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1
New Approaches toRepair of
Spinal Cord Injury
New Approaches toNew Approaches to
Repair ofRepair of
Spinal Cord InjurySpinal Cord Injury
2
WHY IS THE SPINAL CORD SO VULNERABLE?WHY IS THE SPINAL CORD SO VULNERABLE?
Peripheral Nerve Spinal Cord
DRG Neuron
Schwann Cell
Myelin
Collagen
Oligodendrocyte
Myelin
Axon
3
WHY IS THE SPINAL CORD SO VULNERABLE?WHY IS THE SPINAL CORD SO VULNERABLE?
4
WHAT HAPPENS IN A SPINAL CORD INJURY
Awareness
BrainHand
Sensation
Nerve cellAxon or
nerve fiber
Peripheral
Nervous
System
Central
Nervous
System
Disconnection
5
Hand
WHAT HAPPENS IN A SPINAL CORD INJURY
Brain
Nerve cellAxon or
nerve fiber Degeneration
Direct injury and
Secondary tissue damage
Awareness
6
Hand
WHAT ARE THE BARRIERS TO REGENERATION
Brain
Nerve cellAxon or
nerve fiber
RegrowRegrow
ReconnectReconnect
This willThis will
occur occur successfully successfully
in the PNSin the PNS
7
Hand
WHAT ARE THE BARRIERS TO REGENERATION
Brain
Nerve cellAxon or
nerve fiber
Lack ofLack of
GrowthGrowth
factorsfactors
InhibitorsInhibitors
Scar tissueScar tissue
Lack ofLack of
supportsupport
8
Strategies for treatmentStrategies for treatment
• Prevent spinal cord injuries
• Stabilize the spinal cord (surgery)
• Prevent further acute damage
• Promote healing and regeneration
• Clear cell debris
• Prevent inhibitors from working
• Promote growth (cells/pharmaceuticals)
• Pain management, physical therapy and rehabilitation
• Prevent spinal cord injuries
• Stabilize the spinal cord (surgery)
• Prevent further acute damage
• Promote healing and regeneration
• Clear cell debris
• Prevent inhibitors from working
• Promote growth (cells/pharmaceuticals)
• Pain management, physical therapy and rehabilitation
9
Strategies for treatmentStrategies for treatment
• Prevent spinal cord injuries
• Stabilize the spinal cord (surgery)
• Prevent further acute damage
• Promote healing and regeneration
• Clear cell debris
• Prevent inhibitors from working
• Promote growth (cells/pharmaceuticals)
• Pain management, physical therapy and rehabilitation
• Prevent spinal cord injuries
• Stabilize the spinal cord (surgery)
• Prevent further acute damage
• Promote healing and regeneration
• Clear cell debris
• Prevent inhibitors from working
• Promote growth (cells/pharmaceuticals)
• Pain management, physical therapy and rehabilitation
10
Information sourcesInformation sources
• http://www.mcpf.org/
• http://clinicaltrials.gov/
• clinical_trials_public_guide.pdf
• http://www.mcpf.org/
• http://clinicaltrials.gov/
• clinical_trials_public_guide.pdf
11
Cell strategiesCell strategies
• Immune cells (clear debris)
• Schwann cells
• Olfactory ensheathing glia
• Adult stem cells (mesenchymal stem cells)
• Embryonic stem cells
• Immune cells (clear debris)
• Schwann cells
• Olfactory ensheathing glia
• Adult stem cells (mesenchymal stem cells)
• Embryonic stem cells
12
Procord/Proneuron
• Patient-derived activated macrophages
• Initial studies in Israel
• Phase II trial in US 2005 - 2008
• 50 patients enrolled
• Suspended for “financial reasons”
Procord/Proneuron
• Patient-derived activated macrophages
• Initial studies in Israel
• Phase II trial in US 2005 - 2008
• 50 patients enrolled
• Suspended for “financial reasons”
Ongoing or recent trialsOngoing or recent trials
13
Miami Project to Cure Paralysis
• Schwann cells
• Myelin-forming cells from peripheral nerves
• Patient derived
• “pre-IND”
Miami Project to Cure Paralysis
• Schwann cells
• Myelin-forming cells from peripheral nerves
• Patient derived
• “pre-IND”
Planned trialsPlanned trials
14
Olfactory Ensheathing Glia
• Cells from patients olfactory (smell-detecting) system
• Support cell that may promote nerve growth
• Uncontrolled reports from Portugal, China, Australia
• Phase I safety trial proposed in England
Olfactory Ensheathing Glia
• Cells from patients olfactory (smell-detecting) system
• Support cell that may promote nerve growth
• Uncontrolled reports from Portugal, China, Australia
• Phase I safety trial proposed in England
Planned trialsPlanned trials
15
Ongoing or recent trialsOngoing or recent trials
Geron
• Oligodendrocyte progenitor cells (human embryonic)
• Safety study (phase I)
• Repair lost myelin
• Complete
• <14 days after injury
• Seven US centers
Geron
• Oligodendrocyte progenitor cells (human embryonic)
• Safety study (phase I)
• Repair lost myelin
• Complete
• <14 days after injury
• Seven US centers
16
Ongoing or recent trialsOngoing or recent trials
Mesnchymal (adult) Stem Cells (MSC’s
• Phase I safety studies (various levels of rigor)
• China, Korea, Czech Republic, Russia, Brazil
• Cells derived from bone marrow, adipose tissue, peripheral blood
• (Umbilical cord cells)
• Work at Mayo Clinic related to ALS (Lou Gehrig’s Disease)
Mesnchymal (adult) Stem Cells (MSC’s
• Phase I safety studies (various levels of rigor)
• China, Korea, Czech Republic, Russia, Brazil
• Cells derived from bone marrow, adipose tissue, peripheral blood
• (Umbilical cord cells)
• Work at Mayo Clinic related to ALS (Lou Gehrig’s Disease)
17
Ongoing or recent trialsOngoing or recent trials
Other Therapies
Systemic hypothermia
• Miami project single center trial (uncontrolled)
• Multicenter trial being planned
Rolipram (increases cAMP) in phase II trials
Rho inhibitors (Cethrin) planned phase II <72h after injury
Nogo antibody trials (ongoing) in Europe
Other Therapies
Systemic hypothermia
• Miami project single center trial (uncontrolled)
• Multicenter trial being planned
Rolipram (increases cAMP) in phase II trials
Rho inhibitors (Cethrin) planned phase II <72h after injury
Nogo antibody trials (ongoing) in Europe
18
1. What are the properties of the peripheral nervous system that permit regeneration?
2. Make the spinal cord more like the peripheral nerve using tissue engineering tools
1.1. What are the properties of the peripheral What are the properties of the peripheral nervous system that permit nervous system that permit regeneration?regeneration?
2.2. Make the spinal cord more like the Make the spinal cord more like the peripheral nerve using tissue peripheral nerve using tissue engineering toolsengineering tools
19
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are needed to see this picture.
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Future DirectionsFuture Directions
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222.0MOSP
12.6O4
2.3GFAP
0.2ββββIII-tubulin
83.4Nestin
% positiveI J
>90MOSP positive
>90O4 positive
70GFAP positive
% Nestin positive
BB CC DD
FF GG HHEE
AA
NestinNestin ββββββββIIIIII--tubulintubulin GFAPGFAP
O4O4 MOSPMOSP NestinNestin/GFAP/GFAP NestinNestin/MOSP/MOSP
23
PCLF IN SCIATIC NERVE
STUDYING DIFFERENT CELL TYPES STUDYING DIFFERENT CELL TYPES IN SPINAL CORD INJURYIN SPINAL CORD INJURY
PLACE CELLS
INTO SCAFFOLD
TRACER
INJECTION
Fast Blue
25
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are needed to see this picture.
QuickTime™ and aTIFF (LZW) decompressor
are needed to see this picture.
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D
*
*
A B C
F
E
26
HOW ARE WE DOING? HOW ARE WE DOING?
• Normal Rat Spinal Cord ~330,000 MF/cord(at the T/L level)
• Total nerve fibers ~3,000,000/cord
• 7 channels (800/channel) ~5,600/scaffold
• 50% traverse from end to end ~2,800
• 10% travel 0.5 mm distally ~560
• 2% travel 1.0 mm distally ~1-200
• Need about 10% of normal ~300,000 nerves
• Normal Rat Spinal Cord ~330,000 MF/cord(at the T/L level)
• Total nerve fibers ~3,000,000/cord
• 7 channels (800/channel) ~5,600/scaffold
• 50% traverse from end to end ~2,800
• 10% travel 0.5 mm distally ~560
• 2% travel 1.0 mm distally ~1-200
• Need about 10% of normal ~300,000 nerves
27
ConclusionsConclusions
STRATEGIES ARE MULTIPLESTRATEGIES ARE MULTIPLE
28
New approach New approach -- adult stem cells as adult stem cells as ““delivery vehiclesdelivery vehicles””
29
NT3
MSC
NT3MSC
NT3MSC
NT3
MSC
NT3
MSCNT3MSC
NT3-expressing
MSC’s for
ascending
proprioceptive
pathways
New approach New approach -- adult stem cells as adult stem cells as ““delivery vehiclesdelivery vehicles””
30
NT3
MSC
NT3MSC
NT3MSC
NT3
MSC
NT3
MSCNT3MSC
NGF-expressing
MSC’s for
ascending
nociceptive
pathways
NT3-expressing
MSC’s for
ascending
proprioceptive
pathways
New approach New approach -- adult stem cells as adult stem cells as ““delivery vehiclesdelivery vehicles””
NGF
MSC
NGF
MSC
NGF
MSC
NGFMSC
NGF
MSC
NGF
MSC
31
NT3
MSC
NT3MSC
NT3MSC
NT3
MSC
NT3
MSCNT3MSC
NGF-expressing
MSC’s for
ascending
nociceptive
pathways
NT3-expressing
MSC’s for
ascending
proprioceptive
pathways
BDNF
MSC
BDNF
MSC
BDNF
MSCBDNF
MSCBDNF
MSC
BDNF
MSC
BDNFMSC
BDNF-expressing
MSC’s for
descending
motors
pathways
New approach New approach -- adult stem cells as adult stem cells as ““delivery vehiclesdelivery vehicles””
NGF
MSC
NGF
MSC
NGF
MSC
NGFMSC
NGF
MSC
NGF
MSC
32
33
HYPE VS HOPE THE SHARKS AND SHYSTERSHYPE VS HOPE THE SHARKS AND SHYSTERS
How can you tell the differenceHow can you tell the difference
Some simple “rules of thumb”
• If it is offered in a reputable institution inNorth America or Europe as part of a clinical trial it is probably safe
• If you have to pay for the treatment it is probably unproven and unreliable
• If you have to go to a third country (e.g. Mexico) it is probably a fraud
Some simple “rules of thumb”
• If it is offered in a reputable institution inNorth America or Europe as part of a clinical trial it is probably safe
• If you have to pay for the treatment it is probably unproven and unreliable
• If you have to go to a third country (e.g. Mexico) it is probably a fraud
34
A Cell Center in EuropeA Cell Center in Europe
• ・・・・ALS・・・・Alzheimer
• ・・・・Cardiovascular diseases
• ・・・・Cerebral palsy
• ・・・・Diabetes
• ・・・・Erectile dysfunction
• ・・・・Failed Back Surgery Syndrome
• ・・・・ALS・・・・Alzheimer
• ・・・・Cardiovascular diseases
• ・・・・Cerebral palsy
• ・・・・Diabetes
• ・・・・Erectile dysfunction
• ・・・・Failed Back Surgery Syndrome
• ・・・・ Macular degeneration
• ・・・・Multiple sclerosis
• ・・・・Osteoarthritis
• ・・・・Parkinson
• ・・・・Spinal cord injuries
• ・・・・Stroke
• ・・・・ Macular degeneration
• ・・・・Multiple sclerosis
• ・・・・Osteoarthritis
• ・・・・Parkinson
• ・・・・Spinal cord injuries
• ・・・・Stroke
35
Funding
NIH
Wilson Foundation
Neilsen Foundation
MCPF
Mayo
Acknowledgements
36
And Questions??And Questions??
37
WHEN WILL THIS BE COMING TO PATIENTSWHEN WILL THIS BE COMING TO PATIENTS
Polymer scaffolds
• Simple single channel ‘sleeves’ already in clinical use for repair of peripheral nerves in U.S. and Europe(e.g. Neurolac PCL Polyganics, Groningen; NeuraGen Collagen Integra, New Jersey)
• Plans to initiate trials of complex, biodegradable, ‘smart’scaffolds in peripheral nerve in ~2 years (U.S.)
Adult Stem Cells
• Bone marrow stem cell transplants in cancer patients in routine clinical use now
• Adult MSC trial to repair damaged heart muscle planned to begin in ~ 2years (Ireland)
• OEG/brachial plexus trial to begin this year in U.K.
Polymer scaffolds
• Simple single channel ‘sleeves’ already in clinical use for repair of peripheral nerves in U.S. and Europe(e.g. Neurolac PCL Polyganics, Groningen; NeuraGen Collagen Integra, New Jersey)
• Plans to initiate trials of complex, biodegradable, ‘smart’scaffolds in peripheral nerve in ~2 years (U.S.)
Adult Stem Cells
• Bone marrow stem cell transplants in cancer patients in routine clinical use now
• Adult MSC trial to repair damaged heart muscle planned to begin in ~ 2years (Ireland)
• OEG/brachial plexus trial to begin this year in U.K.
38
Spinal Cord Injury (a best guess)
• Proof of concept and biocompatibility studies in peripheral nerve are ongoing
• Injections of stem cells (adult autologous) and matrix-bound, recombinant growth factors 2 - 4 years• proof of safety• acute “neuroprotective”
• Injections of genetically modified stem cells ~5 years• proof of safety• Neurotrophic effects
• Reconstructive approaches with embryonic or adult stem cells in organized matrices ~ 7-10 years
Spinal Cord Injury (a best guess)
• Proof of concept and biocompatibility studies in peripheral nerve are ongoing
• Injections of stem cells (adult autologous) and matrix-bound, recombinant growth factors 2 - 4 years• proof of safety• acute “neuroprotective”
• Injections of genetically modified stem cells ~5 years• proof of safety• Neurotrophic effects
• Reconstructive approaches with embryonic or adult stem cells in organized matrices ~ 7-10 years
WHEN WILL THIS BE COMING TO PATIENTSWHEN WILL THIS BE COMING TO PATIENTS
39
• Acknowledgements• Many Colleagues at NUIG and Mayo
• Funding from National Institutes of Health, the Wilson, Mayo, Neilsen and Morton Foundations
• Funding from Science Foundation Ireland for the ETS Walton Fellowship
• Acknowledgements• Many Colleagues at NUIG and Mayo
• Funding from National Institutes of Health, the Wilson, Mayo, Neilsen and Morton Foundations
• Funding from Science Foundation Ireland for the ETS Walton Fellowship
40
• Acknowledgements• Many Colleagues at NUIG and Mayo
• Funding from National Institutes of Health, the Wilson, Mayo, Neilsen and Morton Foundations
• Funding from Science Foundation Ireland for the ETS Walton Fellowship
Leave you with Dr. Peter Dockery who believes that no problems are insurmountable
• Acknowledgements• Many Colleagues at NUIG and Mayo
• Funding from National Institutes of Health, the Wilson, Mayo, Neilsen and Morton Foundations
• Funding from Science Foundation Ireland for the ETS Walton Fellowship
Leave you with Dr. Peter Dockery who believes that no problems are insurmountable
41
42
ThemesThemes• What are stem cells?
• Future success depends on multi-disciplinary collaboration.
• The central nervous system has the capacity to regenerate.
• Restoration of function depends on bridging or by-passing tissue damage
• What are stem cells?
• Future success depends on multi-disciplinary collaboration.
• The central nervous system has the capacity to regenerate.
• Restoration of function depends on bridging or by-passing tissue damage
43
Stem CellsStem Cells
• Embryonic Stem Cells
• Neural Stem Cells
• Neural Progenitor Cells
• Adult-derived Stem cells
• Tissue derived
• Mesenchymal
• Embryonic Stem Cells
• Neural Stem Cells
• Neural Progenitor Cells
• Adult-derived Stem cells
• Tissue derived
• Mesenchymal
44
THE END RESULT
WHAT HAPPENS IN A SPINAL CORD INJURY?
45
What happens in a spinal cord injury?
Four Major consequences
All are separate therapeutic Targets
WHAT HAPPENS IN A SPINAL CORD INJURY?
46
What happens in a spinal cord injury?
Four Major consequences
All are separate therapeutic Targets
1. Acute traumatic damage (immediate)
Prevention- seat belts- sports safety- ban guns (U.S.)
Rapid spine stabilisation- at the accident site
- surgical fixation
WHAT HAPPENS IN A SPINAL CORD INJURY?
47
What happens in a spinal cord injury?
Four Major consequences
All are separate therapeutic Targets
1. Acute traumatic damage (immediate)
2. Secondary haemorrhagic, inflammatory,oxidative stress (1 -96 hours)
Focus of ongoing trials- Steroids(??)- Anti-apoptotic agents (e.g. minocycline)
- Oxidative stress inhibitors
WHAT HAPPENS IN A SPINAL CORD INJURY?
48
What happens in a spinal cord injury?
Four Major consequences
All are separate therapeutic Targets
1. Acute traumatic damage (immediate)
2. Secondary haemorrhagic, inflammatory,oxidative stress (1 -96 hours)
3. Disruption of axonal connections (0-96 hours)4. Atrophy/dwindling of disconnected muscles,
neurons, supporting cells.
Major focus of our research
WHAT HAPPENS IN A SPINAL CORD INJURY?
49
Strategies to Restore FunctionStrategies to Restore Function
50
Strategies to Restore FunctionStrategies to Restore Function
Injury
51
Strategies to Restore FunctionStrategies to Restore Function
Injury
Injury
ByBy--passpass ElectronicElectronic--roboticrobotic
52
Strategies to Restore FunctionStrategies to Restore Function
Injury
ByBy--passpass ElectronicElectronic--roboticrobotic
BridgeBridge