This consists of the terminal part of the motor neurone which originates from the ventral horn of the spinal cord, losing its myelin as it nears the muscle fibre. Here, the Schwann cell (SC) anchors the nerve to the muscle membrane. SCs play an important role in the maintenance of nerve homeostasis. In addition to providing stability and secreting growth and trophic factors, they also participate in axon development and synaptic formation from the fetal state and throughout life. SCs control the number of NMJs and remove superfluous presynaptic nerve terminals, especially during re-innervation, for instance, after crush injury. The mechanism involves interaction with the immune molecules, major histocompatibility Class 1a (MHC Class 1a), present in motor neurones which mediate non-immune modulation of synaptic function and plasticity. In the absence of MHC Class 1a, NMJ organization is disturbed, and recovery of motor nerve lesions is delayed. The presynaptic terminal also contains AChRs on the surface of the nerve membrane. These are nicotinic receptors identified as neuronal nAChR (a3b2). Non-depolarizing and depolarizing neuromuscular blocking agents (NMBAs) act on these receptors, altering the mobilization of ACh: the former inhibit them and the latter stimulate them. Such mobilization involves the acquisition and synthesis of ACh, its storage in reserve vesicles, and its release by a nerve action potential. ACh is stored in two pools: in vesicles in the reserve pool which contain abundant mitochondria and microtubules to synthesize neurotransmitter; and as readily releasable vesicles. The release of ACh from the readily releasable pool on arrival of a nerve impulse results in sodium channel activation on the prejunctional nerve membrane. This in turn activates voltagedependent calcium channels (P-type fast channels) on the motor neurone causing an influx of calcium into the nerve cytoplasm that promotes further ACh release. Three proteins, synaptobrevin, syntaxin, and synaptosome-associated protein SNAP-25, are involved in the attachment of ACh vesicles to the presynaptic cell membrane. These proteins along with vesicle membrane-associated synaptotagmins cause the docking, fusion, and release (exocytosis) of neurotransmitter from the vesicles. The P-type calcium channels are in contrast to the L-type (slow channels) which are present in the heart. There is evidence that L-type calcium channels may also be present on the nerve terminals which could explain why the action of non-depolarizing NMBAs is prolonged by calcium channel blockers. By blocking the L-type channels, these drugs may prevent calcium accumulation within the prejunctional membrane and thus release of ACh from the vesicles. The P-type calcium channels are blocked by cations such as magnesium, cadmium, and manganese. By blocking calcium entry, magnesium sulphate reduces ACh release from the vesicles, resulting in a reduction in muscle tone. Antibodies to the calcium channels may develop in some forms of cancer (Eaton–Lambert syndrome in small cell lung cancer) causing muscle weakness. An increase in calcium concentration in the prejunctional cytoplasm triggers ACh release. The calcium inflow is balanced by Key points The functioning of the neuromuscular junction (NMJ) and the release of acetylcholine to stimulate the post-synaptic nicotinic receptors is dependent on the interaction of several proteins such as agrin and muscle-specific tyrosine kinase, which are responsible for the formation and maintenance of the NMJ. A new non-depolarizing agent, gantacurium, is being investigated as a replacement for succinylcholine. It is degraded in the plasma non-enzymatically by endogenous L-cysteine. The new antagonist to rocuronium, sugammadex, can reverse profound block when given in the correct dose immediately after rocuronium. Postoperative residual curarization is still common. A train-of-four ratio of .0.9 is necessary before extubation to prevent postoperative respiratory complications.
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