are today directed towards the development of artificial synthetic nerve guides, the use of non-nervous autologous tissue-based conduits (biological tubulization) can still be considered a valuable alternative to nerve autografts. In this paper we will overview the advancements in biological tubulization of nerve defects, with either mono-component or multiple-component autotransplants, with a special focus on the use of a vein segment filled with skeletal muscle fibers, a technique that has been widely investigated in our laboratory and that has already been successfully introduced in the clinical practice.

Neuregulin1 administration increases axonal elongation in dissociated primary sensory neuron cultures

Neuregulin1 is a family of growth and differentiation factors involved in various functions of both peripheral and central nervous system including the regenerative processes that underlie regeneration of damaged peripheral nerves. In the present study we tested in vitro the effect of Neuregulin1 administration on dissociated rat dorsal root ganglion (DRG). Activity of neuregulin1 was compared to the activity of nerve growth factor in the same in vitro experimental model. Results showed that neurite outgrowth is enhanced by the addition of both neuregulin1 and nerve growth factor to the culture medium. While neuregulin1 was responsible for the growth of longer neurites, DRG neurons incubated with nerve growth factor showed shorter and more branched axons. Using enzyme-linked immunosorbent assay we also showed that the release of nerve growth factor, but not of brain derived neurotrophic factor is improved in DRG neuron treated with neuregulin1. On the other hand, the assay with growth factor blocking antibody, showed that effects exerted by neuregulin1 on neurite outgrowth is only partially due to the release of nerve growth factor. Taken together the results of this study provide a better understanding on the role of neuregulin1 in sensory neurons.

Muscle-in-vein nerve guide for secondary reconstruction in digital nerve lesions

PURPOSE

Although vein conduits filled with fresh skeletal muscle have been used to bridge nerve defects both experimentally and clinically with good results, this approach has never been considered a valuable tool for reconstruction of nerve defects, and the technique has been abandoned. The purpose of this study was to evaluate the application of muscle-in-vein conduits for secondary digital nerves reconstruction, with particular emphasis on the surgical technique and results.

METHODS

We present a retrospectively selected consecutive series of 21 digital nerve defects in 17 patients who were treated with vein conduits filled with fresh skeletal muscle for secondary nerve reconstruction. After a minimum follow-up of 18 months, all patients were studied with static and moving 2-point discrimination, Semmes-Weinstein monofilament testing, Visual Analog Scale, and Disabilities of the Arm, Shoulder, and Hand questionnaire. Outcome data were stratified according to the American Society for Surgery of the Hand guidelines, the modified Highet and Sander's criteria, and the Logic Tree.

RESULTS

The average nerve gap bridged with the muscle-in-vein conduit was 2.2 cm (range, 1-3.5 cm). We classified 14 of 22 reconstructed nerves as excellent or good according to American Society for Surgery of the Hand guidelines, whereas 17 were between S4 and S3 using modified Highet and Sander's criteria. The Logic Tree yielded results between S4 and S3 in 14 of 21 reconstructed nerves. The average Disabilities of the Arm, Shoulder, and Hand survey scores were 22.5 for the disability/symptoms module and 21.4 and 17 for the sports/music and work subcomponents, respectively.

CONCLUSIONS

Use of muscle-in-vein conduits should be considered and promoted for sensory nerve reconstruction for a number of reasons: the encouraging results with the technique; the abundant availability of both donor tissues; the flexibility of the conduit resulting from the combination of muscle and vein; the simplicity with which tubes can be fashioned; immunological compatibility; and the absence of adjunctive costs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Effect of low-intensity pulsed ultrasound on the expression of neurotrophin-3 and brain-derived neurotrophic factor in cultured Schwann cells

It is generally known that low-intensity pulsed ultrasound (LIPUS) accelerates peripheral nerve tissue regeneration. However, the precise cellular mechanism involved is still unclear. The purpose of this study was to determine how the Schwann cells respond directly to LIPUS stimuli. Thus, we investigated the effect of LIPUS on cell proliferation, neurotrophin-3 (NT-3), and brain-derived neurotrophic factor (BDNF) mRNA expression in rat Schwann cells. Schwann cells were enzymatically isolated from postnatal 1-3 day rat sciatic nerve tissue and cultured in the six-well plate. The ultrasound was applied at a frequency of 1 MHz and an intensity of 100 mW/cm(2) spatial average temporal average for 5 minutes/day. The control group was cultured in the same way but without the administration of ultrasound. Immunohistochemistry demonstrated that more than 98% of the experimental and control cells were positive for S-100, NT-3, and BDNF. With 5-bromo-2'-deoxyuridine (BrdU) assay, the stimulated cells also exhibited an increase in the rate of cell proliferation on days 4, 7, 10, and 14. Further investigation found that mRNA expression of NT-3 was significantly upregulated in experimental groups compared with the control 14 days after the LIPUS stimulation (the ratio of NT-3/beta-actin was 0.56 +/- 0.13 vs. 0.41 +/- 0.09, P < 0.01), whereas the mRNA expression of BDNF was significantly downregulated in experimental groups compared with the control (the ratio of BDNF/beta-actin was 0.51 +/- 0.05 vs. 0.60 +/- 0.08, P < 0.05). These results demonstrated that the application of LIPUS promotes cell proliferation and NT-3 gene expression in Schwann cells, and involved in the alteration of BDNF gene expression.

Functional recovery after implantation of artificial nerve grafts in the rat- a systematic review

Purpose

The aim of this study was to compare functional data of different nerve-gap bridging materials evaluated in rat experiments by means of a systematic review.

Materials and methods

A systematic review was conducted, searching MEDLINE, HTS and CENTRAL to identify all trials evaluating functional recovery of artificial nerve conduits in the rat model.

Results

There was a trend towards a favourable outcome of conduits coated with Schwann-cells compared to the plain synthetics. Histomorphometry, electrophysiology and muscle-weight correlated poorly with functional outcome.

Conclusion

Schwann-cell coated conduits showed promising results concerning functional recovery. Further standardization in outcome reporting is encouraged.

Comparison of regeneration results of prefabricated nerve graft, autogenous nerve graft, and vein graft in repair of nerve defects

The purpose of this study was to evaluate the effectivity of prefabricated nerve grafts in the repairing nerve defect and to compare them with the autogenous nerve graft and vein graft. Four groups were created, each containing 10 rats. First, nerve prefabrication was carried out in groups I and II during 8 weeks. For this purpose, jugular vein graft was sutured to the epineural windows on the peroneal and tibial nerve at the right side in an end-to-side fashion. To create neurotrophic stimulus, partial incision was performed on the nerves in group I, and gene therapy was performed by plasmid injecting to the adjacent muscles in group II. At the end of the eighth week, prefabricated nerve grafts, jugular vein, and the axons passing through it were taken. Then, gap was created on the left peroneal nerve in all groups. Defect on the peroneal nerve was repaired by using the prefabricated nerve grafts in groups I and II, the autogenous nerve graft in group III, and the vein in group IV. Assessment of nerve regeneration was performed by using electromyography. Morphological assessment was performed after follow-up period. According to electrophysiological and morphological results, the results of first three groups were similar. There was no statistically significant difference between three groups. Prefabricated nerve graft is as effective as autogenous nerve graft, and it can be used in the repair of nerve defects as autogenous nerve graft as an alternative.

Functional and morphological assessment of a standardized crush injury of the rat median nerve

The availability of effective experimental models for investigating nerve regeneration and designing new strategies for promoting this unique repair process is important. The aim of this study was to standardize a rat median nerve crush injury model using a non-serrated clamp exerting a compression force of 17.02 MPa for a duration of 30s. Results showed that functional recovery, evaluated by grasping test, was already detectable at day-12 and progressively increased until day-28 after which animal performance plateaued until the end of testing (day-42), reaching a range of 75-80% of pre-operative values. Morphological analysis on the median nerve segments, distal to the crush lesion, which were withdrawn at the end of the experiment showed that regenerated nerve fibers are significantly more numerous and densely packed; they are also smaller and have a thinner myelin sheath compared to controls. Together, these results provide a baseline characterization of the crush median nerve injury experimental model for its employment in the investigation of nerve regeneration research, especially when a reproducible regeneration process is required, such as for the study of biological mechanisms of peripheral nerve fiber regeneration or development of new therapeutic agents for promoting posttraumatic nerve repair.

Chapter 3: Histology of the peripheral nerve and changes occurring during nerve regeneration

Peripheral nerves are complex organs that can be found throughout the body reaching almost all tissues and organs to provide motor and/or sensory innervation. A parenchyma (the noble component made by the nerve fibers, i.e., axons and Schwann cells) and a stroma (the scaffold made of various connective elements) can be recognized. Although morphological analysis is the most common approach for studying peripheral nerve regeneration, researchers are not always aware of several histological peculiarities of these organs. Therefore, the aim of this review is to describe, at a structural and ultrastructural level, the main features of the parenchyma and the stroma of the normal undamaged nerve as well as the most important morphological changes that occur after nerve damage and during posttraumatic nerve regeneration. The paper is aimed at providing the reader with the basic framework information on nerve morphology. This would enable the correct interpretation of morphological data obtained by many experimental studies on peripheral nerve repair and regeneration such as those outlined in several other papers included in this special issue of the International Review of Neurobiology.

Schwann cell strip for peripheral nerve repair

Many strategies have been investigated to provide an ideal substitute to treat a nerve gap injury. Initially, silicone conduits were used and more recently conduits fabricated from natural materials such as poly-3-hydroxybutyrate (PHB) showed good results but still have their limitations. Surgically, a new concept optimising harvested autologous nerve graft has been introduced as the single fascicle method. It has been shown that a single fascicle repair of nerve grafting is successful. We investigated a new approach using a PHB strip seeded with Schwann cells to mimic a small nerve fascicle. Schwann cells were attached to the PHB strip using diluted fibrin glue and used to bridge a 10-mm sciatic nerve gap in rats. Comparison was made with a group using conventional PHB conduit tubes filled with Schwann cells and fibrin glue. After 2 weeks, the nerve samples were harvested and investigated for axonal and Schwann cell markers. PGP9.5 immunohistochemistry showed a superior nerve regeneration distance in the PHB strip group versus the PHB tube group (> 10 mm, crossed versus 3.17+/- 0.32 mm respectively, P<0.05) as well as superior Schwann cell intrusion (S100 staining) from proximal (> 10 mm, crossed versus 3.40+/- 0.36 mm, P<0.01) and distal (> 10 mm, crossed versus 2.91+/- 0.31 mm, P<0.001) ends. These findings suggest a significant advantage of a strip in rapidly connecting a nerve gap lesion and imply that single fascicle nerve grafting is advantageous for nerve repair in rats.

Use of hybrid chitosan membranes and N1E-115 cells for promoting nerve regeneration in an axonotmesis rat model

Many studies have been dedicated to the development of scaffolds for improving post-traumatic nerve regeneration. The goal of this study was to develop and test hybrid chitosan membranes to use in peripheral nerve reconstruction, either alone or enriched with N1E-115 neural cells. Hybrid chitosan membranes were tested in vitro, to assess their ability in supporting N1E-115 cell survival and differentiation, and in vivo to assess biocompatibility as well as to evaluate their effects on nerve fiber regeneration and functional recovery after a standardized rat sciatic nerve crush injury. Functional recovery was evaluated using the sciatic functional index (SFI), the static sciatic index (SSI), the extensor postural thrust (EPT), the withdrawal reflex latency (WRL) and ankle kinematics. Nerve fiber regeneration was assessed by quantitative stereological analysis and electron microscopy. All chitosan membranes showed good biocompatibility and proved to be a suitable substrate for plating the N1E-115 cellular system. By contrast, in vivo nerve regeneration assessment after crush injury showed that the freeze-dried chitosan type III, without N1E-115 cell addition, was the only type of membrane that significantly improved posttraumatic axonal regrowth and functional recovery. It can be thus suggested that local enwrapping with this type of chitosan membrane may represent an effective approach for the improvement of the clinical outcome in patients receiving peripheral nerve surgery.

The ERBB3 receptor in cancer and cancer gene therapy

ERBB3, a member of the epidermal growth factor receptor (EGFR) family, is unique in that its tyrosine kinase domain is functionally defective. It is activated by neuregulins, by other ERBB and nonERBB receptors as well as by other kinases, and by novel mechanisms. Downstream it interacts prominently with the phosphoinositol 3-kinase/AKT survival/mitogenic pathway, but also with GRB, SHC, SRC, ABL, rasGAP, SYK and the transcription regulator EBP1. There are likely important but poorly understood roles for nuclear localization and for secreted isoforms. Studies of ERBB3 expression in primary cancers and of its mechanistic contributions in cultured cells have implicated it, with varying degrees of certainty, with causation or sustenance of cancers of the breast, ovary, prostate, certain brain cells, retina, melanocytes, colon, pancreas, stomach, oral cavity and lung. Recent results link high ERBB3 activity with escape from therapy targeting other ERBBs in lung and breast cancers. Thus a wide and centrally important role for ERBB3 in cancer is becoming increasingly apparent. Several approaches for targeting ERBB3 in cancers have been tested or proposed. Small inhibitory RNA (siRNA) to ERBB3 or AKT is showing promise as a therapeutic approach to treatment of lung adenocarcinoma.