Histological findings
To evaluate the regeneration efficacy of myelinated and unmyelinated fibers, we examined semi-thin sections of the nerves. Light microscopic examination of toluidine blue-stained cross-sections of these nerves revealed a clear qualitative difference between the experimental and injury groups (Figure 8).
Statistical analysis showed a significant difference in myelin thickness of groups (P=0.022, Table 1). The only statistically significant pairwise comparison (Figure 9) was referred to the injury and sham groups (P=0.045).
The nerve fibers’ densities differed significantly between groups (P=0.027, Table 1). Pairwise comparisons (Figure 10) showed a significant difference between the injury group with others (both P=0.045).
4. Discussion
Injuries to peripheral nerves are among the most challenging microsurgical problems. These damages are associated with considerable disability due to loss of both motor and sensory functions. There is a need to replace autografts because this procedure entails multiple surgeries, loss of function, and sensation at the donor site (Belkas et al., 2004; Li et al., 2014; Fan et al., 2011).
The great hope in regenerative medicine for nerve repair is the exploitation of the regenerative potential of cell-based therapies. This procedure is of particular relevance, especially for long gaps, where the use of nerve guides alone has failed to provide successful regeneration (Faronia et al., 2015). Nerve regeneration by nerve guidance scaffolds is improved because of less myofibroblast infiltration, accumulation of neurotrophic factors in high concentrations, and reduction of scar formation (Evans, 2001).
Because stem cells are essential seeding cells for peripheral nerve regeneration, special attention has been paid to developing a rich and accessible cellular reservoir for this cell type (Amoh et al., 2005a). In this study, we evaluated the effect of transplantation of rHFSCs on the recovery of rat sciatic nerve injury. Several investigators have shown that HFSCs can repair the injury of mice sciatic nerve (Amoh et al., 2005a; Amoh et al., 2012; Amoh, Hamada, Aki, Kawahara Hoffman, & Katsuoka, 2010). However, their methods and results were different, and they have not evaluated the results under similar conditions on the rats. Since rats are the most common and accessible laboratory animals, our research is done on this animal. In addition, our team in previous studies succeeded in isolating, culturing, and differentiating these cells in the rat. Recently, other researchers have studied rHFSC characteristics (Quan et al., 2016). Their study has also taken into consideration HFSCs in rats.
Our study confirmed the presence of HFSCs using anti-nestin antibody and anti-CD34 in vitro. This finding is consistent with previous reports (Hejazian et al., 2012; Amoh et al., 2012).
We cultured and labeled the HFSCs with BrdU. The immunohistochemistry double-stain process showed that BrdU-positive HFSCs can survive in vivo and largely transdifferentiate into SCs (S100 positive cells) at the sciatic nerve injury after 8 weeks.
During peripheral nerve regeneration, trophic factors and supporting substances are essential molecules (Chen et al., 2000; Lee et al., 2003). Researchers have indicated several mechanisms that may promote functional improvement by HFSCs (Amoh et al., 2005a; Amoh et al., 2012, Amoh et al., 2010).
Hair follicle stem cells were implanted into the gap region of mice’s severed sciatic nerve, greatly enhancing the rate of nerve regeneration and the restoration of nerve function. HFSCs can promote axonal regeneration in PNS (Amoh et al., 2005a; Amoh et al., 2010). Neural stem cells are marked by the expression of an intermediated filament of nestin. The expression of the unique protein, nestin, in neural stem cells and hair follicle stem cells suggests their possible relation (Hejazian et al., 2012; Esmaeilzade et al., 2012; Amoh et al., 2005b). These cells mainly transdifferentiate into Schwann cells known to support neuron regrowth (Amoh et al., 2005a; Amoh et al., 2009a; Amoh et al., 2012; Amoh and Hoffman, 2010b). Schwann cells secrete many factors, such as neurotrophic factors that induce tissue plasticity and neuroprotective factors (Rodriguez et al., 2000). SCs can release neurotrophic factors such as NGF, BDNF, GDNF, CNTF, and VEGF, as well as produce extracellular matrix proteins such as collagen I, collagen IV, fibronectin, and laminin (Moradi et al., 2012; Feneley, Fawcett, & Keynes, 1991). Therefore, evidence primarily supports the hypothesis that SCs differentiated from transplant-dated HFSCs may repair peripheral nerve injuries.
In addition, SCs mediated by immunoglobulin superfamily molecules, like the nerve cell adhesion molecule, protein 0 (P0), cadherin, and protocadherins are essential for axonal elongation and organized sprouting. SCs also produce basal lamina components, like collagen IV and laminin, that play an essential role in nerve regeneration. Among the adhesion molecules, laminin is the most potent factor for promoting axonal outgrowth. It thus seems likely that transplantation of SCs may also repair peripheral nerve injuries (Chew, Mi, Hoke, & Leong, 2008; Ide, 1996; Walsh, Biernaskie, Kemp, & Midha, 2009).
Time is one of the several aspects that require specific attention in the clinical treatment of peripheral nerve injury. Delay in nerve injury treatment may cause neurobiological alterations in neurons and Schwann cells, impair functional nerve recovery, and affect neuron survival (Egle De Stefano, Toni, D’Orazi, Ortensi, & Tata, 2013). In this study, we transplanted nestin-expressing cells after two weeks. In another study, cells were cultured for 1–2 months before transplantation to the injured nerve, which would not be optimal for clinical application because the patient should be treated soon after injury.
The condition velocity is a quantitative and valid index for evaluating action potential conduction in peripheral nerves (Ao Q et al., 2011). After the growth of sufficiently regenerated fibers across the nerve bridge, the target muscle can construct muscle action potential, which might be measurable. Additionally, the condition velocity relies directly on factors such as the diameter of axons, the thickness of the myelin sheath, and the length of internodes (Matsumoto K et al., 2000).
The magnitude of EMG correlates directly to the number of nerve fibers that innervate the muscle; thus, the conduction velocity of the motor nerve could be calculated.
EMG examinations give a vital index for the function of conduction in the peripheral nerve (Wang, Hu, Cao, Yao, Wu, & Gu, 2005). In this paper, the recovery index of EMG magnitude and the medium percentage of conduction velocity illustrated that animals in the epineurium and epineurium with cell groups experience a considerable improvement in nerve regeneration.
The recovery index was related to several factors, including the diameter of the regenerating axons, thinner myelin sheaths with shorter internodes, and immaturity of myelinated nerve fibers as a whole (Matsumoto K et al., 2000; Wang X et al., 2005) that was consistent with morphometric findings.
In this study, we showed the benefit of repairing nerve defects using HFSCs, as evidenced by electromyography tests in the gastrocnemius muscle and histological examination measured by myelinated and unmyelinated axonal number analysis. The results of the histological examination showed statistically significant differences between the injury group and the experimental groups (epineurium and epineurium with cells). Our results showed fewer axons, fewer myelinated fibers, reduced nerve fiber density, increased axonal degeneration, some axonal atrophy, and a reduction of the mean thickness of the myelin sheath in the injury group compared with other groups. The epineurium and the epineurium with cell groups showed an increased number of distinct axons, increased nerve fiber density, increased number of regenerating axons, and reduced axonal degeneration. Some previously reported data support our findings (Amoh et al. 2005a). However, there is no significantly higher thickening of myelinated fibers in the experimental groups.
The number of nerve fibers density was higher in the experimental groups compared to the injury group (Figure 10). However, the axonal regeneration seen in the epineurium with cells group is much greater than in other groups.
The latency diagram shows the delay in the conduction of the electric wave, which indicates the velocity of the conduction of the electric wave in the neuromuscular synapse. So, whatever the level of latency is lower, the function of the synapse is better, and the nerve is repaired better. These findings confirm those documented previously (Fan et al., 2011; Ide, 1996).
5. Conclusion
The current work revealed that the injection of hair follicle cells recovers severely injured sciatic nerve, which could develop gastrocnemius muscle via electric stimulation. Eight weeks after transplantation of hair follicle stem cells, the histological evaluation revealed a higher concentration of myelinated and unmyelinated fibers within the nerve in the epineurium with cells group. The results propose that hair follicle stem cells improve axonal growth and functional recovery after peripheral nerve injury.
Ethical Considerations
Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.
Funding
This study was financially supported by grant No. 12311 from Minimally Invasive Surgery Research Center, Rassoul Akram Hospital, and Iran University of Medical Sciences.
Authors' contributions
Conceptualization, Methodology, Investigation, and Writing – original draft: Leila Beigom Hejazian; Banafshe Esmaeilzade; Data collection and Writing – review & editing: Zeinab Akbarnejad, Fatemeh Moghani Ghoroghi; Data analysis: Samira Chaibakhsh.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
We thank the Minimally Invasive Surgery Research Center, Rasoul Akram Hospital, and Iran University of Medical Sciences for their financial support. Also, we would like to acknowledge the Departments of Anatomy and Cellular and Molecular Research Center, School of Medicine, Iran University of Medical Science, Tehran, Iran.
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