A rat study of the use of end-to-side peripheral nerve repair as a “babysitting” technique to reduce the deleterious effect of chronic denervation

Restricted access

OBJECTIVE

Functional recovery is disappointing after surgical repair of nerves that are injured far from their target organs and/or after delayed repair. In the former case, a nerve transfer that transects a distal nerve fascicle to innervate denervated targets is one strategy to promote nerve regeneration and functional recovery. An alternate strategy tested in this study is to perform an end-to-side neurorrhaphy to “babysit” (protect) the denervated distal nerve stump at the time of nerve repair and reduce the deleterious effect of chronic denervation on nerve regeneration.

METHODS

In the hindlimbs of Sprague-Dawley rats, the common peroneal (CP) nerve was transected unilaterally and the distal CP nerve stump inserted through a perineurial window into the intact tibial (TIB) nerve, i.e., CP-TIB end-to-side neurorrhaphy. In the first experiment, TIB nerve motoneurons that had regenerated and/or sprouted axons into the CP nerve within 3 months were stimulated to elicit contractions, and thereafter, identified with retrograde dyes for counting. In the second experiment, the intact TIB nerve was transected and cross-sutured to a 3-month chronically denervated distal CP nerve stump that had either been “protected” by ingrown TIB nerves after CP-TIB neurorrhaphy or remained chronically denervated. Thereafter, the number of retrogradely labeled TIB nerve motoneurons that had regenerated their nerves within 3 months were counted and reinnervated tibialis anterior (TA) muscles weighed.

RESULTS

A mean (± SE) of 231 ± 83 TIB nerve motoneurons grew into the end-to-side CP distal nerve stump with corresponding ankle flexion; 32% regenerated their axons and 24% sprouted axons from the intact TIB nerve, eliciting ankle flexor-extensor co-contraction. In the second experiment, after a 3-month period of TIB nerve regeneration, significantly more TIB motoneurons regenerated their axons into “protected” than “unprotected” CP distal nerve stumps within 3 months (mean 332 ± 43.6 vs 235 ± 39.3 motoneurons) with corresponding and significantly higher numbers of regenerated nerve fibers, resulting in significantly better recovery of reinnervated TA muscle weight.

CONCLUSIONS

These experiments in rats demonstrated that delayed nerve repair is more effective when the deleterious effects of chronic denervation of the distal nerve stump are reduced by protecting the nerve stump with ingrowing nerve fibers across an end-to-side insertion of the distal nerve stump into a neighboring intact nerve. Such an end-to-side neurorrhaphy may be invaluable as a means of preventing the atrophy of distal nerve stumps and target organs after chronic denervation, which allows for effective reinnervation of the protected distal nerve stumps and target organs over distance and time.

ABBREVIATIONS AIN = anterior interosseous nerve; CP = common peroneal; RAG = regeneration-associated gene; SC = Schwann cell; TA = tibialis anterior; TIB = tibial.

Article Information

Correspondence Tessa Gordon: Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada. tessat.gordon@gmail.com.

INCLUDE WHEN CITING Published online September 14, 2018; DOI: 10.3171/2018.3.JNS172357.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    A: In the first surgery, the CP nerve was transected in the right hindlimb in two groups of rats, the control group and experimental groups 1 and 2. In rats in the control group, the CP nerve stumps were each ligated and then sutured to innervated biceps femoris muscle (not shown) to prevent CP nerve regeneration into the unprotected CP distal nerve stump. B: In rats in experimental groups 1 and 2, the distal CP nerve stump was protected from chronic denervation by inserting the stump end-to-side into the TIB nerve through a perineurial window, i.e., a CP-TIB end-to-side neurorrhaphy. C: The second surgery occurred 3 months later. In rats in experimental group 1 (not shown, see Fig. 2), retrograde dyes were applied to the CP and TIB nerves for enumeration of motoneurons. In rats in the control group, the ligated 3-month chronically denervated CP distal nerve stump was refreshed and the TIB nerve was cut in order to cross-suture the proximal TIB nerve stump to the unprotected 3-month chronically denervated CP distal nerve stump. In experimental group 2, the proximal TIB nerve stump was cross-sutured to the 3-month chronically denervated CP distal stump that had been protected by a CP-TIB end-to-side neurorrhaphy 3 months prior. The TIB distal stump was ligated to prevent reinnervation. D: In the third surgery 3 months later, in the control group and experimental group 2, the CP nerve was transected 20 mm from the neurorrhaphy site for Fluoro-Gold retrograde labeling of the TIB motoneurons that had regenerated their axons into the CP nerve stump. Figure is available in color online only.

  • View in gallery

    In the rats in experimental group 1 in which the CP nerve was cut in the first surgery to perform an end-to-side CP-TIB neurorrhaphy (see Fig. 1A and B), retrograde dyes (Fluoro-Gold [FG] and Fluoro-Ruby [FR]) were applied to the CP nerve 20 mm from the neurorrhaphy site and to the TIB nerve 10 mm from the site, respectively, 3 months later. Thereafter, TIB motoneurons that sent axons into the CP distal stump and/or remained within the TIB nerve distal to the neurorrhaphy, respectively, were counted. Figure is available in color online only.

  • View in gallery

    A: In the rats of the experimental group 1, an example of the dye-filled TIB motoneurons is shown on the left and right micrographs after retrograde application of Fluoro-Ruby to the TIB nerve distal to the CP-TIB end-to-side insertion (neurorrhaphy) and Fluoro-Gold to the inserted distal CP nerve stump, respectively (see Fig. 2). B: The mean (± SE) number of TIB motoneurons that were backlabeled from the inserted distal CP nerve stump, the intact TIB nerve, and from both the inserted CP distal nerve stump and the intact TIB nerve, 3 months after the CP-TIB end-to-side insertion of the CP nerve into the intact TIB nerve. The total mean number of TIB motoneurons is also shown with the mean number of TIB motoneurons that supplied the TIB nerve in the contralateral unoperated normal hindlimb. C: The mean (± SE) muscle contraction score on a 0–5 scale for flexor, extensor, and combined muscles that was obtained just prior to the backlabeling of the TIB motoneurons. Figure is available in color online only.

  • View in gallery

    The mean (± SE) of the number of TIB motoneurons that were backlabeled from the distal CP nerve stump (A), and (B) the weight of reinnervated TA muscles 3 months after a TIB-CP cross-suture repair of the transected TIB nerve and a 3-month chronically denervated CP distal nerve stump that was either protected by TIB axons after CP-TIB end-to-side neurorrhaphy (Protected CPn) or not protected (Unprotected CPn). The protection was achieved by inserting the CP distal nerve stump into the intact TIB nerve, a CP-TIB end-to-side neurorrhaphy. The number of TIB motoneurons regenerating nerves into the protected CP nerve, and the TA muscle weights after protection, were significantly greater than when the CP nerve was not protected (p < 0.05). Nonetheless, the number of regenerated TIB motoneurons and the TA muscle weights did not attain the mean (± SE) of the numbers of motoneurons with axons in the intact TIB nerve or the weights of the normally innervated TA muscles in the contralateral unoperated normal hindlimb (horizontal lines). Figure is available in color online only.

  • View in gallery

    Toluidine blue–stained, 3-month regenerated TIB nerve fibers in the CP distal nerve stump after cross-suture of the freshly transected TIB proximal nerve stump to a 3-month chronically denervated CP distal nerve stump that remained denervated without protection (A) or was protected by TIB axons after inserting the CP distal nerve stump into the side of the intact TIB nerve (CP-TIB end-to-side neurorrhaphy; B). Bar = 20 μm. Figure is available in color online only.

  • View in gallery

    Illustration of the use of an end-to-side neurorrhaphy. In this example, the distal stump of the transected ulnar nerve is inserted end-to-side into the AIN branch of the median nerve (A) to protect the denervated distal ulnar nerve stump and its denervated target hand muscles, including the first dorsal interosseous muscle, from denervation atrophy. Thereafter (B), the proximal AIN stump is cross-sutured to the protected distal ulnar nerve, a nerve transfer from the AIN proximal to the neurorrhaphy to the protected distal ulnar nerve. Copyright Tessa Gordon. Published with permission. Figure is available in color online only.

References

  • 1

    Abercrombie M: Estimation of nuclear population from microtome sections. Anat Rec 94:2392471946

  • 2

    Bersaneti JAViterbo FJorge JDenadai R: Muscle reinnervation in one or two stages? Experimental study in rats with end-to-side nerve graft. Acta Cir Bras 27:8418472012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bertelli JAGhizoni MF: Nerve repair by end-to-side coaptation or fascicular transfer: a clinical study. J Reconstr Microsurg 19:3133182003

  • 4

    Biasutti SDart AJDart CMUquillas EJeffcott LB: End-to-side anastomosis of the left ventral colon to the small colon in a neonatal foal with segmental agenesis of the large colon. Aust Vet J 95:2172192017

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Bontioti EKanje MLundborg GDahlin LB: End-to-side nerve repair in the upper extremity of rat. J Peripher Nerv Syst 10:58682005

  • 6

    Brenner MJDvali LHunter DAMyckatyn TMMackinnon SE: Motor neuron regeneration through end-to-side repairs is a function of donor nerve axotomy. Plast Reconstr Surg 120:2152232007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Brushart TMHoffman PNRoyall RMMurinson BBWitzel CGordon T: Electrical stimulation promotes motoneuron regeneration without increasing its speed or conditioning the neuron. J Neurosci 22:663166382002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Brushart TMJari RVerge VRohde CGordon T: Electrical stimulation restores the specificity of sensory axon regeneration. Exp Neurol 194:2212292005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Elzinga KTyreman NLadak ASavaryn BOlson JGordon T: Brief electrical stimulation improves nerve regeneration after delayed repair in Sprague Dawley rats. Exp Neurol 269:1421532015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Foecking EMFargo KNCoughlin LMKim JTMarzo SJJones KJ: Single session of brief electrical stimulation immediately following crush injury enhances functional recovery of rat facial nerve. J Rehabil Res Dev 49:4514582012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Fu SYGordon T: The cellular and molecular basis of peripheral nerve regeneration. Mol Neurobiol 14:671161997

  • 12

    Furey MJMidha RXu QGBelkas JGordon T: Prolonged target deprivation reduces the capacity of injured motoneurons to regenerate. Neurosurgery 60:7237332007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Geuna SPapalia ITos P: End-to-side (terminolateral) nerve regeneration: a challenge for neuroscientists coming from an intriguing nerve repair concept. Brain Res Brain Res Rev 52:3813882006

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14

    Gordon T: Electrical stimulation to enhance axon regeneration after peripheral nerve injuries in animal models and humans. Neurotherapeutics 13:2953102016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Gordon TAmirjani NEdwards DCChan KM: Brief post-surgical electrical stimulation accelerates axon regeneration and muscle reinnervation without affecting the functional measures in carpal tunnel syndrome patients. Exp Neurol 223:1922022010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Gordon THendry MLafontaine CACartar HZhang JJBorschel GH: Nerve cross-bridging to enhance nerve regeneration in a rat model of delayed nerve repair. PLoS One 10:e01273972015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17

    Gordon TTetzlaff W: Regeneration-associated genes decline in chronically injured rat sciatic motoneurons. Eur J Neurosci 42:278327912015

  • 18

    Gordon TTyreman NRaji MA: The basis for diminished functional recovery after delayed peripheral nerve repair. J Neurosci 31:532553342011

  • 19

    Haninec PKaiser RDubový P: A Comparison of collateral sprouting of sensory and motor axons after end-to-side neurorrhaphy with and without the perineurial window. Plast Reconstr Surg 130:6096142012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Hayashi APannucci CMoradzadeh AKawamura DMagill CHunter DA: Axotomy or compression is required for axonal sprouting following end-to-side neurorrhaphy. Exp Neurol 211:5395502008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Höke ARedett RHameed HJari RZhou CLi ZB: Schwann cells express motor and sensory phenotypes that regulate axon regeneration. J Neurosci 26:964696552006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Kale SSGlaus SWYee ANicoson MCHunter DAMackinnon SE: Reverse end-to-side nerve transfer: from animal model to clinical use. J Hand Surg Am 36:16311639.e22011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Kennedy R: On the restoration of coordinated movement after nerve-crossing, with interchange of function of the cerebral cortical centers. Philos Trans R Soc Lond B Biol Sci 194B:127–1631901

    • Search Google Scholar
    • Export Citation
  • 24

    Kline DGHudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries Entrapments and Tumors. Philadelphia: Saunders1995

  • 25

    Ladak ASchembri POlson JUdina ETyreman NGordon T: Side-to-side nerve grafts sustain chronically denervated peripheral nerve pathways during axon regeneration and result in improved functional reinnervation. Neurosurgery 68:165416662011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Lundborg GZhao QKanje MDanielsen NKerns JM: Can sensory and motor collateral sprouting be induced from intact peripheral nerve by end-to-side anastomosis? J Hand Surg Br 19:2772821994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Mackinnon SE: Donor distal, recipient proximal and other personal perspectives on nerve transfers. Hand Clin 32:1411512016

  • 28

    Millesi HSchmidhammer R: End-to-side coaptation—controversial research issue or important tool in human patients. Acta Neurochir Suppl (Wien) 100:1031062007

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 29

    Numajiri TFujiwara TNishino KSowa YUenaka MMasuda S: Double vascular anastomosis for safer free jejunal transfer in unfavorable conditions. J Reconstr Microsurg 24:5315362008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Rafuse VFGordon TOrozco R: Proportional enlargement of motor units after partial denervation of cat triceps surae muscles. J Neurophysiol 68:126112761992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Schmalbruch H: Fiber composition of the rat sciatic nerve. Anat Rec 215:71811986

  • 32

    Sharma NMarzo SJJones KJFoecking EM: Electrical stimulation and testosterone differentially enhance expression of regeneration-associated genes. Exp Neurol 223:1831912010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Sharma NMoeller CWMarzo SJJones KJFoecking EM: Combinatorial treatments enhance recovery following facial nerve crush. Laryngoscope 120:152315302010

  • 34

    Tam SLArchibald VJassar BTyreman NGordon T: Increased neuromuscular activity reduces sprouting in partially denervated muscles. J Neurosci 21:6546672001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Tarasidis GWatanabe OMackinnon SEStrasberg SRHaughey BHHunter DA: End-to-side neurorraphy: a long-term study of neural regeneration in a rat model. Otolaryngol Head Neck Surg 119:3373411998

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 36

    Tarasidis GWatanabe OMackinnon SEStrasberg SRHaughey BHHunter DA: End-to-side neurorrhaphy resulting in limited sensory axonal regeneration in a rat model. Ann Otol Rhinol Laryngol 106:5065121997

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37

    Tos PColzani GCiclamini DTitolo PPugliese PArtiaco S: Clinical applications of end-to-side neurorrhaphy: an update. BioMed Res Int 2014:6461282014Pubmed

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 38

    Viterbo FAmr AHStipp EJReis FJ: End-to-side neurorrhaphy: past, present, and future. Plast Reconstr Surg 124 (6 Suppl):e351e3582009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 39

    Viterbo FRomão ABrock RSJoethy J: Facial reanimation utilizing combined orthodromic temporalis muscle flap and end-to-side cross-face nerve grafts. Aesthetic Plast Surg 38:7887952014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Viterbo FTeixeira EHoshino KPadovani CR: End-to-side neurorrhaphy with and without perineurium. Sao Paulo Med J 116:180818141998

  • 41

    Viterbo FTrindade JCHoshino KMazzoni A: Two end-to-side neurorrhaphies and nerve graft with removal of the epineural sheath: experimental study in rats. Br J Plast Surg 47:75801994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Viterbo FTrindade JCHoshino KMazzoni Neto A: End-to-side neurorrhaphy with removal of the epineurial sheath: an experimental study in rats. Plast Reconstr Surg 94:103810471994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Yan JGMatloub HSSanger JRZhang LLRiley DAJaradeh SS: A modified end-to-side method for peripheral nerve repair: large epineurial window helicoid technique versus small epineurial window standard end-to-side technique. J Hand Surg Am 27:4844922002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Yang WYang JYu CGu Y: End-to-side neurotization with different donor nerves for treating brachial plexus injury: an experimental study in a rat model. Muscle Nerve 50:67722014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45

    Zhang ZSoucacos PNBo JBeris AE: Evaluation of collateral sprouting after end-to-side nerve coaptation using a fluorescent double-labeling technique. Microsurgery 19:2812861999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 30 30 30
Full Text Views 8 8 8
PDF Downloads 18 18 18
EPUB Downloads 0 0 0

PubMed

Google Scholar