Challenges for defining minimal clinically important difference (MCID) after spinal cord injury.

STUDY DESIGN: This is a review article. OBJECTIVES: This study discusses the following: (1) concepts and constraints for the determination of minimal clinically important difference (MCID), (2) the contrasts between MCID and minimal detectable difference (MDD), (3) MCID within the different domains of International Classification of Functioning, disability and health, (4) the roles of clinical investigators and clinical participants in defining MCID and (5) the implementation of MCID in acute versus chronic spinal cord injury (SCI) studies. METHODS: The methods include narrative reviews of SCI outcomes, a 2-day meeting of the authors and statistical methods of analysis representing MDD. RESULTS: The data from SCI study outcomes are dependent on many elements, including the following: the level and severity of SCI, the heterogeneity within each study cohort, the therapeutic target, the nature of the therapy, any confounding influences or comorbidities, the assessment times relative to the date of injury, the outcome measurement instrument and the clinical end-point threshold used to determine a treatment effect. Even if statistically significant differences can be established, this finding does not guarantee that the experimental therapeutic provides a person living with SCI an improved capacity for functional independence and/or an increased quality of life. The MDD statistical concept describes the smallest real change in the specified outcome, beyond measurement error, and it should not be confused with the minimum threshold for demonstrating a clinical benefit or MCID. Unfortunately, MCID and MDD are not uncomplicated estimations; nevertheless, any MCID should exceed the expected MDD plus any probable spontaneous recovery. CONCLUSION: Estimation of an MCID for SCI remains elusive. In the interim, if the target of a therapeutic is the injured spinal cord, it is most desirable that any improvement in neurological status be correlated with a functional (meaningful) benefit.

Effects of methylprednisolone and 4-chloro-3-hydroxyanthranilic acid in experimental spinal cord injury in the guinea pig appear to be mediated by different and potentially complementary mechanisms.

STUDY DESIGN: Blinded, placebo-controlled, parallel treatment group studies of the effects of methylprednisolone (MP) or 4-chloro-3-hydroxyanthranilate (4-Cl-3-HAA) on behavioral outcome and quinolinic acid tissue levels from experimental thoracic spinal cord injury in adult guinea pigs. OBJECTIVES: To compare the effects of treatment with high-dose MP, a corticosteroid, and 4-Cl-3-HAA, a compound that inhibits synthesis of the neurotoxin quinolinic acid (QUIN) by activated macrophages. To explore the effect of different times of treatment using these two approaches to ameliorating secondary tissue damage. SETTING: Laboratory animal studies at the University of North Carolina, Chapel Hill, NC, USA. METHODS: Standardized spinal cord injuries were produced in anesthetized guinea pigs, using lateral compression of the spinal cord. Behavioral impairment and recovery were measured by placing and toe-spread responses (motor function), cutaneus trunci muscle reflex receptive field areas and somatosensory-evoked potentials (sensory function). Tissue quinolinic acid levels were measured by gas chromatograph/mass spectrometry. RESULTS: The current experiments showed a reduction in delayed loss of motor and sensory function in the guinea pig with MP (150 mg kg(-1), intraperitoneally in split doses between 0.5 and 6 h), but no significant reduction in tissue QUIN. Improved sensory function was seen with a single dose of 60 mg kg(-1) MP intraperitoneally at 5 h after injury, but not at 10 h after injury. A single dose of 4-Cl-3-HAA at 5 h in the guinea pig did not produce the sensory and motor improvements seen in previous studies with 12 days of dosing, beginning at 5 h. CONCLUSION: These studies, together with earlier findings, indicate that both drugs can attenuate secondary pathologic damage after SCI, but through separate mechanisms. These are most likely an acute reduction by MP of oxidative processes and reduction by 4-Cl-3-HAA of QUIN synthesis.

Two phase 3, multicenter, randomized, placebo-controlled clinical trials of fampridine-SR for treatment of spasticity in chronic spinal cord injury.

STUDY DESIGN: Two randomized, double-blind, placebo-controlled trials. OBJECTIVE: To evaluate the efficacy and safety of fampridine sustained-release tablets (fampridine-SR) 25 mg twice daily for moderate-to-severe spasticity in patients with chronic spinal cord injury (SCI). SETTING: United States and Canada. METHODS: Patients with incomplete chronic SCI were randomized to twice daily fampridine-SR 25 mg or placebo, with a 2-week single-blind placebo run-in, a 2-week titration, 12 weeks of stable dosing, 2 weeks of downward titration and 2 weeks of untreated follow-up. Co-primary end points were the change from baseline, averaged over the double-blind treatment period, for Ashworth score (bilateral knee flexors and extensors) and a 7-point Subject Global Impression of treatment (SGI; 1, terrible; 7, delighted). Secondary end points were: Penn Spasm Frequency Scale; the motor/sensory score from the International Standards for Neurological Classification of SCI; Clinician's Global Impression of Change of neurological status; and the International Index of Erectile Function (men) or the Female Sexual Function Index (women). RESULTS: The populations were 212 and 203 patients in the two studies, respectively. Changes from baseline in Ashworth score were -0.15 (placebo) and -0.19 (fampridine-SR) in the first study, and -0.16 (placebo) and -0.28 (fampridine-SR) in the second study. The between-treatment difference was not significant for either the Ashworth score or the SGI and, with few exceptions, neither were the secondary end points. Fampridine-SR was generally well tolerated; treatment-emergent adverse events (TEAEs) and serious TEAEs were reported with similar frequency between treatments. CONCLUSION: Fampridine-SR was well tolerated. No significant differences were observed between treatment groups for the primary end points of Ashworth score and SGI.

Characterization of neurological recovery following traumatic sensorimotor complete thoracic spinal cord injury.

STUDY DESIGN: Retrospective, longitudinal analysis of sensory, motor and functional outcomes from individuals with thoracic (T2-T12) sensorimotor complete spinal cord injury (SCI). OBJECTIVES: To characterize neurological changes over the first year after traumatic thoracic sensorimotor complete SCI. METHODS: A dataset of 399 thoracic complete SCI subjects from the European Multi-center study about SCI (EMSCI) was examined for neurological level, sensory levels and sensory scores (pin-prick and light touch), lower extremity motor score (LEMS), ASIA Impairment Scale (AIS) grade, and Spinal Cord Independence Measure (SCIM) over the first year after SCI. RESULTS: AIS grade conversions were limited. Sensory scores exhibited minimal mean change, but high variability in both rostral and caudal directions. Pin-prick and light touch sensory levels, as well as neurological level, exhibited minor changes (improvement or deterioration), but most subjects remained within one segment of their initial injury level after 1 year. Recovery of LEMS occurred predominantly in subjects with low thoracic SCI. The sensory zone of partial preservation (ZPP) had no prognostic value for subsequent recovery of sensory levels or LEMS. However, after mid or low thoracic SCI, ≥3 segments of sensory ZPP correlated with an increased likelihood for AIS grade conversion. CONCLUSION: The data suggest that a sustained deterioration of three or more thoracic sensory levels or loss of upper extremity motor function are rare events and may be useful for tracking the safety of a therapeutic intervention in early phase acute SCI clinical trials, if a significant proportion of study subjects exhibit such an ascent.

Extent of spontaneous motor recovery after traumatic cervical sensorimotor complete spinal cord injury.

STUDY DESIGN: Retrospective, longitudinal analysis of motor recovery data from individuals with cervical (C4-C7) sensorimotor complete spinal cord injury (SCI) according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). OBJECTIVES: To analyze the extent and patterns of spontaneous motor recovery over the first year after traumatic cervical sensorimotor complete SCI. METHODS: Datasets from the European multicenter study about SCI (EMSCI) and the Sygen randomized clinical trial were examined for conversion of American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade, change in upper extremity motor score (UEMS) or motor level, as well as relationships between these measures. RESULTS: There were no overall differences between the EMSCI and Sygen datasets in motor recovery patterns. After 1 year, up to 70% of subjects spontaneously recovered at least one motor level, but only 30% recovered two or more motor levels, with lesser values at intermediate time points. AIS grade conversion did not significantly influence motor level changes. At 1 year, the average spontaneous improvement in bilateral UEMS was 10-11 motor points. There was only moderate relationship between a change in UEMS and a change in cervical motor level (r(2)=0.30, P<0.05). Regardless of initial cervical motor level, most individuals recover a similar number of motor points or motor levels. CONCLUSION: Careful tracking of cervical motor recovery outcomes may provide the necessary sensitivity and accuracy to reliably detect a subtle, but meaningful treatment effect after sensorimotor complete cervical SCI. The distribution of the UEMS change may be more important functionally than the total UEMS recovered.

Behavioral recovery induced by applied electric fields after spinal cord hemisection in guinea pig.

Applied electric fields were used to promote axonal regeneration in spinal cords of adult guinea pigs. A propriospinal intersegmental reflex (the cutaneous trunci muscle reflex) was used to test lateral tract function after hemisection of the thoracic spinal cord. An electrical field (200 microvolts per millimeter, cathode rostral) applied across the lesion led to functional recovery of the cutaneous trunci muscle reflex in 25 percent of experimental animals, whereas the functional deficit remained in control animals, which were implanted with inactive stimulators.

Outcome measures in spinal cord injury: recent assessments and recommendations for future directions.

STUDY DESIGN: Review by the spinal cord outcomes partnership endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations. OBJECTIVES: Assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies. METHODS: a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI. RESULTS: Imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain and psychosocial tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention. CONCLUSION: Significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.

Quinolinic acid is increased in CSF and associated with mortality after traumatic brain injury in humans.

We tested the hypothesis that quinolinic acid, a tryptophan-derived N-methyl-D-aspartate agonist produced by macrophages and microglia, would be increased in CSF after severe traumatic brain injury (TBI) in humans, and that this increase would be associated with outcome. We also sought to determine whether therapeutic hypothermia reduced CSF quinolinic acid after injury. Samples of CSF (n = 230) were collected from ventricular catheters in 39 patients (16 to 73 years old) during the first week after TBI, (Glasgow Coma Scale [GCS] < 8). As part of an ongoing study, patients were randomized within 6 hours after injury to either hypothermia (32 degrees C) or normothermia (37 degrees C) treatments for 24 hours. Otherwise, patients received standard neurointensive care. Quinolinic acid was measured by mass spectrometry. Univariate and multivariate analyses were used to compare CSF quinolinic acid concentrations with age, gender, GCS, time after injury, mortality, and treatment (hypothermia versus normothermia). Quinolinic acid concentration in CSF increased maximally to 463 +/- 128 nmol/L (mean +/- SEM) at 72 to 83 hours after TBI. Normal values for quinolinic acid concentration in CSF are less than 50 nmol/L. Quinolinic acid concentration was increased 5- to 50-fold in many patients. There was a powerful association between time after TBI and increased quinolinic acid (P < 0.00001), and quinolinic acid was higher in patients who died than in survivors (P = 0.003). Age, gender, GCS, and treatment (32 degrees C versus 37 degrees C) did not correlate with CSF quinolinic acid. These data reveal a large increase in quinolinic acid concentration in CSF after TBI in humans and raise the possibility that this macrophage-derived excitotoxin may contribute to secondary damage.

Golgi-staining of "primary" and "secondary" motoneurons in the developing spinal cord of an amphibian.

The Golgi technique was used to study the morphology of spinal motoneurons at various stages in the early development of swimming behaviour in embryos and larvae of the palmate newt, Triturus helveticus ((Razoumowsky). The earliest motoneurons stained appeared to be associated with the Mauthner-cell system. The overall morphology of these "primary" motoneurons seems to be similar throughout the lower vertebrates and the distinctive characteristics found in earlier descriptions of those from caudate amphibia were probably due to misinterpretation. At about the time of hatching and development of low-frequency swimming behaviour, other motoneurons were found to innervate the axial musculature, cells with a central morphology different from those of the "primary" type. It was found likely that these "secondary" motoneurons innervate a separate muscle system concerned with tonic and "slow phasic" activity, while "fast phasic" acitivity in rapid swimming is supplied by "primary" cells.

Transected dorsal column axons within the guinea pig spinal cord regenerate in the presence of an applied electric field.

Using an implanted battery and electrodes, we have imposed a weak, steady electrical field across partially severed guinea pig spinal cords. We have analyzed regeneration of dorsal column axons in experimental animals and sham-treated controls at 50-60 days postinjury by anterograde filling of these axons with the intracellular marker horseradish peroxidase and by employing a marking device to identify precisely the original plane of transection (J. Comp. Neurol. 250: 157-167, '86). In response to electric field applications, axons grew into the glial scar, as far as the plane of transection in most experimental animals. In a few animals axons could be traced around the margins of the lesion (but never through it). Moreover, these fibers returned to their approximate positions within the rostral spinal cord before turning toward the brain. In sham-treated controls, ascending axons were found to terminate caudal to the glial scar, and rarely were any fibers found within the scar itself. Axons were never observed to cross into the rostral cord segment. These findings suggest that an imposed electrical field promotes growth of axons within the partially severed mammalian spinal cord, that a steady voltage gradient may be an environmental component necessary for axonal development and regeneration, and that some component(s) of the scar impede or deflect axonal growth and projection.

Axonal regeneration in spinal cord injury: a perspective and new technique.

A set of techniques is described for determining the response of mammalian spinal axons to transection. The logical selection and the advantages of these techniques are discussed. The dorsal column of guinea pig thoracic spinal cord was transected with a tungsten needle and the position of the lesion was marked by a staple-shaped wire device (Foerster: J. Comp. Neurol. 210:335-356, '82). The morphology of dorsal column axons projecting rostrally toward the lesion was examined between 1 and 50 days postlesion by anterograde staining with horseradish peroxidase, applied to a second lesion of the dorsal column two to three vertebral segments caudal to the first. Axons damaged by the original lesion were found to die back 1-2 mm from the plane of transection and at 18-20 hours were characterized by terminal club-shaped swellings attached to the proximal axon by a thin connection. At 50 days postlesion there was some evidence of limited regenerative responses in terms of growth-cone-like axon terminals, and the presence of aberrant axonal branching, but no evidence of regenerating axons approaching close to the plane of transection. These findings are in agreement with previous studies indicating little or no effective regrowth of myelinated axons in the mammalian spinal cord. These same techniques were used in a succeeding study to examine the effects of applied electric fields on the axonal response to transection.

Cutaneus trunci muscle reflex of the guinea pig.

The cutaneus trunci muscle reflex in guinea pigs was studied with a combination of video analysis, electromyography, lesioning, and light microscopy. The muscle forms a bilateral, subdermal sheet over much of the trunk. Local contractions of the dorsal part of the muscle are produced in response to brief tactile or electrical stimulation of the skin and consist of a twitch centered 1-2 cm rostral of the stimulus site. The reflex receptive field covers most of the thoracic and lumbar dorsal surface. The sensory information is carried via segmental dorsal cutaneous nerves. Receptive fields of adjacent nerves overlap and form rectangular areas perpendicular to the midline, at thoracic levels. Motor innervation projects through the lateral thoracic nerves of the brachial plexus. The motoneurons are located near the cervical thoracic junction (C7-T1). Lesions of the lower thoracic cord indicate that ascending sensory information is carried to the motor nuclei via the ventral half of the lateral funiculus. This pathway conveys information primarily from ipsilateral skin. There is a weaker input from contralateral skin, crossing at segmental levels. Electromyographic responses to brief electrical stimulation of lower thoracic skin occur usually as 10-12 msec bursts at latencies of 10-20 msec, and do not readily habituate or fatigue at stimulus frequencies below 10 Hz. The reflex persists under light pentobarbital anesthesia. This combination of characteristics makes the reflex useful for a variety of physiological and pathophysiological studies.

Functional recovery after spinal cord hemisection in guinea pigs: the effects of applied electric fields.

Right lateral hemisection of the lower thoracic spinal cord was performed in 216 adult guinea pigs. Animals that proved suitable for the study were divided into one control and two experimental groups. Experimental animals were implanted with intraperitoneal stimulators delivering regulated current of 35 or 50 microA through electrodes placed 1 cm rostral and caudal of the hemisection. The cathode was cranial to the lesion in one group (n = 67) and caudal in the other (n = 33). Control animals (n = 62) were implanted with sham stimulators and electrodes delivering no current. The functional status of the animals was measured by tactile stimulation of the back skin to elicit the cutaneus trunci muscle reflex, and by the vestibulospinal free-fall response. The cutaneous response ipsilateral and caudal to the lesion was lost following hemisection and did not recover in any of the control animals or in animals with cathode caudal to the lesion. Recovery of the response was found in 9 of 67 animals in the cathode rostral group, between 56 and 139 days after injury. Toe spreading recovered spontaneously in 80-90% of animals in all groups. Of the possible mechanisms of skin reflex recovery, most current evidence points to regrowth of ascending nerve fibers in the lateral funiculus of the spinal cord local to the lesion.

Axonal physiology of chronic spinal cord injury in the cat: intracellular recording in vitro.

The properties of action potential conduction in single axons of the cat thoracic spinal cord were examined with microelectrode recording and electrical stimulation in vitro. The study included normal animals, animals chronically paralyzed by contusion of the cord, and animals showing some degree of locomotory recovery following a similar injury and several weeks of transient paralysis. The control studies were designed to compare the results of microelectrode sampling in vitro with morphological and in vivo physiological data. The pathophysiological studies were intended to investigate the continuity and function of axons identified morphologically in paralyzing lesions, and to examine the hypothesis that functional loss is associated with chronic axonal dysfunction, as well as direct axonal loss. Most of the recordings were made from dorsal columns and ventral tracts at 23-25 degrees C. The conduction velocities recorded in the normal cord were consistent with morphological data on caliber spectra, given the selectivity of the microelectrodes for larger axons. The refractory period of transmission was approximately 2-4 ms at 23-25 degrees C and 0.7-2 ms at 37 degrees C. Prolonged depolarizing after-potentials were recorded, following action potentials greater than 70 mV amplitude. Axons outside the lesion in injured cord showed only slight reductions from control in the mean and range of conduction velocity and refractory period distributions. The number of axons impaled per electrode track was reduced by up to one half. Relatively few impaled axons conducted through the lesion site in the injured cords: 16% in recovering animals and 7% in chronically paralyzed, as compared with 61% in uninjured controls. The mean conduction velocity of these through-conducting axons was significantly less than that of the normal population, particularly in paralyzed animals, and refractory period was significantly prolonged for conduction through the lesion in the paralyzed group. When axons conducting through the middle of the isolated spinal tract were challenged by raising the temperature, conduction block occurred below physiological temperature (37 degrees C) for 7% of axons in controls, 14% in recovering and 73% in paralyzed cats. The mean temperature of heat block in normal axons was 41 degrees C. Some axons appear to survive in paralyzing contusion trauma of this type. Those axons that remain in the lesion site project through it but their conduction properties are abnormal, particularly in animals that remain chronically paralyzed. Action potentials in many axons may be effectively blocked at the chronic lesion site, contributing to the overall functional d

Cellular morphology of chronic spinal cord injury in the cat: analysis of myelinated axons by line-sampling.

A systematic line-sampling method is described for counting and mapping myelinated axons in transverse sections of the spinal cord. Its advantages over random sampling of small areas are considered. The technique was applied to quantifying experimental weight-drop contusion injuries of cat spinal cord, from several months to more than a year after injury. Contusion of the mid-thoracic cord with a 20 g weight dropped 20 cm was usually sufficient to produce chronic hindlimb paralysis whilst allowing the survival of significant numbers (40,000-110,000) of myelinated axons passing through the lesion site. The axons which survived were concentrated towards the pial surface. There was a proportionally greater loss of larger diameter axons, but this was independent of distance from the pia, indicating that at least two independent factors contribute to selective axonal death following injury, one related to depth within the cord, the other to axon diameter. Myelin sheath thickness was decreased from normal and this deficit also increased with depth. There was overlap in all these quantitative morphological characteristics between animals showing some recovery of hindlimb locomotion and those with maintained spastic paralysis at more than six months after injury. Effective locomotion was found to recover in some cases with the maintenance of a small proportion (5-10%) of the original axonal population, largely concentrated in a rim only 200-300 microns thick. Morphological correlates of paralysis in chronic injuries included severe reduction of axonal number, selective elimination of large fibers, and sustained dysmyelination. Any one or combination of these may be responsible for chronic paralysis in individual animals.

Computer simulation of action potentials and afterpotentials in mammalian myelinated axons: the case for a lower resistance myelin sheath.

Depolarizing afterpotentials, recorded in peripheral nerves [Barrett and Barrett (1982) J. Physiol., Lond. 323, 117-144] and spinal axons [Blight and Someya (1985) Neuroscience 15, 1-12], have been interpreted as representing passive discharge of axolemmal capacitance. This interpretation requires a lower resistance pathway through the myelin sheath than previous measurements have suggested. A computer model was used to examine the contribution of the electrical characteristics of nerve fibers to action potential conduction and afterpotential generation. The model consisted of a resistance-capacitance network representing a chain of 20 internodes. The resistances of node, internode and myelin sheath, deduced from observations in the accompanying paper, [Blight and Someya (1985) Neuroscience, 15] were found to produce suitable length and time constants, and prolonged afterpotentials, when inserted into the model. Similar length and time constants were found using a conventional model of the axon, based on measurements from isolated peripheral fibers, but this did not reproduce the afterpotentials. Action-potential conduction velocity is enhanced by reducing the time constant and increasing the length constant. The problem of minimizing the internodal time constant was met in the conventional model through the low parallel resistance of the node, while in the new model it was met by reducing the resistance of the myelin sheath. The latter strategy required the nodal leakage resistance to be higher than values from single fiber measurements (ca 250 M omega rather than ca 50 M omega) in order to maintain the length constant similar to the conventional model. Simulation of the recorded potentials required the resistance of the myelin lamellae to be approx. 100 omega cm2. The model quantitatively reproduced the voltage response of the axon to injected current pulses and to propagated action potentials, using Frankenhaeuser-Huxley kinetics. [Frankenhaeuser and Huxley (1964) J. Physiol., Lond. 171, 302-315; Frankenhaeuser and Moore (1963) J. Physiol., Lond. 169, 431-437]. The short duration components of the afterpotential, observed in mammalian recordings were reproduced by assuming a leakage pathway in the myelin sheath, at the impalement site. The calculated lower resistance of the myelin sheath was such that it minimized the effective internodal time constant for a given nodal resistance. This appears to free the myelinated fiber from the alternative requirement for a high nodal leakage conductance.(ABSTRACT TRUNCATED AT 400 WORDS)

Effects of silica on the outcome from experimental spinal cord injury: implication of macrophages in secondary tissue damage.

A model of spinal cord trauma in guinea-pigs, using lateral compression to a set thickness, produces a delayed functional loss at one to two days, followed by a partial recovery over several weeks, as measured using hindlimb motor behavior, vestibulospinal reflex testing, and mapping the receptive field of the cutaneous trunci muscle reflex. The role of inflammatory events in these secondary changes, was investigated with intraperitoneal injections of the macrophage toxin, silica. In one experiment, 11 matched pairs of animals were injured. One of each pair was selected randomly and injected with a suspension of 1.2 g of silica dust in sterile saline, immediately after injury and surgical closure. In a second experiment, involving 10 pairs of guinea-pigs, a similar dose of silica was administered to one of each pair at either one or two days before the injury. The animals survived up to three months, then were fixed by perfusion with glutaraldehyde. Histopathology of the lesion was quantified by line sampling of myelinated axons, and by measurement of blood vessels, in plastic sections through the center of the lesion. Surgery, injury, analysis of behavior and histology were all performed without knowledge of the experimental status of the animal. The secondary onset of functional loss below the lesion appeared to be delayed by one to two days in silica-treated animals with respect to controls. The number of myelinated axons at the center of the lesion, examined at two weeks to three months after injury was higher in the animals injected with silica immediately after surgery, most significantly in the dorsal quadrant of the cord. Myelin sheath thickness and axon caliber distribution were not different. Hypervascularity of the lesion was significantly reduced in animals injected with silica within one day of injury. These findings support the hypothesis that inflammatory activity plays an important role in secondary tissue damage, and that it may be responsible for some proportion of long-term neurological deficits, but do not suggest a prominent role for early macrophage activity in the mechanisms of demyelination.

Depolarizing afterpotentials in myelinated axons of mammalian spinal cord.

Microelectrode recordings were made from 5-10 micron dia axons of adult rat spinal cord in vitro. Action potentials in response to electrical stimulation were recorded intracellularly and electrical characteristics of the axons were examined by injecting current pulses through a bridge circuit. All action potentials larger in amplitude than 80 mV were followed by depolarizing afterpotentials, similar to those recorded in peripheral axons [Barrett and Barrett (1982) J. Physiol., Lond. 323, 117-144]. The afterpotential could be described as the sum of three exponential components, the time constants of which (tau 1, tau 2 and tau 3) were 25.2 +/- 5.6, 3.1 +/- 0.8 and 0.8 +/0 0.3 ms, respectively, at 25 degrees C and a membrane potential of -80 mV. The maximal amplitudes of the afterpotential components, obtained by extrapolating to the peak of the action potential, were 3.8 +/- 1.0, 6.4 +/- 5.2 and 21.7 +/- 9.8 mV, for action potential amplitudes of 102 +/- 11 mV. The amplitude of the longest component of the afterpotential decreased with depolarization and increased with hyperpolarization at the recording site. The amplitude decreased markedly with increase of temperature to physiological levels, in conjunction with the expected decrease in action potential duration. Similar afterpotential components were present in the response of the axon to injected hyperpolarizing current pulses. The observations are consistent with the suggestion [Barrett and Barrett (1982) J. Physiol., Lond. 323, 117-144] that the afterpotential results from charging of the axolemmal capacitance by current passing through the myelin sheath during the action potential. They are inconsistent with a number of calculations of electrical characteristics of peripheral axons derived from voltage clamp experiments in isolated fibers. It is argued that the electrical resistance of the myelin lamellae is relatively low, though within the range calculated for other glial membranes. This suggestion is found more compatible with the available morphological data than the alternative proposal that a leakage pathway under the myelin sheath might be responsible for the afterpotential [Barrett and Barrett (1982) J. Physiol., Lond. 323, 117-144]. The significance of this organization for the function of myelinated axons and the electrical basis of the afterpotential are examined further in the accompanying paper [Blight (1985) Neuroscience 15, 13-31].

Differential effects of low and high concentrations of 4-aminopyridine on axonal conduction in normal and injured spinal cord.

Blockade of potassium channels with the drug 4-aminopyridine has been shown to effect recovery of action potential conduction in myelinated axons under a variety of pathological conditions, but the mechanism and significance of this phenomenon are not completely understood. This study examined the effects of a range of 4-aminopyridine concentrations on conduction in an experimental model of chronic spinal cord injury in guinea-pigs, using sucrose-gap recording from isolated spinal cord strips. The amplitude of the compound action potential increased in response to bath application of 4-aminopyridine, with a threshold between 0.5 and 1 microM and the peak response between 10 and 100 microns. Conduction was suppressed at concentrations of 1 and 10 mM. Uninjured white matter showed no effect on the compound potential of 4-aminopyridine below 1 mM, but there was a similar suppression at concentrations above 1 mM, accompanied by marked membrane depolarization. Peripheral nerve showed only slight action potential suppression and depolarization in the presence of 10 mM 4-aminopyridine. The sensitivity of injured axons to 1 microM 4-aminopyridine is consistent with the hypothesis that some beneficial effects of the drug seen in patients with spinal cord injury are related to improved conduction in myelinated axons, since cerebrospinal fluid levels of 4-aminopyridine should approach this concentration following clinical systemic doses, although it remains likely that synaptic effects also play a role. The blockade of action potential conduction produced by much higher levels of 4-aminopyridine in vitro is possibly a consequence of interference with the resting potential mechanism of the axon membrane, which appears to differ between central and peripheral nerve fibers.

Morphometric analysis of experimental spinal cord injury in the cat: the relation of injury intensity to survival of myelinated axons.

The pattern of axonal destruction and demyelination that occurs in experimental contusion injury of cat thoracic spinal cord was studied by line sampling of axons in 1 micron thick plastic sections with the light microscope. Injuries were produced by a weight-drop apparatus, with the vertebral body (T9) below the impact stabilized by supports under the transverse processes. The effects of two combinations of weight and height were examined: 10 or 13 g dropped 20 cm onto an impact area of 5 mm diameter. Animals were kept for 3-5 months after injury, then fixed by perfusion for histological analysis. The number of surviving myelinated axons was found to vary both with the weight used and with the size of the spinal cord. A measure of impact intensity was derived from the calculated momentum of the weight at impact divided by the cross sectional area of the cord (interpolated from dimensions measured rostral and caudal of the lesion following fixation). At impact intensities greater than 0.02 kg-m/s/cm2 there was practically no survival of axons at the center of the injury site, combined with almost complete breakdown of the pial margin. Between 0.08 and 0.2 kg-m/s/cm2 the number of surviving axons varied between 100,000 and 2,000, approximating a negative exponential function (r = -0.88). The number of axons surviving in the outer 100 microns of the cord varied practically linearly (r = -0.82) between near normal and less than 1% of normal over the same range of injury intensity. The number of surviving axons decreased with depth from the pia, also approximating a negative exponential function, with a 10-fold decrease in density over approximately 500 microns. The average slope of this relation with depth remained similar over the range of injury intensity examined, though the slope appeared inversely related to variation in axonal survival for different individuals at a given intensity. It is argued that the loss of axons is probably determined primarily by mechanical stretch at the time of impact. Its centrifugal pattern may be explained by longitudinal displacement of the central contents of the cord, reflecting the viscoelastic "boundary layer" properties of parenchymal flow within the meningeal tube. This is illustrated with reference to the behavior of a gelatin model under compression. The preferential loss of large caliber axons and the characteristic shift to abnormally thin myelin sheaths (resulting from post-traumatic demyelination) both varied in extent independently of injury intensity and overall axonal survival.(ABSTRACT TRUNCATED AT 400 WORDS)