1
|
Knerlich-Lukoschus F. Perspective on inflammatory cytokines in open spinal dysraphism. Neural Regen Res 2023; 18:329-330. [PMID: 35900420 PMCID: PMC9396502 DOI: 10.4103/1673-5374.343901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
2
|
Lee SY, Papanna R, Farmer D, Tsao K. Fetal Repair of Neural Tube Defects. Clin Perinatol 2022; 49:835-848. [PMID: 36328602 DOI: 10.1016/j.clp.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Myelomeningocele is the most common congenital neurologic defect, and the only nonlethal disease addressed by fetal surgery. A randomized control trial has established amelioration of the Arnold-Chiari II malformation, reduced ventriculoperitoneal shunt rate, and improvement in distal neurologic function in patients that receive in utero repair. Long-term follow-up of these school-age children demonstrates the persistence of these effects. The use of stem cells in fetal repair is being investigated to further improve distal motor function.
Collapse
Affiliation(s)
- Su Yeon Lee
- Department of Surgery, Division of Pediatric, Thoracic and Fetal Surgery, University of California Davis Medical Center, 2335 Stockton Boulevard, Room 5107, Sacramento, CA 95817, USA.
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health Science Center at Houston, 6410 Fannin Street, Suite 210, Houston, TX 77030, USA
| | - Diana Farmer
- Department of Surgery, University of California Davis Medical Center, 2335 Stockton Boulevard, Sacramento, CA 95817, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery, UT Health Science Center at Houston, 6410 Fannin Street, Suite 950, Houston, TX 77030, USA
| |
Collapse
|
3
|
Theodorou CM, Stokes SC, Jackson JE, Pivetti CD, Kumar P, Yamashiro KJ, Paxton ZJ, Reynaga L, Hyllen AA, Wang A, Farmer DL. Efficacy of clinical-grade human placental mesenchymal stromal cells in fetal ovine myelomeningocele repair. J Pediatr Surg 2022; 57:753-758. [PMID: 34217509 PMCID: PMC9365331 DOI: 10.1016/j.jpedsurg.2021.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/11/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND While fetal repair of myelomeningocele (MMC) revolutionized management, many children are still unable to walk independently. Preclinical studies demonstrated that research-grade placental mesenchymal stromal cells (PMSCs) prevent paralysis in fetal ovine MMC, however this had not been replicated with clinical-grade cells that could be used in an upcoming human clinical trial. We tested clinical-grade PMSCs seeded on an extracellular matrix (PMSC-ECM) in the gold standard fetal ovine model of MMC. METHODS Thirty-five ovine fetuses underwent MMC defect creation at a median of 76 days gestational age, and defect repair at 101 days gestational age with application of clinical-grade PMSC-ECM (3 × 105 cells/cm2, n = 12 fetuses), research-grade PMSC-ECM (3 × 105 cells/cm2, three cell lines with n = 6 (Group 1), n = 6 (Group 2), and n = 3 (Group 3) fetuses, respectively) or ECM without PMSCs (n = 8 fetuses). Three normal lambs underwent no surgical interventions. The primary outcome was motor function measured by the Sheep Locomotor Rating scale (SLR, range 0: complete paralysis to 15: normal ambulation) at 24 h of life. Correlation of lumbar spine large neuron density with SLR was evaluated. RESULTS Clinical-grade PMSC-ECM lambs had significantly better motor function than ECM-only lambs (SLR 14.5 vs. 6.5, p = 0.04) and were similar to normal lambs (14.5 vs. 15, p = 0.2) and research-grade PMSC-ECM lambs (Group 1: 14.5 vs. 15, p = 0.63; Group 2: 14.5 vs. 14.5, p = 0.86; Group 3: 14.5 vs. 15, p = 0.50). Lumbar spine large neuron density was strongly correlated with motor function (r = 0.753, p<0.001). CONCLUSIONS Clinical-grade placental mesenchymal stromal cells seeded on an extracellular matrix rescued ambulation in a fetal ovine myelomeningocele model. Lumbar spine large neuron density correlated with motor function, suggesting a neuroprotective effect of the PMSC-ECM in prevention of paralysis. A first-in-human clinical trial of PMSCs in human fetal myelomeningocele repair is underway.
Collapse
Affiliation(s)
- Christina M. Theodorou
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA,Corresponding author information: Christina Theodorou, Department of Surgery, University of California Davis Medical Center, 2335 Stockton Blvd, Room 5107, Sacramento, CA 95817, , Phone: 916-453-2080
| | - Sarah C. Stokes
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Jordan E. Jackson
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Christopher D. Pivetti
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Priyadarsini Kumar
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Kaeli J. Yamashiro
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Zachary J. Paxton
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Lizette Reynaga
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Alicia A. Hyllen
- Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Aijun Wang
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| | - Diana L. Farmer
- Department of Surgery, Division of Pediatric General, Thoracic, and Fetal Surgery. University of California Davis Medical Center. Sacramento, CA,Surgical Bioengineering Laboratory, University of California Davis Medical Center. Sacramento, CA
| |
Collapse
|
4
|
Pastuszka A, Bohosiewicz J, Olejek A, Zamłyński J, Horzelska E, Koszutski T. In utero myelomeningocele repair reduces intensification of inflammatory changes in the dura mater and the skin. J Spinal Cord Med 2022; 45:180-185. [PMID: 32223587 PMCID: PMC8986184 DOI: 10.1080/10790268.2020.1736434] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objective: Chemical and mechanical injury in myelomeningocele (MMC) during the fetal life results in functional disorders of multiple organs. Prenatal MMC repair reduces sequelae of spinal cord injury.Design: Histopathological evaluation of dura mater and skin specimens to assess the severity of inflammatory changes.Setting: Histopathological laboratory and operated patients.Participants: 45 cases (Group I)-intrauterine surgery due to MMC and 42 cases (Group II)-postnatal surgery.Outcome measures: Specimens of the skin and of the dura mater adjacent directly to the uncovered section of the spinal cord were collected for assessment. The specimens were histopathologically evaluated to assess the severity of inflammatory changes.Results: The analysis of the severity of inflammatory changes in the skin and the dura mater showed only small lymphocytic infiltration in 5 fetuses (Group I). Medium and large infiltration in the skin and the dura mater was found in all children who underwent postnatal surgery (Group II). Lymphocytic and granulocytic infiltration in the skin and the dura mater were statistically significantly more prevalent in children who underwent postnatal surgery compared to the group of children who underwent prenatal surgery (P < 0.000003).Conclusions: By reducing the time of exposure to damaging factors, prenatal MMC repair statistically reduces the risk of inflammatory changes in the exposed spinal cord and spinal nerves. Prenatal closure of spina bifida before 24 week of gestation does not reduce the severity of inflammatory changes in the exposed spinal cord.
Collapse
Affiliation(s)
- Agnieszka Pastuszka
- Department of Gynaecology, Obstetrics and Oncological Gynaecology, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Bytom, Poland,Correspondence to: Agnieszka Pastuszka, Department of Gynaecology, Obstetrics and Oncological Gynaecology, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, ul. Batorego 15, 41-902Bytom, Poland; Ph: +48 327861540; +48 327861646.
| | - Janusz Bohosiewicz
- Higher School of Strategic Planning in Dąbrowa Górnicza, Katowice, Poland
| | - Anita Olejek
- Department of Gynaecology, Obstetrics and Oncological Gynaecology, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Bytom, Poland
| | - Jacek Zamłyński
- Department of Gynaecology, Obstetrics and Oncological Gynaecology, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Bytom, Poland
| | - Ewa Horzelska
- Department of Gynaecology, Obstetrics and Oncological Gynaecology, School of Medicine with Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Bytom, Poland
| | - Tomasz Koszutski
- Clinical Department of Children’s Surgery, Department of Children’s Surgery and Urology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Katowice, Poland
| |
Collapse
|
5
|
Cohrs G, Blumenröther AK, Sürie JP, Synowitz M, Held-Feindt J, Knerlich-Lukoschus F. Fetal and perinatal expression profiles of proinflammatory cytokines in the neuroplacodes of rats with myelomeningoceles: A contribution to the understanding of secondary spinal cord injury in open spinal dysraphism. J Neurotrauma 2021; 38:3376-3392. [PMID: 34541905 DOI: 10.1089/neu.2021.0091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The cellular and molecular mechanisms that presumably underlie the progressive functional decline of the myelomeningocele (MMC) placode are not well understood. We previously identified key players in posttraumatic spinal cord injury cascades in human MMC tissues obtained during postnatal repair. In this study we conducted experiments to further investigate these mediators in the prenatal time course under standardized conditions in a retinoic-acid-induced MMC rat model. A retinoic acid MMC model was established using time-dated Sprague-Dawley rats, which were gavage-fed with all-trans retinoic acid (RA; 60 mg/kg) dissolved in olive oil at E10. Control animals received olive oil only. Fetuses from both groups were obtained at E16, E18, E22. The spinal cords (SCs) of both groups were formalin-fixed or snap-frozen. Tissues were screened by real-time RT-PCR for the expression of cytokines and chemokines known to play a role in the lesion cascades of the central nervous system after trauma. MMC placodes exhibited inflammatory cells and glial activation in the later gestational stages. At the mRNA level, IL-1b, TNFa, and TNF-R1 exhibited significant induction at E22. IL1-R1 mRNA was induced significantly at E16 and E22. Double labeling experiments confirmed the costaining of these cytokines and their receptors with Iba1 (i.e., inflammatory cells), Vimentin, and Nestin in different anatomical SC areas and NeuN in ventral horn neurons. CXCL12 mRNA was elevated in control and MMC animals at E16 compared to E18 and E22. CX3CL1 mRNA was lower in MMC tissues than in control tissues on E16. The presented findings contribute to the concept that pathophysiological mechanisms, such as cytokine induction in the neuroplacode, in addition to the "first hit", promote secondary spinal cord injury with functional loss in the late fetal time course. Furthermore, these mediators should be taken into consideration in the development of new therapeutic approaches for open spinal dysraphism.
Collapse
Affiliation(s)
- Gesa Cohrs
- Universitatsklinikum Schleswig-Holstein Campus Kiel, 15056, Dept. of Neurosurgery, Arnold-Heller-Straße 3, Kiel, Germany, 24105;
| | - Ann-Kathrin Blumenröther
- Universitätsklinikum Schleswig-Holstein, 54186, Neurosurgery, Kiel, Schleswig-Holstein, Germany;
| | - Jan-Philip Sürie
- Universitätsklinikum Schleswig-Holstein, 54186, Neurosurgery, Kiel, Schleswig-Holstein, Germany;
| | - Michael Synowitz
- Universitatsklinikum Schleswig-Holstein Campus Kiel, 15056, Neurosurgery, Kiel, Schleswig-Holstein, Germany;
| | - Janka Held-Feindt
- Universitatsklinikum Schleswig-Holstein Campus Kiel, 15056, Neurosurgery, Kiel, Schleswig-Holstein, Germany;
| | - Friederike Knerlich-Lukoschus
- Universitätsklinikum Schleswig-Holstein, 54186, Neurosurgery, Kiel, Schleswig-Holstein, Germany.,Asklepios Kinderklinik Sankt Augustin, 248587, Pediatric Neurosurgery, Sankt Augustin, Nordrhein-Westfalen, Germany;
| |
Collapse
|
6
|
Sbragia L, da Costa KM, Nour ALA, Ruano R, Santos MV, Machado HR. State of the art in translating experimental myelomeningocele research to the bedside. Childs Nerv Syst 2021; 37:2769-2785. [PMID: 34333685 DOI: 10.1007/s00381-021-05299-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 11/30/2022]
Abstract
Myelomeningocele (MMC), the commonest type of spina bifida (SB), occurs due to abnormal development of the neural tube and manifest as failure of the complete fusion of posterior arches of the spinal column, leading to dysplastic growth of the spinal cord and meninges. It is associated with several degrees of motor and sensory deficits below the level of the lesion, as well as skeletal deformities, bladder and bowel incontinence, and sexual dysfunction. These children might develop varying degrees of neuropsychomotor delay, partly due to the severity of the injuries that affect the nervous system before birth, partly due to the related cerebral malformations (notably hydrocephalus-which may also lead to an increase in intracranial pressure-and Chiari II deformity). Traditionally, MMC was repaired surgically just after birth; however, intrauterine correction of MMC has been shown to have several potential benefits, including better sensorimotor outcomes (since exposure to amniotic fluid and its consequent deleterious effects is shortened) and reduced rates of hydrocephalus, among others. Fetal surgery for myelomeningocele, nevertheless, would not have been made possible without the development of experimental models of this pathological condition. Hence, the aim of the current article is to provide an overview of the animal models of MMC that were used over the years and describe how this knowledge has been translated into the fetal treatment of MMC in humans.
Collapse
Affiliation(s)
- Lourenço Sbragia
- Division of Pediatric Surgery - Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Karina Miura da Costa
- Division of Pediatric Surgery - Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Antonio Landolffi Abdul Nour
- Division of Pediatric Surgery - Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas, Houston, TX, USA
| | - Marcelo Volpon Santos
- Division of Pediatric Neurosurgery - Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Hélio Rubens Machado
- Division of Pediatric Neurosurgery - Department of Surgery and Anatomy, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
| |
Collapse
|
7
|
Wille DA, Padden B, Moehrlen U, Latal B, Schauer S, Kottke R, Grehten P, Meuli M. Impact of Brain Malformations on Neurodevelopmental Outcome in Children with a History of Prenatal Surgery for Open Spina Bifida. Fetal Diagn Ther 2021; 48:588-595. [PMID: 34380134 DOI: 10.1159/000517972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/08/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This retrospective study investigates brain malformations and their impact on neurodevelopmental outcome in children after prenatal surgery for spina bifida (SB). METHODS Sixty-one patients were included. On neonatal MRI, SB-associated brain malformations were assessed. Ventricular size, ventriculo-peritoneal shunt (VPS), and endoscopic third ventriculostomy (ETV) were also documented. Neurodevelopment was assessed with the Bayley-III and correlated with brain malformations, ventricular size, and VPS/ETV placement. RESULTS Chiari II malformation was detected in all patients. Corpus callosum (CC) abnormality was noted in 40%, heterotopies in 35%, and cerebellar parenchymal defects in 11%. 96% had ventriculomegaly; in 46%, VPS/ETV was performed. Cognitive and language testing yielded results in the low-average range (Bayley-III: Cognitive Composite Score 93.6, Language Composite Score 89.7), motor testing was below average (Motor Composite Score 77.4). CC abnormalities, heterotopies, and cerebellar defects were not associated with poorer Bayley-III scores, whereas patients with severe ventriculomegaly performed poorer in all subtests, significantly so for the language composite score. Patients requiring intervention for hydrocephalus had significantly lower scores in motor testing. DISCUSSION/CONCLUSION Additional brain malformations in open SB do not seem to have an impact on cognitive function at 2 years of age. Severe ventriculomegaly is a risk factor for poorer cognitive outcome; hydrocephalus surgery adds an additional risk for delayed motor function.
Collapse
Affiliation(s)
- David-Alexander Wille
- Department of Pediatric Neurology Kantonsspital Baden, Baden, Switzerland.,Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beth Padden
- Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Division of Pediatric Rehabilitation University Children's Hospital Zurich, Zurich, Switzerland
| | - Ueli Moehrlen
- Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Division Fetal Surgery, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Child Development Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Sonja Schauer
- Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Division Fetal Surgery, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Raimund Kottke
- Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Department of Pediatric Radiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Patrice Grehten
- Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Department of Pediatric Radiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Meuli
- Zurich Center for Spina Bifida, University Children's Hospital Zurich, Zurich, Switzerland.,Spina Bifida Academy, University Children's Hospital and University Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.,Division Fetal Surgery, Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
8
|
Galganski LA, Kumar P, Vanover MA, Pivetti CD, Anderson JE, Lankford L, Paxton ZJ, Chung K, Lee C, Hegazi MS, Yamashiro KJ, Wang A, Farmer DL. In utero treatment of myelomeningocele with placental mesenchymal stromal cells - Selection of an optimal cell line in preparation for clinical trials. J Pediatr Surg 2020; 55:1941-1946. [PMID: 31672407 PMCID: PMC7170747 DOI: 10.1016/j.jpedsurg.2019.09.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/04/2019] [Accepted: 09/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND We determined whether in vitro potency assays inform which placental mesenchymal stromal cell (PMSC) lines produce high rates of ambulation following in utero treatment of myelomeningocele in an ovine model. METHODS PMSC lines were created following explant culture of three early-gestation human placentas. In vitro neuroprotection was assessed with a neuronal apoptosis model. In vivo, myelomeningocele defects were created in 28 fetuses and repaired with PMSCs at 3 × 105 cells/cm2 of scaffold from Line A (n = 6), Line B (n = 7) and Line C (n = 5) and compared to no PMSCs (n = 10). Ambulation was scored as ≥13 on the Sheep Locomotor Rating Scale. RESULTS In vitro, Line A and B had higher neuroprotective capability than no PMSCs (1.7 and 1.8 respectively vs 1, p = 0.02, ANOVA). In vivo, Line A and B had higher large neuron densities than no PMSCs (25.2 and 27.9 respectively vs 4.8, p = 0.03, ANOVA). Line C did not have higher neuroprotection or larger neuron density than no PMSCs. In vivo, Line A and B had ambulation rates of 83% and 71%, respectively, compared to 60% with Line C and 20% with no PMSCs. CONCLUSION The in vitro neuroprotection assay will facilitate selection of optimal PMSC lines for clinical use. LEVEL OF EVIDENCE n/a. TYPE OF STUDY Basic science.
Collapse
Affiliation(s)
- Laura A Galganski
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Priyadarsini Kumar
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Melissa A Vanover
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Christopher D Pivetti
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA; Shriners Hospitals for Children Northern California, 2425 Stockton Blvd, Sacramento, CA 95817, USA.
| | - Jamie E Anderson
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Lee Lankford
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Zachary J Paxton
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Karen Chung
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Chelsey Lee
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Mennatalla S Hegazi
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Kaeli J Yamashiro
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA.
| | - Aijun Wang
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA; Shriners Hospitals for Children Northern California, 2425 Stockton Blvd, Sacramento, CA 95817, USA.
| | - Diana L Farmer
- University of California-Davis, 4625 2nd Ave, Suite 3005, Sacramento, CA 95817, USA; Shriners Hospitals for Children Northern California, 2425 Stockton Blvd, Sacramento, CA 95817, USA.
| |
Collapse
|
9
|
Janik K, Manire MA, Smith GM, Krynska B. Spinal Cord Injury in Myelomeningocele: Prospects for Therapy. Front Cell Neurosci 2020; 14:201. [PMID: 32714152 PMCID: PMC7340150 DOI: 10.3389/fncel.2020.00201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/09/2020] [Indexed: 01/10/2023] Open
Abstract
Myelomeningocele (MMC) is the most common congenital defect of the central nervous system and results in devastating and lifelong disability. In MMC, the initial failure of neural tube closure early in gestation is followed by a progressive prenatal injury to the exposed spinal cord, which contributes to the deterioration of neurological function in fetuses. Prenatal strategies to control the spinal cord injury offer an appealing therapeutic approach to improve neurological function, although the definitive pathophysiological mechanisms of injury remain to be fully elucidated. A better understanding of these mechanisms at the cellular and molecular level is of paramount importance for the development of targeted prenatal MMC therapies to minimize or eliminate the effects of the injury and improve neurological function. In this review article, we discuss the pathological development of MMC with a focus on in utero injury to the exposed spinal cord. We emphasize the need for a better understanding of the causative factors in MMC spinal cord injury, pathophysiological alterations associated with the injury, and cellular and molecular mechanisms by which these alterations are induced.
Collapse
Affiliation(s)
- Karolina Janik
- Shriners Hospitals Pediatric Research Center, Center for Neural Repair and Rehabilitation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Meredith A Manire
- Department of Obstetrics and Gynecology, West Penn Hospital, Allegheny Health Network, Pittsburgh, PA, United States
| | - George M Smith
- Shriners Hospitals Pediatric Research Center, Center for Neural Repair and Rehabilitation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| | - Barbara Krynska
- Shriners Hospitals Pediatric Research Center, Center for Neural Repair and Rehabilitation, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
| |
Collapse
|
10
|
Generation of Induced Pluripotent Stem Cells and Neural Stem/Progenitor Cells from Newborns with Spina Bifida Aperta. Asian Spine J 2017; 11:870-879. [PMID: 29279741 PMCID: PMC5738307 DOI: 10.4184/asj.2017.11.6.870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 04/18/2017] [Accepted: 04/22/2017] [Indexed: 12/13/2022] Open
Abstract
Study Design We established induced pluripotent stem cells (iPSCs) and neural stem/progenitor cells (NSPCs) from three newborns with spina bifida aperta (SBa) using clinically practical methods. Purpose We aimed to develop stem cell lines derived from newborns with SBa for future therapeutic use. Overview of Literature SBa is a common congenital spinal cord abnormality that causes defects in neurological and urological functions. Stem cell transplantation therapies are predicted to provide beneficial effects for patients with SBa. However, the availability of appropriate cell sources is inadequate for clinical use because of their limited accessibility and expandability, as well as ethical issues. Methods Fibroblast cultures were established from small fragments of skin obtained from newborns with SBa during SBa repair surgery. The cultured cells were transfected with episomal plasmid vectors encoding reprogramming factors necessary for generating iPSCs. These cells were then differentiated into NSPCs by chemical compound treatment, and NSPCs were expanded using neurosphere technology. Results We successfully generated iPSC lines from the neonatal dermal fibroblasts of three newborns with SBa. We confirmed that these lines exhibited the characteristics of human pluripotent stem cells. We successfully generated NSPCs from all SBa newborn-derived iPSCs with a combination of neural induction and neurosphere technology. Conclusions We successfully generated iPSCs and iPSC-NSPCs from surgical samples obtained from newborns with SBa with the goal of future clinical use in patients with SBa.
Collapse
|
11
|
Cirugía fetal del mielomeningocele. REVISTA MÉDICA CLÍNICA LAS CONDES 2015. [DOI: 10.1016/j.rmclc.2015.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
12
|
Wang A, Brown EG, Lankford L, Keller BA, Pivetti CD, Sitkin NA, Beattie MS, Bresnahan JC, Farmer DL. Placental mesenchymal stromal cells rescue ambulation in ovine myelomeningocele. Stem Cells Transl Med 2015; 4:659-69. [PMID: 25911465 PMCID: PMC4449103 DOI: 10.5966/sctm.2014-0296] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/27/2015] [Indexed: 12/15/2022] Open
Abstract
UNLABELLED Myelomeningocele (MMC)-commonly known as spina bifida-is a congenital birth defect that causes lifelong paralysis, incontinence, musculoskeletal deformities, and severe cognitive disabilities. The recent landmark Management of Myelomeningocele Study (MOMS) demonstrated for the first time in humans that in utero surgical repair of the MMC defect improves lower limb motor function, suggesting a capacity for improved neurologic outcomes in this disorder. However, functional recovery was incomplete, and 58% of the treated children were unable to walk independently at 30 months of age. In the present study, we demonstrate that using early gestation human placenta-derived mesenchymal stromal cells (PMSCs) to augment in utero repair of MMC results in significant and consistent improvement in neurologic function at birth in the rigorous fetal ovine model of MMC. In vitro, human PMSCs express characteristic MSC markers and trilineage differentiation potential. Protein array assays and enzyme-linked immunosorbent assay show that PMSCs secrete a variety of immunomodulatory and angiogenic cytokines. Compared with adult bone marrow MSCs, PMSCs secrete significantly higher levels of brain-derived neurotrophic factor and hepatocyte growth factor, both of which have known neuroprotective capabilities. In vivo, functional and histopathologic analysis demonstrated that human PMSCs mediate a significant, clinically relevant improvement in motor function in MMC lambs and increase the preservation of large neurons within the spinal cord. These preclinical results in the well-established fetal ovine model of MMC provide promising early support for translating in utero stem cell therapy for MMC into clinical application for patients. SIGNIFICANCE This study presents placenta-derived mesenchymal stromal cell (PMSC) treatment as a potential therapy for myelomeningocele (MMC). Application of PMSCs can augment current in utero surgical repair in the well-established and rigorously applied fetal lamb model of MMC. Treatment with human PMSCs significantly and dramatically improved neurologic function and preserved spinal cord neuron density in experimental animals. Sixty-seven percent of the PMSC-treated lambs were able to ambulate independently, with two exhibiting no motor deficits whatsoever. In contrast, none of the lambs treated with the vehicle alone were capable of ambulation. The locomotor rescue demonstrated in PMSC-treated lambs indicates great promise for future clinical trials to improve paralysis in children afflicted with MMC.
Collapse
Affiliation(s)
- Aijun Wang
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Erin G Brown
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Lee Lankford
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Benjamin A Keller
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher D Pivetti
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nicole A Sitkin
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael S Beattie
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jacqueline C Bresnahan
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Diana L Farmer
- Surgical Bioengineering Laboratory, Department of Surgery, University of California, Davis, Health System, Sacramento, California, USA; Brain and Spinal Injury Center, Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
13
|
Meuli M, Moehrlen U. Fetal surgery for myelomeningocele is effective: a critical look at the whys. Pediatr Surg Int 2014; 30:689-97. [PMID: 24908159 DOI: 10.1007/s00383-014-3524-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
Formerly, the disastrous cluster of neurologic deficits and associated neurogenic problems in patients with myelomeningocele (MMC) was generally thought to solely result from the primary malformation, i.e., failure of neurulation. Today, however, there is no doubt that a dimensional additional pathogenic mechanism exists. Most likely, it contributes much more to loss of neurologic function than non-neurulation does. Today, there is a large body of compelling experimental and clinical evidence confirming that the exposed part of the non-neurulated spinal cord is progressively destroyed during gestation, particularly so in the third trimester. These considerations gave rise to the two-hit-pathogenesis of MMC with non-neurulation being the first and consecutive in utero acquired neural tissue destruction being the second hit. This novel pathophysiologic understanding has obviously triggered the question whether the serious and irreversible functional loss caused by the second hit could not be prevented or, at least, significantly alleviated by timely protecting the exposed spinal cord segments, i.e., by early in utero repair of the MMC lesion. Based on this intriguing hypothesis and the above-mentioned data, human fetal surgery for MMC was born in the late nineties of the last century and has made its way to become a novel standard of care, particularly after the so-called "MOMS Trial". This trial, published in the New England Journal of Medicine, has indisputably shown that overall, open prenatal repair is distinctly better than postnatal care alone. Finally, a number of important other topics deserve being mentioned, including the necessity to work on the up till now immature endoscopic fetal repair technique and the need for concentration of these extremely challenging cases to a small number of really qualified fetal surgery centers worldwide. In conclusion, despite the fact that in utero repair of MMC is not a complete cure and not free of risk for both mother and fetus, current data clearly demonstrate that open fetal-maternal surgery is to be recommended as novel standard of care when pregnancy is to be continued and when respective criteria for the intervention before birth are met. Undoubtedly, it is imperative to inform expecting mothers about the option of prenatal surgery once their fetus is diagnosed with open spina bifida.
Collapse
Affiliation(s)
- Martin Meuli
- Department of Pediatric Surgery, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland,
| | | |
Collapse
|
14
|
Abstract
Building upon over 30 years of experimental and clinical development, fetal surgery can be argued to be a standard of care for selected indications, though application of these techniques remains limited to a small number of highly selected fetuses, and availability to a small number of highly specialized centers. Despite its limited application to date, the field of fetal surgery continues to evolve, spurred both by technological advances allowing earlier and more accurate diagnosis of fetal anomalies as well as improved capability to intervene when appropriate. The efficacy of fetal surgical intervention has now been validated for selected indications by well-designed, randomized controlled trials. In this review, we summarize the evidence or lack thereof supporting the current most common indications for fetal surgical intervention.
Collapse
|
15
|
Abstract
Open spina bifida or myelomeningocele (MMC) is a common birth defect that is associated with significant lifelong morbidity. Little progress has been made in the postnatal surgical management of the child with spina bifida. Postnatal surgery is aimed at covering the exposed spinal cord, preventing infection, and treating hydrocephalus with a ventricular shunt. Experimental and clinical evidence suggest that the primary cause of the neurologic defects associated with MMC is not simply incomplete neurulation, but rather chronic, mechanical and amniotic-fluid induced chemical trauma that progressively damages the exposed neural tissue during gestation. The cerebrospinal fluid leak through the MMC leads to hindbrain herniation and hydrocephalus. In utero repair of open spina bifida is now performed in selected patients and presents an additional therapeutic alternative for expectant mothers carrying a fetus with MMC. In the past, studies in animal models and clinical case series laid the groundwork for a clinical trial to test the safety and efficacy of fetal MMC repair. In the present, a prospective, randomized study (the MOMS trial) has shown that fetal surgery for MMC before 26 weeks' gestation may preserve neurologic function, reverse the hindbrain herniation of the Chiari II malformation, and obviate the need for postnatal placement of a ventriculoperitoneal shunt. However, this study also demonstrates that fetal surgery is associated with significant risks related to the uterine scar and premature birth. In the future, research will expand our understanding of the pathophysiology of MMC, evaluate the long-term impact of in-utero intervention, and to refine timing and technique of fetal MMC surgery using tissue engineering technology.
Collapse
Affiliation(s)
- N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
| |
Collapse
|
16
|
Saadai P, Wang A, Nout YS, Downing TL, Lofberg K, Beattie MS, Bresnahan JC, Li S, Farmer DL. Human induced pluripotent stem cell-derived neural crest stem cells integrate into the injured spinal cord in the fetal lamb model of myelomeningocele. J Pediatr Surg 2013; 48:158-63. [PMID: 23331809 DOI: 10.1016/j.jpedsurg.2012.10.034] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 10/13/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND/PURPOSE Neurological function in patients with myelomeningocele (MMC) is limited even after prenatal repair. Neural crest stem cells (NCSCs) can improve neurological function in models of spinal cord injury. We aimed to evaluate the survival, integration, and differentiation of human NCSCs derived from induced pluripotent stem cells (iPSC-NCSCs) in the fetal lamb model of MMC. METHODS Human iPSCs derived from skin fibroblasts were differentiated into NCSCs in vitro, mixed with hydrogel, and seeded on nanofibrous scaffolds for surgical transplantation. Fetal lambs (n=2) underwent surgical MMC creation and repair with iPSC-NCSC seeded scaffolds. Gross necropsy and immunohistochemistry were performed at term. RESULTS IPSC-NCSCs expressed NCSC markers, maintained > 95% viability, and demonstrated neuronal differentiation in vitro. Immunohistochemical analysis of repaired spinal cords thirty days after transplantation demonstrated the co-localization of human nuclear mitotic apparatus protein (NuMA) and Neurofilament M subunit (NFM) in the area of spinal cord injury. No gross tumors were identified. CONCLUSIONS Human iPSC-NCSCs survived, integrated, and differentiated into neuronal lineage in the fetal lamb model of MMC. This is the first description of human stem cell engraftment in a model of fetal MMC and supports the concept of using NCSCs to address spinal cord damage in MMC.
Collapse
Affiliation(s)
- Payam Saadai
- Division of Pediatric Surgery and Fetal Treatment Center, Department of Surgery, University of California, San Francisco, CA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Adzick NS. Fetal surgery for myelomeningocele: trials and tribulations. Isabella Forshall Lecture. J Pediatr Surg 2012; 47:273-81. [PMID: 22325376 PMCID: PMC3278714 DOI: 10.1016/j.jpedsurg.2011.11.021] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 11/10/2011] [Indexed: 01/13/2023]
Abstract
The rationale for in utero repair of myelomeningocele (MMC) in the context of pathologic observations, animal models, and outcomes from the initial experience with human fetal MMC repair is presented. This has now culminated in a randomized trial, Management of Myelomeningocele Study, the findings of which are listed. The story is focused on the milestone contributions of members of the Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia on the road to successful fetal surgery for spina bifida. This is now performed in selected patients and presents an additional therapeutic alternative for expectant mothers carrying a fetus with MMC.
Collapse
Affiliation(s)
- N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pa 19104, USA.
| |
Collapse
|
18
|
Awad RA. Neurogenic bowel dysfunction in patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease. World J Gastroenterol 2011; 17:5035-48. [PMID: 22171138 PMCID: PMC3235587 DOI: 10.3748/wjg.v17.i46.5035] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Revised: 06/20/2011] [Accepted: 06/27/2011] [Indexed: 02/06/2023] Open
Abstract
Exciting new features have been described concerning neurogenic bowel dysfunction, including interactions between the central nervous system, the enteric nervous system, axonal injury, neuronal loss, neurotransmission of noxious and non-noxious stimuli, and the fields of gastroenterology and neurology. Patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease present with serious upper and lower bowel dysfunctions characterized by constipation, incontinence, gastrointestinal motor dysfunction and altered visceral sensitivity. Spinal cord injury is associated with severe autonomic dysfunction, and bowel dysfunction is a major physical and psychological burden for these patients. An adult myelomeningocele patient commonly has multiple problems reflecting the multisystemic nature of the disease. Multiple sclerosis is a neurodegenerative disorder in which axonal injury, neuronal loss, and atrophy of the central nervous system can lead to permanent neurological damage and clinical disability. Parkinson's disease is a multisystem disorder involving dopaminergic, noradrenergic, serotoninergic and cholinergic systems, characterized by motor and non-motor symptoms. Parkinson's disease affects several neuronal structures outside the substantia nigra, among which is the enteric nervous system. Recent reports have shown that the lesions in the enteric nervous system occur in very early stages of the disease, even before the involvement of the central nervous system. This has led to the postulation that the enteric nervous system could be critical in the pathophysiology of Parkinson's disease, as it could represent the point of entry for a putative environmental factor to initiate the pathological process. This review covers the data related to the etiology, epidemiology, clinical expression, pathophysiology, genetic aspects, gastrointestinal motor dysfunction, visceral sensitivity, management, prevention and prognosis of neurogenic bowel dysfunction patients with these neurological diseases. Embryological, morphological and experimental studies on animal models and humans are also taken into account.
Collapse
|
19
|
Prenatal repair of myelomeningocele with aligned nanofibrous scaffolds-a pilot study in sheep. J Pediatr Surg 2011; 46:2279-83. [PMID: 22152865 DOI: 10.1016/j.jpedsurg.2011.09.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 09/03/2011] [Indexed: 11/21/2022]
Abstract
BACKGROUND/PURPOSE Spinal cord damage in myelomeningocele (MMC) results from abnormal cord development and subsequent local trauma. Prenatal surgery prevents additional neural injury. However, existing damage is not reversed. Biodegradable nanofibrous scaffolds (NSs) promote regeneration of neural tissues. They mimic the microtopography of the extracellular matrix and guide tissue formation and organization. The purpose of this pilot study was to evaluate the practicality and safety of using biodegradable NS as a regenerative device in prenatal MMC repair. METHODS Two fetal lambs underwent a surgically induced MMC defect followed by open fetal repair using aligned biodegradable NS. Lambs were killed at day 138. Spinal cords were examined for inflammation or fibrosis and stained for spinal cord architecture, myelin, and neuron cell bodies. RESULTS Prenatal repair with NS demonstrated technical feasibility. There was no evidence of a surrounding inflammatory response or foreign-body reaction to the scaffold. CONCLUSION Biodegradable NS can be used surgically for the prenatal repair of MMC in a large animal model and does not appear to elicit an inflammatory or fibrotic reaction in fetal tissue. Further studies will determine their potential for neural cell infiltration, delivery of growth factors, drugs or stem cells, and functional recovery greater than standard repair.
Collapse
|
20
|
Saadai P, Runyon T, Farmer DL. Fetal neurosurgery: current state of the art. FUTURE NEUROLOGY 2011; 6:165-171. [PMID: 21709818 DOI: 10.2217/fnl.11.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Congenital CNS abnormalities have been targets for prenatal intervention since the founding of fetal surgery 30 years ago, but with historically variable results. Open fetal neurosurgery for myelomenigocele has demonstrated the most promising results of any CNS malformation. Improvements in the understanding of congenital diseases and in fetal surgical techniques have reopened the door to applying fetal surgery to other congenital CNS abnormalities. Advances in gene therapy, bioengineering and neonatal neuroprotection will aid in the future expansion of fetal neurosurgery to other CNS disorders.
Collapse
Affiliation(s)
- Payam Saadai
- Fetal Treatment Center, UCSF Benioff Children's Hospital, 513 Parnassus Ave, HSW-1601, Box 0570, San Francisco, CA 94143-0570, USA
| | | | | |
Collapse
|
21
|
Fetoscopic coverage of experimental myelomeningocele in sheep using a patch with surgical sealant. Eur J Obstet Gynecol Reprod Biol 2011; 156:171-6. [PMID: 21353374 DOI: 10.1016/j.ejogrb.2010.12.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 11/22/2010] [Accepted: 12/18/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Assess the feasibility of a fetoscopic patch coverage method for myelomeningocele repair in a sheep model. STUDY DESIGN Experimental study. A myelomeningocele-like defect was created in 15 fetal sheep on day 75 of gestation. Six remained untreated, whereas 9 underwent fetoscopic coverage of the defect on day 95 of gestation using an inert patch secured with surgical sealant. Clinical and histological examinations were performed after delivery. RESULTS Four valid newborn lambs were obtained in each group. Mean fetoscopic surgical time was 26.9 (SD=7.4)min. All untreated animals had an open lumbar defect with cerebrospinal fluid leakage, paraplegia, urinary incontinence, and Chiari malformation. All treated animals had a closed defect and were able to walk; one had weak bladder control, and another mild Chiari malformation. CONCLUSION In a chronic myelomeningocele model in fetal sheep, fetoscopic repair using a sealed patch results in simple, fast, satisfactory neural tube closure and averts neurological damage and Chiari malformation.
Collapse
|
22
|
Abstract
Myelomeningocele (MMC) is a common birth defect that is associated with significant lifelong morbidity. Little progress has been made in the postnatal surgical management of the child with spina bifida. Postnatal surgery is aimed at covering the exposed spinal cord, preventing infection, and treating hydrocephalus with a ventricular shunt. In-utero repair of open spina bifida is now performed in selected patients and presents an additional therapeutic alternative for expectant mothers carrying a fetus with MMC. It is estimated that about 400 fetal operations have now been performed for MMC worldwide. Despite this large experience, the technique remains of unproven benefit. Preliminary results suggest that fetal surgery results in reversal of hindbrain herniation (the Chiari II malformation), a decrease in shunt-dependent hydrocephalus, and possibly improvement in leg function, but these findings might be explained by selection bias and changing management indications. A randomized prospective trial (the MOMS trial) is currently being conducted by three centers in the USA, and is estimated to be completed in 2010. Further research is needed to better understand the pathophysiology of MMC, the ideal timing and technique of repair, and the long-term impact of in-utero intervention.
Collapse
Affiliation(s)
- N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia and the University of Pennsylvania School of Medicine, 34th Street & Civic Center Blvd, Philadelphia, PA 19104, USA.
| |
Collapse
|
23
|
Fontecha CG, Peiro JL, Aguirre M, Soldado F, Añor S, Fresno L, Martinez-Ibañez V. Inert patch with bioadhesive for gentle fetal surgery of myelomeningocele in a sheep model. Eur J Obstet Gynecol Reprod Biol 2009; 146:174-9. [PMID: 19615808 DOI: 10.1016/j.ejogrb.2009.06.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Accepted: 06/22/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Current techniques used in foetal myelomeningocele repair can require considerable manipulation of fragile foetal tissues to obtain tension-free closure. The aim of this study was to assess the feasibility of a simple foetal coverage method without foetal tissue manipulation to provide closure of the neural tube defect in myelomeningocele. STUDY DESIGN This is an experimental study performed in 15 foetal sheep with lumbar myelomeningocele, surgically created on day 75 of gestation. Five foetuses remained untreated. Ten underwent coverage with inert sheeting (5 Silastic; 5 Silastic+Marlex) secured by surgical tissue adhesive without suturing on day 95; none of them underwent foetal muscle or skin manipulation. Clinical and subsequent histological examinations were performed at 48h after birth. The Chi-square, Fisher exact, and Mann-Whitney U tests, when appropriate, were used for the comparisons. RESULTS The mean operating time for foetal coverage was 7.1 (SD=1.6)min. All untreated animals were unable to walk, had sphincter incontinence, showed an open defect, histological spinal cord damage, and a large Chiari malformation. All covered animals were able to walk, had sphincter continence, showed almost complete closure of the defect with regeneration of several soft tissue layers, and minimum Chiari malformation. CONCLUSION In a surgical myelomeningocele model in sheep, a simple, fast and gentle coverage method using a sealed patch avoids foetal tissue manipulation and enables adequate closure of the neural tube defect, providing regeneration of several tissue layers that protect the spinal cord, and significantly reducing Chiari II malformation.
Collapse
Affiliation(s)
- Cesar G Fontecha
- Paediatric Orthopaedic Unit, Department of Orthopaedic Surgery, Barcelona, Spain.
| | | | | | | | | | | | | |
Collapse
|
24
|
Stiefel D, Meuli M. The dysraphic levels of skin and vertebrae are different in mouse fetuses and neonates with myelomeningocele. J Pediatr Surg 2008; 43:683-90. [PMID: 18405716 DOI: 10.1016/j.jpedsurg.2007.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Mouse fetuses with spontaneous myelomeningocele (MMC) were investigated, determining the various levels of dysraphism in soft tissue, spinal cord, and vertebrae. Morphology was correlated with hind limb function. METHODS Viable curly tail/loop tail mouse fetuses underwent qualitative standardized ex utero examination of tail and hind limb sensitivity and motor response. Afterward, they were processed either for histology or skeletal preparation. RESULTS All animals displayed identical cranial levels of soft tissue and neural defects. The cranial opening of the vertebral defects were invariably located more cranially (range, 0.5-5 vertebrae; mean = 2.25). The caudal opening of soft/neural tissue and bony defects was invariably at the coccygeal base. The comparison of functional with morphological levels demonstrated that, in 52.5%, the level of the soft/neural tissue dysraphism and, in 47.5%, the level of the bony opening correlated with the neurologic deficit. CONCLUSION The naturally occurring soft tissue coverage over the MMC could exert a protective effect toward the underlying spinal cord. This interpretation supports the concept that in utero acquired destruction of exposed neural tissue is a main factor for the neonatal functional deficit. Thus, these data are consistent with the rationale for prenatal MMC repair in humans.
Collapse
Affiliation(s)
- Dorothea Stiefel
- Department of Pediatric Surgery, University Children's Hospital Zürich, 8032 Zürich, Switzerland.
| | | |
Collapse
|