Ochsner Health System
Neurosciences Symposium
Biologic Therapies for
Peripheral Nerve Pathology
Nick Goyeneche, M.D.
1
Disclosure
I have nothing to disclose
2
Objectives
Biochemical basis for the use of biologic
therapies
Current research in platelet rich plasma
Current research in stem cell therapies
Future outlook
3
Biologic Invasion
PRP
Mesenchymal stem
cells
4
Nerve Regrowth
Axonal regeneration
Re-myelination
Restoration of synaptic connections
Recover physiologic
functions/skeletal muscle
5
Platelet-Rich Plasma (PRP)
PRP is an autologous
concentrate of platelets
made from whole blood.
Platelet concentration:
Not defined.
WBCs/RBCs
present/absent or
concentration: Not
defined.
6
Platelet-Rich Plasma (PRP)
Contents of platelets: Alpha granule: contains 30
bioactive proteins, including PDGF, TGF-beta, IGF, VEGF,
EGF, platelet factor 4, IL-1, platelet derived endothelial
growth factor, epithelial cell growth factor, osteocalcin,
osteonectin, fibrinogen, vitronectin, fibronectin,
thrombospondin.
Delta granule: ADP (pro-coagulant), ATP, ionized
calcium, histamine, serotonin, epinephrine.
Lambda granule: Lysosomal enzymes.
7
Platelet-Rich Plasma (PRP)
Platelets are vehicle for growth factor delivery
IGF-1 required for axon myelination
Trigger mitosis and induce angiogenesis
VEGF can stimulate axonal outgrowth and enhance Schwann cell
proliferation
Provides matrix for migration of tissue forming cells.
Chemotactic for fibroblasts, mesenchymal cells, monocytes, and
neutrophils.
Decreases infections
8
Zheng et al, 2013
Cultured rat Schwann cells with varying concentrations of
PRP (40%, 20%, 10%, 5% and 2.5%)
PRP significantly stimulated SC proliferation and migration
compared to untreated controls in a dose-dependent
manner
Suppression seen with high PRP concentrations (40%)
The expression and secretion of nerve growth factor and
glial cell line-derived neurotrophic factor were significantly
increased
9
Emel et al, 2011
Compared the effects of IGF-I and PRP on Sciatic
Function Index (SFI), sensory function (SF), axon count,
and myelin thickness/axon diameter ratio (G-ratio) in a rat
model of crush-injured sciatic nerves
10
Emel et al, 2011
11
Emel et al, 2011
12
Küçük et al, 2014
Effects of PRP on a sciatic nerve injury model in rats
(N=12/24 sciatic nerves)
Angle of climb was 63.6 degrees in the PRP group, 38.33
in the control group
In the PRP group, CMAP amplitudes of the gastrocnemius
and interdigital muscles were 14.01mV and 0.85mV,
respectively. In the control group, CMAP amplitudes were
5.78mV and 0.24mV, respectively
The average number of total axons in the control group
was 879.3 and 1,969.50 in the PRP group
All differences were statistically significant
13
Malahias et al, 2015, Pilot study
Effects of a single injection of PRP on the clinical
symptoms of carpal tunnel syndrome
N=14 (excluded pts with prior corticosteroid injections,
prior surgery, etc)
Injected 1-2cc of PRP under U/S guidance
No complications
Mean VAS reduced ~50% at 1 month post-injection
Q-DASH score ~70% reduced at 3 months
U/S cross sectional area of the median nerve was
normalized or reduced in 10/14
3 underwent open CTR
14
Kuffler et al 2014
Refreshed both the central and distal nerve stumps of
nerves causing neuropathic pain, inserting the nerve
stumps into a collagen tube, and filling the tube with
autologous PRP
Induced the resected axons to regenerate across long
gaps
Some injuries 3.5 years later
94% of the patients, including one with excruciating
neuropathic pain, had elimination of pain
15
Sánchez et al, 2015
Peripheral motor nerve injury treated with PRP
Group 1 (N=3): No intervention, spontaneous recovery
Group 2 (N=5): Saline injecitons
Group 3 (N=6): PRP with scaffold
Week 8, 70% of PRP group were CMAP-positive; no response in
the other groups
Histomorphometric analysis at 12 weeks: axonal density of groups
1 and 2 were significantly inferior to the control and the PRP group.
No significant differences between the control and PRP groups
Morphometry of the target muscles indicated that the PRP group
had the lowest percentage volume reduction at 12 weeks
16
Sánchez et al, 2014
Application of PRP for the treatment of peroneal nerve
palsy with drop foot secondary to multi-ligament knee
injury
28 y/o M with severe axonotmesis; 11 months post-injury
Serial ultrasound intraneural infiltraions of PRP
Complete but partial useful recovery obtained at 21
months post-injection EMG with complete reinnervation of
the peroneus longus and improved reinnervation of the
tibialis anterior
17
Mesenchymal Stem Cells
Easily expanded, multipotent stromal cells found in most
tissue that can differentiate into a variety of cell types
Can home in on injured tissue
Non-immunogenic, paracrine function (secretome)
Schwann cell collection causes new damage to nerve
segments and prolonged doubling time reduce the
practicality
MSCs are capable of cross oligolineage boundaries
between mesodermal to ectodermal lineages to form a
comparable Schwann cell
Wakao, 2014
18
Mesenchymal Stem Cells
Harvest sites: bone marrow, adipose, umbilical cord,
dental pulp
Source may differ in their differentiation propensity and
secretory profiles
Effects of MSCs on nerve injury models: Modulation of the
inflammatory environment on the site; Modulation of the
Wallerian degeneration stage; Increased thickness of the
myelin sheaths; Accelerated fiber regeneration and in
increased numbers; Improved fiber organization;
Enhanced vascularization of the regenerating site; and
Reduction of fibrotic scaring.
19
Mesenchymal Stem Cells
May use conduits: Polyglycolic Acid (PGA), Polycarprolactone (PCL), Collagen, Polyvinyl alcohol
20
Zarbakhsh et al, 2016
Effects of bone marrow and umbilical cord stromal cell
transplantation in regenerating rat peripheral nerves
10 mm segment of the left sciatic nerve in rats was
removed and replaced with a silicone tube
Bone marrow stromal cells (BMSCs) and human umbilical
cord stromal cells (HUCSCs) were respectively obtained
from rat and human
Cells cultured and placed into the silicone tube
21
Zarbakhsh et al, 2016
22
Zarbakhsh et al, 2016
23
Ke et al, 2015
Effect of transplanting BMSCs that produce netrin-1 in a
rat model of sciatic nerve crush injury
Netrins are a family of secreted proteins that direct the
migration of neuronal cells and axon growth cones during
neural development, are angiogenic, and induce
proliferation of Schwann cells
24
Unanswered Questions
Optimal PRP concentrations/preparations
Best source of harvesting stem cells
Use of differentiated vs undifferentiated cells
Optimal number of injections
Unknown side effects
Combination products
25
References
Caseiro AR, Pereira T, Ivanova G, Luís AL, Maurício AC. Neuromuscular Regeneration: Perspective on the
Application of Mesenchymal Stem Cells and Their Secretion Products. Stem Cells Int. 2016
Emel E, Ergün SS, Kotan D, Gürsoy EB, Parman Y, Zengin A, Nurten A. Effects of insulin-like growth factor-I
and platelet-rich plasma on sciatic nerve crush injury in a rat model. J Neurosurg. 2011 Feb;114(2)
Giannessi E, Coli A, Stornelli MR, Miragliotta V, Pirone A, Lenzi C, Burchielli S, Vozzi G, De Maria C, Giorgetti
M. An autologously generated platelet-rich plasma suturable membrane may enhance peripheral nerve
regeneration after neurorraphy in an acute injury model of sciatic nerve neurotmesis. J Reconstr Microsurg. 2014
Nov;30(9):617-26.
Ke X, Li Q, Xu L, Zhang Y, Li D, Ma J, Mao X. Netrin-1 overexpression in bone marrow mesenchymal stem cells
promotes functional recovery in a rat model of peripheral nerve injury. J Biomed Res. 2015 Sep;29(5):380-9.
Küçük L, Günay H, Erbaş O, Küçük Ü, Atamaz F, Coşkunol E. Effects of platelet-rich plasma on nerve
regeneration in a rat model. Acta Orthop Traumatol Turc. 2014;48(4):449-54.
Kuffler DP. Platelet-rich plasma and the elimination of neuropathic pain. Mol Neurobiol. 2013 Oct;48(2):315-32.
Lichtenfels M, Colomé L, Sebben AD, Braga-Silva J. Effect of Platelet Rich Plasma and Platelet Rich Fibrin on
sciatic nerve regeneration in a rat model. Microsurgery. 2013 Jul;33(5):383-90.
Malahias MA, Johnson EO, Babis GC, Nikolaou VS. Single injection of platelet-rich plasma as a novel treatment
of carpal tunnel syndrome. Neural Regen Res. 2015 Nov;10(11):1856-9.
Sánchez M, Anitua E, Delgado D, Prado R, Sánchez P, Fiz N, Guadilla J, Azofra J, Pompei O, Orive G, Ortega
M, Yoshioka T, Padilla S. Ultrasound-guided plasma rich in growth factors injections and scaffolds hasten motor
nerve functional recovery in an ovine model of nerve crush injury. J Tissue Eng Regen Med. 2015 Sep 7.
26
References
Sánchez M, Yoshioka T, Ortega M, Delgado D, Anitua E. Ultrasound-guided platelet-rich plasma injections for
the treatment of common peroneal nerve palsy associated with multiple ligament injuries of the knee. Knee Surg
Sports Traumatol Arthrosc. 2014 May;22(5):1084-9.
Wakao S, Matsuse D, Dezawa M. Mesenchymal stem cells as a source of Schwann cells: their anticipated use in
peripheral nerve regeneration. Cells Tissues Organs. 2014;200(1):31-41.
Yang CC, Wang J, Chen SC, Jan YM, Hsieh YL. Enhanced functional recovery from sciatic nerve crush injury
through a combined treatment of cold-water swimming and mesenchymal stem cell transplantation. Neurol Res.
2015 Sep;37(9):816-26.
Yu W, Wang J, Yin J. Platelet-rich plasma: a promising product for treatment of peripheral nerve regeneration
after nerve injury. Int J Neurosci. 2011 Apr;121(4):176-80.
Zack-Williams SD, Butler PE, Kalaskar DM. Current progress in use of adipose derived stem cells in peripheral
nerve regeneration. World J Stem Cells. 2015 Jan 26;7(1):51-64.
Zarbakhsh S, Goudarzi N, Shirmohammadi M, Safari M. Histological Study of Bone Marrow and Umbilical Cord
Stromal Cell Transplantation in Regenerating Rat Peripheral Nerve. Cell J. 2016 Winter;17(4):668-77.
Zheng C, Zhu Q, Liu X, Huang X, He C, Jiang L, Quan D. Improved peripheral nerve regeneration using acellular
nerve allografts loaded with platelet-rich plasma. Tissue Eng Part A. 2014 Dec;20(23-24):3228-40.
Zheng C, Zhu Q, Liu X, Huang X, He C, Jiang L, Quan D, Zhou X, Zhu Z. Effect of platelet-rich plasma (PRP)
concentration on proliferation, neurotrophic function and migration of Schwann cells in vitro. J Tissue Eng Regen
Med. 2013 May 31.
27
THANK YOU
28