Recent advances in managing a spinal cord injury secondary to trauma

Abstract

Traumatic spinal cord injuries (SCIs) affect 1.3 million North Americans, producing devastating physical, social, and vocational impairment. Pathophysiologically, the initial mechanical trauma is followed by a significant secondary injury which includes local ischemia, pro-apoptotic signaling, release of cytotoxic factors, and inflammatory cell infiltration. Expedient delivery of medical and surgical care during this critical period can improve long-term functional outcomes, engendering the concept of “Time is Spine”. We emphasize the importance of expeditious care while outlining the initial clinical and radiographic assessment of patients. Key evidence-based early interventions (surgical decompression, blood pressure augmentation, and methylprednisolone) are also reviewed, including findings of the landmark Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). We then describe other neuroprotective approaches on the edge of translation such as the sodium-channel blocker riluzole, the anti-inflammatory minocycline, and therapeutic hypothermia. We also review promising neuroregenerative therapies that are likely to influence management practices over the next decade including chondroitinase, Rho-ROCK pathway inhibition, and bioengineered strategies. The importance of emerging neural stem cell therapies to remyelinate denuded axons and regenerate neural circuits is also discussed. Finally, we outline future directions for research and patient care.

Cell therapy for spinal cord injury with olfactory ensheathing glia cells (OECs)

“…Spinal cord injury (SCI) is a secondary outcome of a compression injury, bleeding and/or ischemia, which compromises the bone component of the spine, the spinal cord (SC) and its coverings. Several mechanisms can cause this type of damage, the most common bone injury being bone disruption produced by flexo‐extension injuries associated with fracture (Ahuja, Martin, & Fehlings, ; McDonald & Sadowsky, ; Rogers & Todd, ). The pathological features of traumatic SCI include axon demyelination, which is in part due to the loss of the glial substrate at the site of injury as a combined result of necrosis, apoptosis and autophagy (McDonald & Sadowsky, ; Plemel et al, ).…”

“…Furthermore, we present evidence of the utility of cell therapy with OECs to treat SCI, both from animal models and clinical studies performed on SCI patients, providing promising results for future treatments. (Ahuja, Martin, & Fehlings, 2016;McDonald & Sadowsky, 2002;Rogers & Todd, 2016). The pathological features of traumatic SCI include axon demyelination, which is in part due to the loss of the glial substrate at the site of injury as a combined result of necrosis, apoptosis and autophagy (McDonald & Sadowsky, 2002;Plemel et al, 2014).…”

Induced Pluripotent Stem Cells for Traumatic Spinal Cord Injury

“…Furthermore, the loss of tissue volume leads to the formation of microcystic cavitation which coalesces into large regions devoid of an extracellular substrate for migration and growth. While the lesion continues to develop over years, attempts at regeneration by endogenous cells are severely hindered by these barriers (Figure 1; Ahuja et al, 2016). …”

Acute spinal cord injuries before and after the New Zealand Spinal Cord Impairment Action Plan

“…There are currently around 1500 people with a spinal cord impairment managed by Accident Compensation Corporation (ACC) . Following injury progressive oedema and haemorrhage contribute to ongoing mechanical pressure on the sensitive microvascular circulation contributing to ongoing ischaemia . Animal and human data demonstrate that urgent decompression appears to greatly improve outcome .…”

“…In current practice, early recognition, triage and supportive management are critical first line components of care. Efficient medical and surgical intervention during this period can improve long‐term functional outcomes . Data from the STASICS prospective multicentre study show that patients undergoing early decompression less than 24 h following injury were twice as likely to have a two‐grade or greater American Spinal Injury Association impairment scale (AIS) improvement at 6‐month follow up – 19.8 versus 8.8%…”