On CNS repair and protection strategies: novel approaches with implications for spinal cord injury and Parkinson's disease

Approaches to repairing the damaged spinal cord: overview

Affecting young people during the most productive period of their lives, spinal cord injury (SCI) is a devastating problem for modern society. In the past, treating SCI seemed frustrating and hopeless because of the tremendous morbidity and mortality, life-shattering impact, and limited therapeutic options associated with the condition. Today, however, an understanding of the underlying pathophysiological mechanisms, the development of neuroprotective interventions, and progress toward regenerative interventions are increasing hope for functional restoration. In this chapter, we provide an overview of various repair strategies for the injured spinal cord. Special attention will be paid to strategies that promote spontaneous regeneration, including functional electrical stimulation, cell replacement, neuroprotection, and remyelination. The concept that limited rebuilding can provide a disproportionate improvement in quality of life is emphasized throughout. New surgical procedures, pharmacological treatments, and functional neuromuscular stimulation methods have evolved over the last decades and can improve functional outcomes after spinal cord injury; however, limiting secondary injury remains the primary goal. Tissue replacement strategies, including the use of embryonic stem cells, become an important tool and can restore function in animal models. Controlled clinical trials are now required to confirm these observations. The ultimate goal is to harness the body's own potential to replace lost central nervous system cells by activation of endogenous progenitor cell repair mechanisms.

Improved survival of young donor age dopamine grafts in a rat model of Parkinson's disease

In an attempt to improve the survival of implanted dopamine cells, we have readdressed the optimal embryonic donor age for dopamine grafts. In a rat model of Parkinson's disease, animals with unilateral 6-hydroxydopamine lesions of the median forebrain bundle received dopamine-rich ventral mesencephalic grafts derived from embryos of crown to rump length 4, 6, 9, or 10.5 mm (estimated embryonic age (E) 11, E12, E13 and E14 days post-coitus, respectively). Grafts derived from 4 mm embryos survived poorly, with less than 1% of the implanted dopamine cells surviving. Grafts derived from 9 mm and 10.5 mm embryos were similar to those seen in previous experiments with survival rates of 8% and 7% respectively. The best survival was seen in the group that received 6 mm grafts, which were significantly larger than all other graft groups. Mean dopamine cell survival in the 6 mm group (E12) was 36%, an extremely high survival rate for primary, untreated ventral mesencephalic grafts applied as a single placement, and more than fivefold larger than the survival rate observed in the 10.5 mm (E14) group. As E12 ventral mesencephalic tissues contain few, if any, differentiated dopamine cells we conclude that the large numbers of dopamine cells seen in the 6 mm grafts must have differentiated post-implantation. We consider the in vivo conditions which allow this differentiation to occur, and the implications for the future of clinical trials based on dopamine cell replacement therapy.

Spinal cord injury--scientific challenges for the unknown future

The history of spinal cord injuries starts with the ancient Egyptian medical papyrus known as the Edwin Smith Surgical Papyrus. The papyrus written about 2500 B.C.by the physician and architect of the Sakkara pyramids Imhotep, describes "crushed vertebra in his neck" as well as symptoms of neurological deterioration. An ailment not to be treated was the massage to the patients at that time. This fatalistic attitude remained until the end of World War II when the first rehabilitation centre focused on the rehabilitation of spinal cord injured patients was opened. Our knowledge of the pathophysiological processes, both the primary as well as the secondary, has increased tremendously. However, all this knowledge has only led to improved medical care but not to any therapeutic method to restore, even partially, the neurological function. Neuroprotection is defined as measures to counteract secondary injury mechanisms and/or limit the extent of damage caused by self-destructive cellular and tissue processes. The co-existence of several distinctly different injury mechanisms after trauma has provided opportunities to explore a large number of potentially neuroprotective agents in animal experiments such as methylprednisolone sodium succinate. The results of this research have been very discouraging and pharmacological neuroprotection for patients with spinal cord injury has fallen short of the expectations created by the extensive research and promising observations in animal experiments. The focus of research has now, instead, been transformed to the field of neural regeneration. This field includes the discovery of regenerating obstacles in the nerve cell and/or environmental factors but also various regeneration strategies such as bridging the gap at the site of injury as well as transplantation of foetal tissue and stem cells. The purpose of this review is to highlight selected experimental and clinical studies that form the basis for undertaking future challenges in the research field of spinal cord injury. We will focus our discussion on methods either preventing the consequences of secondary injury in the acute period (neuroprotection) and/or various techniques of neural regeneration in the sub-acute and chronic phase and finally expose some thoughts about future avenues within this scientific field.

Genetic Manipulation of Neural Stem Cells for Transplantation into the Injured Spinal Cord

The injured adult spinal cord is not conducive for neuronal regeneration and neurogenesis. Engrafted neural precursor cells (NPCs) differentiate largely into astroglia, with only a very small percentage becoming neurons (which might replace injured neurons) or oligodendroglia (which might improve injury induced demyelination of spared neurons). Several recent attempts have been made to enhanced neurogenesis or oligodendroglia differentiation of transplanted NPCs by genetic manipulation. These include exogenous expression of noggin, with the idea of antagonizing the astroglia differentiation promoting Bone Morphogenetic Proteins (BMPs). Direct attempts to enhance neurogenesis have also been made in transgenic over-expression of neurogenic basic helix-loop-helix transcription factors. These experiments resulted in some interesting observations, which we discuss here in the light of recent advances in development of cell-based engraftment therapy for spinal cord injuries.

Nur77 gene knockout alters dopamine neuron biochemical activity and dopamine turnover

BACKGROUND

Transcription factors of the Nur family (Nurr1, Nur77, and Nor-1) are orphan nuclear receptors closely associated with dopamine neurotransmission in the central nervous system. Nur77 expression is strongly modulated by antipsychotic and ant-parkinsonian drugs in dopaminoceptive brain areas. However, the role of Nur77 in dopamine neuron activity and turnover remains elusive.

METHODS

We compared various behavioral and biochemical parameters between Nur77 knockout -/- and wild-type +/+ mice in basal and haloperidol-challenged conditions.

RESULTS

We report here that Nur77-deficient mice display enhanced spontaneous locomotor activity, greater sensitivity to a small dose of the dopamine D2 receptor agonist quinpirole acting mainly at autoreceptor sites, and higher levels of the dopamine metabolite DOPAC relative to wild-type mice. Dopamine turnover disturbances are also found after acute challenge with haloperidol, a dopamine D2 receptor antagonist. These alterations are associated with increased tyrosine hydroxylase expression and activity, and reduced catechol-O-methyltransferase expression.

CONCLUSION

Taken together, these results are consistent with the involvement of Nur77 in dopamine neuron biochemical activity and dopamine turnover.

Immunosuppressants: neuroprotection and promoting neurological recovery following peripheral nerve and spinal cord lesions

No clinical techniques induce restoration of neurological losses following spinal cord trauma. Peripheral nerve damage also leads to permanent neurological deficits, but neurological recovery can be relatively good, especially if the ends of a transected nerve are anastomosed soon after the injury. The time until recovery generally depends on the distance the axons must regenerate to their targets. Neurological recovery following the destruction of a length of a peripheral nerve requires a graft to bridge the gap that is permissive to, and promotes, axon regeneration. But neurological recovery is slow and limited, especially for gaps longer than 1.5 cm, even using autologous peripheral nerve grafts. Without a reliable means of bridging long nerve gaps, such injuries commonly result in amputations. Promoting extensive neurological recovery requires techniques that simultaneously provide protection to injured neurons and increase the numbers of neurons that extend axons, while inducing more rapid and extensive axon regeneration across long nerve gaps. Although conduits filled with various materials enhance axon regeneration across short nerve gaps, pure sensory nerve graft remains the gold standard for use across long nerve gaps, even though they lead to only limited neurological recovery. Consistent results demonstrate that several immunosuppressive agents enhance the number of axons and the rate at which they regenerate. This review examines the roles played by immunosuppressants, especially FK506, with primary focus on its role as a neuroprotectant and neurotrophic agent, and its potential clinical use to promote improved neurological recovery following peripheral nerve and spinal cord injuries.

Stem cell transplantation and other novel techniques for promoting recovery from spinal cord injury

A number of potential approaches aim to optimize functional recovery after spinal cord injury. They include minimizing the progression of secondary injury, manipulating the neuroinhibitory environment of the spinal cord, replacing lost tissue with transplanted cells or peripheral nerve grafts, remyelinating denuded axons, and maximizing the intrinsic regenerative potential of endogenous progenitor cells. We review the application of stem cell transplantation to the spinal cord, emphasizing the use of embryonic stem cells for remyelinating damaged axons. We speculate that harnessing the potential of endogenously born stem cells already present in the spinal cord represents an important therapeutic target. We also discuss the potential application of peripheral nervous system reconstruction to recovery from spinal cord injury. The principles of peripheral nerve regeneration and concepts of nerve grafting are reviewed. Particular attention is given to peripheral nerve allotransplantation for repairing extensively injured tissue when autologous donor nerve material is scarce. The potential role of nerve transfers for reconstructing the injured spinal cord, particularly the cauda equina and lumbosacral plexus, are also described.

Current developments in spinal cord injury research

BACKGROUND CONTEXT

Recent advances in neuroscience have opened the door for hope toward prevention and cure of the devastating effects of spinal cord injury (SCI).

PURPOSE

To highlight the current understanding of traumatic SCI mechanisms, provide information regarding state-of-the-art care for the acute spinal cord-injured patient, and explore future treatments aimed at neural preservation and reconstruction.

STUDY DESIGN/SETTING

A selective overview of the literature pertaining to the neuropathophysiology of traumatic SCI is provided with an emphasis on pharmacotherapies and posttraumatic experimental strategies aimed at improved neuropreservation and late neuroregenerative repair.

METHODS

One hundred fifty-four peer-reviewed basic science and clinical articles pertaining to SCI were reviewed. Articles cited were chosen based on the relative merits and contribution to the current understanding of SCI neuropathophysiology, neuroregeneration, and clinical SCI treatment patterns.

RESULTS

A better understanding of the pathophysiology and early treatment for the spinal cord-injured patient has led to a continued decrease in mortality, decreased acute hospitalization and complication rates, and more rapid rehabilitation and re-entry into society. Progressive neural injury results from a combination of secondary injury mechanisms, including ischemia, biochemical alterations, apoptosis, excitotoxicity, calpain proteases, neurotransmitter accumulation, lipid peroxidation/free radical injury, and inflammatory responses. Experimental studies suggest that the final posttraumatic neurologic deficit is not only a result of the initial impaction forces but rather a combination of these forces and secondary time-dependent events that follow shortly after the initial impact.

CONCLUSIONS

Experimental studies continue to provide a better understanding of the complex interaction of pathophysiologic events after traumatic SCI. Future approaches will involve strategies aimed at blocking the multiple mechanisms of progressive central nervous system injury and promoting neuroregeneration.

Characterization of the 5'-flanking region of the human dopamine transporter gene

The dopamine transporter (DAT) plays a major role in modulating dopamine (DA) neurotransmission by controlling the levels of this neurotransmitter in the extracellular space. We have isolated 8.3 kb of the 5'-flanking regulatory region of the human DAT (hDAT) gene and identified numerous potential elements involved in transcriptional control of the DAT. A series of hDAT-luciferase reporter constructs encompassing increasing amounts of 5'-flanking sequence was utilized in transient transfection assays assessing basal activity and response to selected stimuli. Our results suggest that the proximal hDAT 5'-flanking region displays a strong, nonselective promoter activity that is silenced through regulatory elements present in the distal portion of the 5'-flanking sequence. Although potential cyclic AMP responsive elements (CRE) were identified on the sequence, hDAT constructs were unresponsive to cyclic AMP induction. The transcription factor nurr1 increases the transcriptional activity of several larger hDAT constructs, consistent with the presence of several putative NGFI-B response elements (NBRE). The cloning and functional analysis of an extensive portion of the 5'-flanking regulatory region of the hDAT gene provides further insights into the factors involved in the regulation of this gene.