Axonal regeneration after spinal cord transection and reconstruction

Omentomyelopexy for the Treatment of a Persistent Lumbar Pseudomeningocele: A Case Report With Technical Note

BACKGROUND AND IMPORTANCE

Pseudomeningoceles are extradural accumulations of cerebrospinal fluid. In most cases, they appear as a complication of spinal operations. Omentomyelopexy is a surgery in which an autologous omentum flap is implanted over the dural opening. We describe a case of persistent pseudomeningocele treated with omentomyelopexy.

CLINICAL PRESENTATION

A 37-year-old man sustained a T12-L1 AO B3 fracture during a motorcycle accident. He underwent posterolateral fusion and then neurological rehabilitation. Two years later, however, his condition worsened, and he experienced progressive weakness-he was diagnosed with an intramedullary cyst, which was treated with laminectomy, arachnolysis and cystotomy. A pseudomeningocele developed afterward, and the patient underwent multiple reoperations in the following years, none of which were effective. Omentomyelopexy, a complex procedure aimed to facilitate cerebrospinal fluid absorption and subsequent formation of a permanent membrane, was offered to the patient as a "last resort." After undergoing omentomyelopexy, his pseudomeningocele resolved.

CONCLUSION

Although it should be reserved for exceptionally pertinent cases, omentomyelopexy is a viable option for managing persistent pseudomeningocele. However, further research is needed to better understand the effects and benefits of omentomyelopexy in this context.

The Application of an Omentum Graft or Flap in Spinal Cord Injury

Background: Spinal cord injury (SCI) causes a primary injury at the lesion site and triggers a secondary injury and prolonged inflammation. There has been no definitive treatment till now. Promoting angiogenesis is one of the most important strategies for functional recovery after SCI. The omentum, abundant in blood and lymph vessels, possesses the potent ability of tissue regeneration. Methods: The present work examines the efficacy of autologous omentum, either as a flap (with vascular connection intact) or graft (severed vascular connection), on spinal nerve regeneration. After contusive SCI in rats, a thin sheath of omentum was grafted to the injured spinal cord. Results: Omental graft improved behavior scores significantly from the 3rd to 6th week after injury (6th week, 5.5 ± 0.5 vs. 8.6 ± 1.3, p < 0.05). Furthermore, the reduction in cavity and the preservation of class III β-tubulin-positive nerve fibers in the injury area was noted. Next, the free omental flap was transposed to a completely transected SCI in rats through a pre-implanted tunnel. The flap remained vascularized and survived well several weeks after the operation. At 16 weeks post-treatment, SCI rats with omentum flap treatment displayed the preservation of significantly more nerve fibers (p < 0.05) and a reduced injured cavity, though locomotor scores were similar. Conclusions: Taken together, the findings of this study indicate that treatment with an omental graft or transposition of an omental flap on an injured spinal cord has a positive effect on nerve protection and tissue preservation in SCI rats. The current data highlight the importance of omentum in clinical applications.

LC-QTOF-MS and 1H NMR Metabolomics Verifies Potential Use of Greater Omentum for Klebsiella pneumoniae Biofilm Eradication in Rats

Bacterial wound infections are a common problem associated with surgical interventions. In particular, biofilm-forming bacteria are hard to eradicate, and alternative methods of treatment based on covering wounds with vascularized flaps of tissue are being developed. The greater omentum is a complex organ covering the intestines in the abdomen, which support wound recovery following surgical procedures and exhibit natural antimicrobial activity that could improve biofilm eradication. We investigated changes in rats’ metabolome following Klebsiella pneumoniae infections, as well as the greater omentum’s ability for Klebsiella pneumoniae biofilm eradication. Rats received either sterile implants or implants covered with Klebsiella pneumoniae biofilm (placed in the peritoneum or greater omentum). Metabolic profiles were monitored at days 0, 2, and 5 after surgery using combined proton nuclear magnetic resonance (¹H NMR) and high performance liquid chromatography quadrupole time-of-flight tandem mass spectrometry (LC–QTOF-MS) measurements of urine samples followed by chemometric analysis. Obtained results indicated that grafting of the sterile implant to the greater omentum did not cause major disturbances in rats’ metabolism, whereas the sterile implant located in the peritoneum triggered metabolic perturbations related to tricarboxylic acid (TCA) cycle, as well as choline, tryptophan, and hippurate metabolism. Presence of implants colonized with Klebsiella pneumoniae biofilm resulted in similar levels of metabolic perturbations in both locations. Our findings confirmed that surgical procedures utilizing the greater omentum may have a practical use in wound healing and tissue regeneration in the future.

Regenerative therapies for central nervous system diseases: a biomaterials approach

The central nervous system (CNS) has a limited capacity to spontaneously regenerate following traumatic injury or disease, requiring innovative strategies to promote tissue and functional repair. Tissue regeneration strategies, such as cell and/or drug delivery, have demonstrated promising results in experimental animal models, but have been difficult to translate clinically. The efficacy of cell therapy, which involves stem cell transplantation into the CNS to replace damaged tissue, has been limited due to low cell survival and integration upon transplantation, while delivery of therapeutic molecules to the CNS using conventional methods, such as oral and intravenous administration, have been limited by diffusion across the blood-brain/spinal cord-barrier. The use of biomaterials to promote graft survival and integration as well as localized and sustained delivery of biologics to CNS injury sites is actively being pursued. This review will highlight recent advances using biomaterials as cell- and drug-delivery vehicles for CNS repair.

Spinal cord separation: MRI evidence of healing after omentum–collagen reconstruction

INTRODUCTION

Animal experimentation has demonstrated that omental-collagen bridge reconstruction of a transected spinal cord in cats can result in the growth of axons crossing the transection site which resulted in the return of motor and sensory activity. This paper raises the possibility that a comparable spinal cord reconstruction model could be possible for human application.

METHODS

Cats had their spinal cord transected at the T-9 level. This led to a gap at the transection site that was filled with semi-liquid collagen, followed by omental transposition onto the underlying collagen bridge, which had subsequently hardened. A comparable technique was used on a patient who had, as reported by magnetic resonance imaging (MRI), a complete spinal cord transection at the T-6 level.

RESULTS

Reconstruction of a transected spinal cord in cats using an omental-collagen bridge resulted in axons that grew across the transection site at the rate of 1 mm/day. Several animals developed forelimb and hindlimb locomotion. The patient in this paper had omental-collagen reconstruction of her cord and has clinically progressed to the point where she can ambulate with the use of a walker. The patient had a spinal cord defect of 4 cm, which, with multiple MRI studies, has shown the longitudinal development of a spinal cord connection in the area of the omental-collagen bridge that connects the proximal and distal ends of the transected spinal cord.

CONCLUSION

This report suggests that a transected spinal cord has the ability to heal when the spinal cord separation is reconstructed using an omental-collagen bridge. This technique has led to neurological improvement.

The evolution of omentum transposition: from lymphedema to spinal cord, stroke and Alzheimer's disease

It is now well established that the omentum incorporates into its tissues a variety of biological factors that exert a favorable effect on the central nervous system. Physiological characteristics of the omentum include edema absorption, fibrotic inhibition, blood-brain barrier penetration and, of major importance, angiogenic activity. Over several decades, studies have shown increasing clinical uses of the omentum following its placement on various structures within the body. This paper details the evolution of omental transposition (OT) up to the present at which time OT is being applied to the brain of Alzheimer disease (AD) patients. Success in this area raises the possibility that the omentum may prove to be a present-day treatment for patients with AD until future pharmaceutical and/or genetic forms of treatment are developed.

Cellular basis of tissue regeneration by omentum

The omentum is a sheet-like tissue attached to the greater curvature of the stomach and contains secondary lymphoid organs called milky spots. The omentum has been used for its healing potential for over 100 years by transposing the omental pedicle to injured organs (omental transposition), but the mechanism by which omentum helps the healing process of damaged tissues is not well understood. Omental transposition promotes expansion of pancreatic islets, hepatocytes, embryonic kidney, and neurons. Omental cells (OCs) can be activated by foreign bodies in vivo. Once activated, they become a rich source for growth factors and express pluripotent stem cell markers. Moreover, OCs become engrafted in injured tissues suggesting that they might function as stem cells.

Omentum consists of a variety of phenotypically and functionally distinctive cells. To understand the mechanism of tissue repair support by the omentum in more detail, we analyzed the cell subsets derived from the omentum on immune and inflammatory responses. Our data demonstrate that the omentum contains at least two groups of cells that support tissue repair, immunomodulatory myeloid derived suppressor cells and omnipotent stem cells that are indistinguishable from mesenchymal stem cells. Based on these data, we propose that the omentum is a designated organ for tissue repair and healing in response to foreign invasion and tissue damage.

Activated omentum becomes rich in factors that promote healing and tissue regeneration

In order to study the mechanism by which an omental pedicle promotes healing when applied to an injured site, we injected a foreign body into the abdominal cavity to activate the omentum. One week after the injection, we isolated the omentum and measured blood vessel density, blood content, growth and angiogenesis factors (VEGF and others), chemotactic factors (SDF-1 alpha), and progenitor cells (CXCR-4, WT-1). We found that the native omentum, which consisted mostly of adipose tissue, expanded the mass of its non-adipose part (milky spots) 15- to 20-fold. VEGF and other growth factors increased by two- to four-fold, blood vessel density by three-fold, and blood content by two-fold. The activated omentum also showed increases in SDF-1 alpha, CXCR-4, and WT-1 cells (factors and cells positively associated with tissue regeneration). Thus, we propose that an omentum activated by a foreign body (or by injury) greatly expands its milky-spot tissue and becomes rich in growth factors and progenitor cells that facilitate the healing and regeneration of injured tissue.

Re-growth of catecholaminergic fibers and protection of cholinergic spinal cord neurons in spinal repaired rats

The extent of re-growth of catecholaminergic fibers, the survival of cholinergic neurons and the degree of autonomic dysreflexia were assessed in complete spinal cord-transected adult rats that received a repair treatment of peripheral nerve grafts and acidic fibroblast growth factor (aFGF). The rats were randomly divided into three groups: (1) sham control group (laminectomy only); (2) spinal cord transection at T8 (transected group); and (3) spinal cord transection at T8, followed by aFGF treatment and peripheral nerve graft (repaired group). The spinal cords and brains of all rats were collected at 6 months post-surgery. Immunohistochemistry for tyrosine hydroxylase (TH) and dopamine-beta-hydroxylase (DBH), and fluoro-gold (FG) retrograde tracing were used to evaluate axon growth across the damage site, and immunocytochemistry for choline acetyl transferase (ChAT) was used to evaluate cholinergic neuronal cell survival following the injury and treatment. When comparing with the transected group, the repaired group showed: (1) lower elevation of mean arterial pressure during colorectal distension; (2) retrogradely labeled neurons in the hypothalamus, zona incerta, subcoeruleus nuclei and rostral ventrolateral medulla following application of FG below the repair site; (3) the presence of TH- and DBH-labeled axons below the lesion site; (4) higher numbers of ChAT-positive neurons in ventral horn and intermediolateral column near the lesion site. We conclude that peripheral nerve graft and aFGF treatments facilitate the re-growth of catecholaminergic fibers, also protect sympathetic preganglionic neurons and spinal motor neurons, and reduce autonomic dysfunction in a T-8 spinal cord-transected rat model.

Reconstruction of the transected cat spinal cord following NeuroGel implantation: axonal tracing, immunohistochemical and ultrastructural studies

This study examined the ability of NeuroGel, a biocompatible porous poly [N-(2-hydroxypropyl) methacrylamide] hydrogel, to establish a permissive environment across a 3 mm gap in the cat spinal cord in order to promote tissue reconstitution and axonal regeneration across the lesion. Animals with NeuroGel implants were compared to transection-only controls and observed for 21 months. The hydrogel formed a stable bridge between the cord segments. Six months after reconstructive surgery, it was densely infiltrated by a reparative tissue composed of glial cells, capillary vessels and axonal fibres. Axonal labelling and double immunostaining for neurofilaments and myelin basic protein, showed that descending supraspinal axons of the ventral funiculus and afferent fibres of the dorsal column regenerated across the reconstructed lesion. Fifteen months after reconstructive surgery, axons had grown, at least, 12 mm into the distal cord tissue, and in the rostral cord there was labelling of neurons of the intermediate gray matter. Electron microscopy showed that after 9 months, most of the regenerating axons were myelinated, principally by Schwann cells. Newly formed neurons presumably from precursor cells of the ependyma and/or migrating neurons were observed within the reparative tissue after 21 months. Results indicate that functional deficit, as assessed by treadmill training, and morphological changes following double transection of the spinal cord can be modified by the implantation of NeuroGel. This technology offers the potential to promote the formation of a neural tissue equivalent via a reparative neohistogenesis process, that facilitates and supports regenerative growth of axons.

Neural tissue formation within porous hydrogels implanted in brain and spinal cord lesions: ultrastructural, immunohistochemical, and diffusion studies

A biocompatible heterogeneous hydrogel of poly [N-(2-hydroxypropyl) methacrylamide] (PHPMA), was evaluated for its ability to promote tissue repair and enhance axonal regrowth across lesion cavities in the brain and spinal cord in adult and juvenile (P17 P21) rats. Incorporation of PHPMA hydrogels into surrounding host tissue was examined at the ultrastructural level and using immunohistochemical techniques. In addition, and in parallel to these studies, diffusion parameters (volume fraction and tortuosity of the gel network) of the PHPMA hydrogels were evaluated pre- to postimplantation using an in vivo real-time iontophoretic method. The polymer hydrogels were able to bridge tissue defects created in the brain or spinal cord, and supported cellular ingrowth, angiogenesis, and axonogenesis within the structure of the polymer network. As a result, a reparative tissue grew within the porous structure of the gel, composed of glial cells, blood vessels, axons and dendrites, and extracellular biological matrices, such as laminin and/or collagen. Consistent with matrix deposition and tissue formation within the porous structure of the PHPMA hydrogels, there were measurable changes in the diffusion characteristics of the polymers. Extracellular space volume decreased and tortuosity increased within implanted hydrogels, attaining values similar to that seen in developing neural tissue. PHPMA polymer hydrogel matrices thus show neuroinductive and neuroconductive properties. They have the potential to repair tissue defects in the central nervous system by replacing lost tissue and by promoting the formation of a histotypic tissue matrix that facilitates and supports regenerative axonal growth. () ()

Heterogeneous PHPMA hydrogels for tissue repair and axonal regeneration in the injured spinal cord

A biocompatible heterogeneous hydrogel of poly[N-(2-hydroxypropyl) methacrylamide] (PHPMA) showing an open porous structure, viscoelastic properties similar to the neural tissue and a large surface area available for cell interaction, was evaluated for its ability to promote tissue repair and axonal regeneration in the transected rat spinal cord. After implantation, the polymer hydrogel could correctly bridge the tissue defect, from a permissive interface with the host tissue to favour cell ingrowth, angiogenesis and axonal growth occurred within the microstructure of the network. Within 3 months the polymer implant was invaded by host derived tissue, glial cells, blood vessels and axons penetrated the hydrogel implant. Such polymer hydrogel matrices which show neuroinductive and neuroconductive properties have the potential to repair tissue defects in the central nervous system by promoting the formation of a tissue matrix and axonal growth by replacing the lost of tissue.

Three-dimensional visualization of the distribution, growth, and regeneration of monoaminergic neurons in whole mounts of immature mammalian CNS

At birth, the opossum, Monodelphis domestica, corresponds roughly to a 14-day-old mouse embryo. The aim of these experiments was to compare the distribution of monoaminergic neurons in the two preparations during development and to follow their regeneration after injury. Procedures that allowed antibody staining to be visible in transparent whole mounts of the entire central nervous system (CNS) were devised. Neurons throughout the brain and spinal cord were stained for tyrosine hydroxylase (TH) and for serotonin (5-HT). At birth, patterns of monoaminergic cells in opossum CNS resembled those found in 14-day mouse embryos and other eutherian mammals. By postnatal day 5, immunoreactive cell bodies were clustered in appropriate regions of the midbrain and hindbrain, and numerous axons were already present throughout the spinal cord. Differences found in the opossum were the earlier presence of TH neurons in the olfactory bulb and of 5-HT neuronal perikarya in the spinal cord. Most, if not all, monoaminergic neurons in opossum were already postmitotic at birth. To study regeneration, crushes were made in cervical cords in culture. By 5 days, 8% of all TH-labeled axons and 14% of serotonergic axons had grown beyond lesions. Distal segments of monoaminergic axons degenerated. In CNS preparations from opossums older than 11 days, no regeneration of monoaminergic fibers occurred. Isolated embryonic mouse CNS also showed regeneration across spinal cord lesions, providing the possibility of using knockout and transgenic animals. Our procedures for whole-mount observation of identified cell bodies and their axons obviates the need for serial reconstructions and allows direct comparison of events occurring during development and regeneration.

Coerulospinal fiber regeneration in transected feline spinal cord

After complete cat spinal cord transection, a collagen matrix was used to bridge the gap. Vascular supply was increased to the transection site with an omental pedicle. Before hardening, either 4-aminopyridine, laminin, glia maturation factor, or lipid angiogenic factor were mixed into the collagen. Surgically reconstructed animals were compared to transection-only controls and observed for 90 days. Fluoro-Gold was injected distal to the transection site on day 75. Immunocytochemical examination of brain and spinal cord tissue was done on day 90. Examination revealed supraspinal catecholaminergic fibers present in the collagen bridge and distal cord tissue only in cats with surgical reconstruction. Fluoro-Gold particles were found localized in locus coeruleus and other noradrenergic pontine neurons. Distal to the transection, double immunostaining with synaptophysin and tyrosine hydroxylase or dopamine-beta-hydroxylase revealed dot-like deposits closely apposed to preganglionic sympathetic neurons suggestive of synaptic connectivity to these targets. Results indicate that considerable outgrowth of specific supraspinal fibers can be induced following spinal transection and reconstruction, and that such fibers may be extending and contacting appropriate distal target tissue in the cord.

Cotransmitter-mediated locus coeruleus action on motoneurons

This article reviews evidence for a direct noradrenergic projection from the dorsolateral pontine tegmentum (DLPT) to spinal motoneurons. The existence of this direct pathway was first inferred by the observation that antidromically evoked responses occur in single cells in the locus coeruleus (LC), a region within the DLPT, following electrical stimulation of the ventral horn of the lumbar spinal cord of the cat. We subsequently confirmed that there is a direct noradrenergic pathway from the LC and adjacent regions of the DLPT to the lumbar ventral horn using anatomical studies that combined retrograde tracing with immunohistochemical identification of neurotransmitters. These anatomical studies further revealed that many of the noradrenergic neurons in the LC and adjacent regions of the DLPT of the cat that send projections to the spinal cord ventral horn also contain colocalized glutamate (Glu) or enkephalin (ENK). Recent studies from our laboratory suggest that Glu and ENK may function as cotransmitters with norepinephrine (NE) in the descending pathway from the DLPT. Electrical stimulation of the LC evokes a depolarizing response in spinal motoneurons that is only partially blocked by alpha 1 adrenergic antagonists. In addition, NE mimicks only the slowly developing and not the fast component of LC-evoked depolarization. Furthermore, the depolarization evoked by LC stimulation is accompanied by a decrease in membrane resistance, whereas that evoked by NE is accompanied by an increased resistance. That Glu may be a second neurotransmitter involved in LC excitation of motoneurons is supported by our observation that the excitatory response evoked in spinal cord ventral roots by electrical stimulation of the LC is attenuated by a non-N-methyl-D-aspartate glutamatergic antagonist. ENK may participate as a cotransmitter with NE to mediate LC effects on lumbar monosynaptic reflex (MSR) amplitude. Electrical stimulation of the LC has a biphasic effect on MSR amplitude, facilitation followed by inhibition. Adrenergic antagonists block only the facilitator effect of LC stimulation on MSR amplitude, whereas the ENK antagonist naloxone reverses the inhibition. The chemical heterogeneity of the cat DLPT system and the differential responses of motoneurons to the individual cotransmitters help to explain the diversity of postsynaptic potentials that occur following LC stimuli.