The current state-of-the-art of spinal cord imaging: methods.

A first-ever spinal cord imaging meeting was sponsored by the International Spinal Research Trust and the Wings for Life Foundation with the aim of identifying the current state-of-the-art of spinal cord imaging, the current greatest challenges, and greatest needs for future development. This meeting was attended by a small group of invited experts spanning all aspects of spinal cord imaging from basic research to clinical practice. The greatest current challenges for spinal cord imaging were identified as arising from the imaging environment itself; difficult imaging environment created by the bone surrounding the spinal canal, physiological motion of the cord and adjacent tissues, and small cross-sectional dimensions of the spinal cord, exacerbated by metallic implants often present in injured patients. Challenges were also identified as a result of a lack of "critical mass" of researchers taking on the development of spinal cord imaging, affecting both the rate of progress in the field, and the demand for equipment and software to manufacturers to produce the necessary tools. Here we define the current state-of-the-art of spinal cord imaging, discuss the underlying theory and challenges, and present the evidence for the current and potential power of these methods. In two review papers (part I and part II), we propose that the challenges can be overcome with advances in methods, improving availability and effectiveness of methods, and linking existing researchers to create the necessary scientific and clinical network to advance the rate of progress and impact of the research.

The current state-of-the-art of spinal cord imaging: applications.

A first-ever spinal cord imaging meeting was sponsored by the International Spinal Research Trust and the Wings for Life Foundation with the aim of identifying the current state-of-the-art of spinal cord imaging, the current greatest challenges, and greatest needs for future development. This meeting was attended by a small group of invited experts spanning all aspects of spinal cord imaging from basic research to clinical practice. The greatest current challenges for spinal cord imaging were identified as arising from the imaging environment itself; difficult imaging environment created by the bone surrounding the spinal canal, physiological motion of the cord and adjacent tissues, and small crosssectional dimensions of the spinal cord, exacerbated by metallic implants often present in injured patients. Challenges were also identified as a result of a lack of "critical mass" of researchers taking on the development of spinal cord imaging, affecting both the rate of progress in the field, and the demand for equipment and software to manufacturers to produce the necessary tools. Here we define the current state-of-the-art of spinal cord imaging, discuss the underlying theory and challenges, and present the evidence for the current and potential power of these methods. In two review papers (part I and part II), we propose that the challenges can be overcome with advances in methods, improving availability and effectiveness of methods, and linking existing researchers to create the necessary scientific and clinical network to advance the rate of progress and impact of the research.

A comparative histological analysis of two models of nerve root avulsion injury in the adult rat.

AIMS: This study has investigated the reliability of the artificial surgical model dorsal root rhizotomy (DRR), to the surgical tearing of the roots, avulsion, that occurs clinically. Root avulsion of the limb nerves is common in high-impact motor vehicle accidents and results in paraesthesia, paralysis and intractable pain. Limited treatment options are largely due to a lack of basic research on underlying mechanisms, and few animal models. We assess this limitation by histologically assessing the spatial and temporal injury profile of dorsal root avulsion (DRA) and DRR within the spinal cord. METHODS: Rats underwent DRR, DRA or sham surgery to the L3-L6 dorsal roots unilaterally. At 1, 2, 14, and 28 days post injury, immunohistochemical density staining was used to characterize the progression of spinal cord trauma. Neuronal (NeuN) and vascular degeneration (RECA-1), inflammatory infiltrate (ED1, anti-neutrophil), gliosis (Iba1, GFAP) and apoptosis (TUNEL) were assessed. RESULTS: Unilateral DRA produced a prolonged and bilateral glial and inflammatory response, and vascular degeneration compared to transient and unilateral effects after DRR. Transsynaptic neurodegeneration after DRA was greater than after DRR, and progressed across 28 days coinciding with gliosis and macrophage infiltration. CONCLUSIONS: Rhizotomy leads to a milder representation of the spinal cord trauma that occurs after 'true' avulsion injury. We recommend DRA be used in the future to more reliably model clinical avulsion injury. Avulsion is an injury with a chronic profile of degenerative and inflammatory progression, and this theoretically provides a window of clinical therapeutic opportunity in treatment of secondary trauma progression.

The effects of operative delay on the relief of neuropathic pain after injury to the brachial plexus: a review of 148 cases.

We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the relief from pain and there was a strong correlation between functional recovery and relief from pain.

Pain phenomena and sensory recovery following brachial plexus avulsion injury and surgical repairs.

Seventy-six patients with severe brachial plexus avulsion injuries were studied using pain questionnaires and quantitative sensory testing. There was significant correlation between pain intensity and the number of roots avulsed prior to surgery (P=0.0004) and surgical repairs were associated with pain relief. Sensory recovery to thermal stimuli was observed, mainly in the C5 dermatome. Allodynia to mechanical and thermal stimuli was observed in the border zone of affected and unaffected dermatomes in 18% of patients assessed early (<6 months) and 37% patients at later stages. Pain and sensations referred to the original source of afferents occurred at a later stage (>6 months) in 12% of patients and were related to nerve regeneration. By contrast, "wrong-way" referred sensations (e.g. down the affected arm while shaving or drinking cold fluids) were reported by 44% of patients and often occurred early, suggesting CNS plasticity. Understanding sensory mechanisms will help develop new treatments for severe brachial plexus injuries.

Myelination of S1 dorsal root axons in the cat.

Samples of S1 dorsal root nerve fibers from cats of different pre- and postnatal ages were examined electron microscopically with regard to axon caliber and number of myelin lamellae. Each root was examined at four different cross-sectional levels. Two levels were situation close to the spinal cord entrance on each side of the peripheral (PNS) and central nervous system (CNS) border. The third and fourth levels were located more distally. The first compact myelin lamella was observed in the CNS part of the root in a 47-day-old fetus. In the 53-day-old fetus the degree of myelination was the same in the CNS as distal in the PNS part of the root. Surprisingly, all axons appeared unmyelinated close to the PNS-CNS border and remained so for a further 10-day period. After this time lag, this part of the root became myelinated and showed a rapid increase in myelin sheath thickness. Calculations of axonal growth, mesaxonal length, and myelin volume indicated a maturation process that progressed discontinuously. Myelination did not proceed in a strict somatofugal direction, but was a regionally differentiated process. The maximal myelin production, expressed as the increase in myelin volume per Schwann cell, was found during the second to fourth postnatal months, i.e., very late in development.

Immunolocalization of SNS/PN3 and NaN/SNS2 sodium channels in human pain states.

The tetrodotoxin-resistant (TTX-R) voltage-gated sodium channel SNS/PN3 and the newly discovered NaN/SNS2 are expressed in sensory neurones, particularly in nociceptors. Using specific antibodies, we have studied, for the first time in humans, the presence of SNS/PN3 and NaN/SNS2 in peripheral nerves, including tissues from patients with chronic neurogenic pain. In brachial plexus injury patients, there was an acute decrease of SNS/PN3- and NaN/SNS2-like immunoreactivity in sensory cell bodies of cervical dorsal root ganglia (DRG) whose central axons had been avulsed from spinal cord, with gradual return of the immunoreactivity to control levels over months. In contrast, there was increased intensity of immunoreactivity to both channels in some peripheral nerve fibers just proximal to the site of injury in brachial plexus trunks, and in neuromas. These findings suggest that the expression of these sodium channels in neuronal cell bodies is reduced after spinal cord root avulsion injury in man, but that pre-synthesized channel proteins may undergo translocation with accumulation at sites of nerve injury, as in animal models of peripheral axotomy. The latter may contribute to positive symptoms, as our patients all showed a positive Tinel's sign. Nerve terminals in distal limb neuromas and skin from patients with chronic local hyperalgesia and allodynia all showed marked increases of SNS/PN3-immunoreactive fibers, but little or no NaN/SNS2-immunoreactivity, suggesting that the former may be related to the persistent hypersensitive state. Axonal immunoreactivity to both channels was similar to control nerves in sural nerve biopsies in a selection of neuropathies, irrespective of nerve inflammation, demyelination or spontaneous pain, including a patient with congenital insensitivity to pain. Our studies suggest that the best target for SNS/PN3 blocking agents is likely to be chronic local hypersensitivity.

Regrowth of cholinergic and catecholaminergic neurons along a peripheral and central nervous pathway.

The transitional region between the peripheral and central nervous system in lumbosacral dorsal roots of rats were used in order to test the regeneration capacity of neurons with different metabolic characteristics. Ventral root fibres (cholinergic) and hypogastric nerve fibres (catecholaminergic) were coapted to the central stump of cut lumbosacral dorsal roots and permitted to regrow along the peripheral nervous and central nervous parts of the dorsal root. After a postoperative period of 1.5-9 months the animals were sacrificed and the coapted nerves and roots were investigated by histochemistry, light and electron microscopy. Regrowth of both cholinergic and catecholaminergic neurons had occurred into the peripheral nervous part of the root. In the central nervous part of the root, regeneration was abortive for both types of neurons. The astrocytes of the central nervous part of the root showed different morphological features according to the type of neuron that had been coapted to the dorsal root. The results are discussed in terms of neurotropism, neuron target dependence, microenvironment and type of regenerating neuron.

Motoneurons reinnervate skeletal muscle after ventral root implantation into the spinal cord of the cat.

By use of intracellular recording and staining with horseradish peroxidase it was found that alpha and probably also gamma motoneurons were able to reinnervate ventral root implants after an avulsion of ventral roots at the spinal cord surface in the cat. The reinnervation of the implant was achieved after an initial growth of new axons in central nervous system tissue. Reinnervating neurons could be excited or inhibited by segmental reflex activity and their axons could conduct nerve impulses. The character of muscle twitch responses elicited by electrical stimulation of implanted roots strongly indicated that denervated muscles were reinnervated by new motor axons via the implant.

Galanin expression in adult human dorsal root ganglion neurons: initial observations.

Human dorsal root ganglia (DRGs) were obtained during various procedures and processed for single and double in situ hybridisation using oligonucleotide probes complementary to three peptide mRNAs. Some postmortem ganglia were also analysed. In donor (unlesioned) DRGs 12.5% of the neuron profiles (NPs) were galanin mRNA-positive (mRNA(+)), 47.5% calcitonin gene-related peptide (CGRP) mRNA(+) and 32.7% substance P mRNA(+). The corresponding percentages for cervical/thoracic DRGs from patients suffering from severe brachial plexus injury were 32.8%, 57.4% and 34.5%, respectively. In these DRGs a high proportion of the galanin mRNA(+) NPs contained CGRP mRNA and substance P mRNA. In DRGs from a patient with migraine-like pain a comparatively small proportion expressed galanin, whereas in DRGs from a herpes zoster patient galanin mRNA(+) NPs were comparatively more frequent. The results from human postmortem DRGs revealed only weak peptide mRNA signals. The present results demonstrate that galanin is expressed in DRGs not only in a number of animal species including monkey as previously shown, but also in a considerable proportion of human DRG neurons, often together with CGRP and substance P, and mostly in small neurons. Thus, galanin may play a role in processing of sensory information, especially pain, in human DRGs and dorsal horn. However, to what extent a similarly dramatic upregulation of galanin expression can be seen after peripheral nerve lesion in man, as has been reported for rat, mouse and monkey, remains to be analysed.

Extension of dorsal horn neurons into the severed and implanted dorsal root.

After dorsal root ganglionectomy in adult rats, the dorsal root was cut close to the spinal cord and implanted into the dorsal horn. Outgrowth from neurons in he dorsal horn of the spinal cord into the implanted dorsal root could be demonstrated after 3 months by means of retrograde HRP labeling. Double-labeling experiments showed that some of these neurons had retained their central projections while extending new processes into the implanted root. The possibility to reconstruct the sensory pathway by replacing the damaged primary sensory neuron with peripheral outgrowth from secondary sensory neurons is discussed.

The pia mater - a conduit for regenerating axons after ventral root replantation.

Previous studies have shown that replantation of avulsed ventral roots may lead to functional reinnervation of hindleg muscles. Regenerating motor axons may regrow for a considerable distance within the spinal cord before entering the replanted ventral root. In this study we show, in the rat and monkey, that many regenerating axons utilize an alternative pathway along the surface of the spinal cord, i.e. the pia mater. This type of reinnervation takes place entirely in the peripheral nervous system.

Regeneration after spinal nerve root injury.

Spinal nerve root avulsion has been considered as a central nervous type of injury and therefore not repaired surgically in man. The possibility for axonal regeneration after root avulsion or root lesion has been investigated in laboratory animals by means of up to date neurophysiological, morphological and tracing techniques. It is shown that, after ventral root avulsion and implantation into the spinal cord, alpha and probably also gamma motoneurons are able to regenerate within the spinal cord for a considerable distance before entering the implanted root and reinnervate previously denervated skeletal muscles. The regenerated neurons were found to respond to afferent activity with excitatory or inhibitory responses, and the regenerated axons could conduct action potentials that elicited muscle twitch responses. After dorsal root injury in the adult animal, regeneration into the spinal cord does not occur. However, regeneration of primary sensory neurons into appropriate locations of the spinal cord can be demonstrated in immature animals.

Expression of tenascin R and J1 mRNA in motoneurons after a traumatic lesion in the spinal cord.

We demonstrate, using in situ hybridization, that mRNA for the anti-adhesive molecules tenascin R and J1 in the adult rat spinal motoneurons are down-regulated rapidly as a reaction after a ventral funiculus lesion. Tenascin-R was significantly down-regulated at day 1 and normalized after 3 weeks. Tenascin-J1 declined to its lowest value at day 3 and returned to the initial level after 3 weeks. In adjacent sections, the distribution of macrophages was studied with immuno histochemistry. The density of macrophages reached a maximum 3 days after the injury. Thus, the density of macrophages appeared to be inversely related to the level of tenascin mRNA. These data are compatible with the notion that neuronal tenascins may modulate the adhesion of perincurial inflammatory cells.

Semaphorin and neuropilin expression in motoneurons after intraspinal motoneuron axotomy.

We have examined mRNA and protein distribution for the axon guidance molecules semaphorin3A, 3F, 4F and semaphorin receptors neuropilin-1 and 2, 1-21 days after intramedullary axotomy of rat lumbar spinal cord motoneurons. We show that semaphorin3A mRNA and protein are up-regulated in the scar and in motoneurons from 3 days and upto 3 weeks after injury. Neuropilin-1 mRNA showed no changed expression in axotomized motoneurons. Semaphorin3F mRNA expression was found in ventral roots after ventral funiculus lesion (VFL) and neuropilin-2 mRNA was found in affected motoneurons from 1 day after injury throughout the examined period. Semaphorin4F mRNA was first found in motoneurons 3 weeks after lesion. These results suggest semaphorin/neuropilin involvement in the injury response of intramedullary axotomized motoneurons.

GDNF and its receptor component Ret in injured human nerves and dorsal root ganglia.

Glial cell line-derived neurotrophic factor (GDNF) is trophic to motor and sensory neurones in animal models. GDNF mRNA is up-regulated in Schwann cells after peripheral nerve injury in rats. We have quantified and localized GDNF and its receptor component Ret, for the first time in any species, in injured human peripheral nerves and dorsal root ganglia (DRG) avulsed from the spinal cord. Significantly higher levels of GDNF were found in nerve distal to the site of the injury than in proximal or intact nerve, and in avulsed DRG than in post-mortem control DRG. GDNF immunostaining was seen in Schwann cells and in DRG neurones, especially of small and medium size, with significantly increased numbers of medium sized sensory neurones immunoreactive for GDNF after avulsion. Ret immunoreactivity was restricted to DRG neurones and axons, with no significant changes in numbers of positive DRG cells after injury. Our findings suggest that GDNF may play a role in injured human nerves and sensory ganglia, particularly in medium sized sensory neurones.

Population behaviour of human cutaneous mechanoreceptive units.

Groups of fibres rather than single afferents may be responsible for encoding various intensity aspects of tactile skin stimulation. Reconstruction of population responses of primary afferent fibres to skin displacement provided data in support of this idea, but evidence from direct recordings that demonstrated multifibre activity deriving from groups of single units firing in response to defined skin stimuli were not reported. Procedures are summarised which allow identification and sampling of such recordings in man. For SAII units it was demonstrated how different directions of skin stretch engaging a particular cutaneous area produced different responses of a unit population innervating that site. In response to localised vibratory stimuli synchronous discharges of several co-activated PC afferents were recorded at each vibratory cycle, which is a previously not described pattern of peripheral PC encoding. Population projection of activity within modality segregated clusters of afferents supplying the same skin area might serve as basic projection units and constitute the peripheral counterparts to sensory columns, believed to be the central cognitive correlates, in the cortex. Thus, it is tempting to postulate fibre population projection as a peripheral basis for somatosensory processing in man.

Regrowth of anastomosed ventral root nerve fibers in the dorsal root of rats.

Ventral root fibers were challenged to regrow through a peripheral (PNS)-central nervous (CNS) pathway after being anastomosed to the ipsilateral dorsal root. Regeneration occurred in the PNS part of the root but failed in the CNS part of the root as revealed by electron microscopy.

Regenerating axons form nerve terminals at astrocytes.

In adult rats ventral root (cholinergic axons) or hypogastric nerve (catecholaminergic axons) has been coapted to ganglionectomized dorsal root. The cholinergic and catecholaminergic fibers elongate as far as the peripheral-central nervous border. At this point some fibres were observed to have made synaptoid nerve terminals among astrocytes. The nerve endings accumulated transmitter substance even though they made no neuronal synapses.

Distribution of TGF-beta, the TGF-beta type I receptor and the R-II receptor in peripheral nerves and mechanoreceptors; observations on changes after traumatic injury.

The mechanisms governing the regeneration of denervated peripheral mechanoreceptors are similar to those of peripheral nerves. The ability to regenerate depends partly on changes of the Schwann cell phenotype. The transforming growth factor beta (TGF-beta) family have been implicated in induction of Schwann cell proliferation, production of extracellular matrix and neurotrophin synthesis as well as synthesis or repression of cell adhesion molecules. Hence, they may prove to be of importance for regenerative mechanisms in peripheral mechanoreceptors. The distribution of TGF-beta, the receptors I and II and intra-cellular second messengers, Smad 2/3 and 4 was assessed in sensory neurones, peripheral nerves and mechanoreceptors by immuno-histochemistry, immuno-electron microscopy and in situ hybridisation. TGF-beta2 mRNA and TGF-beta2-like immunoreactivity (IR) were expressed in injured small and medium sized rat sensory neurones of dorsal root ganglia. TGF-beta and receptor II mRNA and immunoreactivities (IR) were present in satellite cells. Intact and injured sensory neurones expressed receptor I mRNA and Smad 2 mRNA. TGF-beta2 mRNA was found in transected nerve stumps and in sensory mechanoreceptors. TGF-beta1, 2 and Smad 4 were also observed in inner core lamellar cells of intact and denervated cat Pacinian corpuscles. Lamellar cells of intact and denervated Meissner corpuscles were TGF-beta immunoreactive. Merkel cells were receptors I and II immunoreactive. In conclusion, cutaneous and subcutaneous mechanoreceptors differ with regard to the expression of TGF-beta isoforms and receptors.