Child's Nervous System

, Volume 35, Issue 2, pp 315–328 | Cite as

Expression profiles of pro-inflammatory and pro-apoptotic mediators in secondary tethered cord syndrome after myelomeningocele repair surgery

  • Gesa Cohrs
  • Bea Drucks
  • Jan-Philip Sürie
  • Christian Vokuhl
  • Michael Synowitz
  • Janka Held-Feindt
  • Friederike Knerlich-LukoschusEmail author
Original Article



The literature on histopathological and molecular changes that might underlie secondary tethered cord syndrome (TCS) after myelomeningocele (MMC) repair surgeries remains sparse. To address this problem, we analyzed specimens, which were obtained during untethering surgeries of patients who had a history of MMC repair surgery after birth.


Specimens of 12 patients were analyzed in this study. Clinical characteristics were obtained retrospectively including pre-operative neurological and bowel/bladder-function, contractures and spasticity of lower extremities, leg and back pain, syringomyelia, and conus position on spinal MRI. Cellular marker expression profiles were established. Further, immunoreactivities (IR) of IL-1ß/IL-1R1, TNF-α/TNF-R1, and HIF-1α/-2α were analyzed qualitatively and semi-quantitatively by densitometry. Co-labeling with cellular markers was determined by multi-fluorescence-labeling. Cytokines were further analyzed on mRNA level. Immunostaining for cleaved PARP and TUNEL was performed to detect apoptotic cells.


Astrocytosis, appearance of monocytes, activated microglia, and apoptotic cells in TCS specimens were one substantial finding of these studies. Besides neurons, these cells co-stained with IL-1ß and TNF-α and their receptors, which were found on significantly elevated IR-level and partially mRNA-level in TCS specimens. Staining for HIF-1α/-2α confirmed induction of hypoxia-related factors in TCS specimens that were co-labeled with IL-1ß. Further, hints for apoptotic cell death became evident by TUNEL and PARP-positive cells in TCS neuroepithelia.


Our studies identified pro-inflammatory and pro-apoptotic mediators that, besides mechanical damaging and along with hypoxia, might promote TCS development. Besides optimizing surgical techniques, these factors should also be taken into account when searching for further options to improve TCS treatment.


Dysraphism Cytokines Real-time RT-PCR Hypoxia 



Cluster of differentiation 3

CD11b/Integrin αM

Cluster of differentiation 11b


Cluster of differentiation 68


Cytokeratin Pan


2′,3′-Cyclic nucleotide 3′-phosphodiesterase


Cleaved poly-ADP-ribose polymerase


Cerebrospinal fluid


Cycle of threshold




Glyceraldehyde-3-phosphate dehydrogenase


Glial fibrillary acidic protein




Hypoxia-inducible factor




Interleukin-1 beta


Interleukin-1 beta receptor type 1






Neuronal nuclear protein


Neurofilament 200-kD fragment


Room temperature


Reverse transcription polymerase chain reaction


Standard deviation


Sodium dodecyl sulfate


Tethered cord syndrome


Tumor necrosis factor alpha


Tumor necrosis factor receptor type 1


Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling


About 10 to 30% of patients who underwent myelomeningocele (MMC) repair surgery after birth develop TCS-related symptoms in their further clinical course [1, 2, 3, 4]. Symptoms typically include development or worsening of lower-limb motor deficits, sensory deficits, bladder dysfunction, and musculoskeletal deformities [5, 6, 7].

The underlying mechanical causes are varied and, in regard to post MMC repair, include scar formation with consecutive adhesion and tension of neural structures at the site of surgical reconstruction [8, 9, 10]. Therefore, continuing efforts addressed in particular surgical aspects such as dura repair to prevent adhesion of neural structures to the surrounding arachnoid space [11, 12]. However, despite development of sophisticated surgical methods, there is no technique that can reliably prevent SC tethering after MMC repair [5]. Secondary TCS after MMC repair cannot be reduced to mechanical problems alone, as some patients do not benefit from an untethering surgery. Besides improving surgical techniques, it is therefore important to investigate further cellular and molecular mechanisms that potentially underlie clinical relevant TCS.

Hypoxia has been identified as one such factor for clinically relevant TCS. Thereby, distraction of the SC is thought to lead to vascular compromise with ischemic alterations occurring especially in the gray matter [8, 9, 13, 14, 15]. The degree of oxidative metabolism impairment has been shown to be predictive for neurological improvement after untethering surgeries [10, 16]. Yamada et al. demonstrated that TCS is associated with metabolic abnormalities at the level of cytochrome α,α3, which reflects impaired mitochondrial function in compromised neuronal cells [17]. Further hints for neural damage were provided recently by Maurya et al.’s clinical investigations in which biomarkers of neuronal damage (S100B) and glia activation (GFAP) were elevated in the CSF of patients operated for primary TCS [18].

Considering our recent studies on cellular and molecular alterations in MMC placodes [19], inflammation might be a further crucial factor in secondary TCS. Compared to normal SC, MMC placodes exhibited significantly elevated GFAP- and Vimentin-immunoreactivity. In addition, chemokines and cytokines, crucial mediators of secondary lesion cascades after SC injury, were found on elevated mRNA and immunoreactivity level. These processes might also be relevant for the development of TCS after MMC repair surgeries.

To check this hypothesis, we now analyzed histological material, which was obtained during secondary untethering surgeries of patients who initially underwent MMC repair in their first days of life. Specimens that were obtained during untethering of placodes from surrounded scar tissue were investigated for inflammatory cellular and molecular alterations along with expression of hypoxia-inducible factors (HIF) 1α and 2α. Because inflammation and hypoxia are involved in apoptotic mechanisms, expression of cPARP (cleaved poly-ADP-ribose polymerase) was investigated as apoptotic-related mediator [20], besides terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL).

Material and methods

Ethical review was obtained from the Clinical Research Ethics Board of the University of Schleswig-Holstein, Kiel, Germany (AZ.: AD 430/15).

Tissue specimens and clinical characteristics

The electronic neuropathological and clinical databank was queried for cases operated for TCS. From these cases, only patients who had a history of MMC repair after birth were considered.

Because tissue samples were obtained during untethering of placodes from the surrounded scarred tissue, hematoxylin- and eosin-stained (H&E) sections of identified cases were screened for probes that harbored neuroepithelial fragments. These cases were then processed further as described in the following sections.

The respective clinical charts were reviewed retrospectively. Control specimens for immunohistochemistry and real-time RT-PCR included lumbar SC tissue from adults for whom no spinal pathology was documented (n = 4).

Histology and immunohistochemistry

Details on the staining protocols were reported previously [19]. Antibody specification and dilutions are provided in Table 1. Sections were mounted with Rotimount® (Roth, Karlsruhe, Germany) and coverslipped for investigation under a Zeiss light microscope (Axiovert; Carl Zeiss AG, Jena, Germany). Sections of different patients were stained simultaneously, and DAB reactions were precisely timed to ensure comparability.
Table 1

Cellular marker and cytokine/cytokine receptor antibodies used for immunohistochemistry





Cytokines and cytokine-receptors


Cleaved poly-ADP-ribose polymerase

116 kDa Nuclear poly (ADP-ribose) polymerase, 1:200

Cell Signaling Technology, Danvers, MA, USA; Cat.#9541


Hypoxia-inducible factor 1-alpha

Fusion protein made to an internal sequence of human HIF1-alpha, 1:100

Novus Biologicals, Littleton, CO, USA; Cat.#NB100-134


Hypoxia-inducible factor 2-alpha

Peptide derived from the C-terminus of mouse/human HIF-2 α protein, 1:100

Novus Biologicals, Littleton, CO, USA; Cat.#NB100-122



Amino acids 117-269 of IL-1ß of human origin, 1:100

Santa Cruz Biotechnology, Santa Cruz, CA, USA; Cat.#sc-7884


Interleukin 1 receptor, type 1

Peptide mapping at the C-terminus of IL-1RI, 1:500

Santa Cruz Biotechnology, Santa Cruz, CA, USA; Cat.#sc-689

 TNF-alpha (L-19)

Tumor necrosis factor alpha

Peptide mapping at the N-terminus of TNF-alpha of mouse origin; polyclonal goat IgG, 1:100

Santa Cruz Biotechnology, Santa Cruz, CA, USA; Cat.#sc-1351


Tumor necrosis factor receptor

Epitope mapping between amino acids 427-454 at the C-terminus of TNF-R1 of mouse origin

Santa Cruz Biotechnology, Santa Cruz, CA, USA; Cat.#sc-374185

Phenotypic marker antibodies


T cells, inflammatory cells

13-mer Peptide corresponding to 156-168 of the epsilon chain of human CD3 protein, 1:100

Thermo Fisher Scientific, Fremont, CA, USA; Cat.#RM-9107

 CD11b (OX-42)

Microglia, macrophages

Rat peritoneal macrophages, mouse monoclonal IgG, 1:50

Morphosys AbD GmbH (Serotec), Düsseldorf, Germany; Cat.#MCA275G

 CD68 (ED1)

Macrophages, monocytes

Single chain glycoprotein of 90-100 kDa; mouse monoclonal IgG, 1:100

Morphosys AbD GmbH (Serotec), Düsseldorf, Germany; Cat.#MCA341R


2′,3′-Cyclic nucleotide 3′-phosphodiesterase; oligodendrocytes

Full length native protein, mouse monoclonal IgG, 1:1000

Biozol, Eching, Germany; Cat.#ab6319


Glial fibrillary acidic protein

Mouse GFAP, mouse monoclonal mouse IgG, 1:100-1:500

Millipore/Chemicon, Schwalbach, Germany, Cat.#3402


Neuron-specific nuclear protein (neuronal nuclei)

Cell nuclei from mouse brain, mouse monoclonal IgG, 1:1000

Millipore/Chemicon, Schwalbach, Germany, Cat.#377


Neurofilament (200 kDa); neuronal cells

Carboxy-terminal tail of porcine H-chain, mouse monoclonal IgG, 1:1000

Millipore/Chemicon, Schwalbach, Germany, Cat.#5266


Neuroendocrine marker synaptophysin

Synthetic peptide of synaptophysin, 1:50

Thermo Fisher Scientific, Fremont, CA, USA; Cat.#RM-9111


Intermediate filament Vimentin

Epitope localized on the coil-2 part of the Vimentin rod domain, 1:200

DAKO, Glostrup, Denmark; Cat.#M7020

Controls included 1) omission of the first antibody; 2) staining with mouse, rabbit, and goat isotype IgG (monoclonal mouse IgG; MAB002 [R&D Systems, Minneapolis, MN]; monoclonal rabbit IgG; ab37415 [Abcam, Cambridge, MA]; monoclonal goat IgG; AB-108-C [R&D Systems, Minneapolis, MN]); and 3) performing IL-1ß and IL-1RI IHC on anonymized encephalitis brain specimens.

TUNEL staining was applied to visualize DNA fragmentation in apoptotic cells (#11684817910, Roche Applied Science). Sections were deparaffinized, rehydrated, boiled in citrate buffer, and immersed in TritonX-100/hydrogen peroxidase. Non-specific staining was reduced by incubating sections with 3% bovine serum albumin/Tris buffered saline (1 h; room temperature) before applying TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling) reaction mixture (1 h, 37 °C in humid chambers). After washing, converter-peroxidase was incubated on the slides for 30 min at 37 °C. Labeling was visualized with DAB substrate (Sigma, Taufkirchen, Germany). Negative controls were performed by omitting the TUNEL reaction mixture. Apoptosis was assessed by light microscopy. Cell death rates were calculated by counting positive cells on fixed areas (5 × 5 mm).

Densitometry for semi-quantitative measurement of immunoreactivities

GFAP-, Vimentin-, IL-1ß-, IL-1RI-, TNF-α-, TNF-R-, and HIF-1α/2α-IR were analyzed semi-quantitatively as described previously [19].

Immunofluorescence-multi-labeling procedures

Cytokines and their receptors were stained in combination with anti-NeuN (1:500), anti-GFAP (1:500), and anti-CD68/ED1 (1:200). IL-1ß and HIF-1/2α were multi-labeled with NeuN. Details on the staining procedures were reported previously [21]. After incubation with the first primary antibodies against NeuN and IL-1ß, sections were stained with anti-rabbit Alexa Fluor 555 (donkey, polyclonal, 1:1000; Invitrogen) and anti-mouse Alexa Fluor 488 (donkey, polyclonal, 1:1000; Invitrogen) as second primary antibodies. After incubation with the second primary antibody (IL-1ß), the second secondary antibody was anti-rabbit Alexa Fluor 647 (donkey, polyclonal, 1:1000; Invitrogen). After embedding in Immu-Mount (Shandon, Pittsburgh, PA), fluorescence was observed under an Axiovert 200 Zeiss microscope and Axiovert Observer with Zeiss ApoTome.2 attachment (Carl Zeiss, Oberkochen, Germany). Pictures were taken both of fluorescence-imaged sections and overlaid using AxioVision software (Carl Zeiss GmbH, Jena, Germany).

mRNA preparation and real-time RT-PCR

IL-1ß-, IL-1R1-, TNF-α-, and TNF-R-mRNA amounts in TCS specimens (n = 6) and in control (n = 4) SC tissues were measured by real-time RT-PCR as described previously [22]. TaqMan primer probes (assays on demand; Applied Biosystems, Foster City, CA) were used. RNAs of individual samples were isolated with High Pure FFPET RNA Isolation Kit (Roche Diagnostics GmbH, Mannheim, Germany) from ten paraffin sections of 5 μm thickness per case. Areas of interest and lumbar SC of controls were scratched from the slides. Eight hundred microliters Xylene (RotiClear, Roth, Karlsruhe, Germany) and 400 μL ethanol were added to the dissected tissue.

Real-time PCR was performed on each sample using a Quantstudio® 5 Single Color Real-time PCR detection system (Applied Biosystems by ThermoFisher Scientific, USA) and TaqMan primer probes (assays on demand; GAPDH, Hs99999905_m1; IL-1ß, Hs01555410_m1; IL-1RI, Hs00991010_m1; TNF-α, Hs00174128_m1; TNF-R Hs01042313_m1; Applied Biosystems, Foster City, CA) using a total reactive volume of 20 μL, which contained 1 μL of 20×Target Assay Mix, 10 μL of 2×TaqMan Universal Master Mix, and 100 ng of cDNA template (diluted in RNase free water to 9 μL). After 10 min at 95 °C for polymerase activation, 50 cycles of 15 s at 95 °C (denaturation) and 1 min at 60 °C (annealing and extension) were run. Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was used as intrinsic positive control and normalizer. The cycle of threshold (CT) of each sample was averaged, and ΔCT values were calculated as CT [Gene of interest] − CT [GAPDH].

Statistical analyses

Results are expressed by means ± SD. Statistical test was performed at the α level of significance of 0.05 by two-tailed analysis using parametric tests. Test of factors including pair-wise comparisons was applied with the Student’s t test. Data management and statistical analysis were performed using SPSS (version 22.0; IBM, Inc., Somers, NY) and Microsoft® Excel 2007.


Clinical characteristics

By analyzing H&E-stained specimens, 12 cases were identified that harbored sufficient neuroepithelial tissue for further analysis. Clinical characteristics of these patients are summarized in Table 2. All patients underwent a second surgery for clinically relevant secondary TCS after being initially operated for open spinal dysraphism after birth. On presurgical MRI imaging, most cases presented with low-lying conus except case 4 (lumbar level L1) and cases 7 and 8 (lumbar level L2). Four patients exhibited progressive syrinx formation of varied extent.
Table 2

Clinical and imaging characteristics of TCS patients

Case #


Age at surgery


Motor function

Back pain

Leg pain

BB dysfunction


Max. diameter of syrinx, mm

Syrinx expansion (vertebral segments)

Conus position



19 mo


Progressive lower-limb deformity








5 mo


Progressive lower-limb deformtiy








46 y


Known pareses






7 y


Leg pain






8 y


Known pareses





3 y


pp (known), progressive spasticity





12 y


pp (known)





11 y


pp (known





3 y


progressive pp








2 y







16 mo


pp (known)








21 y


Sensory deficit lower limbs, known pareses




BB bowel/bladder, f female, m male, mo months, y years, pp paraplegic

Immunohistochemical marker expression profile of specimens under investigation

By analyzing H&E sections, tissue specimens, which contained neuroepithelial elements, were identified for further investigations. Only specimens that contained cells with neuronal morphology (Fig. 1a) exhibiting NeuN-staining (Fig. 1b) and neuronal NF-staining (Fig. 1c) were included in this study. CNPase as a marker for oligodendroglial cells was also confirmed in TCS specimens (Fig. 1d). Synaptophysin as an integral membrane glycoprotein present in presynaptic vesicles in neurons was traced in all cases (Fig. 1e). Round inflammatory cells, positive for CD3 and CD11b, were present in nine out of 12 cases (Fig. 1f, g). CD68 was detected in all 12 cases (Fig. 1h).
Fig. 1

Immunohistochemical expression patterns of phenotypic markers in TCS neuroepithelia. a H&E-stained TCS specimen depicting, among others, cells with neuronal morphology in neuroepithelial tissue element (arrow). Immunostaining confirmed neuronal cells by NeuN (b) and NF200kD (c) labeling. Cells positive for the oligodendroglial marker CNPase were found in neuroepithelial parts of TCS specimens (d). Synaptophysin showed a granular staining pattern around neuronal structures in the neuroepithelium (e). CD3 (f), CD11b (g), and CD68 (h) positive inflammatory cells (arrows in (f)) and microglial cells in neuroepithelial structures of TCS cases. Scale bars 100 μm in all images

Strong GFAP-immunoreactivity (IR) was found in all TC specimens compared to control sections (Fig. 2a, b). Densitometry confirmed a significant GFAP induction in TC specimens (Fig. 2c). This was paralleled by Vimentin IR, which was strongly expressed in TC specimens compared to control SC sections (Fig. 2d, e) with significant higher IR densities (p < 0.001) in all 12 cases (Fig. 2f). In regard to morphological features of GFAP- and VIM-positive astrocytes, cells in TC specimens appeared with thickened cellular processes and pronounced cell bodies, as a hint for an activated cell state.
Fig. 2

GFAP and Vimentin immunoreactivity in TCS neuroepithelia. GFAP-immunoreactivity in adult SC control sections (a) compared to neuroepithelial regions of TCS specimens (b). GFAP-IR density was significantly higher in TCS cases compared to adult SC controls (c): Integrated GFAP-IR densities were plotted for each case and pooled for adult SC control tissue. Vimentin IR was found in adult SC-specimens (d) and TCS-specimens (e). f Densitometric measurements verified elevated Vimentin IR in TCS cases compared to control specimens. Significant differences are indicated by * in comparison to control specimens (significance level **p < 0.01, ***p < 0.001). Scale bar 50 μm in all images

Expression of IL-1/IL-1R1b and TNF-α/TNF-R

IL-1ß-/IL-1RI-IR was detectable in all TCS cases with a highly significant induction when compared to SC control sections (p < 0.001) (Fig. 3A). On mRNA level, IL-1ß was also found on elevated level compared to control SC samples (Fig. 3B), IL-1RI showed no significant difference in mRNA expression (Fig. 3C). Morphological appearances of IL-1ß- and IL-1R1-IR in control and TC specimens are shown exemplarily in Fig. 3: There were no specific IL-1ß staining patterns in adult SC (Fig. 3D), but strong IL-1ß-IR in cells scattered throughout the neuroepithelia (Fig. 3E). These cells exhibited morphological neuronal and microglial characteristics. In adult, SC IL-1RI remained immuno-negative (Fig. 3F) compared to strong IL-1R1 IR in TC specimens (Fig. 3G). Double-immunofluorescence labeling confirmed co-staining of IL-1ß with NeuN (Fig. 3H), and co-staining in subsets of cells labeled with GFAP (Fig. 3I) and CD68 (Fig. 3J). Double-fluorescence labeling also confirmed co-staining of IL-1RI and NeuN (Fig. 3K), as well as IL-1RI and CD68 (Fig. 3L).
Fig. 3

Expression of IL-1ß and its receptor in TCS neuroepithelia. Immunoreactivity density levels for IL-1ß and its ligand are shown in (A) compared to adult controls. IL-1ß- and IL-1RI-IR densities were significantly higher compared to adult SC controls (significance level ***p < 0.001). On mRNA level, IL-1ß (B) and IL-1RI (C) exhibited a tendency towards higher mRNA-expression levels in TCS cases compared to adult SC controls. However, this did not reach statistical significant levels (delta CT values are demonstrated as boxplots for mRNA expression in adult SC- and TCS-tissues). Morphologically control sections exhibited faint IL-1ß-IR (D), whereas TCS sections revealed strong IR for IL-1ß-IR (E). There was no IL-1RI detectible on control sections (F). Neuroepithelia in TCS specimens showed immunoreactive cellular structures, which exhibited glial and neuronal morphology (G). Co-staining reconfirmed these findings, demonstrated in (H) with co-expression of IL-1ß (red) and NeuN (green) (upper panel merged image with IL-1ß (red)/NeuN (green)/nuclear staining (DAPI, blue), lower left panel green channel for NeuN (green) staining, lower right panel red channel for IL-1ß-IR). (I) Co-staining for IL-1ß (red) and GFAP (green) (merged upper panel, lower panels separated channels) confirmed astroglial expression pattern. Co-staining of IL-1ß (red) and CD68 (green) in clusters of inflammatory cells are shown in (J) (merged channels in the upper panel, lower panels separated channels). (K) Double-immunofluorescence staining confirmed co-staining of IL-1R1-IR and neuronal marker NeuN (merged channel in left image; single channel images depicting staining for NeuN as green signal (upper panel) and for IL-1R1 as red signal (lower panel)). Further IL-1R1-IR was co-stained with microglial/macrophage-marker CD68 in (L) (merged channel in left image; single channels for CD68 (green) in the upper panel and for IL-1R1 (red) in the lower panel). Scale bars in all images 50 μm

Staining of TNF-α in adult SC sections showed no specific staining (Fig. 4A); in TCS cases, neuronal staining patterns were detected (Fig. 4B). TNF-R-IR remained negative in staining of adult SC controls (Fig. 4C). TNF-R-IR was confined to cells resembling neurons (Fig. 4D). TNF-α and its receptor TNF-R were found on significantly higher immunoreactivity density level in TC specimens compared to adult SC controls (Fig. 4E). Corresponding to IHC results, the investigation on mRNA level showed a tendency towards higher mRNA expression of TNF-α in TCS cases compared to adult SC controls (Fig. 4F). TNF-R expression on mRNA level was significantly elevated in TCS specimens compared to controls (Fig. 4G). TNF-R and NeuN were co-stained in double-immunofluorescence labeling of TCS specimen (Fig. 4H).
Fig. 4

Expression of TNF-α and TNF-R in TCS neuroepithelia. Faint TNF-α staining in adult control specimens (A) compared to intense TNF-α-IR in TCS neuroepithelia (B) and expression patterns of the respective TNF-R in SC control (C) and TCS specimens (D). In (E) TNF-α-/R-IR, integrated mean densities are plotted for adult controls and TCS neuroepithelia (significance level ***p < 0.001). (F) On mRNA level, TNF-α was not significantly induced in TCS compared to adult SC specimens, which contrasted the significantly higher induction of TNF-R1 on mRNA level compared to adult SC specimens (G) (significance level *p < 0.05). Besides inflammatory cells, there was double labeling for TNF-R (red) and NeuN (green) (DAPI, blue) (H). Scale bars A–D 100 μm, H 50 μm

Expression patterns of hypoxia-inducible factors

A highly significant elevation of HIF-1α-/-2α-IR in TCS specimens compared to SC controls was detected in all TCS cases (Fig. 5A). Staining of HIF-1α/-2α was not specific in SC controls (Fig. 5B, C); in contrast, structures of neuronal resemblance were detected in TCS specimens by staining of HIF-1α (Fig. 5D) and HIF-2α (Fig. 5E). Double-immunofluorescence labeling proved co-staining of NeuN and HIF-1α (Fig. 5F) and CD68 and HIF-1α (Fig. 5G). NeuN co-stained with HIF-2α in TCS specimens (Fig. 5H). Multi-immunofluorescence labeling revealed co-staining of NeuN, HIF-2α, and pro-inflammatory cytokine IL-1ß (Fig. 5I).
Fig. 5

Expression of hypoxia-related molecules. (A) HIF-1α- and HIF-2-IR were detectable at significantly higher density levels in TCS specimens compared to adult control specimens (***p < 0.001 TCS compared to adult control sections). (B) HIF-1α-IR and (C) HIF-2α-IR in adult SC control specimens. (D) HIF-1α-IR and (E) HIF-2α-IR exhibited a morphologically neuronal staining pattern in TCS specimens. (F) Double-immunofluorescence labeling confirmed co-labeling of NeuN (green) and HIF-1α-IR (red) (merged image in the upper panel (plus DAPI, blue nuclear staining), lower left panel NeuN (green), lower right panel HIF-1α (red)). There was also co-staining of CD68 (green) and HIF-1α (red) (merged image in G in the upper panel (DAPI, blue nuclear staining), lower left panel CD68 (green), lower right panel HIF-1α (red)). HIF-2α exhibited similar co-staining with NeuN (H) (merged image in the upper panel (including DAPI, blue nuclear staining), lower left panel NeuN (green), lower right panel HIF-2α (red)). (I) Triple-immunolabeling confirmed co-staining for NeuN (green), IL-1ß (red), and HIF-2α (turquoise) (merged image on the left (DAPI = blue), followed by separated channels for NeuN (green), IL-1ß (red), and HIF-2α (turquoise). Scale bars in all images 50 μm

Apoptotic markers in tethered cord syndrome specimens

Staining with cPARP was not specific in SC control sections (Fig. 6a). Structures positive for cPARP showed morphologic features of apoptotic cell fragments scattered through the investigated sections that were positive for neuroepithelial markers (Fig. 6b). Whereas staining with TUNEL on control sections showed no specific staining (Fig. 6c), there were TUNEL-positive fragments in TCS specimens (Fig. 6d). However, the number of TUNEL-positive cells in fixed areas did not statistically differ between TCS and control cases (Fig. 6e).
Fig. 6

Expression of apoptosis-related molecules and TUNEL of TCS neuroepithelia. No specific immunoreactivity (IR) for cleaved PARP (cPARP) was detectable in control spinal cord sections (a). In TCS specimens, cPARP-IR was found in small cellular fragments dispersed throughout the neuroepithelia (b) (higher magnification demonstrates cells which condensed or fragmented nuclei). To estimate the death rate, TUNEL-positive cells were counted in fixed areas in sections of control SC (c) and TCS specimens (d). There were differences which did not meet statistical significance, as shown in plot in (e) (number of positive cells (on y-axis) are plotted for SC controls (n = 4) and TCS specimens (n = 12 (x-axis)). Error bars represent standard error of the mean. Asterisk indicates outlier. Scale bars ab 200 μm; inlay 20 μm, cd = 50 μm


By analyzing cellular marker expression profiles, it became evident that all TCS specimens exhibited significantly elevated GFAP- and Vimentin-immunoreactivities compared to control tissues with astrocytes exhibiting typical morphological features of activation. Similar findings have been observed in open spinal dysraphism [19, 23, 24, 25, 26, 27]. Besides activated astrocytes, the appearance of monocytes and activated microglia were one further finding of our studies. Compared to controls, most TCS specimens exhibited cellular staining for inflammatory markers like CD3, CD68, and CD11b. This might reflect an unspecific cellular response to stretch-induced injury by TCS or can be considered a component of secondary lesion cascades which typically occurs after SC injury [28, 29].

The detectable induction of IL-1ß and TNF-α plus their receptors in TCS specimens supports the hypothesis of secondary lesion cascades as these inflammatory cytokines typically orchestrate a complex array of responses after different SC lesions: These molecules are induced in response to varied insults to the central nervous system (for review [30]) and are involved among others in immune cell recruitment, promotion of astrogliosis and tissue scarring [28, 31], and induction of apoptotic processes [32, 33]. Consistent with our findings, similar injury-related processes may also contribute to delayed neurological deterioration in symptomatic TCS after MMC repair surgeries.

Another relevant finding of our studies was the co-expression of strongly elevated HIF-IR and pro-inflammatory and pro-apoptotic cytokines in TC specimens. It is assumed that neurological deterioration in TCS is in part caused by stretch-induced ischemia and deprivation of SC energy metabolism [8, 10, 14, 17, 33]. By using experimental in vivo distraction devices, Dolan et al. proved ischemia as an essential factor in the pathophysiology of TCS [14]. There was significantly reduced blood flow in the tethered SC segments and compromised spinal evoked potentials, which correlated with the applied forces on neural structures. By applying intraoperative blood-flow monitoring, Schneider et al. demonstrated reconstituted blood flow in the respective SC segments during untethering surgeries [16]. Specimens of our studies also exhibited strong immunoreactivity of HIF-1 and HIF-2α, which was co-stained with cytokines in subgroups of neuronal and glial cells. TNF-α and IL-1ß were shown to increase the accumulation and transcriptional activity of HIF-1α [34]. In their studies with transgenic mice that were lacking the IL-1R1, Basu et al. found reduced lesion extension after hypoxic insult in adult stroke models [35]. One regulatory site of the IL-1ß promoter includes, among others, HIF, that enables IL-1 mRNA to be transcribed very early in response to ischemic insults [36, 37]. IL-1ß is therefore classified as an early injury signal [30, 38], and hypoxia-inducible factors are considered sensible markers of clinical relevant hypoxic/ischemic episodes [39]. Thus, our findings with elevated HIF-1/-2α in TCS specimens are consistent with the findings of previous studies, which identified hypoxia as one relevant consequence of mechanical tension on the tethered SC [10, 16, 17].

Besides IL-1ß/IL-1R1, TNF-α and its receptor were found with high IR densities in TC specimens. TNF-α is a potent inflammatory mediator with pro-apoptotic characteristics [40, 41]. Like after SC injury, apoptotic processes might also play a role in lesions cascades, which are induced by traction or by the altered microenvironment of post-operative scar formation. In our study, TCS specimens exhibited clusters of TUNEL and PARP-positive cells.

With our approach, we cannot address the aspect of when these processes occur during the clinical course after MMC repair. Expression of cytokines and appearance of inflammatory cells might occur as acute alterations, which lead to neuronal cell loss with consecutive decline of neurological function. On the other hand—in regard to our previous work on MMC specimens obtained during the initial repair surgery—inflammation might also be considered a chronic aspect of (open) spinal dysraphism: Like after SC injury, induction of pro-inflammatory and pro-apoptotic mediators may influence the long-term outcome by promoting the development of varied complications of the affected individuals [42, 43]. This aspect underlines once more the importance of early mmc repair to prevent further molecular lesion cascades and thus chronic sequelae like secondary TCS. Thereby knowing the onset and time-courses of inflammatory or apoptotic lesion cascades is a prerequisite to define the optimal time-point of surgical interventions. Besides laboratory investigations in animal models [44], improving imaging techniques bear the potential to become an important tool to investigate the time-courses of cellular and molecular lesion cascades “in situ” in the spinal cord before and after mmc repair or TCS surgery in the respective patients [45, 46]. Knowing these probably time-dependent processes will facilitate the decision-making of when to operate in those conditions.

The notion that all these reactions are caused solely by surgical manipulation during untethering appears unlikely as induction of apoptotic cell death-related pathways is detectable earliest hours after tissue damage, and the preparation at the placodes during untethering does usually afford less time. There are no studies available on post-surgical induction of inflammatory mediators in neurosurgical procedures. However, there are hints from other disciplines that selected cytokines (IL-β, IL-6, not TNF-a) may be elevated after surgery [47, 48]. Thus, in respect to the surgical technique, our findings may underline once more that a diligent clean and straightforward surgical strategy is essential in the operative management of dysraphic lesions: Blood products may promote, and prolonged surgeries may foster inflammatory reactions. Addressing this open question requires further investigations like determining cytokine serum levels before and after TCS surgery. Another approach would have been to investigate SC tissue obtained from “non-symptomatic” patients with morphological signs for TCS on MRI. For we do not promote “prophylactic” untethering in asymptomatic patients, such controls were unavailable.

Summary and conclusion

Our studies identified specific pro-inflammatory and pro-apoptotic mediators as further elements that, along with mechanical damaging and hypoxia, might underlie secondary TCS after MMC repair. Prevention of these lesion cascades by application of anti-inflammatory and anti-apoptotic factors in addition to a meticulous clean and straightforward surgical technique may result in a better outcome of secondary TCS. Due to its well-known anti-apoptotic, anti-inflammatory abilities and proven clinical applicability of its non-hematopoietic recombinant form, erythropoietin might be such a candidate [49, 50, 51]. The potential effect of such factors as adjuvant therapeutic agent in secondary TCS has to be examined in further studies.



The authors thank Fereshteh Ebrahim, Brigitte Rehmke, and Silvia Iversen for their excellent technical assistance. At this point, we would also like to pay tribute to the memory of Professor Ivo Leuschner who, due to his expertise, cordiality and human warmth, had always been an esteemed discussion and cooperation partner, who passed away too soon in January 2017.

Funding information

This work was funded by Familie Mehdorn Stiftung 2015 (to G.C. and F.K.L.).

Compliance with ethical standards

Conflict of interest

No conflicts of interest concerning materials or methods used in this study or the findings specified in this paper exists.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurosurgeryUniversity Hospital of Schleswig-Holstein Campus KielKielGermany
  2. 2.Department of PathologyUniversity Hospital of Schleswig-Holstein Campus KielKielGermany
  3. 3.Deparment of Pediatric NeurosurgeryAsklepios klinik Sankt Augstin GmbHSankt AugustinGermany

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