Methylprednisolone treatment in acute spinal cord injury: the myth challenged through a structured analysis of published literature

The effects of N-acetyl-cysteine and acetyl-L-carnitine on neural survival, neuroinflammation and regeneration following spinal cord injury

Traumatic spinal cord injury induces a long-standing inflammatory response in the spinal cord tissue, leading to a progressive apoptotic death of spinal cord neurons and glial cells. We have recently demonstrated that immediate treatment with the antioxidants N-acetyl-cysteine (NAC) and acetyl-l-carnitine (ALC) attenuates neuroinflammation, induces axonal sprouting, and reduces the death of motoneurons in the vicinity of the trauma zone 4weeks after initial trauma. The objective of the current study was to investigate the effects of long-term antioxidant treatment on the survival of descending rubrospinal neurons after spinal cord injury in rats. It also examines the short- and long-term effects of treatment on apoptosis, inflammation, and regeneration in the spinal cord trauma zone. Spinal cord hemisection performed at the level C3 induced a significant loss of rubrospinal neurons 8 weeks after injury. At 2 weeks, an increase in the expression of the apoptosis-associated markers BCL-2-associated X protein (BAX) and caspase 3, as well as the microglial cell markers OX42 and ectodermal dysplasia 1 (ED1), was seen in the trauma zone. After 8 weeks, an increase in immunostaining for OX42 and the serotonin marker 5HT was detected in the same area. Antioxidant therapy reduced the loss of rubrospinal neurons by approximately 50%. Treatment also decreased the expression of BAX, caspase 3, OX42 and ED1 after 2 weeks. After 8 weeks, treatment decreased immunoreactivity for OX42, whereas it was increased for 5HT. In conclusion, this study provides further insight in the effects of treatment with NAC and ALC on descending pathways, as well as short- and long-term effects on the spinal cord trauma zone.

Remote neurodegeneration: multiple actors for one play

Remote neurodegeneration significantly influences the clinical outcome in many central nervous system (CNS) pathologies, such as stroke, multiple sclerosis, and traumatic brain and spinal cord injuries. Because these processes develop days or months after injury, they are accompanied by a therapeutic window of opportunity. The complexity and clinical significance of remote damage is prompting many groups to examine the factors of remote degeneration. This research is providing insights into key unanswered questions, opening new avenues for innovative neuroprotective therapies. In this review, we evaluate data from various remote degeneration models to describe the complexity of the systems that are involved and the importance of their interactions in reducing damage and promoting recovery after brain lesions. Specifically, we recapitulate the current data on remote neuronal degeneration, focusing on molecular and cellular events, as studied in stroke and brain and spinal cord injury models. Remote damage is a multifactorial phenomenon in which many components become active in specific time frames. Days, weeks, or months after injury onset, the interplay between key effectors differentially affects neuronal survival and functional outcomes. In particular, we discuss apoptosis, inflammation, oxidative damage, and autophagy-all of which mediate remote degeneration at specific times. We also review current findings on the pharmacological manipulation of remote degeneration mechanisms in reducing damage and sustaining outcomes. These novel treatments differ from those that have been proposed to limit primary lesion site damage, representing new perspectives on neuroprotection.

Effects of the combined administration of vitamins C and E on the oxidative stress status and programmed cell death pathways after experimental spinal cord injury

STUDY DESIGN

Experimental, controlled, animal study.

OBJECTIVES

To assess the effects of vitamins C and E (VCE) treatment on oxidative stress and programmed cell deaths after rat spinal cord injury (SCI), as well as functional recovery.

SETTING

Taiwan.

METHODS

Fifty-four Sprague-Dawley rats were used for the experimental procedure. In the sham group, laminectomy at T10 was performed, followed by impactor contusion of the spinal cord. In the control group, only a laminectomy was performed without contusion. Oxidative stress status was assessed by measuring the spinal cord tissue content of superoxide dismutase (SOD) and gluthatione peroxidase (GSH-Px) activities. We also evaluated the effects of combined VCE treatment using western blot to analyze expression of cleaved caspase-3 and microtubule-associated protein light chain 3 (LC3), and the Basso, Beattie and Bresnahan (BBB) scale to evaluate functional outcomes.

RESULTS

Combined treatment of VCE significantly counteracted the effects of spinal cord contusion on oxidative stress represented by activities of SOD and GSH-Px (P<0.05). The VCE treatment also significantly enhanced LC3-II expression and decreased cleaved caspase-3 compared with the sham (P<0.05). Furthermore, BBB scores significantly improved in the VCE-treated group compared with the sham group (on day 14 and 28 after SCI; P<0.05).

CONCLUSIONS

The combined administration of VCE was clearly capable of modulating the antioxidant effects, and of reducing apoptosis and increasing autophagy at the lesion epicenter leading to an improved functional outcome. Use of such clinically ready drugs could help earlier clinical trials in selected cases of human SCIs.

Rat substrains differ in the magnitude of spontaneous locomotor recovery and in the development of mechanical hypersensitivity after experimental spinal cord injury

A number of different rodent experimental models of spinal cord injury have been used in an attempt to model the pathophysiology of human spinal cord injury. As a result, interlaboratory comparisons of the outcome measures can be difficult. Further complicating interexperiment comparisons is the fact that the rodent response to different experimental models is strain-dependent. Moreover, the literature is abundant with examples in which the same injury model and strain result in divergent functional outcomes. The objective of this research was to determine whether substrain differences influence functional outcome in experimental spinal cord injury. We induced mild contusion spinal cord injuries in three substrains of Sprague-Dawley rats purchased from three different European breeders (Scanbur, Charles River, and Harlan) and evaluated the impact of injury on spontaneous locomotor function, hypersensitivity to mechanical stimulation, and bladder function. We found that Harlan rats regained significantly more hindlimb function than Charles River and Scanbur rats. We also observed substrain differences in the recovery of the ability to empty the bladder and development of hypersensitivity to mechanical stimulation. The Harlan substrain did not show any signs of hypersensitivity in contrast to the Scanbur and Charles River substrains, which both showed transient reduction in paw withdrawal thresholds. Lastly, we found histological differences possibly explaining the observed behavioral differences. We conclude that in spite of being the same strain, there might be genetic differences that can influence outcome measures in experimental studies of spinal cord injury of Sprague-Dawley rats from different vendors.

Dental pulp stem cells and their potential roles in central nervous system regeneration and repair

Functional recovery from injuries to the brain or spinal cord represents a major clinical challenge. The transplantation of stem cells, traditionally isolated from embryonic tissue, may help to reduce damage following such events and promote regeneration and repair through both direct cell replacement and neurotrophic mechanisms. However, the therapeutic potential of using embryonic stem/progenitor cells is significantly restricted by the availability of embryonic tissues and associated ethical issues. Populations of stem cells reside within the dental pulp, representing an alternative source of cells that can be isolated with minimal invasiveness, and thus should illicit fewer moral objections, as a replacement for embryonic/fetal-derived stem cells. Here we discuss the similarities between dental pulp stem cells (DPSCs) and the endogenous stem cells of the central nervous system (CNS) and their ability to differentiate into neuronal cell types. We also consider in vitro and in vivo studies demonstrating the ability of DPSCs to help protect against and repair neuronal damage, suggesting that dental pulp may provide a viable alternative source of stem cells for replacement therapy following CNS damage.

Treatment of neck injuries

Spinal cord injuries are uncommon in sports. Planning and practice for their occurrence, however, remains an essential component of Sideline Medical Team preparedness. Evaluation of cervical nerve injury, cervical cord injury, and cervical disc disease can be complex. Medical management, diagnostic imaging techniques and surgical recommendations in this setting continue to evolve. Most published guidance offers occasionally opposed expert opinion with sport participation after Cervical Cord Neuropraxia in the setting of Cervical Spinal Stenosis appearing particularly polarizing. Such conflicts can present challenges to clinicians in forming management and Return to Play decisions for the health of their athletes.

Microglia response and in vivo therapeutic potential of methylprednisolone-loaded dendrimer nanoparticles in spinal cord injury

The control and manipulation of cells that trigger secondary mechanisms following spinal cord injury (SCI) is one of the first opportunities to minimize its highly detrimental outcomes. Herein, the ability of surface-engineered carboxymethylchitosan/polyamidoamine (CMCht/PAMAM) dendrimer nanoparticles to intracellularly deliver methylprednisolone (MP) to glial cells, allowing a controlled and sustained release of this corticosteroid in the injury site, is investigated. The negatively charged MP-loaded CMCht/PAMAM dendrimer nanoparticles with sizes of 109 nm enable a MP sustained release, which is detected for a period of 14 days by HPLC. In vitro studies in glial primary cultures show that incubation with 200 μg mL(-1) nanoparticles do not affect the cells' viability or proliferation, while allowing the entire population to internalize the nanoparticles. At higher concentrations, microglial cell viability is proven to be affected in response to the MP amount released. Following lateral hemisection lesions in rats, nanoparticle uptake by the spinal tissue is observed 3 h after administration. Moreover, significant differences in the locomotor output between the controls and the MP-loaded nanoparticle-treated animals one month after the lesion are observed. Therefore, MP-loaded CMCht/PAMAM dendrimer nanoparticles may prove to be useful in the reduction of the secondary injury following SCI.

Mn (III) tetrakis (4-benzoic acid) porphyrin scavenges reactive species, reduces oxidative stress, and improves functional recovery after experimental spinal cord injury in rats: comparison with methylprednisolone

BACKGROUND

Substantial experimental evidence supports that reactive species mediate secondary damage after traumatic spinal cord injury (SCI) by inducing oxidative stress. Removal of reactive species may reduce secondary damage following SCI. This study explored the effectiveness of a catalytic antioxidant - Mn (III) tetrakis (4-benzoic acid) porphyrin (MnTBAP) - in removing reactive oxygen species (ROS), reducing oxidative stress, and improving functional recovery in vivo in a rat impact SCI model. The efficiency of MnTBAP was also compared with that of methylprednisolone - the only drug used clinically in treating acute SCI.

RESULTS

In vivo measurements of time courses of ROS production by microdialysis and microcannula sampling in MnTBAP, methylprednisolone, and saline (as vehicle control)-treated SCI rats showed that both agents significantly reduced the production of hydrogen peroxide, but only MnTBAP significantly reduced superoxide elevation after SCI. In vitro experiments further demonstrated that MnTBAP scavenged both of the preceding ROS, whereas methylprednisolone had no effect on either. By counting the immuno-positive neurons in the spinal cord sections immunohistochemically stained with anti-nitrotyrosine and anti-4-hydroxy-nonenal antibodies as the markers of protein nitration and membrane lipid peroxidation, we demonstrated that MnTBAP significantly reduced the numbers of 4-hydroxy-nonenal-positive and nitrotyrosine-positive neurons in the sections at 1.55 to 2.55 mm and 1.1 to 3.1 mm, respectively, rostral to the injury epicenter compared to the vehicle-treated animals. By behavioral tests (open field and inclined plane tests), we demonstrated that at 4 hours post-SCI treatment with MnTBAP and the standard methylprednisolone regimen both significantly increased test scores compared to those produced by vehicle treatment. However, the outcomes for MnTBAP-treated rats were significantly better than those for methylprednisolone-treated animals.

CONCLUSIONS

This study demonstrated for the first time in vivo and in vitro that MnTBAP significantly reduced the levels of SCI-elevated ROS and that MnTBAP is superior to methylprednisolone in removing ROS. Removal of ROS by MnTBAP significantly reduced protein nitration and membrane lipid peroxidation in neurons. MnTBAP more effectively reduced neurological deficits than did methylprednisolone after SCI - the first most important criterion for assessing SCI treatments. These results support the therapeutic potential of MnTBAP in treating SCI.

Mortality and morbidity after high-dose methylprednisolone treatment in patients with acute cervical spinal cord injury: a propensity-matched analysis using a nationwide administrative database

Objective

To examine the magnitude of the adverse impact of high-dose methylprednisolone treatment in patients with acute cervical spinal cord injury (SCI).

Methods

We examined the abstracted data from the Japanese Diagnosis Procedure Combination database, and included patients with ICD-10 code S141 who were admitted on an emergency basis between 1 July and 31 December in 2007–2009. The investigation evaluated the patients’ sex, age, comorbidities, Japan Coma Scale, hospital volume and the amount of methylprednisolone administered. One-to-one propensity-score matching between high-dose methylprednisolone group (>5000 mg) and control group was performed to compare the rates of in-hospital death and major complications (sepsis; pneumonia; urinary tract infection; gastrointestinal ulcer/bleeding; and pulmonary embolism).

Results

We identified 3508 cervical SCI patients (2652 men and 856 women; mean age, 60.8±18.7 years) including 824 (23.5%) patients who received high-dose methylprednisolone. A propensity-matched analysis with 824 pairs of patients showed a significant increase in the occurrence of gastrointestinal ulcer/bleeding (68/812 vs 31/812; p<0.001) in the high-dose methylprednisolone group. Overall, the high-dose methylprednisolone group demonstrated a significantly higher risk of complications (144/812 vs 96/812;OR, 1.66; 95% CI 1.23 to 2.24; p=0.001) than the control group. There was no significant difference in in-hospital mortality between the high-dose methylprednisolone group and the control group (p=0.884).

Conclusions

Patients receiving high-dose methylprednisolone had a significantly increased risk of major complications, in particular, gastrointestinal ulcer/bleeding. However, high-dose methylprednisolone treatment was not associated with any increase in mortality.

The current role of steroids in acute spinal cord injury

BACKGROUND

Acute spinal cord injury (ASCI) is a catastrophic event that can profoundly affect the trajectory of a patient's life. Debate continues over the pharmacologic management of ASCI, specifically, the widespread but controversial use of the steroid methylprednisolone (MP). Treatment efforts are impeded because of limitations in understanding of the pathobiology of ASCI and the difficulty in proving the efficacy of therapies.

METHODS

This review presents the pathophysiology of ASCI and the laboratory and clinical findings on the use of MP.

RESULTS

The use of MP remains a contentious issue in part because of the catastrophic nature of ASCI, the paucity of treatment options, and the legal ramifications. Although historical data on the use of MP in ASCI have been challenged, more recent studies have been used both to support and to oppose treatment of ASCI with steroids.

CONCLUSIONS

ASCI is a devastating event with a complex aftermath of secondary damaging processes that worsen the initial injury. Although the results of NASCIS (National Acute Spinal Cord Injury Study) II and III trials led to the widespread adoption of a high-dose MP regimen for patients treated within 8 hours of injury, subsequent studies have called into question the validity of NASCIS conclusions. Further evidence of the ineffectiveness of the MP protocol has led to declining confidence in the treatment over the last decade. At the present time, high-dose MP cannot be recommended as a standard of care, but it remains an option until supplanted by future evidence-based therapies.

Neuroprotective effects of hypothermia after spinal cord injury in rats: comparative study between epidural hypothermia and systemic hypothermia

STUDY DESIGN

An experimental comparative study on moderate epidural hypothermia (MEH) versus moderate systemic hypothermia (MSH) after spinal cord injury (SCI).

OBJECTIVE

To compare neuroprotective effects of hypothermia between MEH and MSH after SCI in rats.

SUMMARY OF BACKGROUND DATA

Experimental MEH or MSH has been attempted for neuroprotection after ischemic or traumatic SCI. However, there is no comparative study on neuroprotective effect of MEH and MSH after SCI. If hypothermia is to be considered as 1 modality for treating SCI, further studies on the advantages and disadvantages of hypothermia will be mandatory.

METHODS

A spinal cord contusion was produced in all 32 rats, and these rats were randomly divided into 4 groups-8 rats in each group: (1) the control group (spinal cord contusion only), (2) the methylprednisolone group, (3) the MEH group (28°C for 48 hr), and (4) the MSH group (32°C for 48 hr). The functional recovery was assessed using Basso, Beattie, Bresnahan scale and antiapoptotic and anti-inflammatory effects were assessed.

RESULTS

The Basso, Beattie, Bresnahan scale scores in both the hypothermia groups were significantly higher than that in the control group at 6 weeks. The numbers of terminal deoxynucleotidyl transferase dUTP nick end labeling-positive cells and OX-42 positive cells were significantly lower in both the MEH and MSH groups than that in the control group. The p38 mitogen-activated protein kinases expression of the treated groups was significantly lower than that of the control group. The expression of caspase-8 and caspase-9 significantly decreased in the treated groups compared with that of the control group. However, in terms of caspase-3, only the MSH group has shown to be significantly lower than that of the control group.

CONCLUSION

This study presented that both systemic and epidural hypothermia demonstrated neuroprotective effects after SCI. Systemic hypothermia showed more neuroprotective effect by antiapoptotic and anti-inflammatory effects.

The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations

The use of methylprednisolone after acute spinal cord injury has been under discussion for more than 20 years. There is ongoing debate about the efficacy and clinical impact of methylprednisolone in recovery from spinal cord injury, and studies show considerable variability in practice patterns among surgeons. Consensus statements consider methylprednisolone as a treatment option for acute spinal cord injury, but not a standard of care based on available evidence. This review discusses the evidence from prospective trials of methylprednisolone in adults and teenagers after spinal cord injury, consensus statements on the use of methylprednisolone, and practice variability in North America and the United Kingdom over time.

The potential for cellular therapy combined with growth factors in spinal cord injury

Any traumatic spinal cord injury (SCI) may cause symptoms ranging from pain to complete loss of motor and sensory functions below the level of the injury. Currently, there are over 2 million SCI patients worldwide. The cost of their necessary continuing care creates a burden for the patient, their families, and society. Presently, few SCI treatments are available and none have facilitated neural regeneration and/or significant functional improvement. Research is being conducted in the following areas: pathophysiology, cellular therapies (Schwann cells, embryonic stem cells, induced pluripotent stem cells, mesenchymal stem cells, olfactory ensheathing cells), growth factors (BDNF), inhibitory molecules (NG2, myelin protein), and combination therapies (cell grafts and neurotrophins, cotransplantation). Results are often limited because of the inhibitory environment created following the injury and the limited regenerative potential of the central nervous system. Therapies that show promise in small animal models may not transfer to nonhuman primates and humans. None of the research has resulted in remarkable improvement, but many areas show promise. Studies have suggested that a combination of therapies may enhance results and may be more effective than a single therapy. This paper reviews and discusses the most promising new SCI research including combination therapies.

Effect of parenteral l-alanyl-l-glutamine administration on phagocytic responses of polymorphonuclear neutrophilic leukocytes in dogs undergoing high-dose methylprednisolone sodium succinate treatment

OBJECTIVE

To determine whether parenteral l-alanyl-l-glutamine (Ala-Gln) administration modulated phagocytic responses of polymorphonuclear neutrophilic leukocytes (PMNs) from dogs undergoing high-dose methylprednisolone sodium succinate (MPSS) treatment.

ANIMALS

15 healthy Beagles.

PROCEDURES

Dogs were randomly assigned to 3 treatment groups (n = 5/group): 38-hour IV infusion of saline (0.9% NaCl) solution (control group), saline solution with 8.5% amino acids (2.3 g/kg/d), or saline solution with 8.5% amino acids (1.8 g/kg/d) and 20% l-alanyl-l-glutamine (Ala-Gln; 0.5 g/kg/d). High-dose MPSS treatment was initiated at the same time that IV infusions began, such that a total dose of 85 mg of MPSS/kg was administered through multiple IV injections over a 26-hour period. The infusions were maintained until 12 hours after the last MPSS injection. Blood samples collected before MPSS injections began and 2, 12, and 24 hours after injections ceased were used to evaluate PMN function.

RESULTS

MPSS injections resulted in an increase in the total number of circulating leukocytes and increases in neutrophil and monocyte counts but did not affect lymphocyte, eosinophil, or basophil counts. Lymphocyte counts in the Ala-Gln group were higher than in the control group 12 hours after MPSS injections finished. Relative to preinfusion values, phagocytic capacity, oxidative burst activity, and filamentous actin polymerization of PMNs were suppressed in all dogs except those that received Ala-Gln.

CONCLUSIONS AND CLINICAL RELEVANCE

Parenteral Ala-Gln administration in dogs resulted in an increase in PMN phagocytic responses that were suppressed by high-dose MPSS treatment.

Neuroprotective effects of racemic ketamine and (S)-ketamine on spinal cord injury in rat

BACKGROUND

The aim of this study was to investigate and to compare the potential neuroprotective effects of racemic ketamine, (S)-ketamine and methylprednisolone after an experimental spinal cord injury model in rats.

METHODS

Fifty-nine Wistar albino rats were divided into three main groups as acute stage (A), subacute stage (SA) and sham groups and then acute and subacute stage groups were divided into four groups regarding the used drug as control (CONT), racemic ketamine (RK), (S)-ketamine (SK) and methylprednisolone (MP) groups. A dorsal laminectomy was performed; and spinal cord injury was induced by using a temporary aneurysm clip. Four hours later from the clip compression, except those of the sham and control groups, the drugs (60 mg/kg racemic ketamine, 60 mg/kg (S)-ketamine or 30 mg/kg methylprednisolone) were administered intraperitoneally. At 72th h and 7th days of the study, the spinal cords of rats were removed from T8 level to the conus medullaris level. The specimens were and evaluated histopathologically, tissue lipid peroxidation (LPO) and myeloperoxidation (MPO) levels were measured and biochemically.

RESULTS

The histopathological results were similar both in the acute and in the subacute stage groups. There was a statistically significant difference among all groups regarding the tissue LPO levels (p<0.001). There was a statistically significant difference between the CONT-A group and the MP-A, RK-A and SK-A groups (p=0.004, p<0.001 and p=0.007, respectively) in acute stage and between the CONT-SA group and SK-SA group (p=0.002) in subacute stage. There was a statistically significant difference among all groups regarding the tissue MPO levels (p=0.001). The median MPO levels were similar among acute stage groups (p=0.057), but there was a statistical difference among subacute stage groups (p=0.046).

CONCLUSION

(S)-ketamine is more effective than methylprednisolone and racemic ketamine to reduce the LPO levels in subacute stage of spinal cord injury in rats. And, it is as effective as methylprednisolone in preventing secondary spinal cord injury histopathologically.

FRACTURE-DISLOCATION OF THE THORACIC SPINE DURING SECOND TRIMESTER OF PREGNANCY: CASE REPORT AND LITERATURE REVIEW

Spinal fractures associated with spinal cord injury rarely affect pregnant patients. The authors present the case of a 20-year-old woman in her 20^th week of pregnancy, who suffered fracture-dislocation of the thoracic spine (T4-T5) and underwent decompression, reduction and posterior fusion with pedicle screws. Despite the complete spinal cord injury presented, the pregnancy progressed uneventfully and resulted in birth via normal delivery of a healthy newborn at term. Some particular features of this case, like the care needed in using ionizing radiation, the surgical approach and delivery, use of steroids and pregnancy complications in such patients are discussed here. Only a multidisciplinary team composed by physicians from different specialties (spinal surgeons, obstetricians and physiatrists), nurses and physiotherapists is capable of assisting pregnant patients with spinal cord injuries satisfactorily.

The spine-injured patient: initial assessment and emergency treatment

Failure to recognize spinal column or spinal cord injuries, or improper treatment of them, can have catastrophic and often irreversible neurologic consequences. Although the initial assessment is often shared with emergency care personnel, an orthopaedic surgeon's perspective can elevate the priority of spinal care to the level that is warranted. An accurate early appraisal, including complete neurologic assessment, is critical. All aspects of emergent care, including optimal immobilization precautions, resuscitation, and choice of imaging modalities, should be systematically reviewed, and practice guidelines should be adopted by each institution. Increased vigilance is required in patients with underlying ankylosing spinal conditions. The use of CT in the symptomatic patient is established, but the use of cervical MRI in the obtunded individual is contentious. By informing decisions around appropriate preliminary treatment, particularly for persons with neurologic deficits or those at high risk for developing neurologic impairment, long-term outcomes can be optimized.

Should post-traumatic thoracolumbar Frankel A paraplegia be operated as an emergency? Report of three cases and review of the literature

Spinal cord injury is an important contributing factor to morbidity. The thoracolumbar junction is a highly vulnerable axial region due to the biomechanical stresses and the risk of conus medullaris injuries in some cases. In the event of an incomplete neurological injury and if the patient's condition is stable, emergency surgical treatment should be considered. Yet, no clear consensus has emerged regarding the treatment modalities of complete injuries but surgical management is advocated to maximize neurological recovery and reduce the risk of decubitus ulcer formation. We report on the cases of three patients with L1 Frankel A paraplegia resulting from injury to the conus medullaris, treated within the first 6 hours from injury and demonstrating a very satisfactory neurological recovery since independent walking could be resumed at 2.5 years follow-up. Persistent urinary sphincter dysfunctions were observed in two of these patients. Early surgical management appears as an important predictive factor for neurological recovery in conus medullaris injuries. We believe that delayed surgical management in patients with complete paraplegia could be an inappropriate treatment option, which should be further studied.

A review: the role of high dose methylprednisolone in spinal cord trauma in children

BACKGROUND

The use of steroids in traumatic spinal cord injury (SCI) in children is controversial. There is a paucity of literature on its usage. To help clarify recommendations on steroid use in children, we reviewed the current literature on the administration of high dose methylprednisolone (MP) use in traumatic spinal cord injuries with an emphasis in pediatric spinal cord trauma.

METHODS

A retrospective review of the current literature on traumatic spinal cord injuries was conducted. Outcomes were critically reviewed from the National Acute Spinal Cord Injury Studies (NASCIS) II and III and Cochrane review; as well as, other randomized and retrospective studies. Papers describing objective neurological outcomes were only included.

RESULTS

The outcomes of neurological improvement following steroid infusion have not been reproducible outside of the NASCIS and one single Japanese trial. High dose steroids significantly increase the risk of infections leading to prolonged hospital stay and ventilator dependence.

CONCLUSION

Data from adult studies remains controversial with insufficient data to support administration of MP for treatment of traumatic spinal cord injuries. Randomized controlled trials are needed in the pediatric population to assess the advantages of steroid use after SCI in children. On the basis of the current evidence, the use of steroids in patients is associated with increased infectious risks and no neurological improvements.

Oligodendrocyte-protection and remyelination post-spinal cord injuries: a review

In the past four decades, the main focus of investigators in the field of spinal cord regeneration has been to devise therapeutic measures that enhance neural regeneration. More recently, emphasis has been placed on enhancing remyelination and providing oligodendrocyte-protection after a spinal cord injury (SCI). Demyelination post-SCI is part of the cascading secondary injury that takes place immediately after the primary insult; therefore, therapeutic measures are needed to reduce oligodendrocyte death and/or enhance remyelination during the acute stage, preserving neurological functions that would be lost otherwise. In this review a thorough investigation of the oligodendrocyte-protective and remyelinative molecular therapies available to date is provided. The advent of new biomaterials shown to promote remyelination post-SCI is discussed mainly in the context of a combinatorial approach where the biomaterial also provides drug delivery capabilities. The aim of these molecular and biomaterial-based therapies is twofold: (1) oligodendrocyte-protective therapy, which involves protecting already existing oligodendrocytes from undergoing apoptosis/necrosis; and (2) inductive remyelination, which involves harnessing the remyelinative capabilities of endogenous oligodendrocyte precursor cells (OPCs) at the lesion site by providing a suitable environment for their migration, survival, proliferation and differentiation. From the evidence reported in the literature, we conclude that the use of a combinatorial approach including biomaterials and molecular therapies would provide advantages such as: (1) sustained release of the therapeutic molecule, (2) local delivery at the lesion site, and (3) an environment at the site of injury that promotes OPC migration, differentiation and remyelination.

Delayed granulocyte colony-stimulating factor treatment promotes functional recovery in rats with severe contusive spinal cord injury

STUDY DESIGN

We used a severe contusive spinal cord injury (SCI) model and electrophysiologic, motor functional, immunohistochemical, and electron microscopic examinations to analyze the neuroprotective effects of delayed granulocyte colony-stimulating factor (G-CSF) treatment.

OBJECTIVE

To determine the neuroprotective effects of delayed G-CSF treatment using multimodality evaluations after severe contusive SCI in rats.

SUMMARY OF BACKGROUND DATA

Despite some reports that G-CSF treatment in the acute stage of different central nervous system injury models was neuroprotective, it has not been determined whether delayed G-CSF treatment can promote neural recovery in severe contusive SCI.

METHODS

Rats with severe contusive SCI were divided into 2 groups: G-CSF group rats were given serial subcutaneous injections of G-CSF, and control group rats (controls) were given only saline injections on postcontusion days 9 to 13. Using the Basso-Beattie-Bresnahan scale and cortical somatosensory evoked potentials, we recorded functional evaluations weekly. The spinal cords were harvested for protein and immunohistochemical analysis, and for electron microscopy examination.

RESULTS

The preserved spinal cord area was larger in G-CSF group rats than in control group rats. Both sensory and motor functions improved after G-CSF treatment. Detachment and disruption of the myelin sheets in the myelinated axons were significantly decreased, and axons sprouted and regenerated. There were fewer microglia and macrophages in the G-CSF group than in the control group. The levels of brain-derived neurotrophic factor were comparable between the 2 groups.

CONCLUSION

Delayed G-CSF treatment at the subacute stage of severe contusive SCI promoted spinal cord preservation and improved functional outcomes. The mechanism of G-CSF's protection may be related in part to attenuating the infiltration of microglia and macrophages.

Spinal cord injuries in older children: is there a role for high-dose methylprednisolone?

We present a retrospective case series of 15 children (aged 8-16 years) with blunt traumatic spinal cord injury who were treated with methylprednisolone as per the National Acute Spinal Cord Injury Study protocol. Of all patients, 12 (80%) were male. Causes were sports injuries (n = 9), motor vehicle crashes (n = 2), and falls (n = 4). Most injuries were nonskeletal (n = 14), and all patients had incomplete injury of the spinal cord. The most common location of tenderness was cervical (n = 7). Of the 15 patients, methylprednisolone was initiated within 3 hours in 13 patients and between 3 and 8 hours in 2 patients. All patients received the medication for 23 hours as per the National Acute Spinal Cord Injury Study protocol. Of the 15 patients, 13 recovered completely by 24 hours and were discharged with a diagnosis of spinal cord concussion. One patient had compression fracture of T5 and T3-T5 spinal contusion but no long-term neurological deficit. One patient was discharged with diagnosis of C1-C3 spinal cord contusion (by magnetic resonance imaging) and had partial recovery at 2 years after injury. All patients with a diagnosis of cord concussion had normal plain films of the spine and computed tomographic and magnetic resonance imaging findings. None of the patients had any associated major traumatic injuries to other organ systems. The high-dose steroid therapy did not result in any serious bacterial infections.

Non-operative management is superior to surgical stabilization in spine injury patients with complete neurological deficits: A perspective study from a developing world country, Pakistan

Background:

Surgical stabilization of injured spine in patients with complete spinal cord injury is a common practice despite the lack of strong evidence supporting it. The aim of this study is to compare clinical outcomes and cost-effectiveness of surgical stabilization versus conservative management of spinal injury in patients with complete deficits, essentially from a developing country's point of view.

Methods:

A detailed analysis of patients with traumatic spine injury and complete deficits admitted at the Aga Khan University Hospital, Pakistan, from January 2004 till January 2010 was carried out. All patients presenting within 14 days of injury were divided in two groups, those who underwent stabilization procedures and those who were managed non-operatively. The two groups were compared with the endpoints being time to rehabilitation, length of hospital stay, 30 day morbidity/mortality, cost of treatment, and status at follow up.

Results:

Fifty-four patients fulfilled the inclusion criteria and half of these were operated. On comparing endpoints, patients in the operative group took longer time to rehabilitation (P-value = 0.002); had longer hospital stay (P-value = 0.006) which included longer length of stay in special care unit (P-value = 0.002) as well as intensive care unit (P-value = 0.004); and were associated with more complications, especially those related to infections (P-value = 0.002). The mean cost of treatment was also significantly higher in the operative group (USD 6,500) as compared to non-operative group (USD 1490) (P-value < 0.001).

Conclusion:

We recommend that patients with complete SCI should be managed non-operatively with a provision of surgery only if their rehabilitation is impeded due to pain or deformity.

Variability in the treatment of acute spinal cord injury in the United Kingdom: results of a national survey

The aim of this study was to examine how traumatic spinal cord injury is managed in the United Kingdom via a questionnaire survey of all neurosurgical units. We contacted consultant neurosurgeons and neuroanesthetists in all neurosurgical centers that manage patients with acute spinal cord injury. Two clinical scenarios-of complete and incomplete cervical spinal cord injuries-were given to determine local treatment policies. There were 175 responders from the 33 centers (36% response rate). We ascertained neurosurgical views on urgency of transfer, timing of surgery, nature and aim of surgery, as well as neuroanesthetic views on type of anesthetic, essential intraoperative monitoring, drug treatment, and intensive care management. Approximately 70% of neurosurgeons will admit patients with incomplete spinal cord injury immediately, but only 40% will admit patients with complete spinal cord injury immediately. There is no consensus on the timing or even the role of surgery for incomplete or complete injuries. Most (96%) neuroanesthetists avoid anesthetics known to elevate intracranial pressure. What was deemed essential intraoperative monitoring, however, varied widely. Many (22%) neuroanesthetists do not routinely measure arterial blood pressure invasively, central venous pressure (85%), or cardiac output (94%) during surgery. There is no consensus among neuroanesthetists on the optimal levels of arterial blood pressure, or oxygen and carbon dioxide partial arterial pressure. We report wide variability among U.K. neurosurgeons and neuroanesthetists in their treatment of acute traumatic spinal cord injury. Our findings reflect the lack of Class 1 evidence that early surgical decompression and intensive medical management of patients with spinal cord injury improves neurological outcome.

Radiological and clinical results of laminectomy and posterior stabilization for severe thoracolumbar burst fracture : surgical technique for one-stage operation

OBJECTIVE

This study aimed to show the possibility of neural canal enlargement and restoration of bony fragments through laminectomy and minimal facetectomy without pediculectomy or an anterior approach, and also to prove the adequacy of posterior stabilization of vertebral deformities after thoracolumbar bursting fracture.

METHODS

From January 2003 to June 2009, we experienced 45 patients with thoracolumbar burst fractures. All patients enrolled were presented with either a neural canal compromise of more than 40% with a Benzel-Larson Grade of VI, or more than 30% compromise with less than a Benzel-Larson Grade of V. Most important characteristic of our surgical procedure was repositioning retropulsed bone fragments using custom-designed instruments via laminectomy and minimal facetectomy without removing the fractured bone fragments. Beneath the dural sac, these custom-designed instruments could push the retropulsed bone fragments within the neural canal after the decompression and bone fragment repositioning.

RESULTS

The mean kyphotic deformities measured preoperatively and at follow-up within 12 months were 17.7 degrees (±6.4 degrees) and 9.6 degrees (±5.2 degrees), respectively. The mean midsagittal diameter improved from 8.8 mm (±2.8 mm) before surgery to 14.2 mm (±1.6 mm) at follow-up. The mean traumatic vertebral body height before surgery was 41.3% (±12.6%). At follow-up assessment within 12 months, this score showed a statistically significant increase to 68.3% (±12.8%). Neurological improvement occurred in all patients.

CONCLUSION

Though controversy exists in the treatment of severe thoracolumbar burst fracture, we achieved effective radiological and clinical results in the cases of burst fractures causing severe canal compromise and spinal deformity by using this novel custom-designed instruments, via posterior approach alone.

Surgical intensive care unit--the trauma surgery perspective

PURPOSE

This review addresses and summarizes the key issues and unique specific intensive care treatment of adult patients from the trauma surgery perspective.

MATERIALS AND METHODS

The cornerstones of successful surgical intensive care management are fluid resuscitation, transfusion protocol and extracorporeal organ replacement therapies. The injury-type specific complications and unique pathophysiologic regulatory mechanisms of the traumatized patients influencing the critical care treatment are discussed.

CONCLUSIONS

Furthermore, the fundamental knowledge of the injury severity, understanding of the trauma mechanism, surgical treatment strategies and specific techniques of surgical intensive care are pointed out as essentials for a successful intensive care therapy.

Corticoterapia em altas doses no traumatizado medular: benefício ou prejuízo?

As sequelas das lesões traumáticas da espinal medula representam um elevado prejuízo pessoal, familiar e social. Desde 1984, foi investigado e proposto o tratamento com succinato sódico metilprednisolona em altas doses, como forma de reverter ou prevenir o agravamento dessas lesões. Apresentamos uma revisão da literatura sobre essa temática. Sabe-se que essa terapêutica tem uma elevada taxa de complicações, mas, acerca das suas vantagens e real eficácia, não existe concordância entre autores de trabalhos. Enquanto uns a defendem, outros chegam a considerar provada a sua total contraindicação nessa patologia. Já existem, em nível mundial, alguns centros que não fazem a sua administração. Em Portugal é prática generalizada a sua utilização. Não o fazer poderia mesmo ser difícil de defender em situação de litígio. Mas será que estamos mesmo a ajudar os nossos doentes?

Clinical and experimental advances in regeneration of spinal cord injury

Spinal cord injury (SCI) is one of the major disabilities dealt with in clinical rehabilitation settings and is multifactorial in that the patients suffer from motor and sensory impairments as well as many other complications throughout their lifetimes. Many clinical trials have been documented during the last two decades to restore damaged spinal cords. However, only a few pharmacological therapies used in clinical settings which still have only limited effects on the regeneration, recovery speed, or retraining of the spinal cord. In this paper, we will introduce recent clinical trials, which performed pharmacological treatments and cell transplantations for patients with SCI, and evaluate recent in vivo studies for the regeneration of injured spinal cord, including stem-cell transplantation, application of neurotrophic factors and suppressor of inhibiting factors, development of biomaterial scaffolds and delivery systems, rehabilitation, and the combinations of these therapies to evaluate what can be appropriately applied in the future to the patients with SCI.

The effect of mesenchymal stem cell transplantation on the recovery of bladder and hindlimb function after spinal cord contusion in rats

Background

Mesenchymal stem cells are widely used for transplantation into the injured spinal cord in vivo model and for safety, many human clinical trials are continuing to promote improvements of motor and sensory functions after spinal cord injury. Yet the exact mechanism for these improvements remains undefined. Neurogenic bladder following spinal cord injury is the main problem decreasing the quality of life for patients with spinal cord injury, but there are no clear data using stem cell transplantation for the improvement of neurogenic bladder for in vivo studies and the clinical setting.

The purpose of this study was to delineate the effect of human mesenchymal stem cell (hMSCs) transplantation on the restoration of neurogenic bladder and impaired hindlimb function after spinal cord contusion of rats and the relationship between neurotrophic factors such as brain derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) and bladder and hindlimb functions.

Results

Modified moderate contusion injury were performed on the thoracic spinal cord of Sprague-Dawley rats using MASCIS impactor and hMSCs, human fibroblasts or phosphate-buffered saline were transplanted into injured spinal cord 9 days after injury for hMSC and two control groups respectively. Ladder test showed more rapid restoration of hindlimb function in hMSC group than in control group, but Basso, Beattie, and Bresnahan score and coupling score were not different significantly among hMSC and two control groups. Neurogenic bladder was not improved in either group. ED1 positive macrophages were significantly reduced in hMSC group than in two control groups, but ELISA and RT-PCR studies revealed BDNF and NT-3 levels in spinal cord and bladder were not different among hMSC and two control groups regardless the experimental duration.

Conclusion

hMSC transplantation was effective in reducing inflammatory reaction after spinal cord contusion of rats but not sufficient to recover locomotor and bladder dysfunction. BDNF and NT-3 levels in the spinal cord and bladder were not increased 28 and 56 days after hMSC transplantation.

Development of superparamagnetic high-magnetization C18-functionalized magnetic silica nanoparticles as sorbents for enrichment and determination of methylprednisolone in rat plasma by high performance liquid chromatography

In this study, a novel extraction and enrichment technique based on superparamagnetic high-magnetization C(18)-functionalized magnetic silica nanoparticles (C(18)-MNPs) as sorbents was successfully developed for the determination of methylprednisolone (MP) in rat plasma by high performance liquid chromatography (HPLC). The synthesized silica-coated magnetite modified with chlorodimethyl-n-octadecylsilane was about 320 nm in diameter with strong magnetism and high surface area. It provided an efficient way for extraction and concentration of MP in the samples through hydrophobic interaction by the interior C(18) groups. Moreover, MP adsorbed with C(18)-MNPs could be simply and rapidly isolated through placing a strong magnet on the bottom of container, and then easily eluted from C(18)-MNPs by n-hexane solution. Extraction conditions such as amounts of C(18)-MNPs added, adsorption time and desorption solvent, were investigated. Method validations including linear range, detection limit, precision, and recovery were also studied. The results showed that the proposed method based on C(18)-MNPs was a simple, accurate and high efficient approach for the analysis of MP in the complex plasma samples.

Neuroprotective effects of tamoxifen on experimental spinal cord injury in rats

The aim of this study was to evaluate the effects of tamoxifen on tumor necrosis factor alpha (TNF-alpha) and interleukin 1beta (IL-1beta) levels and ultrastructural changes in rats with spinal cord injury. Rats were divided into four groups: control group (laminectomy only), trauma group (laminectomy+spinal trauma), tamoxifen group (laminectomy+spinal trauma+tamoxifen), and vehicle group (laminectomy+spinal trauma+vehicle). Spinal cords were extirpated at the T(7)-T(12) level and tissue samples from the spinal cords were gathered for TNF-alpha and IL-1beta measurements at 1 and 6hours. Spinal cords harvested at 6 hours were evaluated for ultrastructural changes. TNF-alpha and IL-1beta levels at 6 hours were significantly lower in the tamoxifen group than in the trauma group. Electron microscopic examination of tissue from the trauma group revealed gross cell deformities with widespread edema of all structures as well as severe edema in the neuropil. At 6 hours after trauma, these ultrastructural changes were less marked in the tamoxifen group. Our findings support a neuroprotective and restorative role for tamoxifen in the context of secondary pathological biochemical events after SCI.

Cell replacement therapies to promote remyelination in a viral model of demyelination

Persistent infection of the central nervous system (CNS) of mice with the neuroadapted JHM strain of mouse hepatitis (MHV) is characterized by ongoing demyelination mediated by inflammatory T cells and macrophages that is similar both clinically and histologically with the human demyelinating disease multiple sclerosis (MS). Although extensive demyelination occurs in mice persistently infected with MHV there is only limited remyelination. Therefore, the MHV model of demyelination is a relevant model for studying disease and evaluating therapeutic approaches to protect cells of the oligodendrocyte lineage and promote remyelination. This concept is further highlighted as the etiology of MS remains enigmatic, but viruses have long been considered as potential triggering agents in initiating and/or maintaining MS symptoms. As such, understanding mechanisms associated with promoting repair within the CNS in the context of a persistent viral infection is critical given the possible viral etiology of MS. This review focuses on recent studies using either mouse neural stem cells (NSCs) or human oligodendrocyte progenitor cells (OPCs) derived from human embryonic stem cell (hESC) to promote remyelination in mice persistently infected with MHV. In addition, the potential role for chemokines in positional migration of transplanted cells is addressed.

Early metabolic reactivation versus antioxidant therapy after a traumatic spinal cord injury in adult rats

Disability after traumatic spinal cord injury (TSCI) results from physical trauma and from "secondary mechanisms of injury" such as low metabolic energy levels, oxidative damage and lipid peroxidation. In order to prove if early metabolic reactivation is a better therapeutic option than antioxidant therapy in the acute phase of TSCI, spinal cord contusions were performed in adult rats using a well-characterized weight drop technique at thoracic 9 level. After TSCI, pyrophosphate of thiamine or non-degradable cocarboxylase (NDC) enzyme was used to maintain energy levels, antioxidants such as superoxide dismutase and catalase (ANT) were used to decrease oxidative damage and methylprednisolone (MP), which has both therapeutic properties, was used as a control. Rats were divided into one sham group and six with TSCI; one of them received no treatment, and the rest were treated with NDC, MP, NDC + MP, NDC + ANT or ANT. The ANT group decreased lactate and creatine phosphokinase levels and increased the amount of preserved tissue (morphometric analysis) as well as functional recovery (Basso, Beattie and Bresnahan or BBB motor scale). In contrast, NDC treatment increased lipid peroxidation, measured through thiobarbituric acid reactive substances (TBARS) levels, as well as spinal cord tissue destruction and functional deficit. Early metabolic reactivation after a TSCI may be deleterious, while natural early metabolic inhibition may not be a "secondary mechanism of injury" but a "secondary neuroprotective response". While increased antioxidant defence after a TSCI may currently be an ideal therapeutic strategy, the usefulness of metabolic reactivation should be tested in the sub-acute or chronic phases of TSCI and new strategies must continue to be tested for the early ones.

Effect of cyclosporin A on functional recovery in the spinal cord following contusion injury

Considerable evidence has shown that the immunosuppressant drug cyclosporin A (CsA) may have neuroprotective properties which can be exploited in the treatment of spinal cord injury. The aim of this study was to investigate the cellular environment within the spinal cord following injury and determine whether CsA has an effect on altering cellular interactions to promote a growth-permissive environment. CsA was administered to a group of rats 4 days after they endured a moderate contusion injury. Functional recovery was assessed using the Basso Beattie Bresnahan (BBB) locomotor rating scale at 3, 5 and 7 weeks post-injury. The rats were sacrificed 3 and 7 weeks post-injury and the spinal cords were sectioned, stained using histological and immunohistochemical methods and analysed. Using stereology, the lesion size and cellular environment in the CsA-treated and control groups was examined. Little difference in lesion volume was observed between the two groups. An improvement in functional recovery was observed within CsA-treated animals at 3 weeks. Although we did not see significant reduction in tissue damage, there were some notable differences in the proportion of individual cells contributing to the lesion. CsA administration may be used as a technique to control the cell population of the lesion, making it more permissive to neuronal regeneration once the ideal environment for regeneration and the effects of CsA administration at different time points post-injury have been identified.

Acute rolipram/thalidomide treatment improves tissue sparing and locomotion after experimental spinal cord injury

Traumatic spinal cord injury (SCI) causes severe and permanent functional deficits due to the primary mechanical insult followed by secondary tissue degeneration. The cascade of secondary degenerative events constitutes a range of therapeutic targets which, if successfully treated, could significantly ameliorate functional loss after traumatic SCI. During the early hours after injury, potent pro-inflammatory cytokines, including tumor necrosis factor alpha (TNF-alpha) and interleukin-1 beta (IL-1beta) are synthesized and released, playing key roles in secondary tissue degeneration. In the present investigation, the ability of rolipram and thalidomide (FDA approved drugs) to reduce secondary tissue degeneration and improve motor function was assessed in an experimental model of spinal cord contusion injury. The combined acute single intraperitoneal administration of both drugs attenuated TNF-alpha and IL-1beta production and improved white matter sparing at the lesion epicenter. This was accompanied by a significant (2.6 point) improvement in the BBB locomotor score by 6 weeks. There is, at present, no widely accepted intervention strategy that is appropriate for the early treatment of human SCI. The present data suggest that clinical trials for the acute combined application of rolipram and thalidomide may be warranted. The use of such "established drugs" could facilitate the early initiation of trials.

ATLS(R) and damage control in spine trauma

Substantial inflammatory disturbances following major trauma have been found throughout the posttraumatic course of polytraumatized patients, which was confirmed in experimental models of trauma and in vitro settings. As a consequence, the principle of damage control surgery (DCS) has developed over the last two decades and has been successfully introduced in the treatment of severely injured patients. The aim of damage control surgery and orthopaedics (DCO) is to limit additional iatrogenic trauma in the vulnerable phase following major injury. Considering traumatic brain and acute lung injury, implants for quick stabilization like external fixators as well as decided surgical approaches with minimized potential for additional surgery-related impairment of the patient's immunologic state have been developed and used widely. It is obvious, that a similar approach should be undertaken in the case of spinal trauma in the polytraumatized patient. Yet, few data on damage control spine surgery are published to so far, controlled trials are missing and spinal injury is addressed only secondarily in the broadly used ATLS(R) polytrauma algorithm. This article reviews the literature on spine trauma assessment and treatment in the polytrauma setting, gives hints on how to assess the spine trauma patient regarding to the ATLS(R) protocol and recommendations on therapeutic strategies in spinal injury in the polytraumatized patient.