Soluble TNFα Signaling within the Spinal Cord Contributes to the Development of Autonomic Dysreflexia and Ensuing Vascular and Immune Dysfunction after Spinal Cord Injury.

Cardiovascular disease and susceptibility to infection are leading causes of morbidity and mortality for individuals with spinal cord injury (SCI). A major contributor to these is autonomic dysreflexia (AD), an amplified reaction of the autonomic nervous system (hallmarked by severe hypertension) in response to sensory stimuli below the injury. Maladaptive plasticity of the spinal sympathetic reflex circuit below the SCI results in AD intensification over time. Mechanisms underlying this maladaptive plasticity are poorly understood, restricting the identification of treatments. Thus, no preventative treatments are currently available. Neuroinflammation has been implicated in other pathologies associated with hyperexcitable neural circuits. Specifically, the soluble form of TNFα (sTNFα) is known to play a role in neuroplasticity. We hypothesize that persistent expression of sTNFα in spinal cord underlies AD exacerbation. To test this, we intrathecally administered XPro1595, a biologic that renders sTNFα nonfunctional, after complete, high-level SCI in female rats. This dramatically attenuated the intensification of colorectal distension-induced and naturally occurring AD events. This improvement is mediated via decreased sprouting of nociceptive primary afferents and activation of the spinal sympathetic reflex circuit. We also examined peripheral vascular function using ex vivo pressurized arterial preparations and immune function via flow cytometric analysis of splenocytes. Diminishing AD via pharmacological inhibition of sTNFα mitigated ensuing vascular hypersensitivity and immune dysfunction. This is the first demonstration that neuroinflammation-induced sTNFα is critical for altering the spinal sympathetic reflex circuit, elucidating a novel mechanism for AD. Importantly, we identify the first potential pharmacological, prophylactic treatment for this life-threatening syndrome.SIGNIFICANCE STATEMENT Autonomic dysreflexia (AD), a disorder that develops after spinal cord injury (SCI) and is hallmarked by sudden, extreme hypertension, contributes to cardiovascular disease and susceptibility to infection, respectively, two leading causes of mortality and morbidity in SCI patients. We demonstrate that neuroinflammation-induced expression of soluble TNFα plays a critical role in AD, elucidating a novel underlying mechanism. We found that intrathecal administration after SCI of a biologic that inhibits soluble TNFα signaling dramatically attenuates AD and significantly reduces AD-associated peripheral vascular and immune dysfunction. We identified mechanisms behind diminished plasticity of neuronal populations within the spinal sympathetic reflex circuit. This study is the first to pinpoint a potential pharmacological, prophylactic strategy to attenuate AD and ensuing cardiovascular and immune dysfunction.

Inhibition of CXCR1 and CXCR2 chemokine receptors attenuates acute inflammation, preserves gray matter and diminishes autonomic dysreflexia after spinal cord injury.

STUDY DESIGN: Female Wistar rats (225 g) underwent spinal cord injury (SCI) at the T4 segment and were assigned to one of the three groups treated with: (1) saline; (2) 7.5 mg kg(-1) Reparixin; or (3) 15 mg kg(-1) Reparixin. Reparixin is a small molecule, allosteric noncompetitive inhibitor of CXCR1 and CXCR2 chemokine receptors involved in inflammation. METHODS: Spinal cord homogenates at 12 and 72 h post-SCI were assayed for tumor necrosis factor α (TNF-α) and cytokine-induced neutrophil chemoattractant (CINC)-1 using enzyme-linked immunosorbant assay (ELISA). Myeloperoxidase activity and western blots for CD68, Fas and p75 content were used to assess inflammation and death receptor ligands, respectively. Histopathology and neurological outcomes were assessed by immunohistochemistry, locomotion scoring and cardiovascular measurement of autonomic dysreflexia 4 weeks post-SCI. RESULTS: Both 7.5 and 15 mg kg(-1) doses of Reparixin reduced levels of TNF-α and CINC-1 72 h post-SCI and decreased macrophage (CD68) content in the spinal cord lesion. Only 15 mg kg(-1) Reparixin reduced both Fas and p75 levels in the spinal cord compared with untreated SCI. We observed a reduced lesion area and increased neuron number in the gray matter of Reparixin-treated rats. Hindlimb motor scores at 7 and 28 days post-SCI were improved by 15 mg kg(-1) Reparixin treatment. Both 7.5 and 15 mg kg(-1) Reparixin reduced development of autonomic dysreflexia 4 weeks post-SCI. The change in mean arterial pressure, induced by cutaneous or visceral stimulation, was reduced by 40-50%. CONCLUSION: Acute treatment with 15 mg kg(-1) Reparixin reduces acute inflammation and is associated with minor improvements in motor function and a significant reduction in the severity of autonomic dysreflexia.

Spinal cord injury reduces the efficacy of pseudorabies virus labeling of sympathetic preganglionic neurons.

The retrograde transsynaptic tracer pseudorabies virus (PRV) is used as a marker for synaptic connectivity in the spinal cord. Using PRV, we sought to document putative synaptic plasticity below a high thoracic (T) spinal cord transection. This lesion has been linked to the development of a number of debilitating conditions, including autonomic dysreflexia. Two weeks after injury, complete T4-transected and/or T4-hemisected and sham rats were injected with PRV-expressing enhanced green fluorescent protein (EGFP) or monomeric red fluorescent protein (mRFP1) into the kidneys. We expected greater PRV labeling after injury because of the plasticity of spinal circuitry, but 96 hours post-PRV-EGFP inoculation, we found fewer EGFP+ cells in the thoracolumbar gray matter of T4-transected compared with sham rats (p < 0.01); Western blot analysis corroborated decreased EGFP protein levels (p < 0.01). Moreover, viral glycoproteins that are critical for cell adsorption and entry were also reduced in the thoracolumbar spinal cord of injured versus sham rats (p < 0.01). Pseudorabies virus labeling of sympathetic postganglionic neurons in the celiac ganglia innervating the kidneys was also significantly reduced in injured versus sham rats (p < 0.01). By contrast, the numbers and distribution of Fluoro-Gold-labeled (intraperitoneal injection) sympathetic preganglionic neurons throughout the sampled regions appeared similar in injured and sham rats. These results question whether spinal cord injury exclusively retards PRV expression and/or transport or whether this injury broadly affects host cell-viral interactions.

Estrogen reduces the severity of autonomic dysfunction in spinal cord-injured male mice.

Autonomic dysreflexia is an autonomic behavioural condition that manifests after spinal cord injury (SCI) and is characterized by acute, episodic hypertension following afferent stimulation below the level of the injury. Common triggers of autonomic dysreflexia include colorectal distension (CRD), and various somatic stimuli. The development of autonomic dysreflexia is dependent, in part, upon the degree of intraspinal inflammation and the resultant spinal neuroplastic changes that occur following SCI. 17beta-estradiol (E) has neuroprotective, anti-inflammatory and smooth muscle relaxant properties, and is therefore a candidate drug for the treatment and/or prevention of autonomic dysreflexia. Autonomic dysreflexia was assessed in adult male mice treated with E. We investigated whether E could be acting centrally by altering: (1) the size of the small diameter primary afferent arbor, (2) the degree of microglia/macrophage infiltration at the site of the injury, or (3) the amount of fibrous scarring present at the injury site. To determine whether E could be working through uncoupling protein-2 (UCP-2), a protein involved with inflammation and regulated by estrogen in some tissues, autonomic dysreflexia was assessed in E-treated adult male mice lacking UCP-2 (UCP-2 KO). 17beta-estradiol was equipotent at reducing autonomic dysreflexia in both UCP-2 KO and WT mice following CRD but not tail pinch. We have shown that E reduces autonomic dysreflexic responses to visceral but not somatic stimulation in male mice independent of the size of the primary afferent arbour, the degree of chronic inflammation, and the presence of UCP-2.

The expression of Fos-labeled spinal neurons in response to colorectal distension is enhanced after chronic spinal cord transection in the rat.

The present study used Fos-like immunoreactivity to examine neuronal activation in response to colorectal distension in rats at 1 day or 30 days following spinal cord transection or sham transection. Fifty-five Wistar rats were anesthetized and an incision was made to expose the T(5) spinal segment. The dura was reflected away in all rats and a complete transection at the rostral end of the T(5) segment was given to the lesioned group. At 1 day (acute) or 30 days (chronic) post-surgery, conscious rats were subjected to a 2 h period of intermittent colorectal distension. Rats were perfused and spinal segments L(5)-S(2) were removed and processed for Fos-like immunoreactivity. Spinal cord transection alone had no effect on Fos-labeling in either acute or chronic rats. In acute rats, colorectal distension produced significant increases in Fos-labeling in the superficial and deep dorsal horn regions. In chronic rats, colorectal distension produced a three-fold increase in Fos-labeled neurons that was manifest throughout all laminar regions. These results indicate that the number of neurons expressing Fos in response to colorectal distension is much greater after a chronic spinal cord transection than after an acute transection. Since Fos is an indicator of neuronal activation, the results show that many more neurons become active in response to colorectal distension following a chronic spinal injury. This suggests that a functional reorganization of spinal circuits occurs following chronic spinal cord transection. This may ultimately result in altered visceral and somatic functions associated with spinal cord injury in humans.

Neutralizing intraspinal nerve growth factor with a trkA-IgG fusion protein blocks the development of autonomic dysreflexia in a clip-compression model of spinal cord injury.

Increased intraspinal nerve growth factor (NGF) after spinal cord injury (SCI) is detrimental to the autonomic nervous system. Autonomic dysreflexia is a debilitating condition characterized by episodic hypertension, intense headache, and sweating. Experimentally, it is associated with aberrant primary afferent sprouting in the dorsal horn that is nerve growth factor (NGF)-dependent. Therapeutic strategies that neutralize NGF may ameliorate initial apoptotic cellular responses to the injury and aberrant afferent plasticity that occurs weeks after the injury. Subsequently, the development of autonomic disorders may be suppressed. We constructed a protein including the extracellular portion of trkA fused to the Fc portion of human IgG and expressed it using a baculovirus system. Binding of our trkA-IgG fusion protein was specific for NGF with a K(d) = 4.26 x 10(-11) M and blocked NGF-dependent neuritogenesis in PC-12 cells. We hypothesized that binding of NGF in the injured cord by our trkA-IgG fusion protein would diminish autonomic dysreflexia. Severe, high thoracic SCI was induced with clip compression and the rats were treated with intrathecal infusions (4 microg/day) of trkA-IgG or control IgG. At 14 days post-SCI, the magnitude of autonomic dysreflexia was assessed. Colon distension increased mean arterial pressure (MAP) in control rats by 46 +/- 2 from 96 +/- 5 mmHg. In contrast, MAP of rats treated with trkA-IgG increased by only 30 +/- 2 mmHg. Likewise, the MAP response to cutaneous stimulation was also reduced in rats treated with trkA-IgG (20 +/- 1 vs. 29 +/- 2). In contrast, trkA-IgG treatment had no effect on heart rate responses during colon distension or cutaneous stimulation. These results indicate that treatment with trkA-IgG to block NGF suppresses the development of autonomic dysreflexia after a clinically relevant spinal cord injury.