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[Notes from neurological semeiology. XVI. I. The peripheral nerves. b) Spinal nerves. Sacral plexus and sciatic nerve (trunk)].
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[Notes on neurological semeiology. III. (1) Peripheral nerves. (a) Cranial nerves. 3d, 4th and 6th cranial pairs: oculmotor nerves].
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[Notes on neurological semeiology. VI. The peripheral nerves. (a) Cranial nerves. 8th cranial pair: the auditory nerve].
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[The peripheral nerves. a) Cranial nerves. 7th cranial pair: the facial nerve].
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[Regeneration of sensory nerve fibers and nerve endings in the labial mucosa after sectioning of the mental nerve].
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The aberrant retino-retinal projection during optic nerve regeneration in the frog. III. Effects of crushing both nerves.
Previous reports from this laboratory have shown that a substantial number of optic axons are misrouted after optic nerve regeneration in the adult frog, Rana pipiens. Regenerating axons from a crushed optic nerve are distributed throughout the opposite nerve. In this study, we report the effect of crushing both optic nerves (double crush) on the pattern and degree of axonal misrouting. In 28 frogs both optic nerves were crushed at the same time (simultaneous double crush) and animals survived for varying periods before the right eye was injected with 3H-proline and the brain processed for autoradiography 24 hours later. In every frog with postoperative survivals longer than 2 weeks, labeled axons from the right eye were found in the left optic nerve. However, when compared to the amount of label seen in frogs in which only the right optic nerve was crushed (single crush) there was substantially less label within the left nerve of frogs after crushing both nerves. Label was also found only at the edge of the left nerve in material from double crush frogs, unlike that found after single crush. In four of six frogs where the left nerve was crushed 1 week after the right nerve (delayed double crush), the proximal end of the left nerve was completely filled with label, but more distally, label was found only along the edge of this nerve. Although fewer optic axons were labeled in the opposite optic nerve of double crush frogs, label did extend to the optic disc of that eye. However, label was not apparent in the ganglion cell fiber layer of the opposite eye. Instead, it was confined to the edge of the optic disc in a space apparently associated with papilledema resulting from crushing the optic nerve of that eye. In six frogs the retina of the left eye was removed at the same time the right optic nerve was crushed. Labeled axons of the right eye filled the left optic nerve to the retina-less shell of the left eye. Thus, these data show that the amount and distribution of axonal misrouting into the opposite optic nerve during optic nerve regeneration is affected by intact or regenerating optic axons from the other eye.
Nerve regeneration in a 'pseudo-nerve' graft created in a silicone tube.
The pseudo-nerve, which contains longitudinal Schwann cell columns without axons and surrounded by perineurium-like tissue but no axons (Q. Zhao, L.B. Dahlin, M. Kanje, G. Lundborg, Brain Res. 592 (1992) 106-114), was applied as a graft to repair nerve defect in rats. Creation of the pseudo-nerve was accomplished by inserting the proximal and distal stumps of a cut sciatic nerve into a silicone tube. The proximal insert was cut far proximally to prevent axons from entering the tube. After 4 weeks, the pseudo-nerve was harvested, trimmed into a 10-mm long graft and transplanted into a corresponding defect of the contralateral sciatic nerve. Nerve regeneration through the pseudo-nerve was examined by pinch reflex test and neurofilament staining after 6 days or by morphology after 4, 6 or 8 weeks. The results showed that the pseudo-nerve could induce nerve regeneration to a similar extend as a real nerve graft. The neurobiological composition of the pseudo-nerve and the factors influencing its formation were also studied. By double staining of S-100 and laminin we found that the longitudinally organized Schwann cell columns in the pseudo-nerve were surrounded by basal laminae and ensheathed by a layer of vascularized perineurium-like tissue. Macrophages (ED1 and ED2) and their products interleukin-1beta (IL-1beta) and transforming growth factor-beta1 (TGF-beta1) were constantly present in the pseudo-nerve. Besides, the size of tube was a crucial factor in influencing pseudo-nerve formation, e.g. a thicker pseudo-nerve was formed in tubes with larger diameters or shorter gap lengths. No pseudo-nerve was formed when the gap was 15 mm long. When both proximal and distal inserts were isolated nerve segments the pseudo-nerve was still formed but thin, probably because of compromised vascular supply. Taken together, the results suggested that the pseudo-nerve contains the essential neurobiological elements to induce successful axonal elongation.
Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study.
PURPOSE: To experimentally evaluate the feasibility of restoring the motor function of the deltoid muscle in patients with complete C5-C6 root injury (upper brachial plexus injury) by transferring the nerve to the long head of the triceps to the anterior branch of the axillary nerve through a posterior approach. METHODS: The study was performed on shoulder girdles of 36 formalin-embalmed cadavers. The number, diameter, and length of the branches of the axillary nerve at the level of the quadrilateral space were noted. The length and diameter of the nerves to the long head and to the lateral head of triceps at the level of triangular space were recorded. The distances from the acromion angle to the bifurcation of the anterior branch of the axillary nerve, to the origins of the nerve to the long head, and to the origin of the lateral head of the triceps were recorded as well. Nerve biopsy specimens of the axillary nerve and the nerve to the long head of the triceps were obtained from 6 fresh cadavers for histomorphometric evaluation. RESULTS: The average length of the anterior branch of the axillary nerve in this study, measured from the quadrilateral space to the innervating site, was 44.5 mm (range, 26-62 mm), and the average length of the nerve to the long head of triceps, measured from its origin to the innervating site, was 68.5 mm (range, 30-69 mm). The average diameter of the anterior branches of the axillary nerve and the nerve to the long head of the triceps were 2.1 and 1.1 mm, respectively. The average number of axon fibers in the anterior branch of the axillary nerve was 2,704 and in the nerve to the long head of the triceps was 1,233. CONCLUSIONS: Using the acromial angle as the landmark, the combined length of the two 2 nerves was longer than the distance between them. The diameter, the number of axons, and the anatomic proximity of the nerve to the long head of the triceps make it a potential source for reinnervation of the anterior branch of the axillary nerve by direct nerve transfer without nerve grafting through posterior approach for the management of upper brachial plexus injuries.
Vein conduits with interposition of nerve tissue for peripheral nerve defects.
Vein conduits with interposition of autogenous nerve tissue were used in 16 peripheral nerves to reconstruct defects of between 2.0 and 5.8 cm. This technique was applied in nine digital nerves, four ulnar nerves, two median nerves, and one radial sensory nerve. A single vein conduit was used in digital nerve defects and two or three vein segments were used in defects of nerve trunks. Nerve tissue was sectioned from the proximal nerve stump and inserted inside the vein conduits. Follow-up of 2.5 to 3.5 years has revealed motor recovery to M4 in three nerves, M3+ in three, M2 in one nerve, and sensory recovery to S4 in two nerves, S3+ in five, S3 in four, S2+ in three and S0 in two nerves. Signs of muscle reinnervation of the repaired nerves were noted on electromyography. Two digital nerves with defects of over 5.0 cm did not show any signs of sensory recovery. Sectioning and placement of autogenous nerve tissue is thought to create fresh and additional sources for the release of neurotropic factors, and may serve to convey the neurotropic effect over a longer distance. This clinical study suggests that vein conduits with the interposition of nerve tissue is a practical and reliable procedure for nerve defects between 2.0 cm and 4.5 cm.
Reorganisation of primary afferent nerve terminals in the brainstem after peripheral nerve injury. An anatomical study in cats.
A pure sensory nerve (the superficial branch of the radial nerve) in adult cats was cut to investigate the changes in the nerve endings (terminals) on the neurons of the nucleus cuneatus of the brainstem. In one group of cats (n = 22) the ends of the cut nerve were approximated immediately by epineural suturing to promote optimum regeneration. In another group (n = 11) the proximals tump of the nerve was enclosed in a capsule to prevent regeneration. Four to 17 months later the same nerve was re-exposed. The sutured nerves were cut and nerve-tracer was exhibited to the proximal end of the cut nerves and to the proximal stump of the nerves which had been encapsulated. The purpose was to investigate the labelling of nerve terminals in the cuneate nucleus, because it receives an input of primary afferents from the front leg. The nerve and the cuneate nucleus of the opposite side served as controls. Labelled terminals were distributed throughout the dorsal part of the entire rostrocaudal extent of the cuneate nucleus. The distribution was patchy and was superimposed on clusters of nerve cells. The quantity of labelled nerve terminals on the experimental and control sides was compared: 60% of the labelling observed on the control side was in the sutured nerves while the encapsulated nerves exhibited only 32%. This difference was apparent 4 months after transection of the nerve. Up to 17 months after the nerve was cut, however, there was some increase in the quantity of labelled nerve terminals and this was most apparent in cats in which the nerves had been sutured.
Nerve regeneration in a bony bed: vascularized versus nonvascularized nerve grafts.
In a rabbit model, regeneration of the intratemporal facial nerve was studied as vascularized and nonvascularized nerve grafts. Fifteen New Zealand white rabbits weighing 4 to 4.5 kg were used. A 1-cm gap was created in the intratemporal facial nerve. In the vascularized nerve graft group (group 1), the facial nerve was repaired with a vascularized median nerve graft (n = 6), while in the nonvascularized nerve graft group (group 2), the median nerve was used as a nonvascularized graft (n = 6). In group 3, the facial nerve gap was left unrepaired (n = 3). At 3 months postoperatively, electrophysiologic testing, morphologic nerve study, and morphometric muscle analysis were performed. Although the mean numerical values of axonal counting, nerve conduction, and morphometric muscle study results were slightly better in the vascularized nerve graft group, the differences between the two grafted groups were not statistically significant (p > 0.05). Morphometric nerve analysis, i.e., axon diameter and myelin sheath thickness, showed significant differences in nerve regeneration between the two groups (p < 0.05). These results suggest that a bony bed is not optimal for neovascularization of a nerve graft. We conclude that vascularized nerve grafts are superior to nonvascularized nerve grafts when nerve regeneration occurs in a bony recipient bed. This might be of clinical importance in the repair of facial nerve lesions within the temporal bone.
Repair of motor nerve gaps with sensory nerve inhibits regeneration in rats.
OBJECTIVE: Sensory nerve grafts are often used to reconstruct injured motor nerves, but the consequences of such motor/sensory mismatches are not well studied. Sensory nerves have more diverse fiber distributions than motor nerves and may possess phenotypically distinct Schwann cells. Putative differences in Schwann cell characteristics and pathway architecture may negatively affect the regeneration of motor neurons down sensory pathways. We hypothesized that sensory grafts impair motor target reinnervation, thereby contributing to suboptimal outcomes. This study investigated the effect of motor versus sensory grafts on nerve regeneration and functional recovery. STUDY DESIGN: The authors conducted a prospective, randomized, controlled animal study. METHODS: Fifty-six Lewis rats were randomized to seven groups of eight animals each. Five-millimeter tibial nerve defects were reconstructed with motor or sensory nerve grafts comprised of single, double, triple, or quadruple cables. Tibial nerve autografts served as positive controls. Three weeks after reconstruction, nerves were harvested for histologic examination and quantitative histomorphometric analysis. Wet muscle masses provided an index of functional recovery. RESULTS: Nerve regeneration was significantly greater across motor versus sensory nerve grafts independent of graft cross-sectional area or cable number. Motor grafts demonstrated increased nerve density, percent nerve, and total fiber number (P < .05). Normalized wet muscle masses trended toward improved recovery in motor versus sensory groups. CONCLUSIONS: Reconstruction of tibial nerve defects with nerve grafts of motor versus sensory origin enhanced nerve regeneration independent of cable number in a rodent model. Preferential nerve regeneration through motor nerve grafts may also promote functional recovery with potential implications for clinical nerve reconstruction.
[An experimental study on regeneration of the inferior alveolar nerve after lyophilized nerve homografting in the rabbit].
This study was designed to evaluate the differences between the regenerative process in cases of autogenous nerve grafting and lyophilized homologous nerve grafting. Rabbit inferior alveolar nerves (10 mm lengths) were resected and replaced with lyophilized homologous segments from the sciatic nerve. On the opposite side, the resected nerves were autogenously grafted. The experimental subjects were divided into autogenous nerve-graft and the lyophilized nerve-graft groups. Results. 1. Regenerating axons appeared in the autogenous-graft group 2 weeks after the operation and 4 weeks after the operation in the homografted lyophilized group. The difference in regeneration between the 2 groups was significant. 2. Regenerating axons in the autogenously grafted nerves made contact with remaining Schwann cells and endneural tubes. Axons in the homografted lyophilized nerves invaded along newly infiltrated Schwann cells and empty tube skeletal structures. The number of regenerating axons from outside the skeletal structure was greater than the number of regenerating axons from inside the skeletal structure. 3. In the case of autogenous grafting, nerve fibers of diameters greater than 3 microns increased 66.7% after 24 weeks; the corresponding figure for homografted lyophilized nerves was 48.4%. 4. In instances of autogenous grafting, 16 weeks after surgery, the ratio of distal proximal myelinated nerve fibers had grown. In cases of homografted lyophilized nerves, this tendency to increase continued until the twenty-fourth postsurgical week. 5. In both groups, it remained possible to record nerve action potentials 12 weeks after surgery. The sensory nerve conduction velocity of autogenously grafted nerves increased gradually to approach control values 24 weeks after surgery. That of homografted lyophilized nerves recovered more slowly. 6. Increases in number of nerve fibers with a diameter of more than 3 microns were proportional to the rate at which sensory nerve conduction velocity recovered.
[Repair of peripheral nerve defect by xenogeneic acellular nerve basal lamina scaffolds].
OBJECTIVE: To explore the possibility to bridge peripheral nerve defects by xenogeneic acellular nerve basal lamina scaffolds. METHODS: Thirty SD rats were randomly divided into 5 groups; in each group, the left sciatic nerves were bridged respectively by predegenerated or fresh xenogeneic acellular nerve basal lamina scaffolds, autogenous nerve grafting, fresh xenogeneic nerve grafting or without bridging. Two kinds of acellular nerve basal lamina scaffolds, extracted by 3% Triton X-100 and 4% deoxycholate sodium from either fresh rabbit tibial nerves or predegenerated ones for 2 weeks, were transplanted to bridge 15 mm rat sciatic nerve gaps. Six months after the grafting, the recovery of function was evaluated by gait analysis, pinch test, morphological and morphometric analysis. RESULTS: The sciatic nerve function indexes (SFI) were -30.7% +/- 6.8% in rats treated with xenogeneic acellular nerve, -36.2% +/- 9.7% with xenogeneic predegenerated acellular nerve, and -33.9% +/- 11.3% with autograft respectively (P > 0.05). The number of regenerative myelinated axons, diameter of myelinated fibers and thickness of myelin sheath in acellular xenograft were satisfactory when compared with that in autograft. Regenerated microfascicles distributed in the center of degenerated and acellular nerve group. The regenerated nerve fibers had normal morphological and structural characters under transmission electron microscope. The number and diameter of myelinated fibers in degenerated accellular nerve group was similar to that of autograft group (P > 0.05). Whereas the thickness of myelin sheath in degenerated accellular nerve group was significantly less than that of autograft group (P < 0.05). CONCLUSION: The above results indicate that xenogeneic acellular nerve basal lamina scaffolds extracted by chemical procedure can be successfully used to repair nerve defects without any immunosuppressants.
Pelvic nerve plexus trauma at radical and simple hysterectomy: a quantitative study of nerve types in the uterine supporting ligaments.
OBJECTIVE: Using neuropeptide and enzyme markers to autonomic nerves, we sought to demonstrate and quantify the nerve types contained within the uterosacral ligaments (USLs) and cardinal ligaments (CLs) that are divided during radical hysterectomy (RH). METHODS: Cross-sectional biopsies were collected from the lateral third of the USL and the CL in 24 women who had an RH for cervical cancer, and from the uterine insertion of these ligaments in 11 women who had a simple hysterectomy for benign disease. We applied indirect immunofluorescence with FITC-conjugated secondary antibodies, using polyclonal primary antibodies to neuropeptide markers that predominate within somatic and autonomic nerves, to show different populations of the following nerve types within the biopsies: neuropeptide Y (NPY) and tyrosine hydroxylase (TH) for sympathetic nerves; vasoactive intestinal polypeptide (VIP) for parasympathetic nerves; substance P (SP) for nociceptive and sensory-motor nerves; and calcitonin gene-related peptide (CGRP) for sensory and sensory-motor nerves. The percentage area of immunoreactivity (PAI), determined by a computer-assisted image analyzer attached to a fluorescent microscope, was used as an objective quantitative measure of nerve density. Confocal microscopy was used to determine the composition and spatial arrangement of nerve fibers in the ligaments. RESULTS: The PAI was greater for all markers tested in both the USL and CL (P <.001) in RH compared with simple hysterectomy biopsies. For RH specimens, the PAI was greater for the sympathetic, sensory, and sensory-motor nerve markers in the USL compared with the CL (P <.01), but the PAI for VIP was similar (P >.05). Conversely, excluding the large trunks and associated ganglia, the free nerve fiber PAI in the CL was greater than that of the USL for all nerve markers (P <.001). The staining of peripheral autonomic ganglia and associated fibers, for NPY and TH, indicates that some sympathetic nerves are preganglionic with their cell bodies within the pelvic plexus. CONCLUSIONS: Significantly more autonomic nerves are transected in the more lateral division of the uterine supporting ligaments during a radical hysterectomy than during a simple hysterectomy. Sympathetic, parasympathetic, sensory, and sensory-motor nerve types are present within the CL and USL. The proportions of each nerve type differ between the two ligaments, and sympathetic nerves in the USL are the single largest nerve type. The uterine supporting ligaments are a major pathway for autonomic nerves to the pelvic organs.
Effects of motor versus sensory nerve grafts on peripheral nerve regeneration.
Autologous nerve grafting is the current standard of care for nerve injuries resulting in a nerve gap. This treatment requires the use of sensory grafts to reconstruct motor defects, but the consequences of mismatches between graft and native nerve are unknown. Motor pathways have been shown to preferentially support motoneuron regeneration. Functional outcome of motor nerve reconstruction depends on the magnitude, rate, and precision of end organ reinnervation. This study examined the role of pathway type on regeneration across a mixed nerve defect. Thirty-six Lewis rats underwent tibial nerve transection and received isogeneic motor, sensory or mixed nerve grafts. Histomorphometry of the regenerating nerves at 3 weeks demonstrated robust nerve regeneration through both motor and mixed nerve grafts. In contrast, poor nerve regeneration was seen through sensory nerve grafts, with significantly decreased nerve fiber count, percent nerve, and nerve density when compared with mixed and motor groups (P < 0.05). These data suggest that use of motor or mixed nerve grafts, rather than sensory nerve grafts, will optimize regeneration across mixed nerve defects.
Detection of lumbosacral nerve root compression with a novel composite nerve conduction measurement.
STUDY DESIGN: Multivariate logistic regression techniques were used to develop a composite nerve conduction measurement that detects lumbosacral (L5, S1, or both) nerve root compression. OBJECTIVES: To evaluate the diagnostic efficacy of a composite nerve conduction measurement for detection of lumbosacral nerve root compression. SUMMARY OF BACKGROUND DATA: Nerve root involvement is characterized by clinical abnormalities and confirmed by radiologic and electrodiagnostic studies. Imaging studies visualize structural abnormalities; however, they are associated with high false-positive rates. Electrodiagnostic methods assess the physiologic integrity of the nerve roots. One form of electrodiagnostic testing, nerve conduction studies, is widely used for evaluation of musculoskeletal and neuromuscular complaints. Although similar clinical value is expected for the evaluation of nerve root compromise, prior applications of nerve conduction studies have yielded widely varying results. METHODS: Two groups of subjects were compared. The L5-S1 compression group was composed of 25 patients with magnetic resonance imaging-confirmed lumbosacral (L5, S1, or both) nerve root compression and symptoms in the appropriate segmental distribution. The majority of subjects (22) had at least one of the following findings on physical examination: positive straight-leg raise test, diminished ankle reflexes, sensory loss, or weakness. The control group consisted of 35 asymptomatic individuals with no history of radiculopathy or potentially confounding neuropathology. The posterior tibial and deep peroneal nerves were evaluated bilaterally in all study subjects using standard nerve conduction procedures, which consisted of the measurement of distal motor latencies and F-wave latencies that assess nerve root pathophysiology. A composite nerve conduction measurement was determined using multivariate logistic regression analysis. The efficacy of the composite measurement was assessed by receiver operating characteristic curve analysis and by the diagnostic sensitivity and specificity. RESULTS: Five F-wave latency parameters (peroneal mean F-wave latency, odds ratio = 0.42; peroneal seventh F-wave latency decile, odds ratio = 2.71; tibial mean F-wave latency, odds ratio = 8.90; tibial first F-wave latency decile, odds ratio = 0.47; tibial maximum F-wave latency, odds ratio = 0.44) were found to be predictive of nerve root compression. A composite nerve conduction measurement, NC composite, constructed from these five parameters (NC composite = exp(phi)/(1 + exp(phi)), phi = -31.2 + 1.0 * Per7 Decile - 0.88 * PerMean + 2.2 * TibMean - 0.88 * Tib1 Decile - 0.83 * TibMax) yielded an area under the receiver operating characteristic curve of 0.91. At a threshold of 0.20, NC composite had a diagnostic specificity of 84.3% and a sensitivity of 83.3%. CONCLUSION: This preliminary study suggests that a novel composite nerve conduction measurement, based on F-wave latency parameters, may be highly effective at detecting magnetic resonance imaging-confirmed lumbosacral nerve root compression. Because these measurements provide objective evidence of functional nerve root compromise and are noninvasive, they may be of diagnostic value to clinicians evaluating patients presenting with low back and leg pain.