Worldwide Steroid Prescription for Acute Spinal Cord Injury

Mechanisms of nitric oxide in spinal cord injury

Spinal cord injury (SCI) is a primary lesion of the spinal cord that results from external forces or diseases, accompanied by a cascade of secondary events. Nitric oxide, an endogenous gas that functions as a signaling molecule in the human body, plays a crucial role in vasodilation of smooth muscles, regulation of blood flow and pressure, and inflammatory response. This article provides a comprehensive overview of the involvement of nitric oxide in SCI and highlights recent advances in basic research on pharmacological agents that inhibit nitric oxide elevation after SCI, offering valuable insights for future therapeutic interventions targeting SCI.

Corticosteroids in critically ill patients: A narrative review

Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.

Benefits of Early Surgical Treatment for Patients with Multilevel Cervical Canal Stenosis of Acute Traumatic Central Cord Syndrome

INTRODUCTION

Currently, there exists considerable debate surrounding the optimal treatment approaches for different subtypes of patients with spinal cord injury (SCI). The purpose of this study was to conduct a comparative analysis of the benefits associated with conservative treatment and treatments with different surgical periods for patients diagnosed with acute traumatic central cord syndrome (ATCCS) and multilevel cervical canal stenosis (CCS).

METHODS

A retrospective cohort study was conducted, and 93 patients who met inclusion and exclusion criteria in our hospital between 2015 and 2020 were followed for a minimum duration of 2 years. Among them, 30 patients (Group A) received conservative treatment, 18 patients (Group B) received early surgery (≤7 days), and 45 patients (Group C) received late surgery (>7 days). The American Spinal Injury Association (ASIA) grade, Japanese Orthopedic Association (JOA) score, and recovery rate (RR) were evaluated. Multivariate linear regression was used to analyze prognostic determinants. Cost-utility analysis was performed based on the EQ-5D scale.

RESULTS

The ASIA grade, JOA score, and RR of all three groups improved compared with the previous evaluation (P < 0.05). During follow-up, the ASIA grade, JOA score, and RR of Group B were all better than for Group A and Group C (P < 0.05), while there was no significant difference between Group A and C (P > 0.05). The EQ-5D scale in Group B was optimal at the last follow-up. The incremental cost-utility ratio (ICUR) of Group A was the lowest, while that of Group B compared to Group A was less than the threshold of patients' willingness to pay. Age, initial ASIA grade, and treatment types significantly affected the outcomes.

CONCLUSIONS

Both conservative and surgical treatments yield good results. Compared with patients who received conservative treatment and late surgery, patients who received early surgery had better clinical function and living quality. Despite the higher cost, early surgery is cost-effective when compared to conservative treatment. Younger age, initial better ASIA grade, and earlier surgery were associated with better prognosis.

Demographics, Mechanism of Injury, and Outcomes for Acute Upper and Lower Cervical Spinal Cord Injuries: An Analysis of 470 Patients in the Prospective, Multi-Center, North American Clinical Trials Network Registry

There is a paucity of data comparing the demographics, mechanism of injury, and outcomes of upper versus lower cervical spinal cord injuries (cSCI). The study objective was to define different clinical manifestations of cSCI. Data were collected prospectively through centers of the North American Clinical Trials Network (NACTN). Data was collected on 470 patients (21% women, mean age 50 years). Cervical vertebral level was analyzed as an ordinal variable to determine a natural demarcation to classify upper versus lower cSCI. For continuous variable analysis, falls were associated with C3 more than C4 vertebral level injuries (60% vs. 42%; p = 0.0126), while motor vehicle accidents were associated with C4 more than C3 (40% vs. 29%; p = 0.0962). Motor International Standards for Neurological Classification of Spinal Cord Injury scores also demonstrated a natural demarcation between C3 and C4, with C3 having higher median American Spinal Injury Association (ASIA) motor scores (40 [4-73] vs. 11 [3-59], p = 0.0227). There were no differences when comparing C2 to C3 nor C4 to C5. Given the significant differences seen between C3 and C4, but not C2 and C3 nor C4 and C5, upper cSCI was designated as C1-C3, and lower cSCI was designated as C4-C7. Compared with a lower cSCI, patients with an upper cSCI were more likely to have a fall as their mechanism of injury (54% vs. 36%; p = 0.0072). Patients with an ASIA C cSCI were likely to have an upper cervical injury: 23% vs. 11% (p = 0.0226). Additionally, patients with an upper cSCI were more likely to have diabetes prior to injury: 37% versus 22%, respectively (p = 0.0084). Lower cSCI were more likely injured through sports (19% vs. 8%, p = 0.0171) and present with ASIA A (42% vs. 25%, p = 0.0186) neurological grade. Patients with lower cSCI were also significantly more likely to have complications such as shock, pulmonary embolism, and pleural effusion. In conclusion, there appears to be a natural demarcation of injury type between C3 and C4. Upper cSCI (C1-C3) was more associated with falls and diabetes, whereas lower cSCI (C4-C7) was more associated with sports, worse ASIA scores, and more complications. Further research will be needed to understand the mechanistic and biological differences between these two groups and whether different treatments may be appropriate for each of these groups.

Methylprednisolone in acute traumatic spinal cord injury: case-matched outcomes from the NASCIS2 and Sygen historical spinal cord injury studies with contemporary statistical analysis

OBJECTIVE

Methylprednisolone (MP) to treat acute traumatic spinal cord injury (ATSCI) remains controversial since the release of the second National Acute Spinal Cord Injury Study (NASCIS2) in 1990. As two historical studies, NASCIS2 and Sygen in ATSCI, used identical MP dosages, it was possible to construct a new case-level pooled ATSCI data set satisfying contemporary criteria and able to clarify the effect of MP.

METHODS

The new pooled data set was first modernized by excluding patients with injury levels caudal to T10, lower-extremity American Spinal Injury Association (ASIA) motor scores (LEMSs) ≥ 46, Glasgow Coma Scale scores ≤ 11, and age < 15 or > 75 years, and then standardized to the ASIA grading and scoring format. A new updated NASCIS2 data set from this pooled data set contained 31.6% fewer patients than the 1990 NASCIS2 data set.

RESULTS

In the new pooled data set, recovery of LEMSs from baseline to 26 weeks, the primary outcome variable, was separated statistically into five different injury severity cohorts (p < 0.0001). The severity cohorts contained groups with severe floor (62.9%) and ceiling (10.7%) effects, which do not contribute to drug effects. The new NASCIS2 data set duplicated the p value for MP versus placebo in the sub-subgroup analysis of MP initiated ≤ 8 hours (the subgroup) and recovery of motor function on only the right side of the body (a further subgroup within the ≤ 8-hour subgroup), presented as the positive MP effect in the original NASCIS2 reporting. However, current statistical interpretation considers results seen only in post hoc sub-subgroups, without multi-test corrections, to be random effects without clinical significance. The combined case-level pooled data set from the NASCIS2 and Sygen studies increased the MP group from 106 to 431 patients, creating a new MP combined group. This new data set served as a surrogate for a contemporary MP study and found that administration of MP did not enhance ASIA motor score improvement in the lower extremities at 26 weeks. Secondary analysis of descending ASIA motor and sensory cervical neurological levels in cervical ATSCI patients at 26 weeks also found no MP drug effect.

CONCLUSIONS

Analysis of both the new updated NASCIS2 data set and the new case-matched pooled data set from two historical ATSCI studies revealed that administration of MP after spinal cord injury did not demonstrate any enhancement in neurological recovery at 26 weeks. The results of this analysis warrant review by clinical guideline groups.

Treatment of Acute Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 1: Use of High-Dose Corticosteroids

Objective  The aim of the present study was to evaluate the current practice of using of methylprednisolone sodium succinate (MPSS) in acute spinal cord Injuries (ASCIs) among spine surgeons from Iberolatinoamerican countries. Methods  A descriptive cross-sectional study design as a survey was conducted. A questionnaire composed of 2 sections, one on demographic data regarding the surgeons and MPSS administration, was sent by email to members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results  A total of 182 surgeons participated in the study: 65.4% (119) orthopedic surgeons and 24.6% (63) neurosurgeons. Sixty-nine (37.9%) used MPSS in the initial management of ASCIs. There were no significant differences between countries ( p  = 0.451), specialty ( p  = 0.352), or surgeon seniority ( p  = 0.652) for the use of corticosteroids in the initial management of ASCIs. Forty-five (65.2%) respondents reported using an initial high-dose bolus (30 mg/Kg) followed by a perfusion (5.4 mg/kg/h). Forty-six (66.7%) surgeons who used MPSS only prescribed it if the patients presented within 8 hours of the ASCI. Most of the surgeons (50.7% [35]) administered high-dose corticosteroids because of the conviction that it has clinal benefits and improves neurological recovery. Conclusion  Results from the present survey show that MPSS use in ASCI is not widespread within spine surgeons and that the controversy regarding its use remains unresolved. This is probably due to the low level of evidence of the available data, to variations over the years, to inconsistencies in acute care protocols, and to health service pathways.

A critical appraisal of clinical practice guidelines on pharmacological treatments for spinal cord injury

BACKGROUND CONTEXT

Spinal cord injury brings devastating consequences and huge economic burden. Different authoritative organizations have developed different guidelines for pharmacological treatments of spinal cord injury, but there is a lack of a critical appraisal of them.

PURPOSE

To systematically review and appraise guidelines regarding their recommendations for pharmacological treatments for spinal cord injury.

STUDY DESIGN

Systematic review.

METHODS

We searched Medline, Embase, Cochrane, and Web of Science from January 2000 to January 2022 as well as guideline-specific databases (eg, Congress of Neurological Surgeons) and Google Scholar. We included the most updated guideline containing evidence-based recommendations or consensus-based recommendations developed by specific authoritative organizations if multiple versions were available. We appraised guidelines through the Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument consisting of six domains (eg, applicability). With supporting evidence, recommendations were classified as: for, against, neither for nor against. We utilized an evidence assessment system to categorize the quality of supporting evidence as poor, fair, or good.

RESULTS

Eight guidelines developed from 2008 to 2020 were included, but all of them scored lowest in the domain of applicability among all six domains. Twelve pharmacological agents (eg, methylprednisolone) were studied. For methylprednisolone, three guidelines (3/8=37.5%) recommended for (one evidence-based and two consensus-based), three (3/8=37.5%) recommended against (all evidence-based), and two (2/8=25%) recommended neither for nor against. For monosialotetrahexosylganglioside (GM-1), one guideline (1/4=25%) recommended for (consensus-based), one (1/4=25%) recommended against (evidence-based), and two (2/4=50%) recommended neither for nor against. For other agents (eg, minocycline), most guidelines (3/5=60%) recommended neither for nor against, one (1/5=20%) recommended against naloxone (evidence-based) and nimodipine (evidence-based), and one (1/5=20%) recommended for neural growth factor (consensus-based). The quality of most of the supporting evidence was poor, and the rest was fair.

CONCLUSIONS

There were inconsistencies among recommendations for methylprednisolone and GM-1. Evidence-based recommendations tended to recommend against, whereas consensus-based recommendations tended to recommend for.

Immune response following traumatic spinal cord injury: Pathophysiology and therapies

Traumatic spinal cord injury (SCI) is a devastating condition that is often associated with significant loss of function and/or permanent disability. The pathophysiology of SCI is complex and occurs in two phases. First, the mechanical damage from the trauma causes immediate acute cell dysfunction and cell death. Then, secondary mechanisms of injury further propagate the cell dysfunction and cell death over the course of days, weeks, or even months. Among the secondary injury mechanisms, inflammation has been shown to be a key determinant of the secondary injury severity and significantly worsens cell death and functional outcomes. Thus, in addition to surgical management of SCI, selectively targeting the immune response following SCI could substantially decrease the progression of secondary injury and improve patient outcomes. In order to develop such therapies, a detailed molecular understanding of the timing of the immune response following SCI is necessary. Recently, several studies have mapped the cytokine/chemokine and cell proliferation patterns following SCI. In this review, we examine the immune response underlying the pathophysiology of SCI and assess both current and future therapies including pharmaceutical therapies, stem cell therapy, and the exciting potential of extracellular vesicle therapy.

Tauroursodeoxycholic Acid Reduces Neuroinflammation but Does Not Support Long Term Functional Recovery of Rats with Spinal Cord Injury

The bile acid tauroursodeoxycholic acid (TUDCA) reduces cell death under oxidative stress and inflammation. Implants of bone marrow-derived stromal cells (bmSC) are currently under investigation in clinical trials of spinal cord injury (SCI). Since cell death of injected bmSC limits the efficacy of this treatment, the cytoprotective effect of TUDCA may enhance its benefit. We therefore studied the therapeutic effect of TUDCA and its use as a combinatorial treatment with human bmSC in a rat model of SCI. A spinal cord contusion injury was induced at thoracic level T9. Treatment consisted of i.p. injections of TUDCA alone or in combination with one injection of human bmSC into the cisterna magna. The recovery of motor functions was assessed during a surveillance period of six weeks. Biochemical and histological analysis of spinal cord tissue confirmed the anti-inflammatory activity of TUDCA. Treatment improved the recovery of autonomic bladder control and had a positive effect on motor functions in the subacute phase, however, benefits were only transient, such that no significant differences between vehicle and TUDCA-treated animals were observed 1–6 weeks after the lesion. Combinatorial treatment with TUDCA and bmSC failed to have an additional effect compared to treatment with bmSC only. Our data do not support the use of TUDCA as a treatment of SCI.

Efficacy of Annona muricata (graviola) in experimental spinal cord injury: biochemical and histopathological analysis

BACKGROUND

Annona muricata (AM) (graviola) is a plant that grows in tropical regions and is thought to be good for many diseases by local people. Unfortunately, there is no acceptable medical treatment for spinal cord injury (SCI) yet. In our study, we investigated the neuropeotective effects of AM leaf extract on SCI in an experimental rat model.

METHODS

A total of 40 Wistar albino rats were randomly divided into five equal groups (n=8). Group 1 was the control group in which only laminectomy was performed. Trauma was induced in four groups after laminectomy. Group 2 (untreated trauma group) was given no medication. In Group 3, a single intraperitoneal dose of methylprednisolone (30 mg/kg) was administered after trauma. The rats in Groups 4 received a low dose (100 mg/kg) of AM leaf extracts by oral gavage one week before trauma while the rats in Group 5 received a high-dose (300 mg/kg) of these extracts by oral gavage one week before trauma. All rats, including the control group, were sacrificed 24 h after the trauma was created.

RESULTS

Tissue samples taken to evaluate the neuroprotective effect were examined biochemically and histopathologically. Inflam-matory findings in the trauma group were significantly better in both groups treated with AM. There was no difference between the groups in terms of clinical motor examination and inclined plane test results.

CONCLUSION

Our histopathological and biochemical results showed that AM is an agent with neuroprotective effects in trau-matic SCI.

Melatonin Synergizes With Methylprednisolone to Ameliorate Acute Spinal Cord Injury

Methylprednisolone (MP) is the drug of choice for treating spinal cord injury (SCI), but the aggressive dosage regimen used often results in adverse side effects. Therefore, MP should be combined with other drugs to lower the required dose. Melatonin is effective in alleviating nerve damage and inhibiting axonal degeneration. The combination of melatonin and half-dose methylprednisolone (HMP) for spinal cord injury treatment has never been reported. In this study, we established a rat model of T9 spinal cord injury by the Allen's method and assessed the synergistic therapeutic effects of melatonin and HMP by factorial design. Our results demonstrated that melatonin could synergize with HMP to ameliorate acute SCI through PI3K-AKT1 pathway. Combining melatonin with HMP significantly reduced the standard-dose of methylprednisolone and limited its adverse reactions, representing a promising option for treating acute SCI.

The Potential Therapeutic Effects of Agmatine, Methylprednisolone, and Rapamycin on Experimental Spinal Cord Injury

OBJECTIVE

In spinal cord injury (SCI), the primary mechanical damage leads to a neuroinflammatory response and the secondary neuronal injury occurs in response to the release of reactive oxygen species (ROS). In addition to the suppression of inflammation, autophagy plays a significant role in the survival of neurons during secondary SCI. The present study aimed to examine the anti-inflammatory and autophagic effects of agmatine and rapamycin in SCI and to compare the results with methylprednisolone (MP) used in the clinic.

MATERIALS AND METHODS

In this animal-based experimental study, thirty adult male Sprague-Dawley rats were randomly divided into five groups as sham-control, injury, injury+MP, injury+rapamycin, injury+agmatine groups. SCI was induced by compressing the T7-8-9 segments of the spinal cord, using an aneurysm clip for one minute, and then rats were treated daily for 7 days. Seven days post-treatment, damaged spinal cord tissues of sacrificed rats were collected for microscopic and biochemical examinations using histopathologic and transmission electron microscope (TEM) scores. Malondialdehyde (MDA) and glutathione peroxidase (GPx) levels were spectrophotometrically measured.

RESULTS

The results of this study showed that the damaged area was smaller in the rapamycin group when compared to the MP group. Many autophagic vacuoles and macrophages were observed in the rapamycin group. Degeneration of axon, myelin, and wide edema was observed in SCI by electron microscopic observations. Fragmented myelin lamellae and contracted axons were also noted. While MDA and GPx levels were increased in the injury group, MDA levels were significantly decreased in the agmatine and MP groups, and GPx levels were decreased in the rapamycin group.

CONCLUSION

The results of our study confirmed that rapamycin and agmatine can be an effective treatment for secondary injury of SCI.

Spine Surgeons Burnout and Quality of Life: Results of a Worldwide Survey

STUDY DESIGN

Cross-sectional survey study.

OBJECTIVE

To evaluate the prevalence of burnout, assess the personal and professional characteristics associated with burnout in spine surgeons and determine their quality of life.

SUMMARY OF BACKGROUND DATA

Burnout is a syndrome characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment that leads to decreased effectiveness at work. To date, there has been a lack of information on the prevalence of burnout among spine surgeons worldwide and the risk factors associated with this condition.

METHODS

An electronic survey with members of AO Spine was performed in May 2018. The survey evaluated demographic variables, practice characteristics, burnout, and quality of life. Maslach Burnout Inventory (MBI) and EuroQol 5-dimensions (EQ5D) were used to evaluate burnout and quality of life, respectively.

RESULTS

A total of 818 surgeons from 86 countries completed the survey. The prevalence of burnout was 30.6%. In the multiple linear model, emotional fatigue was independently associated with younger age (B = -0.17, CI95% = -0.26 to -0.07, P < 0.0001), and longer working hours per week (B = -2.71, CI95% = -4.34 to -1.07, P = 0.001); depersonalization was independently associated with younger age (B = -0.13, CI95% = -0.19 to -0.07, P < 0.0001), practicing outside Latin America (LA) (B = 0.71, CI95% = 0.41-1.01, P < 0.0001) and currently being a fellow (B = 0.54, CI95% = 0.06-1.02, P = 0.02); and higher scores of personal fulfilment was associated with practicing in LA (B = -1.27, CI95% = -1.69 to -0.85, P < 0.0001).

CONCLUSION

Burnout is a common condition among spine surgeons worldwide. There is a significant association between burnout scores and decreased general quality of life. These results highlight the need to develop interventional programs to better identify, prevent, and manage this condition among practicing spine surgeons.Level of Evidence: 4.

Meta-analysis of the Effectiveness of Steroid Pulse Therapy in Treating Patients with Spinal Cord Injury

Background:

High-dose steroid injection therapy is effective in reducing anti-inflammation and edema and is often used to treat patients with acute spinal cord injury. To evaluate the effectiveness of steroid pulse therapy and identify the factors that affect its effectiveness in patients with acute traumatic spinal cord injury.

Methods:

A comprehensive literature search of the databases Pubmed, Medline, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL was performed on July 31, 2019, with no language and time limits. For analysis, studies conducted within the last 10 years were included to reflect on the recent trend.

Results:

A total of 3 randomized controlled trials and 5 observational studies with 2418 patients were included in this meta-analysis. High-dose steroid injection therapy was found to have a high effect on patients with acute spinal cord injury. The following factors had a strong influence on the effectiveness of high-dose steroid treatment in patients with acute spinal cord injuries: injury, onset ASIA, onset neurological assessment scales, time to start treatment after injury, age, BMI, and gender.

Conclusion:

It is necessary to accurately assess the scope of spinal injury in the early stages and actively provide nursing interventions to identify and mediate factors affecting the treatment effect.

On the therapeutic targets and pharmacological treatments for pain relief following spinal cord injury: A mechanistic review

Spinal cord injury (SCI) is globally considered as one of the most debilitating disorders, which interferes with daily activities and life of the affected patients. Despite many developments in related recognizing and treating procedures, post-SCI neuropathic pain (NP) is still a clinical challenge for clinicians with no distinct treatments. Accordingly, a comprehensive search was conducted in PubMed, Medline, Scopus, Web of Science, and national database (SID and Irandoc). The relevant articles regarding signaling pathways, therapeutic targets and pharmacotherapy of post-SCI pain were also reviewed. Data were collected with no time limitation until November 2020. The present study provides the findings on molecular mechanisms and therapeutic targets, as well as developing the critical signaling pathways to introduce novel neuroprotective treatments of post-SCI pain. From the pathophysiological mechanistic point of view, post-SCI inflammation activates the innate immune system, in which the immune cells elicit secondary injuries. So, targeting the critical signaling pathways for pain management in the SCI population has significant importance in providing new treatments. Indeed, several receptors, ion channels, excitatory neurotransmitters, enzymes, and key signaling pathways could be used as therapeutic targets, with a pivotal role of n-methyl-D-aspartate, gamma-aminobutyric acid, and inflammatory mediators. The current review focuses on conventional therapies, as well as crucial signaling pathways and promising therapeutic targets for post-SCI pain to provide new insights into the clinical treatment of post-SCI pain. The need to develop innovative delivery systems to treat SCI is also considered.

Updated Review: The Steroid Controversy for Management of Spinal Cord Injury

BACKGROUND

Acute spinal cord injury (ASCI) is a devastating event that can have a profound impact on the lives of patients and their families. While no definitive medical treatment exists, the role of methylprednisolone (MP) in the management of ASCI and other spinal cord pathologies has been investigated in depth; however, its use remains contentious. While MP initially showed promise in the efficacy of ASCI treatment, more recent studies have questioned its use citing numerous systemic adverse effects. Pharmacologic treatments in this area are poorly understood due to the scarcity of knowledge surrounding the pathophysiology and heterogeneity of patients presenting with these conditions. Despite these shortcomings and due to the lack of alternative treatment options, MP is still widely used by physicians.

METHODS

We review prior and current literature on the use of MP treatment for ASCI patients with a discussion of novel drug delivery systems that have demonstrated the potential to improve MP's bioavailability at the site of injury while minimizing systemic side effects. In addition, current views on the role of MP and dexamethasone in metastatic spinal cord compression and postoperative infection are reviewed.

RESULTS

While some data support benefits in the use of steroids on spinal cord pathology, extensive research suggests at best limited effects and an unresolvable risk/benefit problem.

CONCLUSIONS

At present, evidence regarding use of dexamethasone for MSCC is contentious, especially regarding dose regiments. Ultimately, further investigation into the use of steroids is required to determine its utility in treating patients with spinal cord pathology.

Timing of Surgery in Thoracolumbar Spine Injury: Impact on Neurological Outcome

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We aimed to evaluate the improvement in neurological deficit following early versus late decompression and stabilization of thoracolumbar junctional fractures.

METHODS

This is a retrospective evaluation of all patients with a traumatic spinal cord injury (SCI) from T11 to L2 treated at a teaching hospital between 2010 and 2017. Grouped analysis was performed comparing the cohort of patients who received early surgery within 24 hours (group 1) with those operated within 24 to 72 hours (group 2) and more than 72 hours after SCI (group 3). The primary outcome was the change in ASIA (American Spinal Injury Association) motor score at 12-month follow-up.

RESULTS

There were 317 patients (225 males and 92 females with mean age of 31.55 ± 12.43 years). A total of 144, 77, and 96 patients belonged to groups 1, 2, and 3 respectively. Improvement of at least 1 grade on ASIA classification was observed in 80, 45, and 33 patients in groups 1, 2, and 3 respectively (P = .001). Overall, 32, 12, and 10 patients improved ≥2 grades on ASIA classification in groups 1, 2, and 3, respectively (P = .069). On logistic regression analysis, early surgery and severity of initial injury (complete [ASIA A] vs incomplete SCI [ASIA B-D]) were found to significantly influence the potential for neurologic improvement (P = .004 and P < .0001, respectively).

CONCLUSION

We believe that the earlier the decompression, the better. The 72-hour cutoff represents the most promising time window during which surgical decompression has the potential to confer a neuroprotective effect in the setting of incomplete SCI (ASIA B-D) in the distal region of the spinal cord (conus medullaris).

Treatment of rats with spinal cord injury using human bone marrow-derived stromal cells prepared by negative selection

Background

Spinal cord injury (SCI) is a highly debilitating pathology without curative treatment. One of the most promising disease modifying strategies consists in the implantation of stem cells to reduce inflammation and promote neural regeneration. In the present study we tested a new human bone marrow-derived stromal cell preparation (bmSC) as a therapy of SCI.

Methods

Spinal cord contusion injury was induced in adult male rats at thoracic level T9/T10 using the Infinite Horizon impactor. One hour after lesion the animals were treated with a sub-occipital injection of human bmSC into the cisterna magna. No immune suppression was used. One dose of bmSC consisted, on average, of 2.3 million non-manipulated cells in 100 μL suspension, which was processed out of fresh human bone marrow from the iliac crest of healthy volunteers. Treatment efficacy was compared with intraperitoneal injections of methylprednisolone (MP) and saline. The recovery of motor functions was assessed during a surveillance period of nine weeks. Adverse events as well as general health, weight and urodynamic functions were monitored daily. After this time, the animals were perfused, and the spinal cord tissue was investigated histologically.

Results

Rats treated with bmSC did not reject the human implants and showed no sign of sickness behavior or neuropathic pain. Compared to MP treatment, animals displayed better recovery of their SCI-induced motor deficits. There were no significant differences in the recovery of bladder control between groups. Histological analysis at ten weeks after SCI revealed no differences in tissue sparing and astrogliosis, however, bmSC treatment was accompanied with reduced axonal degeneration in the dorsal ascending fiber tracts, lower Iba1-immunoreactivity (IR) close to the lesion site and reduced apoptosis in the ventral grey matter. Neuroinflammation, as evidenced by CD68-IR, was significantly reduced in the MP-treated group.

Conclusions

Human bmSC that were prepared by negative selection without expansion in culture have neuroprotective properties after SCI. Given the effect size on motor function, implantation in the acute phase was not sufficient to induce spinal cord repair. Due to their immune modulatory properties, allogeneic implants of bmSC can be used in combinatorial therapies of SCI.

Human umbilical cord mesenchymal stem cells to treat spinal cord injury in the early chronic phase: study protocol for a prospective, multicenter, randomized, placebo-controlled, single-blinded clinical trial

Human umbilical cord mesenchymal stem cells (hUC-MSCs) support revascularization, inhibition of inflammation, regulation of apoptosis, and promotion of the release of beneficial factors. Thus, they are regarded as a promising candidate for the treatment of intractable spinal cord injury (SCI). Clinical studies on patients with early chronic SCI (from 2 months to 1 year post-injury), which is clinically common, are rare; therefore, we will conduct a prospective, multicenter, randomized, placebo-controlled, single-blinded clinical trial at the Third Affiliated Hospital of Sun Yat-sen University, West China Hospital of Sichuan University, and Shanghai East Hospital, Tongji University School of Medicine, China. The trial plans to recruit 66 early chronic SCI patients. Eligible patients will undergo randomization at a 2:1 ratio to two arms: the observation group and the control group. Subjects in the observation group will receive four intrathecal transplantations of stem cells, with a dosage of 1 × 10⁶/kg, at one calendar month intervals. Subjects in the control group will receive intrathecal administrations of 10 mL sterile normal saline in place of the stem cell transplantations. Clinical safety will be assessed by the analysis of adverse events and laboratory tests. The American Spinal Injury Association (ASIA) total score will be the primary efficacy endpoint, and the secondary efficacy outcomes will be the following: ASIA impairment scale, International Association of Neural Restoration-Spinal Cord Injury Functional Rating Scale, muscle tension, electromyogram, cortical motor and cortical sensory evoked potentials, residual urine volume, magnetic resonance imaging-diffusion tensor imaging, T cell subtypes in serum, neurotrophic factors and inflammatory factors in both serum and cerebrospinal fluid. All evaluations will be performed at 1, 3, 6, and 12 months following the final intrathecal administration. During the entire study procedure, all adverse events will be reported as soon as they are noted. This trial is designed to evaluate the clinical safety and efficacy of subarachnoid transplantation of hUC-MSCs to treat early chronic SCI. Moreover, it will establish whether cytotherapy can ameliorate local hostile microenvironments, promote tracking fiber regeneration, and strengthen spinal conduction ability, thus improving overall motor, sensory, and micturition/defecation function in patients with early chronic SCI. This study was approved by the Stem Cell Research Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University, China (approval No. [2018]-02) on March 30, 2018, and was registered with ClinicalTrials.gov (registration No. NCT03521323) on April 12, 2018. The revised trial protocol (protocol version 4.0) was approved by the Stem Cell Research Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University, China (approval No. [2019]-10) on February 25, 2019, and released on ClinicalTrials.gov on April 29, 2019.