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Kwon BK, Hillyer J, Tetzlaff W. Translational research in spinal cord injury: a survey of opinion from the SCI community. J Neurotrauma 2010; 27:21-33. [PMID: 19751098 DOI: 10.1089/neu.2009.1048] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Much like our colleagues studying neuroprotection for acute stroke, we in the spinal cord injury (SCI) community have witnessed the preclinical emergence of numerous promising neuroprotective and neuro-regenerative treatments that have then disappointingly failed to demonstrate convincing efficacy in clinical trials. In contrast to the stroke field, the SCI community lacks guidelines to steer the preclinical development of therapies and maximize their chance of success prior to translation into expensive and laborious clinical trials. We conducted a survey of the SCI research community to garner perspectives on the question of what preclinical evidence was required before translating an experimental treatment into clinical trials. The opinions of the 324 respondents about what constitutes necessary preclinical evidence before moving to human SCI trials revealed strong support for the demonstration of efficacy in large-animal models, cervical injury models, and for independent replication of promising results. Marked differences exist between the sentiments of the respondents and the translational experience of our field. A framework for guiding the preclinical development of novel therapies prior to human translation would be helpful for ensuring clinical success. Greater dialogue on this issue is necessary to improve our chances of successfully bringing effective treatments to patients with this devastating injury.
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Affiliation(s)
- Brian K Kwon
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.
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202
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Pandya KA, Weant KA, Cook AM. High-dose methylprednisolone in acute spinal cord injuries: proceed with caution. Orthopedics 2010; 33:327-31. [PMID: 20507035 DOI: 10.3928/01477447-20100225-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Komal A Pandya
- University of Kentucky, UK HealthCare, Lexington, KY, USA
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203
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Potentializing the effects of GM1 by hyperbaric oxygen therapy in acute experimental spinal cord lesion in rats. Spinal Cord 2010; 48:808-13. [PMID: 20421874 DOI: 10.1038/sc.2010.37] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Experimental, controlled, animal study. OBJECTIVES To evaluate the effect of GM1 ganglioside, hyperbaric oxygen and both in combination, in the treatment of experimental spinal cord lesions in rats. SETTING Brazil. METHODS Thirty-two Wistar rats with spinal cord lesions were divided into four groups: one group received GM1 ganglioside, one was submitted to hyperbaric oxygen therapy (HBOT), the third received both treatments and the fourth received no treatment (control). RESULTS There were no significant differences between the groups in the histological analysis, for any of the variables (necrosis, hemorrhage, hyperemia, cystic degeneration, P>0.06). Neither were there any significant differences in the comparison of left and right sides in the functional tests (P>0.06 for all). No significant differences were found in the locomotor ratings, in the comparison of groups at 2, 7, 21 and 28 days after the surgical procedure. However, in the evaluation on day 14, group 3, which received the combined therapy, showed a significantly higher Basso Beattie and Bresnahan score than the other groups (P=0.015). CONCLUSION The therapeutic effect of GM1 in locomotor evaluation of rats submitted to spinal cord lesion is anticipated by HBOT.
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A phase 2 autologous cellular therapy trial in patients with acute, complete spinal cord injury: pragmatics, recruitment, and demographics. Spinal Cord 2010; 48:798-807. [PMID: 20386555 DOI: 10.1038/sc.2010.29] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
STUDY DESIGN Post hoc analysis from a randomized controlled cellular therapy trial in acute, complete spinal cord injury (SCI). OBJECTIVES Description and quantitative review of study logistics, referral patterns, current practice patterns and subject demographics. SETTING Subjects were recruited to one of six international study centers. METHODS Data are presented from 1816 patients pre-screened, 75 participants screened and 50 randomized. RESULTS Of the 1816 patients pre-screened, 53.7% did not meet initial study criteria, primarily due to an injury outside the time window (14 days) or failure to meet neurological criteria (complete SCI between C5 motor/C4 sensory and T11). MRIs were obtained on 339 patients; 51.0% were ineligible based on imaging criteria. Of the 75 participants enrolled, 25 failed screening (SF), leaving 50 randomized. The primary reason for SF was based on the neurological exam (51.9%), followed by failure to meet MRI criteria (22.2%). Of the 50 randomized subjects, there were no significant differences in demographics in the active versus control arms. In those participants for whom data was available, 93.8% (45 of 48) of randomized participants received steroids before study entry, whereas 94.0% (47 of 50) had spine surgery before study enrollment. CONCLUSION The 'funnel effect' (large numbers of potentially eligible participants with a small number enrolled) impacts all trials, but was particularly challenging in this trial due to eligibility criteria and logistics. Data collected may provide information on current practice patterns and the issues encountered and addressed may facilitate design of future trials.
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205
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Kwon BK, Stammers AM, Belanger LM, Bernardo A, Chan D, Bishop CM, Slobogean GP, Zhang H, Umedaly H, Giffin M, Street J, Boyd MC, Paquette SJ, Fisher CG, Dvorak MF. Cerebrospinal Fluid Inflammatory Cytokines and Biomarkers of Injury Severity in Acute Human Spinal Cord Injury. J Neurotrauma 2010; 27:669-82. [DOI: 10.1089/neu.2009.1080] [Citation(s) in RCA: 213] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Brian K. Kwon
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthea M.T. Stammers
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Lise M. Belanger
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Arlene Bernardo
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Donna Chan
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Carole M. Bishop
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Gerard P. Slobogean
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hongbin Zhang
- Vancouver Spine Program, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Hamed Umedaly
- Department of Anaesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mitch Giffin
- Department of Anaesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John Street
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael C. Boyd
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Surgery, Division of Neurosurgery, University of British Columbia Vancouver, British Columbia, Canada
| | - Scott J. Paquette
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Surgery, Division of Neurosurgery, University of British Columbia Vancouver, British Columbia, Canada
| | - Charles G. Fisher
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marcel F. Dvorak
- Combined Neurosurgical and Orthopaedic Spine Program (CNOSP), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Levi AD, Casella G, Green BA, Dietrich WD, Vanni S, Jagid J, Wang MY. Clinical Outcomes Using Modest Intravascular Hypothermia After Acute Cervical Spinal Cord Injury. Neurosurgery 2010; 66:670-7. [DOI: 10.1227/01.neu.0000367557.77973.5f] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Although a number of neuroprotective strategies have been tested after spinal cord injury (SCI), no treatments have been established as a standard of care.
OBJECTIVE
We report the clinical outcomes at 1-year median follow-up, using endovascular hypothermia after SCI and a detailed analysis of the complications.
METHODS
We performed a retrospective analysis of American Spinal Injury Association and International Medical Society of Paraplegia Impairment Scale (AIS) scores and complications in 14 patients with SCI presenting with a complete cervical SCI (AIS A). All patients were treated with 48 hours of modest (33°C) intravascular hypothermia. The comparison group was composed of 14 age- and injury-matched subjects treated at the same institution.
RESULTS
Six of the 14 cooled patients (42.8%) were incomplete at final follow-up (50.2 [9.7] weeks). Three patients improved to AIS B, 2 patients improved to AIS C, and 1 patient improved to AIS D. Complications were predominantly respiratory and infectious in nature. However, in the control group, a similar number of complications was observed. Adverse events such as coagulopathy, deep venous thrombosis, and pulmonary embolism were not seen in the patients undergoing hypothermia.
CONCLUSION
This study is the first phase 1 clinical trial on the safety and outcome with the use of endovascular hypothermia in the treatment of acute cervical SCI. In this small cohort of patients with SCI, complication rates were similar to those of normothermic patients with an associated AIS A conversion rate of 42.8%.
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Affiliation(s)
- Allan D. Levi
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - Gizelda Casella
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - Barth A. Green
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - W. Dalton Dietrich
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - Steven Vanni
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - Jonathan Jagid
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
| | - Michael Y. Wang
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, Miami, Florida
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207
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Baptiste DC, Tighe A, Fehlings MG. Spinal cord injury and neural repair: focus on neuroregenerative approaches for spinal cord injury. Expert Opin Investig Drugs 2010; 18:663-73. [PMID: 19379122 DOI: 10.1517/13543780902897623] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This review discusses the urgent need for improved therapeutic approaches aimed at restoring function following traumatic spinal cord injury (SCI). The focus of this paper is neuroregenerative approaches for SCI, with a highlighted comparison of recent advances in the field and comparisons to that made by Cethrin (Alseres Pharmaceuticals, Inc.), the leading nerve repair product. OBJECTIVE This review first provides the reader with an understanding of SCI. The market for promising therapeutics that can either intervene in secondary etiological mechanisms or ameliorate symptoms associated with SCI are then discussed. The reader will also learn about Cethrin and its current status in clinical evaluation. METHODS Review of the preclinical literature and clinical SCI trials relevant to the discovery and current development of Cethrin. RESULTS/CONCLUSION In a recently concluded Phase I/IIa clinical trial involving 37 patients with either cervical or thoracic SCIs, the evidence for Cethrin indicates that topical administration of either 0.3, 1, 3 or 6 mg of the recombinant rho inhibitor following surgical decompression is safe. Alseres has announced that planning is underway for a Phase IIB trial of Cethrin to include a placebo arm to assess better the drugs' clinical efficacy.
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Affiliation(s)
- Darryl C Baptiste
- University Health Network, Toronto Western Hospital, Toronto Western Research Institute, Krembil Neuroscience Centre, Toronto, Ontario, Canada.
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208
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Vlasova YA, Zakharova IO, Sokolova TI, Furaev VV, Rychkova MP, Avrova NF. Role of tyrosine kinase of Trk-Receptors in realization of antioxidant effect of ganglioside GM1 in PC12 cells. J EVOL BIOCHEM PHYS+ 2009. [DOI: 10.1134/s0022093009050028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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209
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Extrinsic and intrinsic factors controlling axonal regeneration after spinal cord injury. Expert Rev Mol Med 2009; 11:e37. [PMID: 19968910 DOI: 10.1017/s1462399409001288] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Spinal cord injury is one of the most devastating conditions that affects the central nervous system. It can lead to permanent disability and there are around two million people affected worldwide. After injury, accumulation of myelin debris and formation of an inhibitory glial scar at the site of injury leads to a physical and chemical barrier that blocks axonal growth and regeneration. The mammalian central nervous system thus has a limited intrinsic ability to repair itself after injury. To improve axonal outgrowth and promote functional recovery, it is essential to identify the various intrinsic and extrinsic factors controlling regeneration and navigation of axons within the inhibitory environment of the central nervous system. Recent advances in spinal cord research have opened new avenues for the exploration of potential targets for repairing the cord and improving functional recovery after trauma. Here, we discuss some of the important key molecules that could be harnessed for repairing spinal cord injury.
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210
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Nitric oxide and potassium channels mediate GM1 ganglioside-induced vasorelaxation. Naunyn Schmiedebergs Arch Pharmacol 2009; 380:487-95. [PMID: 19894035 DOI: 10.1007/s00210-009-0469-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2009] [Accepted: 10/15/2009] [Indexed: 12/13/2022]
Abstract
Monosialotetrahexosylganglioside (GM1) is a glycosphingolipid present in most cell membranes that displays antioxidant and neuroprotective properties. It has been recently described that GM1 induces pial vessel vasodilation and increases NO( x ) content in cerebral cortex, which are fully prevented by the nitric oxide synthase inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME). However, it is not known whether GM1 relaxes larger vessels, as well as the mechanisms by which GM1 causes vasorelaxation. In this study, we demonstrate that GM1 (10, 30, 100, 300 microM, 1 and 3 mM) induces vascular relaxation determined by isometric tension studies in rat mesenteric artery rings contracted with 1 microM phenylephrine. The vasorelaxation induced by GM1 was abolished by endothelium removal, by incubation with L-NAME (1 microM), and partially inhibited by the blockade of potassium channels by 1 mM tetraethylammonium, 10 microM glibenclamide, by the soluble guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo[4,3-alpha]quinoxalin-1-one (10 microM), and by 50 nM charybdotoxin, a blocker of large and intermediate conductance calcium-activated potassium channels. Moreover, GM1-induced relaxation was not affected by apamin (50 nM), a small conductance calcium-activated potassium channel blocker. The results indicate that direct and indirect nitric oxide pathways play a pivotal role in vasorelaxation induced by GM1, which is mediated mainly by potassium channels activation. We suggest that vasodilation may underlie some of the biological effects of exogenous GM1 ganglioside.
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211
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Abstract
STUDY DESIGN Retrospective review of prospective database. OBJECTIVE To define the variability of neurologic examination and recovery after nonpenetrating complete thoracic spinal cord injuries (American Spinal Injury Association [ASIA] A). SUMMARY OF BACKGROUND DATA Neurologic examinations after spinal cord injury (SCI) can be difficult and inconsistent. Unlike cervical SCI patients, alterations in thoracic (below T1) complete SCI (ASIA A-based on the ASIA Impairment Scale [AIS]) patients' examinations are based only on sensory testing, thus changes in the neurologic level (NL) are determined only by sensory changes. METHODS A retrospective review of the placebo control patients in a multicenter prospective database used for the pharmacologic trial of Sygen. Patients were included if they had a complete thoracic SCI on initial evaluation, with completed ASIA examinations at follow-up weeks 4, 8, 16, 26, and 52. Specifically, pin prick (PP) and light touch (LT) were assessed and the absolute change was calculated as the number of spinal levels at a given observation time. RESULTS Three thousand one hundred sixty-five patients were initially screened for the Sygen clinical trial, of which 51 were the control placebo patients used in this analysis. Alterations from the baseline examination (PP and LT) were fairly consistent and the median change/recovery in neurologic examination was 1 spinal level. Across all observations postbaseline, the average change for PP was 1.48 +/- 0.13 (mean +/- SE), and for LT, 1.40 +/- 0.13. There were equal proportions of directional changes (none, improved, lost). CONCLUSION Changes in a thoracic complete (ASIA A) SCI patients ASIA examination as measured through sensory methods (PP/LT) are fairly uncommon. The overall examination had only 1- to 2-level variability across patients, indicating minimal change in the sensory examination over the follow-up period. Stability in the ASIA examination as measured through sensory methods has thus been demonstrated over time, making it an excellent tool to monitor changes in neurologic function.
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212
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Geffner LF, Santacruz P, Izurieta M, Flor L, Maldonado B, Auad AH, Montenegro X, Gonzalez R, Silva F. Administration of autologous bone marrow stem cells into spinal cord injury patients via multiple routes is safe and improves their quality of life: comprehensive case studies. Cell Transplant 2009; 17:1277-93. [PMID: 19364066 DOI: 10.3727/096368908787648074] [Citation(s) in RCA: 155] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Presently, there is no cure or effective treatment for spinal cord injury (SCI). Studies in SCI patients have shown that for a treatment to be effective it must primarily improve their quality of life. Numerous studies have shown that stem cells represent an alternative treatment for various disorders and have shown promise in several disease/trauma states. For instance, the use of autologous CD34+ stem cells has been shown to ameliorate symptoms of several disorders such as leukemia, cardiomyopathy, diabetes, and several autoimmune diseases, including multiple sclerosis. For the first time, we report eight case studies of SCI (four acute, four chronic) with approximately 2 years of follow-up that were administered bone marrow stem cells (BMSCs) via multiple routes: directly into the spinal cord, directly into the spinal canal, and intravenous. Magnetic resonance imaging illustrated morphological changes in the spinal cord of some of the patients following BMSCs administration. Comprehensive evaluations demonstrate improvements in ASIA, Barthel (quality of life), Frankel, and Ashworth scoring. Moreover, in order to assess bladder function, we designed a simple numerical clinical scoring system that demonstrates significant changes in bladder function following BMSCs administration. To date, we have administration BMSCs into 52 patients with SCI and have had no tumor formations, no cases of infection or increased pain, and few instances of minor adverse events. These studies demonstrate that BMSCs administration via multiple routes is feasible, safe, and may improve the quality of life for patients living with SCI.
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Affiliation(s)
- L F Geffner
- Hospital Luis Vernaza, JBGYE, Guayaquil, Ecuador
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213
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Risk factors for mortality in traumatic cervical spinal cord injury: Brazilian data. ACTA ACUST UNITED AC 2009; 67:67-70. [PMID: 19590310 DOI: 10.1097/ta.0b013e3181aa63f3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Predictive factors for mortality are different among countries; knowledge of risk factors is important for planning strategies to reduce mortality in trauma. The objective of this study was to identify predictors of death in traumatic cervical spinal cord injury (TSCI) in Brazil. METHODS From 2001 to 2005, 84 patients with clinically detectable TSCI were identified in this retrospective study. For each patient, neurologic and associated injuries, physiologic variables, complications, treatment, and hospital mortality were recorded. Bivariate and multivariate logistic regression analyses were done to identify predictors of mortality. RESULTS Twenty-two (26.2%) patients died in hospital. Car crash (39%) and falls (37.85) were the most frequent causes of trauma. The causes of death were as follows: neurologic, 8 (36.4%); respiratory, 4 (18.2%); septic complications, 2 (9.1%); venous thrombosis and embolism, 2 (9.1%); and undetermined, 4 (18.2%). Bivariate analysis identified absent neurologic function (risk ratios [RR] = 4.5; 95% confidence intervals [CI], 1.6-12.7), high injury severity score (p = 0.001) and low revised trauma score (p = 0.001); Glasgow Coma Scale (GCS) score <9 (RR = 47.4; 95% CI, 5.4-413.2); shock at admission (RR = 2.5; 95% CI, 0.8-7.9); vasopressor use (RR = 25.8; 95% CI, 6.1-109.6); mechanical ventilation (RR = 31.9; 95% CI, 6.6-154.0); acute renal insufficiency (RR = 10.0; 95% CI, 0.98-102.1) as associated with mortality. The mainly independents predictors for mortality were GCS score <9 and vasopressor use. Lowest mortality rate (5.2%) was observed for patients with TSCI alone. CONCLUSIONS GCS score <9, mechanical ventilation, and vasopressor use were predictors of mortality with TCSI, and if these risk factors were absent, we observed low mortality rate.
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214
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Protective and antioxidative effects of GM1 ganglioside in PC12 cells exposed to hydrogen peroxide are mediated by Trk tyrosine kinase. Neurochem Res 2009; 35:85-98. [PMID: 19621257 DOI: 10.1007/s11064-009-0033-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Accepted: 07/03/2009] [Indexed: 10/20/2022]
Abstract
GM1 ganglioside was found to increase the survival of PC12 cells exposed to H(2)O(2), its action was blocked by Trk tyrosine kinase inhibitor K-252a. Thus, the inhibition of H(2)O(2) cytotoxic action by GM1 constituted 52.8 +/- 4.3%, but in the presence of 1.0 microM K-252a it was only 11.7 +/- 10.8%, i.e. the effect of GM1 became insignificant. Exposure to GM1 markedly reduced the increased accumulation of reactive oxygen species (ROS) and diminished the inactivation of Na(+),K(+)-ATPase induced in PC12 cells by H(2)O(2), but in the presence of K-252a GM1 did not change these metabolic parameters. The inhibitors of extracellular signal-regulated protein kinase, phosphatidyl inositol 3-kinase and protein kinase C decreased the effects of GM1. A combination of these protein kinase inhibitors reduced inhibition of H(2)O(2) cytotoxic action by GM1 to the larger extent than each of the inhibitors and practically abolished the ability of GM1 to decrease H(2)O(2)-induced ROS accumulation. The protective and antioxidative effects of GM1 in PC12 cells exposed to H(2)O(2) appear to be mediated by activation of Trk receptor tyrosine kinase and the protein kinases downstream from this enzyme.
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216
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Kulbatski I, Tator CH. Region-specific differentiation potential of adult rat spinal cord neural stem/precursors and their plasticity in response to in vitro manipulation. J Histochem Cytochem 2009; 57:405-23. [PMID: 19124840 PMCID: PMC2675070 DOI: 10.1369/jhc.2008.951814] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 12/08/2008] [Indexed: 11/22/2022] Open
Abstract
This study characterized the differentiation of neural stem/precursor cells (NSPCs) isolated from different levels of the spinal cord (cervical vs lumbar cord) and different regions along the neuraxis (brain vs cervical spinal cord) of adult male Wistar enhanced green fluorescent protein rats. The differentiation of cervical spinal cord NSPCs was further examined after variation of time in culture, addition of growth factors, and changes in cell matrix and serum concentration. Brain NSPCs did not differ from cervical cord NSPCs in the percentages of neurons, astrocytes, or oligodendrocytes but produced 26.9% less radial glia. Lumbar cord NSPCs produced 30.8% fewer radial glia and 6.9% more neurons compared with cervical cord NSPCs. Spinal cord NSPC differentiation was amenable to manipulation by growth factors and changes in in vitro conditions. This is the first study to directly compare the effect of growth factors, culturing time, serum concentration, and cell matrix on rat spinal cord NSPCs isolated, propagated, and differentiated under identical conditions.
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Affiliation(s)
- Iris Kulbatski
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.
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217
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218
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Ahn H, Fehlings MG. Prevention, identification, and treatment of perioperative spinal cord injury. Neurosurg Focus 2009; 25:E15. [PMID: 18980475 DOI: 10.3171/foc.2008.25.11.e15] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this report, the authors suggest evidence-based approaches to minimize the chance of perioperative spinal cord injury (POSCI) and optimize outcome in the event of a POSCI. METHODS A systematic review of the basic science and clinical literature is presented. RESULTS Authors of clinical studies have assessed intraoperative monitoring to minimize the chance of POSCI. Furthermore, preoperative factors and intraoperative issues that place patients at increased risk of POSCI have been identified, including developmental stenosis, ankylosing spondylitis, preexisting myelopathy, and severe deformity with spinal cord compromise. However, no studies have assessed methods to optimize outcomes specifically after POSCIs. There are a number of studies focussed on the pathophysiology of SCI and the minimization of secondary damage. These basic science and clinical studies are reviewed, and treatment options outlined in this article. CONCLUSIONS There are a number of treatment options, including maintenance of mean arterial blood pressure > 80 mm Hg, starting methylprednisolone treatment preoperatively, and multimodality monitoring to help prevent POSCI occurrence, minimize secondary damage, and potentially improve the clinical outcome of after a POSCI. Further prospective cohort studies are needed to delineate incidence rate, current practice patterns for preventing injury and minimizing the clinical consequences of POSCI, factors that may increase the risk of POSCI, and determinants of clinical outcome in the event of a POSCI.
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Affiliation(s)
- Henry Ahn
- Division of Orthopaedic Surgery, University of Toronto Spine Program, Toronto, Canada
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219
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Hawryluk GWJ, Rowland J, Kwon BK, Fehlings MG. Protection and repair of the injured spinal cord: a review of completed, ongoing, and planned clinical trials for acute spinal cord injury. Neurosurg Focus 2009; 25:E14. [PMID: 18980474 DOI: 10.3171/foc.2008.25.11.e14] [Citation(s) in RCA: 185] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Over the past 2 decades, advances in understanding the pathophysiology of spinal cord injury (SCI) have stimulated the recent emergence of several therapeutic strategies that are being examined in Phase I/II clinical trials. Ten randomized controlled trials examining methylprednisolone sodium succinate, tirilizad mesylate, monosialotetrahexosylganglioside, thyrotropin releasing hormone, gacyclidine, naloxone, and nimodipine have been completed. Although the primary outcomes in these trials were laregely negative, a secondary analysis of the North American Spinal Cord Injury Study II demonstrated that when administered within 8 hours of injury, methylprednisolone sodium succinate was associated with modest clinical benefits, which need to be weighed against potential complications. Thyrotropin releasing hormone (Phase II trial) and monosialotetrahexosylganglioside (Phase II and III trials) also showed some promise, but we are unaware of plans for future trials with these agents. These studies have, however, yielded many insights into the conduct of clinical trials for SCI. Several current or planned clinical trials are exploring interventions such as early surgical decompression (Surgical Treatment of Acute Spinal Cord Injury Study) and electrical field stimulation, neuroprotective strategies such as riluzole and minocycline, the inactivation of myelin inhibition by blocking Nogo and Rho, and the transplantation of various cellular substrates into the injured cord. Unfortunately, some experimental and poorly characterized SCI therapies are being offered outside a formal investigational structure, which will yield findings of limited scientific value and risk harm to patients with SCI who are understandably desperate for any intervention that might improve their function. Taken together, recent advances suggest that optimism for patients and clinicians alike is justified, as there is real hope that several safe and effective therapies for SCI may become available over the next decade.
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Affiliation(s)
- Gregory W J Hawryluk
- Division of Genetics and Development, Toronto Western Research Institute, Toronto, Ontario, Canada
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220
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The efficacy of erythropoietin on acute spinal cord injury. An experimental study on a rat model. Arch Orthop Trauma Surg 2009; 129:189-94. [PMID: 18309506 DOI: 10.1007/s00402-008-0594-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The accumulated knowledge of erythropoietin (EPO) interaction in neural injury has led to potentially novel therapeutic strategies. Previous experimental studies of recombinant human EPO (rhEPO) administration have shown favorable results after central and peripheral neural injury. In the present study we used the aneurysmal clip model to evaluate the efficacy of two different regimes of rhEPO administration on the functional outcome after severe acute spinal cord injury (ASCI). MATERIALS AND METHODS Thirty rats were operated on with posterior laminectomy at thoracic 10th vertebra. Spinal cord trauma produced by extradural placement of the aneurysm clip, for 1 min. Animals were divided into three groups; the first group received a low total EPO dose (EPO-L), (2 doses of 1,000 IU each s.c.). The second group was administered the high total EPO dose (EPO-H), (14 doses of 1,000 IU each s.c.), and the third was the Control group, which received normal saline in the same time fashion with EPO-H group. Follow-up was for 6 weeks. Estimation of the functional progress of each rat was calculated using the locomotor rating scale of Basso et al, with a range from 0 to 21. RESULTS After surgery the animals suffered paraplegia with urinary disturbances. Rats that received EPO demonstrated statistically significant functional improvement compared to the Control group, throughout study interval. On the last follow-up at 6 weeks the EPO-L rats achieved a mean score 17.3 +/- 1.15, the EPO-H 14.7 +/- 1.82, and the control group 8.2 +/- 0.78. Comparison between the two EPO groups reveals superior final outcome of the group treated with lower total dose. CONCLUSION Our study supports current knowledge, that EPO administration has a positive effect on functional recovery after experimental ASCI. These data reflect the positive impact of EPO on the pathophysiologic cascade of secondary neural damage. However, we observed a dose-related effect on functional recovery. Interestingly, large doses do not seem to favor the neurological recovery as lower doses do.
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Sharma HS. New perspectives for the treatment options in spinal cord injury. Expert Opin Pharmacother 2009; 9:2773-800. [PMID: 18937612 DOI: 10.1517/14656566.9.16.2773] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Spinal cord injury (SCI) is a serious clinical disorder that leads to lifetime disability for which no suitable therapeutic agents are available so far. Further research is needed to understand the basic mechanisms of spinal cord pathology that results in permanent disability and poses a heavy burden on our society. In the past, a lot of effort was placed on improving functional outcome with the help of various therapeutic agents, however less attention has been paid on the development and propagation of spinal cord pathology over time. Thus, it is still unclear whether improvement of functional outcome is related to spinal cord pathology or vice versa. Few drugs are able to influence functional outcome without having any improvement on cord pathology. Some drugs, however, can lessen cord pathology but fail to influence the functional outcome. The goal of future treatment options for SCI is therefore to find suitable new drugs or a combination of existing drugs and to use various cellular transplants, neurotrophic factors, myelin-inhibiting factors, tissue engineering and nano-drug delivery to improve both the functional and the pathological outcome in the inured patient. This review deals with the key aspects of the latest treatments for SCI and suggests some possible future therapeutic measures to enhance healthcare in clinical situations.
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Affiliation(s)
- Hari Shanker Sharma
- Uppsala University, University Hospital, Laboratory of Cerebrovascular Research, Department of Surgical Sciences, Anaesthesiology & Intensive Care Medicine, SE-75185 Uppsala, Sweden.
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van Middendorp JJ, Hosman AJF, Pouw MH, Van de Meent H. ASIA impairment scale conversion in traumatic SCI: is it related with the ability to walk? A descriptive comparison with functional ambulation outcome measures in 273 patients. Spinal Cord 2008; 47:555-60. [DOI: 10.1038/sc.2008.162] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Transcriptomic screening of microvascular endothelial cells implicates novel molecular regulators of vascular dysfunction after spinal cord injury. J Cereb Blood Flow Metab 2008; 28:1771-85. [PMID: 18612314 PMCID: PMC2756605 DOI: 10.1038/jcbfm.2008.76] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Microvascular dysfunction is a critical pathology that underlies the evolution of secondary injury mechanisms after traumatic spinal cord injury (SCI). However, little is known of the molecular regulation of endothelial cell (EC) plasticity observed acutely after injury. One reason for this is the relative lack of methods to quickly and efficiently obtain highly enriched spinal microvascular ECs for high-throughput molecular and biochemical analyses. Adult C57Bl/6 mice received an intravenous injection of fluorescein isothiocyanate (FITC)-conjugated Lycopersicon esculentum lectin, and FITC-lectin-bound spinal microvessels were greatly enriched by fluorescence-activated cell sorter (FACS) purification. This technique allows for rapid (<1.5 h postmortem) isolation of spinal cord microvascular ECs (smvECs). The results from cell counting, reverse-transcription polymerase chain reaction (RT-PCR), and western blot analyses show a high degree of EC enrichment at mRNA and protein levels. Furthermore, a focused EC biology microarray analysis identified multiple mRNAs dramatically increased in the EC compartment 24 h after SCI, which is a time point associated with the pathologic loss of spinal vasculature. These included thrombospondin-1, CCL5/RANTES, and urokinase plasminogen activator, suggesting they may represent targets for therapeutic intervention. Furthermore, these novel methodologic approaches will likely facilitate the discovery of molecular regulators of endothelial dysfunction in a variety of central nervous system (CNS) disorders including stroke and other neurodegenerative diseases having a vascular component.
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Furlan JC, Fehlings MG, Tator CH, Davis AM. Motor and Sensory Assessment of Patients in Clinical Trials for Pharmacological Therapy of Acute Spinal Cord Injury: Psychometric Properties of the ASIA Standards. J Neurotrauma 2008; 25:1273-301. [DOI: 10.1089/neu.2008.0617] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Julio C. Furlan
- Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Canada
- Toronto Rehabilitation Institute, University of Toronto, Toronto, Canada
| | - Michael G. Fehlings
- Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Canada
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, and Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Charles H. Tator
- Division of Genetics and Development, Toronto Western Research Institute, University Health Network, Toronto, Canada
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, and Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Aileen M. Davis
- Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, Toronto, Canada
- Department of Physical Therapy and Surgery, and Departments of Rehabilitation Science, Health Policy, Management and Evaluation (Clinical Epidemiology), and Institute of Medical Science, University of Toronto, Toronto, Canada
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Abstract
Biomaterials are widely used to help treat neurological disorders and/or improve functional recovery in the central nervous system (CNS). This article reviews the application of biomaterials in (i) shunting systems for hydrocephalus, (ii) cortical neural prosthetics, (iii) drug delivery in the CNS, (iv) hydrogel scaffolds for CNS repair, and (v) neural stem cell encapsulation for neurotrauma. The biological and material requirements for the biomaterials in these applications are discussed. The difficulties that the biomaterials might face in each application and the possible solutions are also reviewed in this article.
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Affiliation(s)
- Yinghui Zhong
- Neurological Biomaterials and Therapeutics, Laboratory for Neuroengineering, Wallace H Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA 30332, USA
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Sokolova TV, Zakharova IO, Furaev VV, Rychkova MP, Vlasova YA, Avrova NF. A Decrease of neuroprotective effect of ganglioside GM1 on PC12 cells under conditions of oxidative stress in the presence of inhibitor of tyrosine kinase of Trk-receptors. J EVOL BIOCHEM PHYS+ 2008. [DOI: 10.1134/s0022093008040042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Curt A, Van Hedel HJA, Klaus D, Dietz V. Recovery from a spinal cord injury: significance of compensation, neural plasticity, and repair. J Neurotrauma 2008; 25:677-85. [PMID: 18578636 DOI: 10.1089/neu.2007.0468] [Citation(s) in RCA: 211] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Clinical recovery after a lesion of the central nervous system (CNS) can be attributed to mechanisms of functional compensation, neural plasticity, and/or repair. The relative impact of each of these mechanisms after a human spinal cord injury (SCI) has been explored in a prospective European multi-center study in 460 acute traumatic SCI subjects. Functional (activities of daily living and ambulatory capacity), neurological (sensory-motor deficits), and spinal conductivity (motor- and somato-sensory evoked potentials) measures were repeatedly followed over 12 months. In accordance with previous studies, complete SCI subjects (cSCI; n = 217) improved in activities of daily living unrelated to changes of the neurological condition, while incomplete SCI subjects (iSCI; n = 243) showed a greater functional and neurological recovery. The functional recovery in iSCI subjects was not related to an improvement of spinal conductivity, as reflected in unchanged latencies of the evoked potentials. This is in line with animal studies, where spinal conductivity of damaged spinal tracts has been reported to remain unchanged. These findings support the assumption that functional recovery occurs by compensation, especially in cSCI and by neural plasticity leading to a greater improvement in iSCI. Relevant repair of damaged spinal pathways does not take place.
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Affiliation(s)
- Armin Curt
- Spinal Cord Injury Centre, Balgrist University Hospital, Forchstrasse 340, Zurich, Switzerland
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Secondary pathology following contusion, dislocation, and distraction spinal cord injuries. Exp Neurol 2008; 212:490-506. [DOI: 10.1016/j.expneurol.2008.04.038] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Revised: 04/24/2008] [Accepted: 04/28/2008] [Indexed: 12/17/2022]
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Knafo S, Choi D. Clinical studies in spinal cord injury: moving towards successful trials. Br J Neurosurg 2008; 22:3-12. [PMID: 18224516 DOI: 10.1080/02688690701593595] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Spinal cord injury is a devastating condition for which there is still no cure. Many new therapies have emerged in the past few decades that have attempted to improve the outcome after injury, with varying levels of supporting experimental and clinical data. Most studies have been preliminary and have lacked control groups, but positive results can often be embraced by clinicians and patients who are faced without an alternative, despite the poor design and bias of many studies. This article is a review of clinical studies in spinal cord injury and discusses guidelines for future clinical trial design.
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Affiliation(s)
- S Knafo
- Institute of Neurology, University College London, London, UK
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Carvalho MOP, Barros Filho TEPD, Tebet MA. Effects of methylprednisolone and ganglioside GM-1 on a spinal lesion: a functional analysis. Clinics (Sao Paulo) 2008; 63:375-80. [PMID: 18568249 PMCID: PMC2664232 DOI: 10.1590/s1807-59322008000300015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 02/25/2006] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The pharmacological effects of methylprednisolone (MP) and ganglioside GM-1 on spinal injuries have been thoroughly investigated, but only a few studies have evaluated the interaction between these two drugs. METHODS Twenty-four Wistar rats were subjected to contusive injury of the spinal cord produced by the NYU system. These animals were divided into four groups: group I was injected with MP; group II was injected with GM-1; group III was injected with MP together with GM-1; and group control received physiological serum. The animals were evaluated with regard to their recovery of locomotive function by means of the BBB test on the second, seventh and fourteenth days after receiving the contusive injury to the spinal cord. They were sacrificed on the fourteenth day. RESULTS This study demonstrated that the MP and GM-1 groups presented functional results that were better than those of the control group, although the enhanced recovery of group II (GM-1) relative to the control group was not statistically significant (p>0.05). The most notable recovery of locomotive function was observed in the group that received MP alone (p<0.05). The group that received MP together with GM-1 presented results that were better than those of the control group (p<0.05). CONCLUSION Administration of methylprednisolone alone or with GM-1 was shown to be effective for recovery of locomotive function. Combined administration of these drugs resulted in better outcomes than administration of methylprednisolone alone.
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Abstract
BACKGROUND This review summarizes several promising pharmacological approaches for the therapeutic management of traumatic spinal cord injury (SCI), which are either in early-phase clinical trials or nearing clinical translation. OBJECTIVE This review provides the reader with an understanding of the key pathophysiological mechanisms that contribute to neurological deficits after SCI. Through discussion of the mechanism(s) of action of the selected therapeutic approaches potentially important targets to aid further drug discovery will be highlighted. METHODS Systematic literature review of the pre-clinical literature and clinical SCI trials related to neuroprotective, immunomodulatory and regenerative therapeutic approaches. RESULTS/CONCLUSION The next decade will witness an unprecedented number of clinical trials which will seek to translate key biomedical research discoveries. The promising drug-based therapeutic approaches include regenerative strategies to neutralize myelin-mediated neurite outgrowth inhibition, neuroprotective strategies to reduce apoptotic triggers, the targeting of cationic/glutamatergic toxicity, anti-inflammatory strategies and the use of approaches to stabilize disrupted cell membranes.
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Affiliation(s)
- Darryl C Baptiste
- Toronto Western Hospital, Division of Cellular & Molecular Biology, Toronto Western Research Institute and Krembil Neuroscience Centre, 12th Floor Room 407 McLaughlin Pavilion, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada
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Alexander MS. Autonomic function and spinal cord injury: are we at a crossroads? Spinal Cord 2008; 46:402-5. [DOI: 10.1038/sj.sc.3102165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Acute spinal cord injury is a devastating disease with enormous repercussions, not only for the victims and their families but for society as a whole. Despite the advent of novel medical therapies for the treatment of these injuries, many patients with spinal cord injury remain severely incapacitated and dependent on their families and/or specialized nursing care. Much of the controversy in the treatment of these injuries stems from insufficient knowledge about the pathophysiology of the disease as well as the timing of certain treatments such as surgery. We discuss the diagnosis and management of these injuries as well as novel therapies on the horizon. The recent emphasis on evidence-based medicine has resulted in the creation of guidelines from the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, which will hopefully result in some standardization of care. It is our opinion that early recognition of spinal cord injury and careful management in an intensive care setting can prevent many of the medical complications that are the major source of morbidity and mortality in these patients.
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Affiliation(s)
- Ricardo Cortez
- Allan D. Levi, MD, PhD Department of Neurological Surgery, The University of Miami, Miller School of Medicine and The Miami Project to Cure Paralysis, Lois Pope Life Center, 1095 Northwest 14th Terrace, D4-6, Miami, FL 33136, USA.
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Traumatic Injury of the Spine. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ditunno JF, Barbeau H, Dobkin BH, Elashoff R, Harkema S, Marino RJ, Hauck WW, Apple D, Basso DM, Behrman A, Deforge D, Fugate L, Saulino M, Scott M, Chung J. Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial. Neurorehabil Neural Repair 2007; 21:539-50. [PMID: 17507642 PMCID: PMC4080923 DOI: 10.1177/1545968307301880] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To demonstrate criterion (concurrent and predictive) and construct validity of the Walking Index for Spinal Cord Injury (WISCI) scale and other walking measures in the Spinal Cord Injury Locomotor Trial (SCILT). DESIGN Prospective multicenter clinical trial of a walking intervention for patients with acute traumatic spinal cord injury (SCI). PARTICIPANTS/ METHODS: Body weight-supported treadmill training was compared to overground mobility training in 146 patients with incomplete SCI (C4 to L3) enrolled within 8 weeks of onset and treated for 12 weeks. Primary outcome measures were the Functional Independence Measure (FIM), 50-foot walking speed (50FW-S), and 6-minute walking distance (6MW-D), tested 3, 6, and 12 months after entry. Secondary measures were the Lower Extremity Motor Score (LEMS), Berg Balance Scale (BBS), WISCI, and FIM locomotor score (LFIM), assessed at 6 centers by blinded observers. Data for the 2 arms were combined since no significant differences in outcomes had been found. RESULTS Correlations with WISCI at 6 months were significant with BBS (r = .90), LEMS (r = .85), LFIM (r = .89), FIM (r = .77), 50FW-S (r = .85), and 6MW-D ( r = .79); similar correlations occurred at 3 and 12 months. Correlations of change scores from baseline WISCI were significant for change scores from baseline of LEMS/BBS/LFIM. Correlation of baseline LEMS and WISCI at 12 months were most significant (r = .73). The R(2) of baseline LEMS explained 57% of variability of WISCI levels at 3 months. CONCLUSION Concurrent validity of the WISCI scale was supported by significant correlations with all measures at 3, 6, and 12 months. Correlation of change scores supports predictive validity. The LEMS at baseline was the best predictor of the WISCI score at 12 months and explained most of the variance, which supported both predictive and construct validity. The combination of the LEMS, BBS, WISCI, 50FW-S, and LFIM appears to encompass adequate descriptors for outcomes of walking trials for incomplete SCI.
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Affiliation(s)
- John F Ditunno
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Behrman AL, Harkema SJ. Physical rehabilitation as an agent for recovery after spinal cord injury. Phys Med Rehabil Clin N Am 2007; 18:183-202, v. [PMID: 17543768 DOI: 10.1016/j.pmr.2007.02.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The initial level of injury and severity of volitional motor and clinically detectable sensory impairment has been considered the most reliable for predicting neurologic recovery of function after spinal cord injury (SCI). This consensus implies a limited expectation for physical rehabilitation interventions as important in the facilitation of recovery of function. The development of pharmacologic and surgical interventions has always been pursued with the intent of altering the expected trajectory of recovery after SCI, but only recently physical rehabilitation strategies have been considered to improve recovery beyond the initial prognosis. This article reviews the recent literature reporting emerging activity-based therapies that target recovery of standing and walking based on activity-dependent neuroplasticity. A classification scheme for physical rehabilitation interventions is also discussed to aid clinical decision making.
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Affiliation(s)
- Andrea L Behrman
- Department of Physical Therapy, College of Public Health and Health Professions, P.O. Box 100154, University of Florida, Gainesville, FL 32610-0154, USA.
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Zakharova IO, Sokolova TV, Furaev VV, Rychkova MP, Avrova NF. Effects of oxidative stress inhibitors, neurotoxins, and ganglioside GM1 on Na+,K+-ATPase activity in PC12 Cells and brain synaptosomes. J EVOL BIOCHEM PHYS+ 2007. [DOI: 10.1134/s0022093007020056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Sokolova TV, Zakharova IO, Furaev VV, Rychkova MP, Avrova NF. Neuroprotective effect of ganglioside GM1 on the cytotoxic action of hydrogen peroxide and amyloid beta-peptide in PC12 cells. Neurochem Res 2007; 32:1302-13. [PMID: 17401655 DOI: 10.1007/s11064-007-9304-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 01/30/2007] [Indexed: 03/15/2023]
Abstract
Ganglioside GM1 was shown to increase the viability of PC12 cells exposed to hydrogen peroxide or amyloid beta-peptide (Abeta(25-35)). The PC12 cells transfected with mutant gene (expressing APP(SW)) were found to be more sensitive to oxidative stress than the cells transfected with wild type gene (expressing APP(WT)) or vector-transfected cells, GM1 being effective in enhancing the viability of the cells transfected with mutant gene. The exposure to hydrogen peroxide or Abeta(25-35) results in a partial inactivation of Na(+),K(+)-ATPase in PC12 cells, H(2)O(2) increases MDA accumulation in these cells. But these effects could be partially prevented or practically abolished by GM1 ganglioside. In the presence of the inhibitor of tyrosine kinase of Trk receptors (K-252a) the protective and metabolic effects of GM1 on PC12 cells in conditions of oxidative stress caused by hydrogen peroxide are not observed or are markedly diminished.
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Affiliation(s)
- Tatyana V Sokolova
- Department of Comparative Neurochemistry, Institute of Evolutionary Physiology and Biochemistry of Russian Academy of Sciences, St. Petersburg, Russia
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Dobkin B, Barbeau H, Deforge D, Ditunno J, Elashoff R, Apple D, Basso M, Behrman A, Harkema S, Saulino M, Scott M. The evolution of walking-related outcomes over the first 12 weeks of rehabilitation for incomplete traumatic spinal cord injury: the multicenter randomized Spinal Cord Injury Locomotor Trial. Neurorehabil Neural Repair 2007; 21:25-35. [PMID: 17172551 PMCID: PMC4110057 DOI: 10.1177/1545968306295556] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Spinal Cord Injury Locomotor Trial (SCILT) compared 12 weeks of step training with body weight support on a treadmill (BWSTT) that included overground practice to a defined but more conventional overground mobility intervention (CONT) in patients with incomplete traumatic SCI within 8 weeks of onset. No previous studies have reported walking-related outcomes during rehabilitation. METHODS This single-blinded, randomized trial entered 107 American Spinal Injury Association (ASIA) C and D patients and 38 ASIA B patients with lesions between C5 and L3 who were unable to walk on admission for rehabilitation. The Functional Independence Measure (FIM-L) for walking, 15-m walking speed, and lower extremity motor score (LEMS) were collected every 2 weeks. RESULTS No significant differences were found at entry and during the treatment phase (12-week mean FIM-L = 5, velocity = 0.8 m/s, LEMS = 35, distance walked in 6 min = 250 m). Combining the 2 arms, a FIM-L >or= 4 was achieved in < 10% of ASIA B patients, 92% of ASIA C patients, and all of ASIA D patients. Walking speed of >or= 0.6 m/s correlated with a LEMS near 40 or higher. CONCLUSIONS Few ASIA B and most ASIA C and D patients achieved functional walking ability by the end of 12 weeks of BWSTT and CONT, consistent with the primary outcome data at 6 months. Walking-related measures assessed at 2-week intervals reveal that time after SCI is an important variable for entering patients into a trial with mobility outcomes. By about 6 weeks after entry, most patients who will recover have improved their FIM-L to >3 and are improving in walking speed. Future trials may reduce the number needed to treat by entering patients with FIM-L < 4 at > 8 weeks after onset if still graded ASIA B and at > 12 weeks if still ASIA C.
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Affiliation(s)
- B Dobkin
- Department of Neurology, University of California Los Angeles, Los Angeles, CA 90095, USA.
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Baptiste DC, Fehlings MG. Update on the treatment of spinal cord injury. PROGRESS IN BRAIN RESEARCH 2007; 161:217-33. [PMID: 17618980 DOI: 10.1016/s0079-6123(06)61015-7] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Acute spinal cord injury (SCI) is a devastating neurological disorder that can affect any individual at a given instance. Current treatment options for SCI include the use of high dose methylprednisolone sodium succinate, a corticosteroid, surgical interventions to stabilize and decompress the spinal cord, intensive multisystem medical management, and rehabilitative care. While utility of these therapeutic options provides modest benefits, there is a critical need to identify novel approaches to treat or repair the injured spinal cord in hope to, at the very least, improve upon the patient's quality of life. Thankfully, several discoveries at the preclinical level are now transitioning into the clinical arena. These include the Surgical Treatment for Acute Spinal Cord Injury Study (STASCIS) Trial to evaluate the role and timing of surgical decompression for acute SCI, neuroprotection with the semisynthetic second generation tetracycline derivative, minocycline; aiding axonal conduction with the potassium channel blockers, neuroregenerative/neuroprotective approaches with the Rho antagonist, Cethrin; the use of anti-NOGO monoclonal antibodies to augment plasticity and regeneration; as well as cell-mediated repair with stem cells, bone marrow stromal cells, and olfactory ensheathing cells. This review overviews the pathobiology of SCI and current treatment choices before focusing the rest of the discussion on the variety of promising neuroprotective and cell-based approaches that have recently moved, or are very close, to clinical testing.
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Affiliation(s)
- Darryl C Baptiste
- Division of Cell and Molecular Biology, Toronto Western Research Institute and Krembil Neuroscience Centre, Toronto Western Hospital, University of Toronto, ON, Canada
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Tuli S, Tuli J, Coleman WP, Geisler FH, Krassioukov A. Hemodynamic parameters and timing of surgical decompression in acute cervical spinal cord injury. J Spinal Cord Med 2007; 30:482-90. [PMID: 18092565 PMCID: PMC2141731 DOI: 10.1080/10790268.2007.11754582] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2006] [Accepted: 04/17/2007] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND/OBJECTIVES To evaluate the relationship between the severity of cervical spinal cord injury (SCI) (American Spinal Injury Association [ASIA] grade), presence of neurogenic shock, and timing of surgical intervention. This is a post-hoc analysis from the Sygen multicenter randomized controlled trial. METHODS Blood pressure (BP) and heart rate (HR) data were collected when patients were first assessed in the emergency room (Time A) and at the time of randomization (Time B). Individuals were subdivided by ASIA grade and by the level of the systolic BP (SBP). RESULTS Only individuals with cervical SCI from the Sygen trial (n = 577) were evaluated. Severe complete SCI (ASIA grade = A) was established in 57% of these patients. A total of 74 (13%) patients with neurogenic shock (SBP < 90 mmHg) at Time A were identified. The SBP increased significantly from Time A to Time B (P < 0.0001). The median time from SCI to surgical intervention, for ASIA A, was 80.9 hours for patients with initial SBP < 90 mmHg and 58 hours for patients with initial SBP > or = 90 mmHg (P = 0.025). Multivariable analysis after adjusting for confounders revealed a statistically significant difference in the time to surgical intervention based on SBP for ASIA A (P = 0.026), yet not for ASIA B or C/D. CONCLUSIONS The presence of neurogenic shock was associated with a delay in the timing of surgical intervention in patients with cervical SCI. Detailed evaluation of autonomic dysfunctions following SCI including cardiovascular instability could improve our understanding of the complexities of clinical presentations and possible neurological outcomes.
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Affiliation(s)
- Sagun Tuli
- ICORD, University of British Columbia, Vancouver, BC, Canada
| | - Jayshree Tuli
- ICORD, University of British Columbia, Vancouver, BC, Canada
| | | | - Fred H Geisler
- ICORD, University of British Columbia, Vancouver, BC, Canada
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244
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Fawcett JW, Curt A, Steeves JD, Coleman WP, Tuszynski MH, Lammertse D, Bartlett PF, Blight AR, Dietz V, Ditunno J, Dobkin BH, Havton LA, Ellaway PH, Fehlings MG, Privat A, Grossman R, Guest JD, Kleitman N, Nakamura M, Gaviria M, Short D. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord 2006; 45:190-205. [PMID: 17179973 DOI: 10.1038/sj.sc.3102007] [Citation(s) in RCA: 632] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The International Campaign for Cures of Spinal Cord Injury Paralysis (ICCP) supported an international panel tasked with reviewing the methodology for clinical trials in spinal cord injury (SCI), and making recommendations on the conduct of future trials. This is the first of four papers. Here, we examine the spontaneous rate of recovery after SCI and resulting consequences for achieving statistically significant results in clinical trials. We have reanalysed data from the Sygen trial to provide some of this information. Almost all people living with SCI show some recovery of motor function below the initial spinal injury level. While the spontaneous recovery of motor function in patients with motor-complete SCI is fairly limited and predictable, recovery in incomplete SCI patients (American spinal injury Association impairment scale (AIS) C and AIS D) is both more substantial and highly variable. With motor complete lesions (AIS A/AIS B) the majority of functional return is within the zone of partial preservation, and may be sufficient to reclassify the injury level to a lower spinal level. The vast majority of recovery occurs in the first 3 months, but a small amount can persist for up to 18 months or longer. Some sensory recovery occurs after SCI, on roughly the same time course as motor recovery. Based on previous data of the magnitude of spontaneous recovery after SCI, as measured by changes in ASIA motor scores, power calculations suggest that the number of subjects required to achieve a significant result from a trial declines considerably as the start of the study is delayed after SCI. Trials of treatments that are most efficacious when given soon after injury will therefore, require larger patient numbers than trials of treatments that are effective at later time points. As AIS B patients show greater spontaneous recovery than AIS A patients, the number of AIS A patients requiring to be enrolled into a trial is lower. This factor will have to be balanced against the possibility that some treatments will be more effective in incomplete patients. Trials involving motor incomplete SCI patients, or trials where an accurate assessment of AIS grade cannot be made before the start of the trial, will require large subject numbers and/or better objective assessment methods.
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Affiliation(s)
- J W Fawcett
- Cambridge University Centre for Brain Repair, Robinson Way, Cambridge, UK
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245
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Steeves JD, Lammertse D, Curt A, Fawcett JW, Tuszynski MH, Ditunno JF, Ellaway PH, Fehlings MG, Guest JD, Kleitman N, Bartlett PF, Blight AR, Dietz V, Dobkin BH, Grossman R, Short D, Nakamura M, Coleman WP, Gaviria M, Privat A. Guidelines for the conduct of clinical trials for spinal cord injury (SCI) as developed by the ICCP panel: clinical trial outcome measures. Spinal Cord 2006; 45:206-21. [PMID: 17179972 DOI: 10.1038/sj.sc.3102008] [Citation(s) in RCA: 331] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An international panel reviewed the methodology for clinical trials of spinal cord injury (SCI), and provided recommendations for the valid conduct of future trials. This is the second of four papers. It examines clinical trial end points that have been used previously, reviews alternative outcome tools and identifies unmet needs for demonstrating the efficacy of an experimental intervention after SCI. The panel focused on outcome measures that are relevant to clinical trials of experimental cell-based and pharmaceutical drug treatments. Outcome measures are of three main classes: (1) those that provide an anatomical or neurological assessment for the connectivity of the spinal cord, (2) those that categorize a subject's functional ability to engage in activities of daily living, and (3) those that measure an individual's quality of life (QoL). The American Spinal Injury Association impairment scale forms the standard basis for measuring neurologic outcomes. Various electrophysiological measures and imaging tools are in development, which may provide more precise information on functional changes following treatment and/or the therapeutic action of experimental agents. When compared to appropriate controls, an improved functional outcome, in response to an experimental treatment, is the necessary goal of a clinical trial program. Several new functional outcome tools are being developed for measuring an individual's ability to engage in activities of daily living. Such clinical end points will need to be incorporated into Phase 2 and Phase 3 trials. QoL measures often do not correlate tightly with the above outcome tools, but may need to form part of Phase 3 trial measures.
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Affiliation(s)
- J D Steeves
- ICORD, University of British Columbia (UBC) and Vancouver Coastal Health (VCH) Research Institute, Vancouver, BC, Canada
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246
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Lammertse D, Tuszynski MH, Steeves JD, Curt A, Fawcett JW, Rask C, Ditunno JF, Fehlings MG, Guest JD, Ellaway PH, Kleitman N, Blight AR, Dobkin BH, Grossman R, Katoh H, Privat A, Kalichman M. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: clinical trial design. Spinal Cord 2006; 45:232-42. [PMID: 17179970 PMCID: PMC4106695 DOI: 10.1038/sj.sc.3102010] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The International Campaign for Cures of Spinal Cord Injury Paralysis established a panel tasked with reviewing the methodology for clinical trials for spinal cord injury (SCI), and making recommendations on the conduct of future trials. This is the fourth of four papers. Here, we examine the phases of a clinical trial program, the elements, types, and protocols for valid clinical trial design. The most rigorous and valid SCI clinical trial would be a prospective double-blind randomized control trial utilizing appropriate placebo control subjects. However, in specific situations, it is recognized that other trial procedures may have to be considered. We review the strengths and limitations of the various types of clinical trials with specific reference to SCI. It is imperative that the design and conduct of SCI clinical trials should meet appropriate standards of scientific inquiry to insure that meaningful conclusions about efficacy and safety can be achieved and that the interests of trial subjects are protected. We propose these clinical trials guidelines for use by the SCI clinical research community.
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247
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Syková E, Jendelová P, Urdzíková L, Lesný P, Hejcl A. Bone marrow stem cells and polymer hydrogels--two strategies for spinal cord injury repair. Cell Mol Neurobiol 2006; 26:1113-29. [PMID: 16633897 DOI: 10.1007/s10571-006-9007-2] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2005] [Accepted: 01/05/2006] [Indexed: 12/20/2022]
Abstract
1. Emerging clinical studies of treating brain and spinal cord injury (SCI) led us to examine the effect of autologous adult stem cell transplantation as well as the use of polymer scaffolds in spinal cord regeneration. We compared an intravenous injection of mesenchymal stem cells (MSCs) or the injection of a freshly prepared mononuclear fraction of bone marrow cells (BMCs) on the treatment of an acute or chronic balloon-induced spinal cord compression lesion in rats. Based on our experimental studies, autologous BMC implantation has been used in a Phase I/II clinical trial in patients (n=20) with a transversal spinal cord lesion. 2. MSCs were isolated from rat bone marrow by their adherence to plastic, labeled with iron-oxide nanoparticles and expanded in vitro. Macroporous hydrogels based on derivatives of 2-hydroxyethyl methacrylate (HEMA) or 2-hydroxypropyl methacrylamide (HPMA) were prepared, then modified by their copolymerization with a hydrolytically degradable crosslinker, N,O-dimethacryloylhydroxylamine, or by different surface electric charges. Hydrogels or hydrogels seeded with MSCs were implanted into rats with hemisected spinal cords. 3. Lesioned animals grafted with MSCs or BMCs had smaller lesions 35 days postgrafting and higher scores in BBB testing than did control animals and also showed a faster recovery of sensitivity in their hind limbs using the plantar test. The functional improvement was more pronounced in MSC-treated rats. In MR images, the lesion populated by grafted cells appeared as a dark hypointense area and was considerably smaller than in control animals. Morphometric measurements showed an increase in the volume of spared white matter in cell-treated animals. In the clinical trial, we compared intraarterial (via a. vertebralis, n=6) versus intravenous administration of BMCs (n=14) in a group of subacute (10-33 days post-SCI, n=8) and chronic patients (2-18 months, n=12). For patient follow-up we used MEP, SEP, MRI, and the ASIA score. Our clinical study revealed that the implantation of BMCs into patients is safe, as there were no complications following cell administration. Partial improvement in the ASIA score and partial recovery of MEP or SEP have been observed in all subacute patients who received cells via a. vertebralis (n=4) and in one out of four subacute patients who received cells intravenously. Improvement was also found in one chronic patient who received cells via a. vertebralis. A much larger population of patients is needed before any conclusions can be drawn. The implantation of hydrogels into hemisected rat spinal cords showed that cellular ingrowth was most pronounced in copolymers of HEMA with a positive surface electric charge. Although most of the cells had the morphological properties of connective tissue elements, we found NF-160-positive axons invading all the implanted hydrogels from both the proximal and distal stumps. The biodegradable hydrogels degraded from the border that was in direct contact with the spinal cord tissue. They were resorbed by macrophages and replaced by newly formed tissue containing connective tissue elements, blood vessels, GFAP-positive astrocytic processes, and NF-160-positive neurofilaments. Additionally, we implanted hydrogels seeded with nanoparticle-labeled MSCs into hemisected rat spinal cords. Hydrogels seeded with MSCs were visible on MR images as hypointense areas, and subsequent Prussian blue histological staining confirmed positively stained cells within the hydrogels. 4. We conclude that treatment with different bone marrow cell populations had a positive effect on behavioral outcome and histopathological assessment after SCI in rats; this positive effect was most pronounced following MSC treatment. Our clinical study suggests a possible positive effect in patients with SCI. Bridging the lesion cavity can be an approach for further improving regeneration. Our preclinical studies showed that macroporous polymer hydrogels based on derivatives of HEMA or HPMA are suitable materials for bridging cavities after SCI; their chemical and physical properties can be modified to a specific use, and 3D implants seeded with different cell types may facilitate the ingrowth of axons.
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Affiliation(s)
- Eva Syková
- Institute of Experimental Medicine ASCR, Videnská, 1083 142 20, Prague 4, Czech Republic.
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248
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Adams M, Carlstedt T, Cavanagh J, Lemon RN, McKernan R, Priestley JV, Raisman G, Verhaagen J. International spinal research trust research strategy. III: A discussion document. Spinal Cord 2006; 45:2-14. [PMID: 16883299 DOI: 10.1038/sj.sc.3101963] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
STUDY DESIGN Discussion document. OBJECTIVES/METHODS To review the Research Strategy of the International Spinal Research Trust (ISRT), which identifies key areas of basic and clinical research that are likely to be beneficial in developing potential treatments for spinal cord injury for funding. This strategy is intended to both guide the programme of research towards areas of priority and stimulate discussion of the different avenues of research. This latest document has been developed to take into account the scientific progress in the 6 years since publication of the previous Research Strategy. RESULTS/DISCUSSION The latest scientific developments in research designed to repair the spinal cord and restore function following injury and how they might impact on spinal cord injury research are highlighted.
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Affiliation(s)
- M Adams
- Research Division, International Spinal Research Trust, Bramley Business Centre, Bramley, Guildford, Surrey, UK
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249
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Abstract
Acute traumatic spinal cord injury (SCI) results in a devastating loss of neurological function below the level of injury and adversely affects multiple systems within the body. The pathobiology of SCI involves a primary mechanical insult to the spinal cord and activation of a delayed secondary cascade of events, which ultimately causes progressive degeneration of the spinal cord. Whereas cell death from the mechanical injury is predominated by necrosis, secondary injury events trigger a continuum of necrotic and apoptotic cell death mechanisms. These secondary events include vascular abnormalities, ischemia-reperfusion, glutamate excitotoxicity and disturbances in ionic homeostasis, oxidative cell injury, and a robust inflammatory response. No gold standard therapy for SCI has been established, although clinical trials with methylprednisolone (NASCIS II and III) and GM-1 ganglioside (Maryland and Sygen) have demonstrated modest, albeit potentially important therapeutic benefits. In light of the overwhelming impact of SCI on the individual, other therapeutic interventions are urgently needed. A number of promising pharmacological therapies are currently under investigation for neuroprotective abilities in animal models of SCI. These include the sodium (Na+) channel blocker riluzole, the tetracycline derivative minocycline, the fusogen copolymer polyethylene glycol (PEG), and the tissue-protective hormone erythropoietin (EPO). Moreover, clinical trials investigating the putative neuroprotective and neuroregenerative properties ascribed to the Rho pathway antagonist, Cethrin (BioAxone Therapeutic, Inc.), and implantation of activated autologous macrophages (ProCord; Proneuron Biotechnologies) in patients with thoracic and cervical SCI are now underway. We anticipate that these studies will harken an era of renewed interest in translational clinical trials. Ultimately, due to the multi-factorial pathophysiology of traumatic SCI, effective therapies will require combined approaches.
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Affiliation(s)
- Darryl C Baptiste
- Division of Cell and Molecular Biology, Toronto Western Research Institute and Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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250
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Abstract
STUDY DESIGN : Literature review. OBJECTIVE : The purpose of this paper is to review clinical treatment strategies and future developments in the treatment of acute spinal cord injury. SUMMARY OF BACKGROUND DATA : The treatment of acute spinal cord injury continues to be supportive. The search for specialized pharmacologic agents to prevent secondary injury and promote repair or regeneration remains heated. METHODS : Medline search from 1996 to present limited to clinical research and basic science review articles in the English Language. RESULTS : Steroids continue to be administered in the clinical setting of acute spinal cord injury primarily out of peer pressure and fear of litigation. Basic science experiments suggest that modulation of post-traumatic inflammation may provide the best opportunity to arrest the secondary injury cascade. Protein kinase and metalloproteinase inhibition are promising treatment strategies. Regeneration techniques are concentrating on cell transplantation and manipulating glial receptors and protein production. Clinical investigations are limited to Phase III trials on a very select few of these drugs. CONCLUSIONS : While many advances in the basic science of spinal cord injury provide optimism for future treatments, clinical science lags. At present, there are no pharmacologic strategies of proven benefit. Although steroids continue to be given to patients with spinal cord injury in many institutions, evidence of deleterious effects continues to accumulate. Current standard of care management includes support of arterial oxygenation and spinal cord perfusion pressure.
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Affiliation(s)
- R John Hurlbert
- From the University of Calgary Spine Program, Foothills Hospital and Medical Centre, Calgary, Alberta, Canada
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