P0 mRNA expression increases during gradual nerve elongation in adult rats

Direct End-to-End Neurorrhaphy for Wrist-Level Long Nerve Defect with Fixation of the Wrist in Flexion: Technique Note

Background  For a nerve gap, end-to-end neurorrhaphy would either be difficult or would include tension. The use of a nerve graft or conduit could be a solution, but it might compromise the reinnervation. We describe a method for wrist-level ulnar and/or median long nerve injury by fixing the wrist in the flexion position with K-wire (s) to make possible an end-to-end and tension-free neurorrhaphy. Patients and Methods  Two patients had wrist-level ulnar nerve injury for 2 and 3 months and nerve gaps of 2.5 cm and 3.5 cm, respectively, after the neuroma excision. K-wires were used to transfix from the radius to carpal bones, in order to keep their wrists in flexion of 45 and 65 degrees, respectively, with which the tension-free end-to-end neurorrhaphy could be achieved. The K-wires were removed in 6 weeks after surgery, and their wrists were kept in the splint for a progressive extension program. Results  Both patients were noted to have an improved claw hand deformity 4 months after the surgery. The ulnar nerve motor and sensory function could be recovered mostly in the 12-month follow-up. The wrist flexion and extension motion arc both achieved, at least, 150 degree in the 12-month follow-up. There were no complications related to the K-wire fixation. Conclusion  With the wrist fixed in a flexed position, maintaining a longer nerve gap to achieve a direct end-to-end and tension-free neurorrhaphy would be more likely and safer. Without the use of nerve graft, innervation of the injured nerve would be faster.

mTOR regulates peripheral nerve response to tensile strain

While excessive tensile strain can be detrimental to nerve function, strain can be a positive regulator of neuronal outgrowth. We used an in vivo rat model of sciatic nerve strain to investigate signaling mechanisms underlying peripheral nerve response to deformation. Nerves were deformed by 11% and did not demonstrate deficits in compound action potential latency or amplitude during or after 6 h of strain. As revealed by Western blotting, application of strain resulted in significant upregulation of mammalian target of rapamycin (mTOR) and S6 signaling in nerves, increased myelin basic protein (MBP) and β-actin levels, and increased phosphorylation of neurofilament subunit H (NF-H) compared with unstrained (sham) contralateral nerves (P < 0.05 for all comparisons, paired two-tailed t-test). Strain did not alter neuron-specific β3-tubulin or overall nerve tubulin levels compared with unstrained controls. Systemic rapamycin treatment, thought to selectively target mTOR complex 1 (mTORC1), suppressed mTOR/S6 signaling, reduced levels of MBP and overall tubulin, and decreased NF-H phosphorylation in nerves strained for 6 h, revealing a role for mTOR in increasing MBP expression and NF-H phosphorylation, and maintaining tubulin levels. Consistent with stretch-induced increases in MBP, immunolabeling revealed increased S6 signaling in Schwann cells of stretched nerves compared with unstretched nerves. In addition, application of strain to cultured adult dorsal root ganglion neurons showed an increase in axonal protein synthesis based on a puromycin incorporation assay, suggesting that neuronal translational pathways also respond to strain. This work has important implications for understanding mechanisms underlying nerve response to strain during development and regeneration.NEW & NOTEWORTHY Peripheral nerves experience tensile strain (stretch) during development and movement. Excessive strain impairs neuronal function, but moderate strains are accommodated by nerves and can promote neuronal growth; mechanisms underlying these phenomena are not well understood. We demonstrated that levels of several structural proteins increase following physiological levels of nerve strain and that expression of a subset of these proteins is regulated by mTOR. Our work has important implications for understanding nerve development and strain-based regenerative strategies.

Limb lengthening and peripheral nerve function-factors associated with deterioration of conduction

BACKGROUND

and purpose Limb lengthening is performed for a diverse range of orthopedic problems. A high rate of complications has been reported in these patients, which include motor and sensory loss as a result of nerve damage. We investigated the effect of limb lengthening on peripheral nerve function.

PATIENTS AND METHODS

36 patients underwent electrophysiological testing at 3 points: (1) preoperatively, (2) after application of external fixator/corticotomy but before lengthening, and (3) after lengthening. The limb-length discrepancy was due to a congenital etiology (n = 19), a growth disturbance (n = 9), or a traumatic etiology (n = 8).

RESULTS

2 of the traumatic etiology patients had significant changes evident on electrophysiological testing preoperatively. They both deteriorated further with lengthening. 7 of the 21 patients studied showed deterioration in nerve function after lengthening, but not postoperatively, indicating that this was due to the lengthening process and not to the surgical procedure. All of these patients had a congenital etiology for their leg-length discrepancy.

INTERPRETATION

As detailed electrophysiological tests were carried out before surgery, after surgery but before lengthening, and finally after completion of lengthening, it was possible to distinguish between the effects of the operation and the effects of lengthening on nerve function. The results indicate that the etiology, site (femur or tibia), and nerve (common peroneal or tibial) had a bearing on the risk of nerve injury and that these factors had a far greater effect than the total amount of lengthening.

FUNCTIONAL AND MORPHOLOGICAL EFFECTS OF INDIRECT GRADUAL ELONGATION OF PERIPHERAL NERVE: ELECTROPHYSIOLOGICAL AND MORPHOLOGICAL CHANGES AT DIFFERENT ELONGATION RATES

We investigated the neuropathy induced by leg lengthening histological evaluation using teased nerve fiber specimens and electrophysiological evaluation. Indirect elongation of the sciatic nerve associated with leg lengthening was performed at 1 and 3 mm/day over 30 mm in rats. Electrophysiological evaluation was performed immediately and 60 days after the end of elongation, teased nerve fiber specimens were prepared, and the mean axonal diameter was calculated. The electrophysiological results were more wrong, and the recovery was poorer, in the 3-mm than in the 1-mm group. In the 1-mm group, the nerve conduction velocity (NCV) and the duration of the compound nerve action potential (C-NAP) recovered to a level close to the intact side, but the decrease in the amplitude of the C-NAP persisted. In the teased fiber study, while paranodal demyelination was observed in both groups immediately after elongation, demyelination was decreased in the 1-mm group indicationg recovery compared to the 3-mm group. Paranodal demyelination caused by indirect nerve elongation is considered to have induced electrophysiological disorders.

Electrophysiological and morphological damages appeared to be more severe according to elongation speed. The nerve disorder were remained even at 1 mm per day in 60 days.

The morphologic characteristics of nerve shortening following traumatic bone loss

Little is known about peripheral nerve shortening secondary to joint contracture or traumatic bone loss. We used the rat sciatic nerve as a model to study nerve shortening secondary to leg shortening. Nerve shortening was induced by surgically removing 16 mm of the femur. The histology of the ipsilateral and contralateral (control) sciatic nerves were compared at 1 h, 3 weeks, and 6 weeks. Transverse semithin sections of sciatic nerve were prepared and examined; single fibers also were teased from the nerve for study. The epineurium was shortened about 25% at 6 weeks. Axonal diameter was unchanged at 1 h, but increased over time, and was 0.68 microm larger than controls at 6 weeks (p < 0.05). In teased-fiber preparations, internodal length decreased 2.3% at 6 weeks, but not significantly. Peripheral nerve shortening secondary to leg shortening shortens the epineurium, but does not effect on internodal length.

White matter in learning, cognition and psychiatric disorders

White matter is the brain region underlying the gray matter cortex, composed of neuronal fibers coated with electrical insulation called myelin. Previously of interest in demyelinating diseases such as multiple sclerosis, myelin is attracting new interest as an unexpected contributor to a wide range of psychiatric disorders, including depression and schizophrenia. This is stimulating research into myelin involvement in normal cognitive function, learning and IQ. Myelination continues for decades in the human brain; it is modifiable by experience, and it affects information processing by regulating the velocity and synchrony of impulse conduction between distant cortical regions. Cell-culture studies have identified molecular mechanisms regulating myelination by electrical activity, and myelin also limits the critical period for learning through inhibitory proteins that suppress axon sprouting and synaptogenesis.

Effect of progesterone on recovery from nerve injury during leg lengthening in rats

We investigated the effect of progesterone on the nerve during lengthening of the limb in rats. The sciatic nerves of rats were elongated by leg lengthening for ten days at 3 mm per day. On alternate days between the day after the operation and nerve dissection, the progesterone-treated group received subcutaneous injections of 1 mg progesterone in sesame oil and the control group received oil only. On the fifth, tenth and 17th day, the sciatic nerves were excised at the midpoint of the femur and the mRNA expression level of myelin protein P0 was analysed by quantitative real time polymerase chain reaction. On day 52 nodal length was examined by electron microscopy, followed by an examination of the compound muscle action potential (C-MAP) amplitude and the motor conduction velocity (MCV) of the tibial nerve on days 17 and 52. The P0 (a major myelin glycoprotein) mRNA expression level in the progesterone-treated group increased by 46.6% and 38.7% on days five and ten, respectively. On day 52, the nodal length in the progesterone-treated group was smaller than that in the control group, and the MCV of the progesterone-treated group had been restored to normal. Progesterone might accelerate the restoration of demyelination caused by nerve elongation by activating myelin synthesis.

Repair of peripheral nerve defect with direct gradual lengthening of the proximal nerve stump in rats

We investigated the effect of direct gradual lengthening on the proximal nerve stump and subsequent nerve regeneration in rats. A 10-mm-long nerve segment was resected from the sciatic nerve of each rat. The proximal nerve stump was directly lengthened at a rate of 1 mm/day using an original external nerve distraction device. Experiment I: After distraction periods of 10, 15, and 20 days, the length of each nerve was evaluated, and the lengthened nerve stump was also examined by immunohistochemical analysis. Experiment II: After a distraction period of 20 days, both nerve stumps were refreshed and direct end-to-end neurorrhaphy was performed. For control, 10-mm nerve grafting was immediately performed after nerve resection. Nerve regeneration was evaluated electrophysiologically and histologically 7, 9, and 15 weeks after nerve resection in both groups. The whole proximal nerve stump, including the endoneurium and the axon, could be lengthened in proportion to the distraction period. There were no significant differences in motor nerve conduction velocity and tetanic muscle contraction force between both groups. Histologically, the total number of myelinated fibers was significantly greater in the nerve lengthening group than in the autografting group. This study demonstrated that the whole proximal nerve stump including the endoneurium and the axon could be lengthened by direct gradual distraction, and that this method might have potential application in the repair of peripheral nerve defects.

Structure and biomechanics of peripheral nerves: nerve responses to physical stresses and implications for physical therapist practice

The structural organization of peripheral nerves enables them to function while tolerating and adapting to stresses placed upon them by postures and movements of the trunk, head, and limbs. They are exposed to combinations of tensile, shear, and compressive stresses that result in nerve excursion, strain, and transverse contraction. The purpose of this appraisal is to review the structural and biomechanical modifications seen in peripheral nerves exposed to various levels of physical stress. We have followed the primary tenet of the Physical Stress Theory presented by Mueller and Maluf (2002), specifically, that the level of physical stress placed upon biological tissue determines the adaptive response of the tissue. A thorough understanding of the biomechanical properties of normal and injured nerves and the stresses placed upon them in daily activities will help guide physical therapists in making diagnoses and decisions regarding interventions.

Induction of tumor necrosis factor-alpha in Schwann cells after gradual elongation of rat sciatic nerve

BACKGROUND

Although limb lengthening has become a common treatment, the biochemical responses underlying the adaptation of elongated nerves are unclear. The purpose of this study was to clarify whether expression of cytokines and neurotrophins is altered in gradually elongated peripheral nerves.

METHODS

Left sciatic nerves of adult rats were elongated by lengthening the femur up to 20 mm at a rate of 1, 2, or 20 mm/day. The ipsilateral and contralateral sciatic nerves of each group were resected 1, 4, 8, and 16 days after 20 mm of lengthening. mRNAs for interleukin-1beta, interleukin-6, tumor necrosis factor-alpha (TNFalpha), nerve growth factor, brain-derived neurotrophic factor, neurotrophin-3, and neurotrophin-4/5 were semiquantified by reverse transcription-polymerase chain reaction. Histological changes were assessed by immunoperoxidase and immunofluorescence staining.

RESULTS

Expression of TNFalpha mRNA was markedly induced in the ipsilateral sciatic nerves of the gradually elongated, 1 mm/day and 2 mm/day groups, although to a lesser extent than in the acutely elongated, 20 mm/day group. In contrast, mRNAs for other factors remained undetectable. The mRNA level for TNFalpha in each group was highest 1 day after 20 mm of lengthening. The highly up-regulated level in the acute group declined rapidly within 4 days and slowly thereafter; in contrast, the decrease in the gradual groups was always slow. Even 16 days later, the levels in all groups remained significantly elevated. Unexpectedly, TNFalpha mRNA expression was also induced in the contralateral side of all groups. Immunohistochemical staining showed that TNFalpha-immunoreactive cells in gradually elongated nerves were also positive for S-100 protein but negative for proliferating nuclear cell antigen, indicating that TNFalpha was produced by nonproliferating Schwann cells.

CONCLUSIONS

Gradual nerve elongation by limb lengthening induces production of TNFalpha in Schwann cells. Presumably, TNFalpha plays a critical role in the adaptation of peripheral nerves to elongation.

Induction of interleukin-6 in dorsal root ganglion neurons after gradual elongation of rat sciatic nerve

In the reconstruction of a segmental defect in injured peripheral nerves, gradual nerve elongation has become an important alternative to nerve grafting. To clarify biochemical responses in peripheral sensory neurons after nerve elongation, we examined the expression of cytokines and neurotrophins related to nerve regeneration. We first established rat elongation models by lengthening left femurs up to 20.0 mm at the rate of 1.0, 2.0, or 20.0 mm/day. In toluidine blue staining, the acutely elongated, 20-mm/day group showed nuclear eccentricity in the nerve cell body in L5 dorsal root ganglion (DRG) and axonal degeneration in the sciatic nerves; in contrast, the gradually elongated, 1- and 2-mm/day groups remained intact, indicating adaptation. Reverse transcription-polymerase chain reaction analysis revealed that interleukin-6 (IL-6) mRNA was induced in ipsilateral L4-6 DRG in an elongation rate-dependent manner. In contrast, none of the elongated groups exhibited a significant change in mRNA levels for interleukin-1beta, tumor necrosis factor-alpha, nerve growth factor, brain-derived neurotrophic factor, neurotropnin-3, and neurotrophin-4/5. Levels of IL-6 mRNA in all the elongated groups reached the maximum level at day 4 after 20-mm lengthening, while the axotomized group showed a decrease from the maximum level at day 1. Induction of IL-6 mRNA was also detected in the contralateral L4-6 DRG of all the elongated groups, but not detected in the axotomized group. In histochemical analysis, IL-6-immunoreactivity was predominant in neurofilament-positive, medium to large DRG neurons. Application of IL-6 to cultured Schwann cells increased mRNA for peripheral myelin protein 22 (PMP22), a major myelin component. These results suggest that IL-6 plays a key role in biochemical responses in peripheral sensory neurons after gradual nerve elongation.

Disruption of Mtmr2 produces CMT4B1-like neuropathy with myelin outfolding and impaired spermatogenesis

Mutations in MTMR2, the myotubularin-related 2 gene, cause autosomal recessive Charcot-Marie-Tooth (CMT) type 4B1, a demyelinating neuropathy with myelin outfolding and azoospermia. MTMR2 encodes a ubiquitously expressed phosphatase whose preferred substrate is phosphatidylinositol (3,5)-biphosphate, a regulator of membrane homeostasis and vesicle transport. We generated Mtmr2-null mice, which develop progressive neuropathy characterized by myelin outfolding and recurrent loops, predominantly at paranodal myelin, and depletion of spermatids and spermatocytes from the seminiferous epithelium, which leads to azoospermia. Disruption of Mtmr2 in Schwann cells reproduces the myelin abnormalities. We also identified a novel physical interaction in Schwann cells, between Mtmr2 and discs large 1 (Dlg1)/synapse-associated protein 97, a scaffolding molecule that is enriched at the node/paranode region. Dlg1 homologues have been located in several types of cellular junctions and play roles in cell polarity and membrane addition. We propose that Schwann cell-autonomous loss of Mtmr2-Dlg1 interaction dysregulates membrane homeostasis in the paranodal region, thereby producing outfolding and recurrent loops of myelin.