Granulocyte-colony stimulating factor administration for neurological improvement in patients with postrehabilitation chronic incomplete traumatic spinal cord injuries: a double-blind randomized controlled clinical trial

Effect of granulocyte colony-stimulating factor (G-CSF) in functional outcome of acute spinal cord injury patients: A single-blinded randomized controlled trial

Background

Spinal Cord Injury (SCI) is a major public health issue causing significant disability and economic burden. Current treatments primarily focus on mitigating secondary injury, with limited effective therapies available. This study explores the efficacy of the Granulocyte Colony-Stimulating Factor (G-CSF) in improving functional outcomes in acute SCI patients.

Materials and methods

This single-blinded randomized control trial was conducted at JIPMER's orthopedic department. Patients with acute spinal cord injury (SCI) were enrolled based on specific inclusion and exclusion criteria. Participants were divided into two groups: Group A (n = 16) received a G-CSF injection whereas Group B (n = 18) received a placebo (normal saline) injection. The primary evaluation was based on the changes in the ASIA impairment scale at 1-, 3-, and 6-months post-injury.

Results

The study involved 34 participants, predominantly male. Initial assessments showed significant differences in ASIA scores between the groups. Group A demonstrated marked improvement in neurological status at 1, 3, and 6 months post-treatment compared to Group B. The frequency of adverse events was comparable between the two groups.

Conclusion

G-CSF showed significant improvement in ASIA scores at various time points post-administration compared to placebo. These findings suggest G-CSF as a potential therapeutic agent in acute SCI treatment. However, due to the small sample size, further research is necessary to confirm these results.

Pharmacological intervention for chronic phase of spinal cord injury

Spinal cord injury is an intractable traumatic injury. The most common hurdles faced during spinal cord injury are failure of axonal regrowth and reconnection to target sites. These also tend to be the most challenging issues in spinal cord injury. As spinal cord injury progresses to the chronic phase, lost motor and sensory functions are not recovered. Several reasons may be attributed to the failure of recovery from chronic spinal cord injury. These include factors that inhibit axonal growth such as activated astrocytes, chondroitin sulfate proteoglycan, myelin-associated proteins, inflammatory microglia, and fibroblasts that accumulate at lesion sites. Skeletal muscle atrophy due to denervation is another chronic and detrimental spinal cord injury-specific condition. Although several intervention strategies based on multiple outlooks have been attempted for treating spinal cord injury, few approaches have been successful. To treat chronic spinal cord injury, neural cells or tissue substitutes may need to be supplied in the cavity area to enable possible axonal growth. Additionally, stimulating axonal growth activity by extrinsic factors is extremely important and essential for maintaining the remaining host neurons and transplanted neurons. This review focuses on pharmacotherapeutic approaches using small compounds and proteins to enable axonal growth in chronic spinal cord injury. This review presents some of these candidates that have shown promising outcomes in basic research ( in vivo animal studies) and clinical trials: AA-NgR(310)ecto-Fc (AXER-204), fasudil, phosphatase and tensin homolog protein antagonist peptide 4, chondroitinase ABC, intracellular sigma peptide, (-)-epigallocatechin gallate, matrine, acteoside, pyrvate kinase M2, diosgenin, granulocyte-colony stimulating factor, and fampridine-sustained release. Although the current situation suggests that drug-based therapies to recover function in chronic spinal cord injury are limited, potential candidates have been identified through basic research, and these candidates may be subjects of clinical studies in the future. Moreover, cocktail therapy comprising drugs with varied underlying mechanisms may be effective in treating the refractory status of chronic spinal cord injury.

Mechanisms and Therapeutic Prospects of Microglia-Astrocyte Interactions in Neuropathic Pain Following Spinal Cord Injury

Neuropathic pain is a prevalent and debilitating condition experienced by the majority of individuals with spinal cord injury (SCI). The complex pathophysiology of neuropathic pain, involving continuous activation of microglia and astrocytes, reactive gliosis, and altered neuronal plasticity, poses significant challenges for effective treatment. This review focuses on the pivotal roles of microglia and astrocytes, the two major glial cell types in the central nervous system, in the development and maintenance of neuropathic pain after SCI. We highlight the extensive bidirectional interactions between these cells, mediated by the release of inflammatory mediators, neurotransmitters, and neurotrophic factors, which contribute to the amplification of pain signaling. Understanding the microglia-astrocyte crosstalk and its impact on neuronal function is crucial for developing novel therapeutic strategies targeting neuropathic pain. In addition, this review discusses the fundamental biology, post-injury pain roles, and therapeutic prospects of microglia and astrocytes in neuropathic pain after SCI and elucidates the specific signaling pathways involved. We also speculated that the extracellular matrix (ECM) can affect the glial cells as well. Furthermore, we also mentioned potential targeted therapies, challenges, and progress in clinical trials, as well as new biomarkers and therapeutic targets. Finally, other relevant cell interactions in neuropathic pain and the role of glial cells in other neuropathic pain conditions have been discussed. This review serves as a comprehensive resource for further investigations into the microglia-astrocyte interaction and the detailed mechanisms of neuropathic pain after SCI, with the aim of improving therapeutic efficacy.

Pharmacological management of secondary chronic spinal cord injury: a systematic review

INTRODUCTION

Spinal cord injury (SCI) may bring lifelong consequences for affected patients and a high financial burden to the health care system.

SOURCE OF DATA

Published peer-reviewed scientific articles identified from EMBASE, Google Scholar, PubMed and Scopus.

AREAS OF AGREEMENT

Surgery and blood pressure management are the main targets in acute SCI to avoid secondary damage.

AREAS OF CONTROVERSY

The management of secondary chronic SCI is challenging, with unpredictable outcomes.

GROWING POINTS

Given the lack of consensus on pharmacological therapy for acute and secondary chronic SCI, the present study analyses the currently available drugs and treatment options to manage secondary chronic SCI.

AREAS TIMELY FOR DEVELOPING RESEARCH

Different approaches exist for the pharmacological management of secondary chronic SCI. One of the most investigated drugs, 4-aminopyridine, improves central motor conduction and shows improvement in neurological signs. Positive results in different areas have been observed in patients receiving the anti-spastic drugs tizanidine and baclofen or Granulocyte colony-stimulating factor. Growth hormone showed only minimal or no significant effects, and the therapy of secondary chronic SCI with riluzole has been poorly researched to date.

Granulocyte-Colony Stimulating Factor Improves Neurological and Functional Outcomes in Patients With Traumatic Incomplete Spinal Cord Injuries: A Systematic Review With Meta-Analyses

Spinal cord injury (SCI) is a cause for significant morbidity, often resulting in long-term disability. We compared outcomes after administration of granulocyte-colony stimulating factor (G-CSF) versus controls. MEDLINE, Embase, and Cochrane Library database searches yielded 222 records; six met study inclusion criteria. Fixed-effect and random-effects models were used to establish odds ratios (ORs) and mean difference (MD) with 95% confidence intervals (CIs) for each outcome. The results of the pooled analysis showed that in patients with incomplete SCI, G-CSF resulted in increased American Spinal Cord Injury Association (ASIA) motor scores at 3 months (MD = 0.57 [95% CI = 0.04, 1.10], I 2 = 63.84%, p = 0.036), 6 months (MD = 4.18 [95% CI = 0.55, 7.80], I 2 = 98.75%, p = 0.024), change in ASIA pinprick scores at 6 months (MD = 3.38 [95% CI = 1.48, 5.28], I 2 = 89.78%, p < 0.001), and increased Spinal Cord Independence Measure (SCIM) III score at 6 months (MD = 3.27 [95% CI = 1.13, 5.41], I 2 = 91.86%, p = 0.003). G-CSF resulted in more adverse events than the non-MP control groups (OR = 1.44 [95% CI = 0.38, 2.50], I 2 = 0%, p = 0.008), but fewer than the MP control groups (OR = -4.2 [95% CI = -5.72, -2.68], I 2 = 0%, p < 0.001). Systemic white blood cell count increased after administration of G-CSF in comparison to baseline (MD = 3.57 [95% CI = 2.79, 4.35], I 2 = 55.06%, p < 0.001). G-CSF did not statistically increase ASIA Impairment Scale at 3 months (MD = 0.48 [95% CI = -0.33, 1.28], I 2 = 0%, p = 0.246) or at 6 months (MD = 1.84 [95% CI = -0.10, 3.79], I 2 = 50.09%, p = 0.063). These meta-analyses of six studies suggest that G-CSF for the treatment of incomplete SCI may result in improved neurological outcomes when compared to the controls. The results are limited by a small sample size with heterogeneity between studies. More robust prospective, randomized studies are necessary to help inform the safety and efficacy of G-CSF.

Traumatic Human Spinal Cord Injury: Are Single Treatments Enough to Solve the Problem?

Traumatic spinal cord injury (SCI) results in partial or complete motor deficits, such as paraplegia, tetraplegia, and sphincter control, as well as sensory disturbances and autonomic dysregulation such as arterial hypotension, lack of sweating, and alterations in skin lability. All this has a strong psychological impact on the affected person and his/her family, as well as costs to healthcare institutions with an economic burden in the short, medium, and long terms. Despite at least forty years of experimental animal studies and several clinical trials with different therapeutic strategies, effective therapy is not universally accepted. Most of the published works on acute and chronic injury use a single treatment, such as medication, trophic factor, transplant of a cell type, and so on, to block some secondary injury mechanisms or promote some mechanisms of structural/functional restoration. However, despite significant results in experimental models, the outcome is a moderate improvement in muscle strength, sensation, or eventually in sphincter control, which has been considered non-significant in human clinical trials. Here we present a brief compilation of successful individual treatments that have been applied to secondary mechanisms of action. These studies show limited neuroprotective or neurorestorative approaches in animal models and clinical trials. Thus, the few benefits achieved so far represent a rationale to further explore other strategies that seek better structural and functional restoration of the injured spinal cord.

Positive and negative cell therapy in randomized control trials for central nervous system diseases

Neurorestorative cell therapies have been tested to treat patients with nervous system diseases for over 20 years. Now it is still hard to answer which kinds of cells can really play a role on improving these patients' quality of life. Non-randomized clinical trials or studies could not provide strong evidences in answering this critical question. In this review, we summarized randomized clinical trials of cell therapies for central nervous diseases, such as stroke, spinal cord injury, cerebral palsy (CP), Parkinson's disease (PD), multiple sclerosis (MS), brain trauma, amyotrophic lateral sclerosis (ALS), etc. Most kinds of cell therapies demonstrated negative results for stoke, brain trauma and amyotrophic lateral sclerosis. A few kinds of cell therapies showed neurorestorative effects in this level of evidence-based medicine, such as olfactory ensheating cells for chronic ischemic stroke. Some kinds of cells showed positive or negative effects from different teams in the same or different diseases. We analyzed the possible failed reasons of negative results and the cellular bio-propriety basis of positive results. Based on therapeutic results of randomized control trials and reasonable analysis, we recommend: (1) to further conduct trials for successful cell therapies with positive results to increase neurorestorative effects; (2) to avoid in repeating failed cell therapies with negative results in same diseases because it is nonsense for them to be done with similar treatment methods, such as cell dosage, transplanting way, time of window, etc. Furthermore, we strongly suggest not to do non-randomized clinical trials for cells that had shown negative results in randomized clinical trials.

Pediatric Spinal Cord Injury: A Review

A spinal cord injury (SCI) can be a devastating condition in children, with profound implications for their overall health and quality of life. In this review, we aim to provide a concise overview of the key aspects associated with SCIs in the pediatric population. Firstly, we discuss the etiology and epidemiology of SCIs in children, highlighting the diverse range of causes. We explore the unique anatomical and physiological characteristics of the developing spinal cord that contribute to the specific challenges faced by pediatric patients. Next, we delve into the clinical presentation and diagnostic methods, emphasizing the importance of prompt and accurate diagnosis to facilitate appropriate interventions. Furthermore, we approach the multidisciplinary management of pediatric SCIs, encompassing acute medical care, surgical interventions, and ongoing supportive therapies. Finally, we explore emerging research as well as innovative therapies in the field, and we emphasize the need for continued advancements in understanding and treating SCIs in children to improve their functional independence and overall quality of life.

Granulocyte colony-stimulating factor effects on neurological and motor function in animals with spinal cord injury: a systematic review and meta-analysis

Background

Spinal cord injury (SCI) is a severe neurological injury for which no effective treatment exists. Granulocyte colony-stimulating factor (G-CSF) is used to treat autologous bone marrow transplantation, chemotherapy-induced granulocytopenia, Acquired Immune Deficiency Syndrome (AIDS), etc. Recent research has revealed the potential application of G-CSF on neuroprotective effectiveness. In central nervous system diseases, G-CSF can be used to alleviate neuronal injury.

Objective

To investigate the effects of G-CSF on Basso, Beattie, and Bresnahan (BBB) scale score, inclined plane test, electrophysiologic exam, quantitative analysis of TUNEL-positive cells, and quantitative analysis of glial fibrillary acidic protein (GFAP) immunostaining images in animal models of SCI.

Methods

We searched PubMed, Web of Science, and Embase databases for all articles on G-CSF intervention with animal models of SCI reported before November 2022. A total of 20 studies met the inclusion criteria.

Results

Results revealed that G-CSF intervention could improve the BBB scale score in both groups at 3, 7, 14, 28, and 35 days [at 35  days, weighted mean differences (WMD) = 2.4, 95% CI: 1.92-2.87, p < 0.00001, I² = 69%]; inclined plane test score; electrophysiologic exam; quantitative analysis of TUNEL-positive cell numbers; quantitative analysis of GFAP immunostaining images in animal models of SCI. Subgroup analysis revealed that treatment with normal saline, phosphate-buffered saline, and no treatment resulted in significantly different neurological function effectiveness compared to the G-CSF therapy. SD rats and Wistar rats with SCI resulted in significant neurological function effectiveness. C57BL/6 mice showed no difference in the final effect. The T9-T10 or T10 segment injury model and the T8-T9 or T9 segment injury model resulted in significant neurological function effectiveness. The BBB score data showed no clear funnel plot asymmetry. We found no bias in the analysis result (Egger's test, p = 0.42). In our network meta-analysis, the SUCRA ranking showed that 15 mg/kg-20 mg/kg was an optimal dose for long-term efficacy.

Conclusion

Our meta-analysis suggests that G-CSF therapy may enhance the recovery of motor activity and have a specific neuroprotective effect in SCI animal models.Systematic review registration: PROSPERO, identifier: CRD42023388315.

Advances in Neurorestoratology-Current status and future developments

Neurorestoratology constitutes a novel discipline aimed at the restoration of damaged neural structures and impaired neurological functions. This area of knowledge integrates and compiles all concepts and strategies dealing with the neurorestoration. Although currently, this discipline has already been well recognized by physicians and scientists throughout the world, this article aimed at broadening its knowledge to the academic circle and the public society. Here we shortly introduced why and how Neurorestoratology was born since the fact that the central nervous system (CNS) can be repaired and the subsequent scientific evidence of the neurorestorative mechanisms behind, such as neurostimulation or neuromodulation, neuroprotection, neuroplasticity, neurogenesis, neuroregeneration or axonal regeneration or sprouting, neuroreplacement, loop reconstruction, remyelination, immunoregulation, angiogenesis or revascularization, and others. The scope of this discipline is the improvement of therapeutic approaches for neurological diseases and the development of neurorestorative strategies through the comprehensive efforts of experts in the different areas and all articulated by the associations of Neurorestoratology and its journals. Strikingly, this article additionally explores the "state of art" of the Neurorestoratology field. This includes the development process of the discipline, the achievements and advances of novel neurorestorative treatments, the most efficient procedures exploring and evaluating outcome after the application of pioneer therapies, all the joining of a multidisciplinary expert associations and the specialized journals being more and more impact. We believe that in a near future, this discipline will evolve fast, leading to a general application of cell-based comprehensive neurorestorative treatments to fulfill functional recovery demands for patients with neurological deficits or dysfunctions.

Clinical results of neurorestorative cell therapies and therapeutic indications according to cellular bio-proprieties

Cell therapies have been explored to treat patients with nervous diseases for over 20 years. Even though most kinds of cell therapies demonstrated neurorestorative effects in non-randomized clinical trials; the effects of the majority type cells could not be confirmed by randomized controlled trials. In this review, clinical therapeutic results of neurorestorative cell therapies according to cellular bio-proprieties or cellular functions were introduced. Currently it was demonstrated from analysis of this review that some indications of cell therapies were not appropriate, they might be reasons why their neurorestorative effects could not be proved by multicenter, randomized, double blind, placebo-controlled clinical trials. Theoretically if one kind of cell therapy has neurorestorative effects according to its cellular bio-proprieties, it should have appropriate indications. The cell therapies with special bio-properties is promising if the indication selections are appropriate, such as olfactory ensheathing cells for chronic ischemic stroke, and their neurorestorative effects can be confirmed by higher level clinical trials of evidence-based medicine.

Edema after CNS Trauma: A Focus on Spinal Cord Injury

Edema after spinal cord injury (SCI) is one of the first observations after the primary injury and lasts for few days after trauma. It has serious consequences on the affected tissue and can aggravate the initial devastating condition. To date, the mechanisms of the water content increase after SCI are not fully understood. Edema formation results in a combination of interdependent factors related to mechanical damage after the initial trauma progressing, along with the subacute and acute phases of the secondary lesion. These factors include mechanical disruption and subsequent inflammatory permeabilization of the blood spinal cord barrier, increase in the capillary permeability, deregulation in the hydrostatic pressure, electrolyte-imbalanced membranes and water uptake in the cells. Previous research has attempted to characterize edema formation by focusing mainly on brain swelling. The purpose of this review is to summarize the current understanding of the differences in edema formation in the spinal cord and brain, and to highlight the importance of elucidating the specific mechanisms of edema formation after SCI. Additionally, it outlines findings on the spatiotemporal evolution of edema after spinal cord lesion and provides a general overview of prospective treatment strategies by focusing on insights to prevent edema formation after SCI.

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.

Established and Emerging Therapies in Acute Spinal Cord Injury

Acute spinal cord injury (SCI) is devastating for patients and their caretakers and has an annual incidence of 20–50 per million people. Following initial assessment with appropriate physical examination and imaging, patients who are deemed surgical candidates should undergo decompression with stabilization. Earlier intervention can improve neurological recovery in the post-operative period while allowing earlier mobilization. Optimized medical management is paramount to improve outcomes. Emerging strategies for managing SCI in the acute period stem from an evolving understanding of the pathophysiology of the injury. General areas of focus include ischemia prevention, reduction of secondary injury due to inflammation, modulation of the cytotoxic and immune response, and promotion of cellular regeneration. In this article, we review established, emerging, and novel experimental therapies. Continued translational research on these methods will improve the feasibility of bench-to-bedside innovations in treating patients with acute SCI.

Reliability validity and responsiveness of the spinal cord independence measure 4th version in a multicultural setup

OBJECTIVE

To examine the fourth version of the Spinal Cord Independence Measure for reliability and validity.

DESIGN

Partly blinded comparison with the criterion standard Spinal Cord Independence Measure III, and between examiners and examinations.

SETTING

A multicultural cohort from 19 spinal cord injury units in 11 countries.

PARTICIPANTS

Six hundred and forty-eight patients with spinal cord injury.

INTERVENTION

Assessment with Spinal Cord Independence Measure (SCIM IV) and Spinal Cord Independence Measure (SCIM III) on admission to inpatient rehabilitation and before discharge.

MAIN OUTCOME MEASURES

SCIM IV interrater reliability, internal consistency, correlation with and difference from SCIM III, and responsiveness.

RESULTS

Total agreement between examiners was above 80% on most SCIM IV tasks. All Kappa coefficients were above 0.70 and statistically significant (p<0.001). Pearson's coefficients of the correlation between the examiners were above 0.90, and intraclass correlation coefficients were above 0.90. Cronbach's alpha was above 0.96 for the entire SCIM IV, above 0.66 for the subscales, and usually decreased when an item was eliminated. Reliability values were lower for the subscale of respiration and sphincter management, and on admission than at discharge. SCIM IV and SCIM III mean values were very close, and the coefficients of Pearson correlation between them were 0.91-0.96 (p<0.001). The responsiveness of SCIM IV was not significantly different from that of SCIM III in most of the comparisons.

CONCLUSIONS

The validity, reliability, and responsiveness of SCIM IV, which was adjusted to assess specific patient conditions or situations that SCIM III does not address, and which includes more accurate definitions of certain scoring criteria, are very good and quite similar to those of SCIM III. SCIM IV can be used for clinical and research trials, including international multi-center studies, and its group scores can be compared with those of SCIM III.

First-in-human clinical trial of transplantation of iPSC-derived NS/PCs in subacute complete spinal cord injury: Study protocol

Introduction

Our group has conducted extensive basic and preclinical studies of the use of human induced pluripotent cell (iPSC)-derived neural stem/progenitor cell (hiPSC-NS/PC) grafts in models of spinal cord injury (SCI). Evidence from animal experiments suggests this approach is safe and effective. We are preparing to initiate a first-in-human clinical study of hiPSC-NS/PC transplantation in subacute SCI.

Setting

NS/PCs were prepared at a Good Manufacturing Practice-grade cell processing facility at Osaka National Hospital using a clinical-grade integration-free hiPSC line established by the iPSC Stock Project organized by the Kyoto University Center for iPS Cell Research and Application. After performing all quality checks, the long-term safety and efficacy of cells were confirmed using immunodeficient mouse models.

Methods

The forthcoming clinical study uses an open-label, single-arm design. The initial follow-up period is 1 year. The primary objective is to assess the safety of hiPSC-NS/PC transplantation in patients with subacute SCI. The secondary objective is to obtain preliminary evidence of its impact on neurological function and quality-of-life outcomes. Four patients with C3/4-Th10 level, complete subacute (within 24 days post-injury) SCI will be recruited. After obtaining consent, cryopreserved cells will be thawed and prepared following a multi-step process including treatment with a γ-secretase inhibitor to promote cell differentiation. A total of 2 × 10⁶ cells will be transplanted into the injured spinal cord parenchyma 14–28 days post-injury. Patients will also receive transient immunosuppression. This study protocol has been reviewed and approved by the Certified Committee for Regenerative Medicine and the Japanese Ministry of Health, Labor and Welfare (University Hospital Medical Information Network Clinical Trials Registry [UMIN-CTR] number, UMIN000035074; Japan Registry of Clinical Trials [jRCT] number, jRCTa031190228).

Discussion/conclusion

We plan to start recruiting a patient as soon as the COVID-19 epidemic subsides. The primary focus of this clinical study is safety, and the number of transplanted cells may be too low to confirm efficacy. After confirming safety, a dose-escalation study is planned.

•

A first-in-human clinical study for spinal cord injury using iPSC-derived cells is about to begin.

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The primary objective is to assess the safety of human iPSC-derived neural stem/progenitor cells.

•

Further clinical trials are expected to be conducted to statistically assess efficacy.

A review of emerging neuroprotective and neuroregenerative therapies in traumatic spinal cord injury

Traumatic spinal cord injuries (SCIs) have far-reaching physical, social, and financial consequences. While medical advancements have improved supportive therapeutic measures for SCI patients, no effective neuroregenerative therapeutic options exist to date. Instead, the paradigm of SCI therapy is inevitably directed towards damage control rather than the restoration of a state of functional independence. Facing a continuous increase in the prevalence of spinal cord injured patients, neuroprotective and neuroregenerative strategies have earned tremendous scientific interest. This review intends to provide a robust summary of the most promising neuroprotective and neuroregenerative therapies currently under investigation. While we highlight encouraging neuroprotective strategies as well, the focus of this review lies on neuroregenerative therapies, including neuropharmacological and cell-based approaches. We finally point to the exciting investigational areas of biomaterial scaffolds and neuromodulation therapies.

Reliability and validity of the international standards for neurological classification of spinal cord injury in patients with non-traumatic spinal cord lesions

STUDY DESIGN

Prospective, observational study.

OBJECTIVES

The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) represent the gold standard for the assessment of patients with spinal cord injury (SCI) and their measurement properties have been evaluated in patients with traumatic lesions. Albeit the ISNCSCI are widely used also for the assessment and prognosis of patients with non-traumatic SCI, a validation of this grading system in this sample has never been performed. Therefore, the aim of this study is to evaluate the measurement properties of the ISNCSCI in a population of persons with non-traumatic SCI.

SETTING

Three Italian rehabilitation hospitals.

METHODS

The sample included 140 patients with non-traumatic SCI of different etiology, level and grade, for a total of 169 evaluations performed by two examiners. Cronbach's Alpha was used to evaluate the internal consistency of the ISNCSCI various components. The agreement between two examiners of each center in the definition of different components was used to assess the inter-rater reliability. The construct validity was evaluated through the correlation of the ISNCSCI with the Spinal Cord Independence Measure (SCIM).

RESULTS

The ISNCSCI showed substantial internal consistency, and substantial inter-rater agreement for AIS grade, cumulative motor and sensory scores. The motor scores for upper and lower extremity showed fair to moderate correlation with SCIM self-care and motility subscores, respectively. The ISNCSCI total motor score correlated with the total SCIM score.

CONCLUSIONS

Our study demonstrates that the ISNCSCI are a valid and reliable tool for the assessment of patients with non-traumatic SCI.

Acute spinal cord injury: Pathophysiology and pharmacological intervention (Review)

Spinal cord injury (SCI) is one of the most debilitating of all the traumatic conditions that afflict individuals. For a number of years, extensive studies have been conducted to clarify the molecular mechanisms of SCI. Experimental and clinical studies have indicated that two phases, primary damage and secondary damage, are involved in SCI. The initial mechanical damage is caused by local impairment of the spinal cord. In addition, the fundamental mechanisms are associated with hyperflexion, hyperextension, axial loading and rotation. By contrast, secondary injury mechanisms are led by systemic and cellular factors, which may also be initiated by the primary injury. Although significant advances in supportive care have improved clinical outcomes in recent years, a number of studies continue to explore specific pharmacological therapies to minimize SCI. The present review summarized some important pathophysiologic mechanisms that are involved in SCI and focused on several pharmacological and non‑pharmacological therapies, which have either been previously investigated or have a potential in the management of this debilitating injury in the near future.

Traumatic Spinal Cord Disorders: Current Topics and Future Directions

Traumatic spinal cord injury (tSCI) is a life-changing and potentially overwhelming event. The sudden disruption of the spinal cord's integrity necessitates rapid attention at a specialized medical center, and involves a multilateral collaboration between neurologists, spine surgeons, critical care physicians, and trauma specialists. Even with care under ideal conditions, many tSCI patients have significant disability that persists for the rest of their lives. However, recently, we have seen a proliferation in clinical and translational trials that offer the promise that new treatments may be available soon.

Pharmacological management of secondary spinal cord injury

Introduction: Secondary spinal cord injury (SCI) sets on immediately after trauma and, despite prompt treatment, may become chronic. SCI is a complex condition and presents numerous challenges to patients and physicians alike, also considering the lack of an approved pharmacological therapy.Areas covered: This review describes the pathophysiological mechanisms leading to secondary SCI to highlight possible targets for pharmacological therapy. Furthermore, an extensive search of the literature on different databases (PubMed, Google scholar, Embase, and Scopus) and of the current clinical trials (clinicaltrials.gov) was performed to investigate the current outlook for the pharmacological management of SCI. Only drugs with performed or ongoing clinical trials were considered.Expert opinion: Pharmacological therapy aims to improve motor and sensory function in patients. Overall, drugs are divided into neuroprotective compounds, which aim to limit the damage induced by the pro-inflammatory and pro-apoptotic milieu of SCI, and neuroregenerative drugs, which induce neuronal and axonal regrowth. While many compounds have been trialed with promising results, none has yet completed a stage III trial and has been approved for the pharmacological management of SCI.

MicroRNA-24-3p Inhibits Microglia Inflammation by Regulating MK2 Following Spinal Cord Injury

Spinal cord injury (SCI) is a functional impairment of the spinal cord caused by external forces, accompanied by limb movement disorders and permanent paralysis, which seriously lowers the life quality of SCI patients. Secondary injury caused by inflammation attenuated the therapeutic effects of SCI. Therefore, the exploration of biomarkers associated with the inflammatory response following SCI might provide novel therapy strategy against SCI.SCI rat model was established as previously reported and evaluated by BBB score. The expression of microRNA-24-3p (miR-24-3p) and MAPK-activated protein kinase 2 (MK2) in spinal cord tissues of SCI rats and HAPI cells was analyzed by qRT-PCR. Protein expression of MK2, ionized calcium-binding adapter molecule-1 (Iba-1), tumor necrosis factor-alpha (TNF-α), and interleukin-1β (IL-1β) was assessed by western blot assay. The release of inflammatory cytokines TNF-α and IL-1β was measured by enzyme-linked immunosorbent assay (ELISA). The interaction between miR-24-3p and MK2 was examined by the luciferase reporter system. Basso-Beattie-Bresnahan (BBB) score dramatically reduced in rats following SCI compared with sham rats. Moreover, the expression of miR-24-3p was down-regulated, while MK2 was up-regulated in the spinal cord tissues of SCI rats and LPS-induced microglia cells compared with the corresponding control group. Luciferase reporter system confirmed the interaction between miR-24-3p and MK2. In addition, miR-24-3p upregulation or MK2 knockdown attenuated LPS induced activation of microglial cells and expression of inflammatory cytokine TNF-α and IL-1β. Besides, we discovered that miR-24-3p regulated inflammation of highly aggressively proliferating immortalized (HAPI) cells by targeting MK2.In our study, we clarified that miR-24-3p repressed inflammation of microglia cells following SCI by regulating MK2, thereby providing promising biomarkers for SCI therapy.

Granulocyte colony-stimulating factor in traumatic spinal cord injury

Granulocyte colony-stimulating factor (G-CSF) is a cytokine used in pharmaceutical preparations for the treatment of chemotherapy-induced neutropenia. Evidence from experimental studies indicates that G-CSF exerts relevant activities in the central nervous system (CNS) in particular after lesions. In acute, subacute, and chronic CNS lesions, G-CSF appears to have strong anti-inflammatory, antiapoptotic, antioxidative, myelin-protective, and axon-regenerative activities. Additional effects result in the stimulation of angiogenesis and neurogenesis as well as in bone marrow stem cell mobilization to the CNS. There are emerging preclinical and clinical data indicating that G-CSF is a safe and effective drug for the treatment of acute and chronic traumatic spinal cord injury (tSCI), which we summarize in this review.

Hydrogels as delivery systems for spinal cord injury regeneration

Spinal cord injury is extremely debilitating, both at physiological and psychological levels, changing completely the patient's lifestyle. The introduction of biomaterials has opened a new window to develop a therapeutic approach to induce regeneration after injury due to similarities with extracellular matrix. Particularly, hydrogels have the ability to support axonal growth and endogenous regeneration. Moreover, they can also act as potential matrixes in which to load and deliver therapeutic agents at injury site. In this review, we highlight some important characteristics to be considered when designing hydrogels as delivery systems (DS), such as rheology, mesh size, swelling, degradation, gelation temperature and surface charge. Additionally, affinity-based release systems, incorporation of nanoparticles, or ion-mediated interactions are also pondered. Overall, hydrogel DS aim to promote a sustained, controlled and prolonged release at injury site, allowing a targeted oriented action of the therapeutic agent that will be used.

Clinical Neurorestorative Therapeutic Guidelines for Spinal Cord Injury (IANR/CANR version 2019)

Functional restoration after spinal cord injury (SCI) is one of the most challenging tasks in neurological clinical practice. With a view to exploring effective neurorestorative methods in the acute, subacute, and chronic phases of SCI, “Clinical Therapeutic Guidelines of Neurorestoration for Spinal Cord Injury (China Version 2016)” was first ​proposed in 2016 by the Chinese Association of Neurorestoratology (CANR). Given the rapid advances in this field in recent years, the International Association of Neurorestoratology (IANR) and CANR formed and approved the “Clinical Neurorestorative Therapeutic Guidelines for Spinal Cord Injury (IANR/CANR version 2019)”. These guidelines mainly introduce restoring damaged neurological structure and functions by varying neurorestorative strategies in acute, subacute, and chronic phases of SCI. These guidelines can provide a neurorestorative therapeutic standard or reference for clinicians and researchers in clinical practice to maximally restore functions of patients with SCI and improve their quality of life.

The translational potential of this article

This guideline provided comprehensive management strategies for SCI, which contains the evaluation and diagnosis, pre-hospital first aid, treatments, rehabilitation training, and complications management. Nowadays, amounts of neurorestorative strategies have been demonstrated to be benefit in promoting the functional recovery and improving the quality of life for SCI patients by clinical trials. Also, the positive results of preclinical research provided lots of new neurorestorative strategies for SCI treatment. These promising neurorestorative strategies are worthy of translation in the future and can promote the advancement of SCI treatments.

Regenerative Therapies for Spinal Cord Injury

Spinal cord injury (SCI) is a serious problem that primarily affects younger and middle-aged adults at its onset. To date, no effective regenerative treatment has been developed. Over the last decade, researchers have made significant advances in stem cell technology, biomaterials, nanotechnology, and immune engineering, which may be applied as regenerative therapies for the spinal cord. Although the results of clinical trials using specific cell-based therapies have proven safe, their efficacy has not yet been demonstrated. The pathophysiology of SCI is multifaceted, complex and yet to be fully understood. Thus, combinatorial therapies that simultaneously leverage multiple approaches will likely be required to achieve satisfactory outcomes. Although combinations of biomaterials with pharmacologic agents or cells have been explored, few studies have combined these modalities in a systematic way. For most strategies, clinical translation will be facilitated by the use of minimally invasive therapies, which are the focus of this review. In addition, this review discusses previously explored therapies designed to promote neuroregeneration and neuroprotection after SCI, while highlighting present challenges and future directions. Impact Statement To date there are no effective treatments that can regenerate the spinal cord after injury. Although there have been significant preclinical advances in bioengineering and regenerative medicine over the last decade, these have not translated into effective clinical therapies for spinal cord injury. This review focuses on minimally invasive therapies, providing extensive background as well as updates on recent technological developments and current clinical trials. This review is a comprehensive resource for researchers working towards regenerative therapies for spinal cord injury that will help guide future innovation.

Acidic Fibroblast Growth Factor in Spinal Cord Injury

Spinal cord injury (SCI), with an incidence rate of 246 per million person-years among adults in Taiwan, remains a devastating disease in the modern day. Elderly men with lower socioeconomic status have an even higher risk for SCI. Despite advances made in medicine and technology to date, there are few effective treatments for SCI due to limitations in the regenerative capacity of the adult central nervous system. Experiments and clinical trials have explored neuro-regeneration in human SCI, encompassing cell- and molecule-based therapies. Furthermore, strategies have aimed at restoring connections, including autologous peripheral nerve grafts and biomaterial scaffolds that theoretically promote axonal growth. Most molecule-based therapies target the modulation of inhibitory molecules to promote axonal growth, degrade glial scarring obstacles, and stimulate intrinsic regenerative capacity. Among them, acidic fibroblast growth factor (aFGF) has been investigated for nerve repair; it is mitogenic and pluripotent in nature and could enhance axonal growth and mitigate glial scarring. For more than 2 decades, the authors have conducted multiple trials, including human and animal experiments, using aFGF to repair nerve injuries, including central and peripheral nerves. In these trials, aFGF has shown promise for neural regeneration, and in the future, more trials and applications should investigate aFGF as a neurotrophic factor. Focusing on aFGF, the current review aimed to summarize the historical evolution of the utilization of aFGF in SCI and nerve injuries, to present applications and trials, to summarize briefly its possible mechanisms, and to provide future perspectives.

Subcutaneous granulocyte colony-stimulating factor administration for subacute traumatic spinal cord injuries, report of neurological and functional outcomes: a double-blind randomized controlled clinical trial

In BriefSpinal cord injury is among the most devastating neurological conditions affecting humans. The authors assessed the therapeutic efficacy of subcutaneous recombinant granulocyte colony-stimulating factor as an adjunct to classic surgical and rehabilitative treatments for subacute traumatic spinal cord injuries. This safe and noninvasive treatment may be helpful for better care and satisfaction of patients with this devastating condition throughout the world.

2018 Yearbook of Neurorestoratology

The Neurorestoratology discipline is getting worldwide attention from the clinicians, basic scientists, students and policy makers alike. Accordingly, this year too, the discipline has made profound advances and great achievements for the benefit of the mankind. In this report, of the 2018 Neurorestoratology Yearbook, salient features of new developments are summarized. This Yearbook consists 3 key themes namely (i) the new findings on pathogenesis of neurological diseases or degeneration; (ii) the new mechanisms of neurorestorative aspects; and (iii) the achievements and progresses made in the clinical field of neurorestorative therapies. The new trend has emerged in clinical studies that are based on greater levels of evidence-based medical practices both in clinical therapies and clinical trials based on standard designs.

Review of clinical neurorestorative strategies for spinal cord injury: Exploring history and latest progresses

Clinical neurorestorative therapies recently made great progress for patients with spinal cord injury (SCI). This paper systemically reviews historical perspectives, recent advancements and achievements in SCI through key neurorestorative strategies. In this study, a search was performed in the PubMed, Scopus, and Scholar Google search engines using the keywords “neurorestorative strategies”, “spinal cord injury”, “cell therapy”, “neuromodulation”, and “nerve bridges”. Clinical studies published in the English language were included. It is paramount for academic community involved in this field to take the initiative of a multicenter randomized, double-blind, and placebo-control clinical study with high level of evidence-based treatments for most SCI neurorestorative strategies in patient management. It is of utmost need to establish standard therapeutic methods for patients with SCI as early as possible.