The pathophysiological role of acute inflammation after spinal cord injury
© The Author(s) 2016
Received: 8 June 2016
Accepted: 10 August 2016
Published: 17 October 2016
Traumatic spinal cord injury (SCI) causes irreparable severe motor and sensory dysfunction. Mechanical trauma rapidly leads to blood-spinal cord barrier disruption, neural cell death, axonal damage, and demyelination, followed by a cascade of secondary injury that expands the additional inflammatory reaction at the lesion site. Although the role of inflammation in this phase is complex, a number of studies have suggested that inflammatory responses spread the damage to the surrounding tissue, induce apoptotic cell death, and impair spontaneous regeneration and functional recovery. However, recent advances in experimental technology, such as the depletion antibodies for a specific fraction of inflammatory cells and the genetically engineered mice deficient only in specific cells, suggest the beneficial aspects of inflammatory cells, such as a neuroprotective effect, the removal of cellular debris, and the attenuation of the inflammatory reaction in general. In this review, I summarize our recent findings about the biological role of inflammatory cells, especially infiltrating neutrophils and activated microglia after SCI. A better understanding of the pathophysiological role of inflammation in the acute phase of SCI will aid in the development of therapeutic strategy to enhance the functional recovery after SCI.
KeywordsSpinal cord injury Neutrophil Microglia
Traumatic spinal cord injury (SCI) is a major public health problem and a devastating event for individuals that causes permanent severe motor/sensory dysfunction and significantly degrades the quality of life. SCI is known to result in neurological deficits through both the primary and secondary damage. The “primary” injury encompasses the immediate mechanical damage to the spinal cord tissue that occurs at the moment of impact, which is irreversible and not preventable. The “secondary” injury, by contrast, is incurred as a result of the pathological processes initiated at the time of the primary injury and continues for several days or months after injury and is amenable to therapy.
Inflammatory reaction and the secondary injury
In the secondary injury process of SCI, the infiltration of leukocytes and activation of glial cells can aggravate tissue damage by releasing proteases, reactive oxygen intermediates, lysosomal enzymes, and proinflammatory cytokines/chemokines [1, 2]. Although the role of inflammation in this phase is complex, with certain beneficial aspects as well, such as the removal of cellular debris, a number of studies have suggested that inflammatory responses spread the damage to surrounding tissue, induce apoptotic cell death, and impair spontaneous regeneration and functional recovery . To protect the injured spinal cord from these secondary pathological processes, several approaches to manipulate the inflammatory responses have been assessed and found effective. These approaches include the blockage or neutralization of specific cytokine signaling using a monoclonal antibody, the delivery of anti-inflammatory drugs, and the use of genetically modified animals. Indeed, we previously examined whether or not the administration of IL-6 receptor antibody immediately after SCI attenuated the secondary injury and caused a therapeutic effect, since IL-6 is a principal proinflammatory cytokine in SCI .
IL-6 signaling plays roles in regulating various steps in inflammatory reactions, such as the activation and infiltration of neutrophils, monocytes, macrophages, and lymphocytes. Indeed, previous studies from other research groups have reported that the delivery of the IL-6/sIL-6R fusion protein to spinal cord injury sites induced a sixfold increase in neutrophils and a twofold increase in macrophages and microglial cells and expanded the damaged area . We therefore speculated that blockage of IL-6 signaling would suppress the inflammatory response and ameliorate the secondary injury after SCI. We found that the number of infiltrated macrophages as well as scar tissue formation was significantly reduced, resulting in improved functional recovery . The same strategy conducted later by other groups also demonstrated that the temporary inhibition of IL-6 signaling reduced the infiltration of hematogenous macrophages and the activation of the phagocytic activity of microglial cells [6, 7]. In addition to the anti-inflammatory effect, this approach also had a number of additional effects, including the attenuation of glial scar formation and preservation of neuroprotective phosphatidylcholine . Moreover, a clinical merit of this strategy is that humanized antibody to human IL-6R (ACTEMRA®, tocilizumab) has already been in widespread use for rheumatoid arthritis and its efficacy as well as safety profile was confirmed.
However, in contrast to these reports, IL-6 itself was reported to enhance spinal cord repair by modifying the migration of reactive astrocytes or enhancing axonal regrowth [9, 10]. Although these results seem inconsistent, this contributes to the consequence of the context-dependent pleiotropic actions of IL-6 in SCI. During the acute phase of SCI, IL-6 family cytokines act primarily as potent proinflammatory mediators and cause secondary injury but also enhance the repair process after the subacute phase of SCI. These findings for IL-6 signaling suggest that the inflammatory response in SCI is very complicated and has context-dependent pleiotropic actions.
Flow cytometric evaluation of infiltrating leukocytes in SCI
Modulation of infiltrating neutrophils after SCI
Among the infiltrating leukocytes in the acute phase of SCI, neutrophils are considered to be one of the most potent triggers of post-traumatic spinal cord damage, which occurs through the release of proteases, reactive oxygen intermediates, nitric oxide, and lysosomal enzymes. Despite the fact that neutrophils are essential for innate immunity and important as anti-infectious factors in host defense, several studies focusing on the suppression of neutrophil infiltration have reported reduced severity of secondary injury and better functional recovery after SCI [15, 16].
The process of neutrophil infiltration to the lesion site is enhanced and amplified by variety of factors, such as proinflammatory cytokines, eiconosides, and adhesion molecules. Of these factors, leukotriene B4 (LTB4) is a highly potent lipid chemoattractant for neutrophils. LTB4 is produced rapidly by arachidonic acid cascade from membrane phospholipids without any requirement of transcription or translation and is mediated by its high-affinity specific receptor LTB4 receptor 1 (BLT1) . In addition to this effect, LTB4 activates neutrophils that promote lysosomal enzyme release and superoxide production. This LTB4 biosynthesis system exerts its effect on the injured tissue faster than other inflammatory cytokines and chemokines, implying that LTB4 might have a superior influence on the inflammatory cascade .
Previous studies have demonstrated that LTB4 is not only an important mediator in the regulation of microbial infection but also deeply related to several inflammatory diseases, autoimmune diseases, and atherosclerosis [19–22]. However, as for traumatic injury, the physiological role of LTB4 is not yet well understood. In addition, few analyses have examined the relationship between LTB4 and pathophysiology after SCI, although LTB4 may be a major contributive factor for inflammatory cell infiltration.
We therefore analyzed the pathophysiological involvement of LTB4 in a mouse SCI model using BLT1-deficient mice. Our results showed that BLT1-knockout mice exhibited a 23 % decrease in neutrophils and 10 % decrease in macrophages after SCI compared to the wild-type mice . These reduced numbers of infiltrated leukocytes resulted in the suppression of neural apoptosis, less demyelination, and reduced proinflammatory cytokine expression as well as better functional recovery in BLT1-knockout mice than in wild-type mice . These results showed that the LTB4-BLT1 pathway was indeed involved in the pathogenesis of traumatic secondary damage through the amplification of neutrophils and macrophages infiltration, suggesting that neutralizing LTB4 has potential as a therapeutic strategy during the acute phase of SCI.
Pathophysiological role of microglia in SCI
Microglial cells constitute about 10 % of the adult central nervous system (CNS) cell population and represent the innate immune system of the spinal cord. Under pathological conditions such as neurodegenerative disease, stroke, tumor invasion, and traumatic injury, these cells become activated, surround damaged and dead cells, and clear cellular debris from the area, much like the phagocytic macrophages of the immune system . In healthy mammalian brain tissue, microglia display characteristically elongated cell bodies with spine-like processes that often branch perpendicularly. Although microglia were initially believed to be essentially quiescent cells, recent studies have revealed that they are continually surveying their microenvironment and represent the first line of defense against invading pathogens or other types of CNS tissue injury [24, 25]. Indeed, we found that the spinal microglial secretory activity was quickly stimulated at 3 h post SCI in response to pathological changes, while the infiltration of other leukocytes peaked at 12 h post SCI [11, 26]. In addition, we demonstrated that microglial activity was significantly attenuated in young mice compared to adult mice, with reduced leukocyte infiltration and neural damage as well as better functional recovery in the younger mice than in the older ones . The expressions of potent chemoattractant for neutrophil infiltration, IL-6, and CXCL1 were also significantly reduced in the microglia isolated from the young mice. Considering that these chemoattractants are dominantly secreted by activated microglia and that microglial activation occurred prior to the infiltration of leukocytes, microglial activity appears to be critical for the trigger of propagation and enhancement of the inflammatory response. Leukocytes that infiltrate the lesion site also produce cytokines/chemokines by interaction with the other immune cells or microglial cells, leading to the amplification of the chemotactic gradient and to further infiltration of leukocytes to the lesion site . We therefore believe that the reduced immediate activation of microglial cells in young mice results in the decreased infiltration of neutrophils, leading to reduced amplification/exaggeration of the inflammatory response in SCI.
Although the precise mechanisms of microglial activation remains unclear, several basic research studies have reported that hyperglycemia is involved in the activation of resident monocytic cells, including microglia. For example, the number of pancreatic resident monocytes is increased in hyperglycemic rodents, leading to the up-regulation of islet-derived inflammatory factors, such as IL-6 and IL-8 . In addition, peritoneal monocytes are activated under hyperglycemic conditions, subsequently inducing a greater production of TNFα than that associated with a normoglycemic state . Furthermore, hyperglycemia correlates with worsening of tactile allodynia accompanied by the hyperactivation of dorsal horn microglia .
With regard to the mechanisms involved in the hyperglycemia-related overactivation of NF-kB in microglia, NADPH oxidase is considered to possibly play a role. NADPH oxidase is present in several types of phagocytes, including microglia, causing inflammatory activation of these cells . In addition, several studies have reported that hyperglycemia enhances the NADPH oxidase activity in innate immune cells [33, 34]. Furthermore, NADPH oxidase is known to produce reactive oxygen species (ROS) , which may promote the translocation of NF-kB . Therefore, hyperglycemia may promote the translocation of NF-kB in microglial cells via the NADPH oxidase/ROS/NF-kB pathway. The fact that the increased expression of NADPH oxidase and ROS has been confirmed in spinal microglial cells after injury also supports the role of this pathway . These findings shed light on the importance of achieving tight glycemic control in acute human SCI to obtain better neurological outcomes, also providing a better understanding of the inflammatory machinery after SCI.
Resolution of acute inflammation after SCI
Although the acute inflammation after SCI spontaneously diminishes within a short period of time, the mechanism underlying this inflammatory resolution is largely unknown. Recently, we demonstrated that the infiltrating Ly6C+Ly6G− immature monocyte fraction exhibited the same characteristics as myeloid-derived suppressor cells (MDSCs) and played a critical role in the resolution of acute inflammation and in the subsequent tissue repair after SCI .
Among the anti-inflammatory factors from Ly6C+ MDSCs, IL-10 functions as a potent inducer of HO-1 in macrophages . HO-1 is a heme-degrading enzyme that protects tissues from free heme toxicity. In addition, it also has a direct effect of attenuating inflammation . We confirmed that transplantation of MDSCs significantly up-regulated HO-1 expression, suggesting that MDSCs created an environment favorable for tissue repair. In addition, the expression of both arginase 1 and iNOS was enhanced in the lesion areas after MDSC transplantation for 1 week after SCI . This up-regulation of both arginase 1 and iNOS was a determining factor for defining the characteristics of MDSCs. These findings clarified the role of MDSCs after traumatic SCI and suggested the potential utility of an MDSC-based therapeutic strategy for the acute phase of SCI.
Although inflammatory reactions lead to further damage and dysfunction after SCI, we confirmed that complete neutrophil depletion using the Gr-1 antibody severely impaired the functional recovery in a mouse SCI model. Thus, whether or not neuroinflammation after SCI has a neurotoxic or neuroprotective effect remains highly controversial. Although only minor attention has been paid to the role of inflammation in tissue protection after SCI thus far, it could be an essential factor for a well-balanced inflammatory reaction under pathological conditions. Nevertheless, more basic research should be conducted to clarify the detailed pathophysiological role of inflammation after SCI, which suggest a new approach for SCI treatment by modifying the inflammatory response in SCI.
Leukotriene B4 receptor 1
C-C chemokine receptor type 2
Central nervous system
Chemokine (C-X3-C motif) receptor 1
Chemokine (C-X-C motif) ligand 1
Fluorescence activated cell sorting
Heme oxygenase 1
Inducible nitric oxide synthase
Myeloid-derived suppressor cells
Nicotinamide adenine dinucleotide phosphate
Nuclear factor-kappa B
Reactive oxygen species
Spinal cord injury
Transforming growth factor β
Tumor necrosis factor α
Vascular endothelial growth factor
This work was supported by Grants-in-Aid for Scientific Research to SO (16H05450) from the Japan Society for the Promotion of Science (JSPS).
Availability of data and materials
Any materials in this manuscript are available by asking.
SO wrote the review and approved to submit the final manuscript.
The author declares that he has no competing interests.
Ethics approval and consent to participate
The studies in this review were approved by the ethics committee of our institute.
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