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Khaing ZZ, Chen JY, Safarians G, Ezubeik S, Pedroncelli N, Duquette RD, Prasse T, Seidlits SK. Clinical Trials Targeting Secondary Damage after Traumatic Spinal Cord Injury. Int J Mol Sci 2023; 24:3824. [PMID: 36835233 PMCID: PMC9960771 DOI: 10.3390/ijms24043824] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/06/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
Spinal cord injury (SCI) often causes loss of sensory and motor function resulting in a significant reduction in quality of life for patients. Currently, no therapies are available that can repair spinal cord tissue. After the primary SCI, an acute inflammatory response induces further tissue damage in a process known as secondary injury. Targeting secondary injury to prevent additional tissue damage during the acute and subacute phases of SCI represents a promising strategy to improve patient outcomes. Here, we review clinical trials of neuroprotective therapeutics expected to mitigate secondary injury, focusing primarily on those in the last decade. The strategies discussed are broadly categorized as acute-phase procedural/surgical interventions, systemically delivered pharmacological agents, and cell-based therapies. In addition, we summarize the potential for combinatorial therapies and considerations.
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Affiliation(s)
- Zin Z. Khaing
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195, USA
| | - Jessica Y. Chen
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Gevick Safarians
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Sohib Ezubeik
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Nicolas Pedroncelli
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Rebecca D. Duquette
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX 78712, USA
| | - Tobias Prasse
- Department of Neurological Surgery, University of Washington, Seattle, WA 98195, USA
- Department of Orthopedics and Trauma Surgery, University of Cologne, 50931 Cologne, Germany
| | - Stephanie K. Seidlits
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Biomedical Engineering, University of Texas at Austin, Austin, TX 78712, USA
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Kent M, Barber RM, Glass EN, Arnold SA, Bibi KF, Stewart GV, Ruby JL, Perlini M, Platt SR. Poliomyelomalacia in three dogs that underwent hemilaminectomy for intervertebral disk herniation. J Am Vet Med Assoc 2021; 257:397-405. [PMID: 32715880 DOI: 10.2460/javma.257.4.397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
CASE DESCRIPTION 3 dogs were examined because of a sudden onset of signs of pain (1 dog) or paraparesis (2 dogs). CLINICAL FINDINGS Neurologic findings consisted of myelopathy affecting the lumbar intumescence (1 dog) and T3-L3 myelopathy (2 dogs). In all dogs, MRI revealed spinal cord compression caused by L3-4 disk herniation. All dogs underwent routine surgical decompression of the intervertebral disk herniation. During MRI and decompressive surgery, physiologic variables were monitored. Immediately after surgery, all dogs were paraplegic with pelvic limb neurologic dysfunction consistent with myelopathy affecting the L4 through caudal spinal cord segments. TREATMENT AND OUTCOME Within 24 hours after surgery, repeated MRI in all dogs revealed hyperintensity in the spinal cord gray matter of the lumbar intumescence on T2-weighted images. In the absence of neurologic improvement, dogs were euthanized at 3, 91, and 34 days after surgery. Postmortem microscopic examination of each dog's spinal cord at the lumbar intumescence revealed necrosis of the gray matter with relative white matter preservation suggestive of an ischemic injury. CLINICAL RELEVANCE Dramatic neurologic deterioration following decompressive surgery for intervertebral disk herniation in dogs may be associated with the development of poliomyelomalacia secondary to ischemia. In these 3 dogs, ischemia developed despite probable maintenance of normal spinal cord blood flow and perfusion during anesthesia. To exclude other causes, such as compression or hemorrhage, MRI was repeated and revealed hyperintensity of the spinal cord gray matter on T2-weighted images, which microscopically corresponded with ischemic neurons and neuronal loss.
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Zhang X, Liu CB, Yang DG, Qin C, Dong XC, Li DP, Zhang C, Guo Y, Du LJ, Gao F, Yang ML, Li JJ. Dynamic changes in intramedullary pressure 72 hours after spinal cord injury. Neural Regen Res 2019; 14:886-895. [PMID: 30688275 PMCID: PMC6375044 DOI: 10.4103/1673-5374.249237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Intramedullary pressure increases after spinal cord injury, and this can be an important factor for secondary spinal cord injury. Until now there have been no studies of the dynamic changes of intramedullary pressure after spinal cord injury. In this study, telemetry systems were used to observe changes in intramedullary pressure in the 72 hours following spinal cord injury to explore its pathological mechanisms. Spinal cord injury was induced using an aneurysm clip at T10 of the spinal cord of 30 Japanese white rabbits, while another 32 animals were only subjected to laminectomy. The feasibility of this measurement was assessed. Intramedullary pressure was monitored in anesthetized and conscious animals. The dynamic changes of intramedullary pressure after spinal cord injury were divided into three stages: stage I (steep rise) 1–7 hours, stage II (steady rise) 8–38 hours, and stage III (descending) 39–72 hours. Blood-spinal barrier permeability, edema, hemorrhage, and histological results in the 72 hours following spinal cord injury were evaluated according to intramedullary pressure changes. We found that spinal cord hemorrhage was most severe at 1 hour post-spinal cord injury and then gradually decreased; albumin and aquaporin 4 immunoreactivities first increased and then decreased, peaking at 38 hours. These results confirm that severe bleeding in spinal cord tissue is the main cause of the sharp increase in intramedullary pressure in early spinal cord injury. Spinal cord edema and blood-spinal barrier destruction are important factors influencing intramedullary pressure in stages II and III of spinal cord injury.
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Affiliation(s)
- Xin Zhang
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Chang-Bin Liu
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - De-Gang Yang
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Chuan Qin
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Xue-Chao Dong
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Da-Peng Li
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Chao Zhang
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Yun Guo
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Liang-Jie Du
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Feng Gao
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Ming-Liang Yang
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
| | - Jian-Jun Li
- School of Rehabilitation Medicine, Capital Medical University; Department of Spinal and Neural Function Reconstruction, China Rehabilitation Research Center; Center of Neural Injury and Repair, Beijing Institute for Brain Disorders; China Rehabilitation Science Institute; Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
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Trampus P, Goepfert C, Welle M, Henke D, Forterre F, Schweizer-Gorgas D. Magnetic Resonance Imaging Signal Alterations in Paraspinal Muscles in Dogs with Acute Thoracolumbar Intervertebral Disk Extrusion. Front Vet Sci 2018; 5:16. [PMID: 29497616 PMCID: PMC5819315 DOI: 10.3389/fvets.2018.00016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/29/2018] [Indexed: 11/17/2022] Open
Abstract
Muscle signal alteration detected on MRI is seen in diverse pathologic conditions. We observed signal alterations within the paraspinal muscles in dogs with acute thoracolumbar intervertebral disk extrusion. The aim of this retrospective study was to describe MRI features of paraspinal muscle signal alteration in dogs with acute thoracolumbar intervertebral disk extrusion and to investigate an association of the signal alterations with neurological grade, type and location of intervertebral disk extrusion, degree of spinal cord compression, and presence of epidural hemorrhage. Medical records of dogs undergoing MRI because of thoracolumbar intervertebral disk extrusion between August 2014 and June 2016 were reviewed. MRI was evaluated for SI changes within the paravertebral musculature, their location, extension, affected muscles, contrast enhancement, and signal void in T2* sequences. Intervertebral disk herniation was categorized as acute non-compressive nucleus pulposus extrusion (ANNPE) or compressive intervertebral disk disease. In five patients, muscle biopsies of areas with signal intensity changes were taken during surgery. In total, 103 dogs were enrolled in the study. Paraspinal muscle signal alterations were visible in 37 dogs (36%) affecting the epaxial musculature (n = 17), hypaxial musculature (n = 12), or both (n = 8). All signal alterations were hyperintense on T2-weighted images and iso- or hypointense in T1-weighted images. Signal void in T2* was not observed in any dog. Postcontrast sequences were available in 30 of the 37 dogs and showed enhancement in 45%. There was neither an association with degree of compression nor epidural hemorrhage. Intervertebral disk extrusion caudal to L1 and a higher neurological grade was associated with the presence of muscle changes. Histopathology revealed mild to moderate acute muscle fiber degeneration with edema and necrosis in three of five samples. The MRI, as well as the muscle samples, show rather unspecific changes. The underlying pathomechanism might be related to ischemia or muscle spasm, but also denervation edema may explain the signal alteration.
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Affiliation(s)
- Peter Trampus
- Division of Clinical Radiology, Vetsuisse-Faculty, University of Bern, Bern, Switzerland
| | - Christine Goepfert
- Institute of Animal Pathology, Vetsuisse-Faculty, University of Bern, Bern, Switzerland
| | - Monika Welle
- Institute of Animal Pathology, Vetsuisse-Faculty, University of Bern, Bern, Switzerland
| | - Diana Henke
- Division of Clinical Neurology, Vetsuisse-Faculty, University of Bern, Bern, Switzerland
| | - Franck Forterre
- Division of Small Animal Surgery, Vetsuisse-Faculty, University of Bern, Bern, Switzerland
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Diogo C, Tudury E, Bonelli M, Araújo B, Figueiredo MD, Fernandes T, Silva A, Baraúna Júnior D, Santos C, Amorim M, Arias MB. Consequences of intraoperative spinal cord manipulation in dogs with thoracolumbar intervertebral disc extrusion. ARQ BRAS MED VET ZOO 2017. [DOI: 10.1590/1678-4162-9520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT The objective of the present study was to evaluate if extradural contact during hemilaminectomy would cause neurological deterioration in the early and/or late postoperative period in dogs with intervertebral disc extrusion. Nineteen dogs with thoracolumbar intervertebral disc extrusion underwent hemilaminectomy for spinal cord decompression and removal of extruded disc material. Meningeal contacts during surgery were quantified. Paraplegia (with nociception) and paraparesis were observed in 11/19 and 8/19 of dogs, respectively, before surgery. At the end of our study, only two (2/19) had paraplegia and one (1/19), paraparesis. There were more extradural contacts when extruded intervertebral disc material was at a ventrolateral position. Extradural contacts during surgery had no influence on neurological progression nor on time to recovery of motor function. Immediately (24 and 48 hours) after surgery, 13/19 dogs had the same neurological stage before surgery. At 7 and 90 days, 13/19 and 17/19 dogs, respectively, showed neurological improvement, compared with their preoperative stage. There was no influence of the number of extradural contacts on neurological recovery. These findings indicate that a careful inspection of the vertebral canal for removal of as much extruded disc material as possible does not cause neurologic deterioration.
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Affiliation(s)
- C.C. Diogo
- Universidade Federal Rural de Pernambuco, Brazil
| | - E.A. Tudury
- Universidade Federal Rural de Pernambuco, Brazil
| | - M.A. Bonelli
- Universidade Federal Rural de Pernambuco, Brazil
| | - B.M. Araújo
- Universidade Federal Rural de Pernambuco, Brazil
| | | | | | - A.C. Silva
- Universidade Federal Rural de Pernambuco, Brazil
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Fenn J, Laber E, Williams K, Rousse CA, Early PJ, Mariani CL, Muñana KR, De Decker S, Volk HA, Olby NJ. Associations Between Anesthetic Variables and Functional Outcome in Dogs With Thoracolumbar Intervertebral Disk Extrusion Undergoing Decompressive Hemilaminectomy. J Vet Intern Med 2017; 31:814-824. [PMID: 28295616 PMCID: PMC5435081 DOI: 10.1111/jvim.14677] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/06/2017] [Accepted: 01/18/2017] [Indexed: 12/19/2022] Open
Abstract
Background Outcome of acute experimental spinal cord injury is strongly associated with tissue perfusion and oxygenation. Cardiopulmonary depression could affect outcome in dogs undergoing general anesthesia for surgical treatment of thoracolumbar intervertebral disk extrusion (IVDE). Hypothesis/Objectives To evaluate the effects of general anesthesia on functional outcome in dogs undergoing surgery to treat thoracolumbar IVDE. Animals Eighty‐four client‐owned dogs with acute thoracolumbar IVDE treated by decompressive hemilaminectomy. Methods Exploratory, retrospective observational study. Medical records were reviewed for clinical presentation and anesthetic monitoring variables, including duration of anesthesia and surgery, hypotension, bradycardia, temperature, and respiratory parameters. Multivariable regression tree analysis was performed to explore associations between anesthetic variables and functional outcome scores after 6 weeks, as well as return to ambulatory status. Results Episodes of bradycardia (69%) and hypotension (57%) were frequent. Across all outcome measures, regression tree analysis highlighted functional grade at presentation as the primary determining factor, and among pain perception negative dogs, there was a possible association between increased duration of surgery and poorer outcome. In dogs with intact pain perception, duration of bradycardia, mean body temperature, and mean end‐tidal carbon dioxide were highlighted. Conclusions and Clinical Importance Exploratory statistical methods can facilitate hypothesis‐generating studies to inform prospective investigations in veterinary medicine. Although the mechanism is uncertain, increased duration of surgery might be associated with poorer outcome in pain perception negative dogs with thoracolumbar IVDE.
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Affiliation(s)
- J Fenn
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - E Laber
- Department of Statistics, North Carolina State University, Raleigh, NC
| | - K Williams
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - C A Rousse
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - P J Early
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC
| | - C L Mariani
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC.,Comparative Medicine Institute, North Carolina State University, Raleigh, NC
| | - K R Muñana
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC.,Comparative Medicine Institute, North Carolina State University, Raleigh, NC
| | - S De Decker
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - H A Volk
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, UK
| | - N J Olby
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC.,Comparative Medicine Institute, North Carolina State University, Raleigh, NC
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Khaing ZZ, Cates LN, Fischedick AE, McClintic AM, Mourad PD, Hofstetter CP. Temporal and Spatial Evolution of Raised Intraspinal Pressure after Traumatic Spinal Cord Injury. J Neurotrauma 2017; 34:645-651. [DOI: 10.1089/neu.2016.4490] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Zin Z. Khaing
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
| | - Lindsay N. Cates
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
| | - Amanda E. Fischedick
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
| | - Abbi M. McClintic
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
| | - Pierre D. Mourad
- Department of Neurological Surgery, The University of Washington, Seattle, Washington
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Longitudinal extension of myelomalacia by intramedullary and subdural hemorrhage in a canine model of spinal cord injury. Spine J 2016; 16:82-90. [PMID: 26386168 DOI: 10.1016/j.spinee.2015.09.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 08/12/2015] [Accepted: 09/03/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In canine intervertebral disc (IVD) extrusion, a spontaneous animal model of spinal cord injury, hemorrhage is a consistent finding. In rodent models, hemorrhage might be involved in secondary tissue destruction by biochemical mechanisms. PURPOSE This study aimed to investigate a causal association between the extents of intramedullary, subdural and epidural hemorrhage and the severity of spinal cord damage following IVD extrusion in dogs. STUDY DESIGN/SETTING A retrospective study using histologic spinal cord sections from 83 dogs euthanized following IVD extrusion was carried out. METHODS The degree of hemorrhage (intramedullary, subdural, epidural), the degree of spinal cord damage in the epicenter (white and gray matter), and the longitudinal extent of myelomalacia were graded. Associations between the extent of hemorrhage and the degree of spinal cord damage were evaluated statistically. RESULTS Intramedullary and subdural hemorrhages were significantly associated with the degree of white (p<.001/ p=.004) and gray (both p<.001) matter damage, and with the longitudinal extension of myelomalacia (p<.001/p=.005). Intriguingly, accumulation of hemorrhagic cord debris inside or dorsal to a distended and ruptured central canal in segments distant to the epicenter of the lesion was observed exhibiting a wave-like pattern on longitudinal assessment. The occurrence of this debris accumulation was associated with high degrees of tissue destruction (all p<.001). CONCLUSIONS Tissue liquefaction and increased intramedullary pressure associated with hemorrhage are involved in the progression of spinal cord destruction in a canine model of spinal cord injury and ascending or descending myelomalacia. Functional and dynamic studies are needed to investigate this concept further.
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