Betulinic Acid Inhibits ROS-Mediated Pyroptosis in Spinal Cord Injury by Augmenting Autophagy via the AMPK-mTOR-TFEB Signaling Pathway

Background (cid:0) Spinal cord injury (SCI) results in a wide range of disabilities. Its complex pathophysiological process limits the effectiveness of many clinical treatments. Betulinic acid (BA) has been shown to be an effective treatment for some neurological diseases, but it has not been studied in SCI. In this study, we assessed the role of BA in SCI and investigated its underlying mechanism. Methods (cid:0) Using a mouse model of SCI, survival and functional outcomes following injury were assessed. Western blotting, ELISA, and immunouorescence techniques were employed to analyze levels of autophagy, mitophagy, and pyroptosis; ROS- and AMPK-related signaling pathways were also examined. Results (cid:0) Our results showed that BA signicantly improves functional recovery following SCI. Furthermore, autophagy, mitophagy, ROS-activity and pyroptosis were implicated in the mechanism of BA in the treatment of SCI. Specically, our results suggest that BA restored autophagy ux following injury, which induces mitophagy to eliminate the accumulation of ROS and subsequently inhibits pyroptosis. Further mechanistic studies revealed that BA likely regulates autophagy and mitophagy via the AMPK-mTOR-TFEB signaling pathway. Conclusion: the known phenomenon that following SCI, autophagy substrates accumulate despite an upregulation autophagosome- and autolysosome-related markers. These results also demonstrate that BA is not only able to increase autophagosome- and autolysosome-related markers, it also alleviates autophagy substrate burden, likely due to an inducing an overall increase in autophagic activity following SCI. the expression of TFEB. our results revealed that leads to increased phosphorylation of AMPK and inhibited the phosphorylation of mTOR. using compound C (CC), an AMPK blocker, we showed that inhibition of AMPK-mTOR-TFEB signaling pathway led to diminished effects of BA on autophagy, and mitophagy, and pyroptosis.


Introduction
Spinal cord injury (SCI) is a disabling disease that often results in signi cant motor and sensory dysfunctions [1], and it affects over 500,000 patients in the United States alone [2]. Currently, there are only a few therapeutic interventions for SCI, with high-dose methylprednisolone [3], ganglioside [4], immunoglobulin G [5], and exogenous basic broblast growth factor [6] showing some clinical bene t in select patients; however, these agents have largely been unable to improve recovery following SCI. The dearth of therapeutic options for SCI is likely due to its complex pathophysiology. In brief, SCI is thought to involve two distinct injury mechanisms: primary and secondary. Primary injury occurs as a direct consequence of mechanical damage of the spinal cord, whereas secondary injury is triggered by a

Animal Model of SCI and Survival Rate Analysis
Prior to procedure, anesthesia was administered to all animals with intraperitoneal injections of one percent (w/v) pentobarbital sodium (50 mg/kg). Then, standard laminectomy was performed at the T9-T10 vertebra to expose a circle of the dura. Then, a weight-drop injury model was employed to cause a spinal contusion injury as previously described [34]. In brief, a bar with a diameter of 3.0mm and a weight of 15g was dropped onto the exposed spinal cord from a 15 mm height. After injury, muscle, fascia, and skin was closed in layers using 4-0 nonabsorbable silk sutures. Mice in the sham group (n = 20) received the same operation as above without weight-drop injury. Following the procedure, all mice had their bladders arti cially emptied three times a day. Survival of mice was recorded on days 1, 7, 14, 21 and 28 after the procedure.

Drug Administration
All drugs were dissolved in 2% DMSO in normal saline and administered intraperitoneally. Daily injections of 20 mg/kg BA was administered to the SCI+BA group. 3-MA (15 mg/kg) and Dorsomorphin (Compound C, 1.5 mg/kg) were injected 30 min before BA administration (20 mg/kg) for BA + 3MA and BA+ CC groups. For the BA + 3MA+MnTBAP group, mice received daily regimen of MnTBAP (3mg/kg), followed by BA in 30 minutes (20 mg/kg), and 3MA 1 hour afterwards (15 mg/kg). All drugs were injected for 3 days after SCI. All animals were sacri ced by overdose of pentobarbital sodium and histological samples were harvested on day 3, with the exception of 40 rats designated for Hematoxylin and Eosin (H&E) and Masson staining and to assess locomotion recovery.

Functional behavior assessment
The Basso mouse scale (BMS) locomotion scale and the footprint test were administered at 0, 1, 7, 14, 21, and 28 days after SCI to evaluate functional recovery [35]. The BMS score ranges from 0 to 9 points, with 0 indicating complete paralysis and indicating normal motor functions. Footprint analysis was performed by rst immersing the hind paws in black dye, and then allowing the animals to walk for 5 min as described previously [36]. Outcome measures were measured by two independent examiners blinded to experimental conditions.

Tissue slides preparation for HE and Masson staining
On postoperative day 28, mice (n = 10 per group) in the Sham, SCI, BA, and BA +3MA groups were reanesthetized with 2% (w/v) pentobarbital sodium and perfused with normal saline, followed by addition of 4% (w/v) paraformaldehyde in phosphate-buffered saline. Then, we separated the rostral spinal cord segments (1mm in length, 4mm far from epicenter) and the whole segments (10mm in length, epicenter in middle), then post-xed them for 24h in 4% (w/v) paraformaldehyde. Subsequently, the each specimen was prepared for longitudinal para n sections after being embedded in para n. Using a microtome, 4μm sections were cut and mounted on poly-L-lysine-coated slides for histopathological examination by HE staining as previously described [1,37]. For Masson staining, we used 10% potassium dichromate and 10% trichloroacetic acid to mordant longitudinal sections and we used hematoxylin to stain nuclei. Then, using hydrochloric acid and ethanol, slides were differentiated, returned to blue with weak ammonia, and stained with the Masson solution; this staining protocol was previously described [38]. Finally, a light microscope (Olympus, Tokyo, Japan) was used to photograph images.

Western blot analysis.
After mice had been euthanized on day 3 following SCI, the spinal cord segments in mice (1.5cm; containing the injury epicentre) (n = 5 per group) were dissected and stored for Western blot analyses at −80°C. We used protein extraction reagents to purify total proteins from spinal cord specimens and used the BCA assay to measure the proteins. 12% (w/v) gel electrophoresis was used to separate an equal amount of 60 μg protein, which were then transferred to polyvinylidene uoride (PVDF) membranes (Roche Applied Science, Indianapolis, IN, USA). After blocking for 2h at room temperature with 5% (w/v) non-fat milk, the membranes were then incubated overnight at 4°C with the subsequent (1:1,000), Vps34 (1:1,000), and GAPDH (1:1,000). Finally, membranes were incubated for 2h at room temperature with HRP-conjugated IgG secondary antibody (1:5,000). ECL Plus Reagent Kit was used to visualize band signals, and Image Lab 3.0 software (Bio-Rad, Hercules, CA, USA) was used to quantify band intensities.

Enzyme-linked immunosorbent assay (ELISA)
We homogenized, frozen and thawed spinal cord specimens repeatedly in liquid nitrogen. Then, we centrifuged (at 10,000g) the homogenate at 4°C for 10 minutes, and collected the supernatant for ELISA. ELISA kits were used to evaluate the levels of AOPP, 8-OHdG, and MDA in spinal cord specimens according to manufacturer's protocols (Boyun Biotech, Shanghai, China). Finally, the quanti cations of AOPP, 8-OHdG, and MDA were performed using a microplate reader at 550 nm with a correction wavelength of 450 nm.

Immuno uorescence Staining
Immuno uorescence staining for tissue sections were performed as previously described [32]. We depara nized, rehydrated, washed, and then treated sections at 95 °C for 20 min with 10.2mM sodium citrate buffer. Then, 0.1% (v/v) PBS-Triton X-100 was used to permeabilize the sections (10 minutes), and used 10% (v/v) bovine serum albumin in PBS was used for blocking (1 hour). After that, slides were incubated overnight at 4°C with antibodies against p62 ( . Then, we washed the sections for 10 minutes at room temperature three times and incubated the sections at room temperature for 1 hour with FITC-conjugated secondary antibody. Finally, we captured and assessed images taken by a uorescence microscope (Olympus, Tokyo, Japan) in 6 randomly selected elds from 3 random sections of each sample.

Statistical Analyses
All statistical analyses were performed on SPSS 19.0 (SPSS, Chicago, IL). All data are presented as mean ± Standard Error of Mean (SEM). Independent-sample t-test and one-way ANOVA with LSD (equal variances assumed) were used as appropriate. P < 0.05 was considered statistically signi cant.

BA promotes functional recovery.
Compared to sham control, the SCI group showed an expanded area of glial scar (p<0.001), downregulated MAP2 (p<0.001), and less SYN-positive synapses onto ventral motor neurons (p<0.001). With BA treatment, animals had less glial scar, higher neuronal MAP2 expression, and more SYN-positive synapses onto ventral motor neurons compared with the untreated SCI group (p < 0.001, p < 0.001, p = 0.006, respectively; Fig. 1A-F). Moreover, footprint analysis showed that the BA group fared better than SCI group for functional recovery at 28 days after injury (Fig. 1G). For the Sham group, the BMS scores were notably higher compared to the SCI group at days 1, 7, 14, 21 and 28 post-procedure (p<0.001 for all). Similarly, the BA group also had higher BMS scores at days 1, 7, 14, 21 and 28 post-procedure compared with the SCI group (P = 0.018, P = 0.021, P = 0.022, P = 0.021, P = 0.005, respectively; Fig. 1H). Finally, analysis of survival rate revealed that the BA group fared better than the SCI group (P = 0.027; Fig.  1I). Together, these results demonstrate that BA promotes functional recovery and survival following SCI.
ASC, GSDMD, Caspase-1, NLRP3, IL-1β, and IL-18 were assessed in the spinal cord after SCI to assess pyroptotic activity in Sham, SCI and BA groups. As shown in Fig. 2A-D, immuno uorescence staining showed that Caspase-1 and GSDMD density in neurons were signi cantly increased in the spinal cord lesions in the SCI group relative to the Sham group (P < 0.001 for both), while BA decreased the densities of Caspase-1 and GSDMD compared with the SCI group (p = 0.016, p = 0.013, respectively). Western blots for ASC, GSDMD, Caspase-1, NLRP3, IL-1β, and IL-18 expressions levels were also assessed (Fig. 2E). Results demonstrated that the OD values for ASC, Caspase-1, GSDMD, IL-1β, IL-18 and NLRP3 were higher in the SCI group compared with the Sham group (P < 0.001 for all), and that BA decreases in the OD values for these markers relative to the SCI group (P < 0.001, P = 0.009, P = 0.003, P = 0.004, P = 0.004, P = 0.013, respectively; Fig. 2F). These results suggest that BA reduces pyroptosis-related markers, suggestive of an inhibitory effect on pyroptosis following SCI.

BA enhances autophagy after SCI.
To assess autophagic activity in the spinal cord lesion after SCI, we measured protein levels of autophagosomal markers (LC3II, Beclin1 and Vps34), an autolysosome-related marker (CTSD), and an autophagic substrate protein (p62). As shown in Fig. 3A, immuno uorescence staining revealed p62 levels in the neurons at the lesion; a green label was used to mark p62 was labeled green, a red label for neurons, and a blue label for nuclei. Quantitative analyses showed that after SCI, the percentage of p62positive neurons signi cantly increased (P < 0.001); however, the BA group had a lower percentage of p62-positive neurons compared with the SCI group (P < 0.001; Fig. 3B). To assess LC3II levels, a green label was applied for LC3II, a red label for neurons (NeuN), and blue label for nuclei (DAPI). As shown in Fig. 3C, the spinal cord exhibited higher LC3 signals in the SCI group than in the Sham group (P < 0.001); BA treatment further increased LC3 signals compared with the SCI group (P < 0.001; Fig. 3D). The amount of p62, LC3II, Beclin1, Vps34, and CTSD proteins were measured by Western blot (Fig. 3E). Results showed that the OD of p62, LC3II, Beclin1, Vps34, were higher in the SCI group than in the Sham group (P < 0.001, P = 0.001, P = 0.001, P < 0.001, respectively), with lower OD values for CTSD in the SCI group (P < 0.001). BA enhanced the level of LC3II, Beclin1, Vps34, and CTSD as well as decreased level of p62 in the BA group compared with the SCI group (p<0.001 for all; Fig. 3F). These results recapitulate the known phenomenon that following SCI, autophagy substrates accumulate despite an upregulation autophagosome-and autolysosome-related markers. These results also demonstrate that BA is not only able to increase autophagosome-and autolysosome-related markers, it also alleviates autophagy substrate burden, likely due to an inducing an overall increase in autophagic activity following SCI.
1.4 Inhibition of autophagy reverses the effects of BA on pyroptosis after SCI.
3MA, an autophagy inhibitor, was co-administered with BA to assess whether BA's bene cial effects on outcomes following SCI is due to autophagy activation. Immuno uorescence and neuron co-localization analyses revealed increased p62 density and decreased LC3 signals BA+3MA group compared with the BA group (P < 0.001, P < 0.001, respectively; Fig. 4A-D). The expression levels of p62, LC3II, Beclin1, Vps34, and CTSD were detected by Western blot (Fig. 4E). Results showed that the OD values for LC3II, Beclin1, Vps34, and CTSD were lower in the BA+3MA group than in the BA group (P = 0.004, P = 0.001, P = 0.017, P < 0.001, respectively), with a higher OD value for p62 in the BA+3MA group (P = 0.001; Fig. 4F). These results demonstrate that 3MA was effective in inhibiting autophagy when co-administered with BA. Next, pyroptotic activity was assessed in BA-treated animals via immuno uorescence staining and Western blotting after co-administration of 3-MA. Immuno uorescence showed that Caspase-1 and GSDMD densities in neurons were higher in the BA+3MA group than in the BA group (P < 0.001 for both; Fig. 4G-J). The expression levels of ASC, GSDMD, Caspase-1, NLRP3, IL-1β, and IL-18 were also measured by Western blot (Fig. 4K). Results revealed that the OD values for ASC, Caspase-1, GSDMD, IL-1β, IL-18 and NLRP3 were higher in the BA+3MA group than in the BA group (P < 0.001, P < 0.001, P = 0.001, P =0.002, P =0.002, P < 0.001 respectively; Fig. 4L). These results show that co-administration of 3MA with BA leads to a reduction in BA's effect on reducing pyroptosis, suggesting that the autophagy-enhancing effects of BA may underly the mechanism by which it inhibits pyroptosis.

Autophagy inhibition reverts the effects of BA on functional recovery after SCI.
Compared to the BA group, the BA+3MA group showed an increased area of glial scar (P = 0.005, Fig. 5A-B), decreased MAP2 levels (P < 0.001, Fig. 5C-D) and lower number of SYN-positive synapses onto ventral motor neurons following SCI (P < 0.001, Fig. 5E-F). At day 28 after injury, the BA group showed a signi cant restoration of hind legs movement with coordinated crawling, whereas the BA+3MA group was still dragging their hind legs (Fig. 5G). In the BA+3MA group, the BMS scores were signi cantly lower than those in the BA group after SCI at days 1, 7, 14, 21 and 28 (P = 0.032, P = 0.017, P = 0.025, P = 0.008, P = 0.005, respectively; Fig. 5H). Furthermore, the survival rate of the BA+3MA group was notably lower than the BA group (P = 0.033, Fig. 5I). These results suggest that BA's autophagy enhancing effects may be responsible for improved outcomes and survival with BA treatment following SCI.

BA enhances mitophagy and reduces ROS accumulation after SCI.
ROS oxidation products -AOPP, 8-OHdG, and MDA -were measured by ELISA to evaluate changes in ROS levels after SCI. The levels of AOPP, 8-OHdG, and MDA were all higher in the SCI group compared with the Sham group (P < 0.001 for all). BA treatment decreased the levels of AOPP, 8-OHdG, and MDA (P < 0.001, P < 0.001, P = 0.041, respectively), and the levels of AOPP, 8-OHdG, and MDA were all higher in the BA+3MA group compared with the BA group (P= 0.004, P = 0.010, P = 0.013, respectively, Fig. 6A). Biomarkers Bnip3, Nix and Parkin assessed to measure mitophagy in the Sham, SCI, BA and BA+3MA groups. Immuno uorescence showed that there were signi cantly more Nix-positive neurons in the SCI group relative to the Sham group (P = 0.026), and more Nix-positive neurons were observed in the BA group compared with the SCI group (P =0.001; Fig. 6B, C). Furthermore, compared to BA group, there were more Nix-positive neurons in the BA+3MA group (P < 0.001; Fig. 6D, E). The expression levels of Bnip3, Nix and Parkin were also measured by Western blot (Fig. 6F, H). Results showed that Bnip3, Nix and Parkin levels were signi cantly higher in the SCI group compared to the Sham group (P = 0.001, P = 0.002, P = 0.001, respectively), and these levels were even higher in the BA group compared with the SCI group (P = 0.001, P < 0.001, P = 0.003, respectively; Fig. 6G). Finally, compared to BA group, the expression levels of Bnip3, Nix and Parkin in the BA+3MA group were all higher (P = 0.041, P = 0.018, P = 0.002, respectively; Fig. 6I). Together, these results indicate that BA reduces ROS accumulation and augments mitophagy in SCI, and that these effects are likely due to its autophagy enhancing effects.
Finally, we sought to investigate the mechanism underlying how BA modulates pyroptosis, autophagy and mitophagy. We assessed whether TFEB, a known activator of autophagy, is involved. Western blot analysis revealed that p-AMPK and TFEB levels were higher in the SCI group compared with the Sham group (P = 0.038, P = 0.008, respectively), while p-mTOR was lower (P = 0.005). BA increased the levels of p-AMPK and TFEB and decreased p-mTOR level (P = 0.039, P = 0.044, P = 0.004, respectively, Fig. 8A, D). Next, we explored the effects of compound C (CC), an AMPK blocker, on the effects of BA. Here, p-AMPK and TFEB levels were lower in the BA+CC group compared with the BA group (P <0.001, P = 0.001, respectively), while p-mTOR levels in the BA+CC group was higher (P = 0.008, Fig. 8B, E). We also evaluated whether the AMPK-mTOR -TFEB axis is also involved in the mechanism by which BA modulates pyroptosis, autophagy, and mitophagy related proteins. Our results demonstrated that Caspase-1, NLRP3 and GSDMD levels were higher in the BA+CC group when compared to the BA group (P = 0.046, P = 0.018, P = 0.012, respectively); p62 levels were higher in the BA+CC group when compared to the BA group (P = 0.004), with a lower level of LC3II (P = 0.009). Finally, Bnip3, Nix and Parkin were lower in the BA+CC group when compared to the BA group (P = 0.012, P = 0.005, P <0.001, respectively, Fig. 8C, F). Together, these ndings suggest that BA activates autophagy, inhibits pyroptosis, and augments mitophagy via the AMPK-mTOR-TFEB pathway.

Discussion
Betulinic acid (BA), a natural pentacyclic triterpenoid, has gained considerable attention in recent years for its strong biological and medicinal properties [39]. Increasing evidence suggest that BA plays a substantial role in the treatment of various nervous system diseases such Alzheimer's disease [40] peripheral neuropathies [41]. Spinal cord injury is a devastating and common disease that in icts substantial physiological, emotional, and economic damage to patients, their families and societies worldwide. In this study, we present novel preclinical evidence that BA may contribute functional and survival outcomes following SCI. Mechanistically, our results demonstrate that BA's therapeutic effect was likely due to autophagy augmentation via the AMPK-mTOR-TFEB pathway, subsequently inducing mitophagy, suppressing ROS accumulation, and inhibiting pyroptosis.
Autophagy, a lysosomal-dependent degradation pathway for intracellular proteins and organelles, plays an important role in human health and disease [42]. In the context of SCI, autophagy has shown to play an important role, albeit a complicated one. On one hand, melatonin-induced increase in autophagy has been shown to promote locomotor recovery in SCI [43], but on the other hand, induction of autophagy may lead to neuronal cell death [44]. Despite lingering controversy, accumulating evidence seems to suggest that autophagy is primarily bene cial in the context of SCI [45,46]. Our previous work revealed that BA was an effective activator of autophagy [47], and thus, we hypothesized that BA may be effective in improving outcomes following SCI. In the present study, not only did we nd that BA improved outcomes following SCI, WB and immuno uorescence staining results also suggested that these bene cial effects are largely due to up-regulation of autophagy, and that 3MA reverses these bene ts.
Pyroptosis is another cellular pathway that has also been implicated in a variety of pathologies such as colitis, myocardial dysfunction, and neuronal damage [48][49][50]. In brief, pyroptosis is a form of in ammatory programmed cell death characterized by in ammasome activation, membrane poreformation, swelling, rupture, and ultimate dissolution and release of intracellular contents [51]. In the canonical in ammasome pathway, NLRP3 in ammasomes are activated to recruit ASC to form ASC focus [51,52]. Then, ASC focus activated Caspase-1, which cleaves pro-IL-18/1β and gasdermin D (GSDMD) to release their mature forms [51]. IL-18/1β and GSDMD are then released to the extracellular domain and subsequently trigger a robust in ammatory response [53]. In this study, we hypothesized that BA's augmentation of autophagy may be able to suppress pyroptosis in SCI. Our Western blot and immuno uorescence results showed that BA was able to signi cantly depressed pyroptosis-associated markers such as ASC, NLRP3, GSDMD, Caspase-1, IL-1β and IL-1B, suggesting that BA may be an effective inhibitor of pyroptosis in SCI. Furthermore, we found that 3-MA co-administration abates these pyroptosis inhibiting effects, suggesting that BA likely suppresses pyroptosis via enhancing autophagy.
Increasing evidence demonstrates that the secondary injury stage after SCI is closely related to mitochondrial injury and excessive ROS generation [54]. Damaged mitochondria leads to a massive accumulation of ROS, which can induce NLRP3 in ammasome activation and subsequently trigger caspase-1-dependent pyroptosis [55,56]. Mitophagy, a selective autophagic degradation of damaged mitochondria [57], can reduce ROS accumulation [58,59], and may play a central role in curtailing pyroptosis following SCI. To explore this postulation, we investigated whether BA-mediated autophagy enhancement promotes mitophagy, and whether mitophagy underlies the mechanism by which BA inhibits pyroptosis following SCI. Our results showed that BA signi cantly elevated the levels of Bnip3, Nix and Parkin following SCI, suggesting an upregulation of mitophagy. Furthermore, our ndings demonstrate that BA decreased ROS oxidation products, including 8-OHdG, AOPP and MDA. These changes were abated by co-administration of 3-MA, suggesting that mitophagy activation and ROS reduction occurred downstream of autophagy enhancement. We also found that MnTBAP, a ROS scavenger, decreased expressions levels of the pyroptosis group, suggesting that in SCI, ROS is likely responsible for pyroptosis activation, and that autophagy-induced mitophagy activation and ROS reduction may underly the mechanism by which BA suppresses pyroptosis.
In order to further to elucidate the underlying mechanism of how BA promotes autophagy in SCI, we also examined upstream mechanisms of autophagy. Transcription factor EB (TFEB) is a central regulator of autophagy [60,61]. Past studies have shown that TFEB activation occurs in response to a variety of cellular stress [62], which impacts the ATP to ADP ratio, triggering the phosphorylation of AMPK.
Subsequently, AMPK regulates cell metabolism [63], inhibiting mTOR (a master regulator of cell growth and metabolism) in the cytoplasm to allow nuclear translocation of TFEB [64]. In our present work, we showed that BA increases the expression of TFEB. Furthermore, our results revealed that BA leads to increased phosphorylation of AMPK and inhibited the phosphorylation of mTOR. Finally, using compound C (CC), an AMPK blocker, we showed that inhibition of AMPK-mTOR-TFEB signaling pathway led to diminished effects of BA on autophagy, and mitophagy, and pyroptosis.
Naturally, there are several limitations in our study that need to be further investigated. For example, previous studies revealed that AMPK-SPK2-CARM1 signaling pathway is another important pathway regulating TFEB in the nucleus [65,66], and future investigations should explore whether BA also acts through AMPK -SPK2-CARM1-TFEB signaling pathway in SCI. Studies have shown that besides ROS, CTSB and K + can also cause pyroptosis [67,68], and future studies should also explore whether BA in uences CTSB and K + in SCI. Finally, while these preclinical ndings are promising, more work is needed to be done to explore optimal dosing and toxicities of BA in the treatment of SCI prior to clinical translation.

Conclusions
Our ndings demonstrate that BA activates the AMPK-mTOR-TFEB signaling pathway, which enhances autophagy in SCI. Increased autophagy induces mitophagy and reduces ROS accumulation, subsequently inhibiting pyroptosis. Ultimately, these effects of BA culminate in improved outcomes and survival following SCI. A schematic illustration of our ndings is presented in Fig. 8G. Overall, these results provide novel preclinical evidence demonstrating the therapeutic bene t of BA in SCI. Future investigations are now eagerly awaited to further the clinical translation of BA as a treatment for SCI patients.