PERIPHERAL NERVE REPAIR AND REGENERATION RESEARCH: A HISTORICAL NOTE
Bruno Battiston,* Igor Papalia,y Pierluigi Tos,* and Stefano Geunaz *Reconstructive Microsurgery Unit, Department of Orthopedics, C.T.O. Hospital, Turin 10126, Italy y Department of Surgical Disciplines, University of Messina, Messina, Italy z Department of Clinical and Biological Sciences, San Luigi Gonzaga School of Medicine, University of Turin, Turin 10043, Italy
I. II. III. IV.
Introduction The 19th Century The 20th Century Conclusions References
Although the most significant advances in nerve repair and regeneration have been acquired over the last few decades, the study of nerve repair and regeneration potential dates back to ancient times namely to Galen in the second century A.D. This brief historical note outlines the milestones which have guided us to our present knowledge. In particular, we focus on the nineteenth century and the first decades of the twentieth century, an age in which the fathers of neurosurgery and neurobiology established the basis for most of the nerve repair and regeneration concepts used today. Finally, we shine a light on the most current history to show how recent pressure to use modern interdisciplinary and translational approach represents a sort of rediscovery of the scientific habits of the fathers of modern biomedicine, who used to carry out research from an integrated and broad point of view rather than from a super-specialized and specific one as it is often used today.
I. Introduction
Although the study of peripheral nerve regeneration potential dates back to ancient times (NaV and Ecklund, 2001; Terzis et al., 1997), it is only since the second half of nineteenth century that a body of literature on nerve regeneration and nerve repair strategies began to accumulate, starting with the milestone observations of Augustus Waller (1850) (reprinted in Stoll et al., 2002). INTERNATIONAL REVIEW OF NEUROBIOLOGY, VOL. 87 DOI: 10.1016/S0074-7742(09)87001-3
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Copyright 2009, Elsevier Inc. All rights reserved. 0074-7742/09 $35.00
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The aim of this historical note is to quickly trace the long history from the ancient anecdotal evidence to last century’s scientific advancements which has led to the present state of the art knowledge in nerve regeneration research. Several historical articles have already reviewed various aspects of peripheral nerve regeneration and reconstruction and should be referred to further information (Ijpma et al., 2008; NaV and Ecklund, 2001; Papalia et al., 2007; Terzis et al., 1997). While the first written descriptions of peripheral nerves date back to the fourth century B.C. in Hippocrates’ writings (Adams, 1868), the first descriptions of nerve repair and regeneration potential can be found in Galen’s writings in the second century A.D. (Terzis et al., 1997). Further descriptions of nerve sutures were reported by Paul von Aegina in the seventh century (Streppel et al., 2000) and the Persian physicians Rahzes and Avicenna in the last years of the first millennium (Sunderland, 1981). During the first half of the second millennium, further reports on nerve regeneration potential can be found in the work of several distinguished surgeons such as Guglielmo di Saliceto, Guido Lanfranchi, Guy de Chauliac, and Leonardo di Bertapaglia (Ladenheim, 1989; Terzis et al., 1997). In spite of the above-mentioned references to nerve sutures, it has been proposed that the birth date of nerve reconstruction should be dated in the sixteenth century and attributed to Gabriele Ferrara who was the first to provide a detailed and clear description of a technique for suturing a severed nerve (Artico et al., 1996).
II. The 19th Century
Although the regenerative potential of peripheral nerves after surgical repair was supported by works published in the seventeenth and eighteenth centuries, including the notable work of Cruikshank (1795) on the physiological aspects of nerve regeneration, it was during the nineteenth century that the study of neural repair significantly increased. The nineteenth century was the beginning of the new age of Life Sciences due to the introduction of the new histological techniques which would shed light on the fine structure of tissues and cells. The study of the nervous system too saw an impressive surge during this century and interest in the potential of the peripheral nerve to regenerate and the possible strategies to repair it grew from the milestone observations of Augustus Waller (1850) (reprinted in Stoll et al., 2002). In his seminal paper entitled Experiments on the section of the glossopharyngeal and hypoglossal nerves of the frog, and observations of the alterations produced thereby in the structure of their primitive fibres (Waller, 1850), Waller described for the first time the progressive disorganization of the medulla of the nerve (i.e., the axons) which occurs downstream to nerve transection and which also involved the white substance of Schwann (i.e., the
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myelin sheaths). Since then, the study of the surgical repair of severed nerves has grown together with the study of the mechanisms of nerve regeneration, as carried out by neuroscientists, including some of the fathers of modern neurobiology such as Camillo Golgi, the discoverer of the black reaction, and Santiago Ramon y Cajal (Guillery, 2005). Noteworthy is the work of Paget who, in 1947, reported functional recovery after median nerve primary repair in a young patient (Koopmans et al., 2009, this issue) and of Le´tie´vant (1873) who published the Traite´ des Sections Nerveuses where he provided a comprehensive overview of the diVerent surgical approaches for repairing a complete nerve transection (‘‘synthe´se du nerf’’) (p. 427) also including the first description of end-to-side nerve repair (Papalia et al., 2007). The first description of an autograft nerve reconstruction was reported by Philipeaux and Vulpian (1870) followed by the work of Albert (1878, 1885) who also was the first to perform an allograft nerve repair. The first described attempt to bridge a nerve defect using a tube was made by Glu¨ck (1880), who employed a piece of bone to bridge a nerve gap based on the study carried out by Neuber one year before using reabsorbable decalcified bone tubes (Ijpma et al., 2008; Neuber, 1879). Though unsuccessful, this attempt was followed by experiments by Vanlair, who obtained successful nerve fiber regeneration across a 3-cm-long tube made of decalcified bone (Vanlair, 1882, 1885).
III. The 20th Century
Two very nice overviews of the works of peripheral nerve repair and regeneration carried out throughout the nineteenth century can be found in the comprehensive papers by Powers (1904) and Sherren (1906). In the first paper, Powers (1904) summarized the work carried out during the previous century on the bridging of nerve defects, including a paper written in Russian by Spijarny where nearly 200 cases of nerve suture were reported, and concluded that although it hardly seems possible to say definitively what is the best form for bridging nerve defects, nerve anastomosis ‘‘. . . for the present it would seem that they should be preferred.’’ In his work, Sherren (1906) tabled a number of previous studies including 8 experiments on human nerve grafts, 22 on animal nerve grafts, 73 on nerve anastomosis, and 8 on nerve crossing. For each work, the author noted the conditions of employment, the method and the results and concluded by emphasizing the importance of ‘‘operations upon peripheral nerves’’ thus trying to point out the limitation of the knowledge and to outline the direction in which he believed it must proceed in order to obtain still greater success.
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Another nice paper is that published by Sachs and Malone (1922), reporting on their experimental studies on nerve regeneration across nerve gaps. One of the strongest points of this paper is the use of histology to support the surgical finding as a demonstration of the growing synergies that used to take place between basic and clinical science in nerve regeneration research in the first half of the twentieth century. Noteworthy is also the paper by Ballance et al. (1926), where these authors reported on their experience on nerve anastomosis and nerve crossing in monkeys and cats. In particular, they reported various types of end-to-side and side-to-end including double lateral anastomosis and they documented their findings with nice histological drawings too. In the same years, some negative results were also reported including the papers by Stookey (1922) and Babcock (1927). While the former paper was specifically negative towards the possibility that nerve flaps can be successful in repairing nerve defects (‘‘On the futility of bridging nerve defects by means of nerve flaps’’), the second paper even raised doubts also about the usefulness of various nerve repair techniques including also some techniques that are currently used today, namely nerve grafting and tubulization (Fig. 1). During the first three decades of the twentieth century, the interest in peripheral nerve repair and regeneration was lively and saw a synergism between basic and clinical scientists; however, in the second half of the past century this trend had decreased probably because of the arising criticisms about the real usefulness of the nerve reconstruction techniques in promoting nerve regeneration. Although very important works were carried out by many surgeons worldwide (including very famous surgeons such as Herbert Seddon and Sydney Sunderland), research along most of the remaining years of the twentieth century was mainly dedicated to optimization of the surgical techniques for nerve reconstruction. The observation that peripheral nerve axons retain a capability for spontaneous regeneration after trauma led researchers to focus on how to repair the nerves and not on how to improve nerve regeneration. On the other hand, basic neurosciences saw a great expansion towards neurochemistry and molecular neurobiology and the interest towards the study of the regeneration of peripheral nerves decreased.
IV. Conclusions
It is just over the last years that research synergy between surgical science and the new tendencies of molecular neurobiology began to rise again. The increasing awareness that, although possible, peripheral regeneration is far from being optimal (Battiston et al., 2009, this issue; Lundborg, 2002) led to the awareness among surgeons that the next advancements in peripheral nerve reconstruction
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FIG. 1. Drawing from Babcock’s 1927 paper illustrating the faulty methods for nerve reconstruction which include some techniques that are currently used today, namely nerve grafting and tubulization.
would need a stronger biological basis and, on the other hand, and continuous increase in basic scientists’ commitment to peripheral nerve regeneration research occurred, as shown by the dedication of special issues of important international neuroscience journals over the last years. This new trend towards interdisciplinary and multitranslational research opens several new scientific fields and makes it possible to foresee that the next decades will see significant scientific advancements in nerve repair and regeneration. In addition, revisiting history of nerve regeneration can be important not only to understand how we arrived to the state of the art scientific knowledge but also to rediscover some old ideas that, although innovative, have not been expanded adequately because of the technical limitations but might become innovative
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when reappraised today. What happened with end-to-side nerve repair is paradigmatic of how an innovation can be reported and investigated for many years, then forgotten for a long lapse of time, and eventually rediscovered concurrently with the advances in the scientific technology and knowledge (Papalia et al., 2007). Perhaps, a careful revisiting of the long history of nerve repair and regeneration research may reveal other old discoveries that are worthy of being reappraised today. Acknowledgments
This work was supported by grants from the MUR (Italian Ministry of University and Research), the Compagnia di San Paolo (Bando Programma Neuroscienze), and the Regione Piemonte (Bando Ricerca Sanitaria Finalizzata).
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