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PubMed2002

Spinal cord injury.

Pediatric spinal cord injury is a relatively uncommon problem, responsible for approximately 5% of all spinal cord injuries. Anatomic and behavioral differences between adults and children lead to variation in injury type and severity. Young children are more prone to high cervical injuries, with nearly 80% of injuries in children < 2 yrs old affecting this area. As the child approaches 8-10 yrs of age, the spinal anatomy and therefore injury pattern more closely approximates adult injuries. Although the prevalence of spine injuries is lower in children, clearing the spine becomes more complex due to radiographic differences and the inability to "clinically" clear the cervical spine in young children. In this article, the types of injuries seen in children are discussed, with an emphasis on acute management and clearance of the cervical spine. Treatment options and long-term issues are also discussed.

Adolescent↗
PubMed2005

Spinal cord injury triggers sensitization of wide dynamic range dorsal horn neurons in segments rostral to the injury.

A spinal cord injury (SCI) was produced in adult rats by complete spinal cord transection at L6-S1. Neuropathic pain behaviors similar to the chronic central pain (CCP) syndrome in human, such as thermal hyperalgesia, mechanical allodynia and autotomy, were present in these rats after spinal cord injury. Meanwhile, wide dynamic range (WDR) neurons recorded in the spinal dorsal horn rostral to the lesion responded as high frequency of spontaneous activities, long duration of after-discharges to noxious electrical stimuli and an augmented wind-up to 0.5 Hz stimuli. By using bupivacaine powder, a sodium channel blocker, at the locus of transection immediate after nerve injury, the chronic pain behaviors were prevented; the hyperexcitability of WDR neurons was also substantially reduced. It is suggested that spinal cord transection induces the CCP syndromes, which may be evoked and maintained by the hyperexcitability in WDR neurons rostrally. Reducing the neuronal activity at the site of lesion following injury may prevent the development of CCP after SCI.

Animals↗
PubMed2004

In vivo and in vitro characterization of novel neuronal plasticity factors identified following spinal cord injury.

Following spinal cord injury, there are numerous changes in gene expression that appear to contribute to either neurodegeneration or reparative processes. We utilized high density oligonucleotide microarrays to examine temporal gene profile changes after spinal cord injury in rats with the goal of identifying novel factors involved in neural plasticity. By comparing mRNA changes that were coordinately regulated over time with genes previously implicated in nerve regeneration or plasticity, we found a gene cluster whose members are involved in cell adhesion processes, synaptic plasticity, and/or cytoskeleton remodeling. This group, which included the small GTPase Rab13 and actin-binding protein Coronin 1b, showed significantly increased mRNA expression from 7-28 days after trauma. Overexpression in vitro using PC-12, neuroblastoma, and DRG neurons demonstrated that these genes enhance neurite outgrowth. Moreover, RNAi gene silencing for Coronin 1b or Rab13 in NGF-treated PC-12 cells markedly reduced neurite outgrowth. Coronin 1b and Rab13 proteins were expressed in cultured DRG neurons at the cortical cytoskeleton, and at growth cones along with the pro-plasticity/regeneration protein GAP-43. Finally, Coronin 1b and Rab13 were induced in the injured spinal cord, where they were also co-expressed with GAP-43 in neurons and axons. Modulation of these proteins may provide novel targets for facilitating restorative processes after spinal cord injury.

Animals↗
PubMed1999

Surgical treatment for acute spinal cord injury study pilot study #2: evaluation of protocol for decompressive surgery within 8 hours of injury.

Acute spinal cord injury (SCI) is a major public health problem for which there is still only limited treatment available. The National Acute Spinal Cord Injury Study-2 (NASCIS-2) and -3 clinical trials demonstrated that the use of acute pharmacotherapy with methylprednisolone can attenuate the secondary injury cascade if administered within 8 hours of acute SCI. However, no trial has been performed to examine whether acute surgical decompressive procedures within this critical 8-hour time window can improve patients' neurological outcome. The purpose of the current prospective Surgical Treatment for Acute Spinal Cord Injury Study (STASCIS) pilot study was to determine the feasibility of obtaining a radiological diagnosis of spinal canal compromise of 25% or more and to perform spinal cord (C3-T1) decompressive procedures by 8 hours postinjury. One of the following three decompressive methods was used: 1) traction alone; 2) traction and surgery; or 3) surgery alone. Twenty-six patients from eight North American centers were entered into the study between 1996 and 1997. Significant difficulties were encountered in many centers in performing immediate magnetic resonance imaging examination in patients with acute SCI. Fewer than 10% of acute cervical SCI patients could be enrolled into this protocol mainly because the combination of the required time for rescue, resuscitation, transport, imaging study, and surgical preparation exceeded the 8-hour injury-to-decompressive surgery window. Eleven patients underwent decompressive procedures initially by being placed in traction at a mean time of 10.9 hours postinjury. Those patients not undergoing this procedure underwent decompressive surgery at a mean time of 40.1 hours. However, the surgical decompressive procedure was completed within 12 hours in seven patients. As a result of these findings, several major changes have been made to the STASCIS protocol for early decompressive therapy.

Journal Article↗
PubMed2004

Vaccinia virus complement control protein reduces inflammation and improves spinal cord integrity following spinal cord injury.

Traumatic spinal cord injury (SCI) claims approximately 10,000 new victims each year in the United States alone. The injury usually strikes those under the age of 30 years, often leading to a lifetime of pain, suffering, and disability. Therapeutic agents targeting spinal cord injury are sorely lacking, and therefore our laboratory endeavored to evaluate the potential therapeutic benefits of immediate post-injury administration of the vaccinia virus complement control protein (VCP). VCP is a multifunctional anti-inflammatory protein that can inhibit both pathways of complement activation and bind heparin. Utilizing a common animal model of contusion SCI, motor function recovery tests, and immunochemical stains, we evaluated the effects of VCP injected into spinal cord tissue following injury. Results demonstrate that VCP administration inhibits macrophage infiltration, reduces spinal cord destruction, and improves hind-limb function, establishing VCP as a strong candidate for further investigation in the treatment of SCI.

Animals↗
PubMed1999

Activation of the caspase-3 apoptotic cascade in traumatic spinal cord injury.

Traumatic spinal cord injury often results in complete loss of voluntary motor and sensory function below the site of injury. The long-term neurological deficits after spinal cord trauma may be due in part to widespread apoptosis of neurons and oligodendroglia in regions distant from and relatively unaffected by the initial injury. The caspase family of cysteine proteases regulates the execution of the mammalian apoptotic cell death program. Caspase-3 cleaves several essential downstream substrates involved in the expression of the apoptotic phenotype in vitro, including gelsolin, PAK2, fodrin, nuclear lamins and the inhibitory subunit of DNA fragmentation factor. Caspase-3 activation in vitro can be triggered by upstream events, leading to the release of cytochrome c from the mitochondria and the subsequent transactivation of procaspase-9 by Apaf-1. We report here that these upstream and downstream components of the caspase-3 apoptotic pathway are activated after traumatic spinal cord injury in rats, and occur early in neurons in the injury site and hours to days later in oligodendroglia adjacent to and distant from the injury site. Given these findings, targeting the upstream events of the caspase-3 cascade has therapeutic potential in the treatment of acute traumatic injury to the spinal cord.

Animals↗
PubMed1993

Secondary injury mechanisms in acute spinal cord injury.

Experimental studies in animal spinal cord injury models suggest that preservation of a relatively small number of spinal axons can support neurological recovery. The second National Acute Spinal Cord Injury Study (NASCIS 2) was the first clinical trial to demonstrate that a treatment given after injury can enhance neurological recovery. In this trial, patients treated with high-dose methylprednisolone within 8 hours of spinal cord injury recovered more sensory and motor function than did those treated with placebo. In addition to demonstrating the first effective pharmacological intervention in central nervous system injury, NASCIS 2 identified several critical issues that must be investigated in future preclinical and clinical research. These include drug dose, initiation time, and duration of treatment, as well as combination therapy and injury severity. Addressing these issues systematically will require more reproducible animal models and more accurate outcome measures.

Animals↗
PubMed1989

Functional outcome following spinal cord injury. A comparison of specialized spinal cord injury center vs general hospital short-term care.

The functional outcomes of 185 patients with spinal cord injuries undergoing rehabilitation who were initially treated in a specialized short-term care unit (center patients) were compared with those of 153 patients initially treated in general hospitals (noncenter patients). After stabilization, all patients were admitted to the Rehabilitation Institute of Chicago (Ill) and received the same rehabilitation program. The groups were comparable in terms of demographic, injury, and medical characteristics at the time of rehabilitation center admission, but the duration from injury to rehabilitation was more than twice as long for noncenter patients. While center patients were discharged from the rehabilitation center at equivalent functional skill levels, their daily rate of functional gains during the rehabilitation center stay was significantly greater than that of noncenter patients although the length of stay at the rehabilitation center was comparable for the two groups. These results support the practice of specialized short-term spinal cord injury care as a means of enhancing rehabilitation outcome.

Activities of Daily Living↗
PubMed2001

Management of acute cervical spinal cord injury.

BACKGROUND: Spinal cord injury affects approximately 10,000 new persons each year in the United States. Motor vehicle crashes, violence, and falls are the most common causes. The purpose of this review is to provide a rational management strategy for treating acute cervical spinal cord injuries. REVIEW SUMMARY: History-taking in these patients should focus on a few key points. Physical examination consists of determining the level of the lesion by a tailored motor, sensory, and reflex examination. An algorithm for the judicious use of plain radiographs, computed tomography scans, and emergent magnetic resonance imaging is presented. Management goals include protection of uninjured tissue, restoration of reversibly injured tissue, and achieving alignment and permanent spinal stability. The role of early surgery and high-dose steroids are discussed. CONCLUSION: Maximizing neurological function after cervical spinal cord injuries relies on rapid diagnosis and appropriate management. Although prognosis generally remains poor, recent advances in the basic sciences offer hope for the future.

Journal Article↗
PubMed1992

Protective effect of methylprednisolone on vascular injury in rat spinal cord injury.

High-dose methylprednisolone (MP) given to patients within 8 h of traumatic spinal cord improved neural function at 6 and 12 months, suggesting a probable secondary injury process that may be amenable to therapeutic intervention. Vascular injury plays an important role in the secondary injury process of CNS trauma. We have examined the effect of MP on vascular changes, including tissue edema, vascular permeability, and polymorphonuclear (PMN) cell infiltration in a rat model of spinal cord impact injury. MP significantly reduced extravasation of fluorescein isothiocyanate dextran (FITC-D), a macromolecular tracer, by 64.3% and 50.7% with trauma forces of 20 and 40 g-cm, respectively, when MP was administered IV immediately after trauma at a bolus of 165 mg/kg, with a subsequent continuous MP infusion at 31.5 mg/kg/h for 23 h. MP reduced the water content in the 40 g-cm traumatic cord lesion to 73.0% compared to the traumatic control (74.3%, p < 0.001) at the same schedule of large dose 24-h infusion. The same doses of MP showed a trend to decrease the extent of neutrophil infiltration as determined by myeloperoxidase (MPO) activity, but the change was not significant. MP had little effect in decreasing FITC-D extravasation and cord edema when given at a lower dose (bolus of 30 mg/kg with continued infusion of 1.3 mg/kg/h for 23 h). MP did not reduce extravasation of FITC-D and edema when administered IV as one bolus injection at high (165 mg/kg) or low (30 mg/kg) doses.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2002

Neonatal spinal cord injury.

Neonatal spinal cord injury (SCI) is well described in the literature, though its diagnosis is often delayed or missed in the neonatal period. We present a neonate who was referred with upper gastrointestinal bleed and a diagnosis of spinal cord injury was subsequently made clinically and confirmed radiologically.

Birth Injuries↗
PubMed2002

Neurological and functional status 1 year after acute spinal cord injury: estimates of functional recovery in National Acute Spinal Cord Injury Study II from results modeled in National Acute Spinal Cord Injury Study III.

OBJECT: In the second National Acute Spinal Cord Injury Study (NASCIS II) investigators evaluated several standard neurological parameters but not functional activity. This has led to questions concerning the clinical importance of the increase in neurological recovery observed following administration of methylprednisolone (MP) within 8 hours of acute spinal cord injury (SCI). The safety of the therapy has also been questioned. METHODS: Both neurological and functional recovery were assessed in NASCIS III, a trial that followed an almost identical protocol to NASCIS II. In the current analysis locally weighted scatterplot smoothing (LOESS) nonparametric regression is used to model the extent of recovery in the Functional Independence Measure (FIM) that is predicted by improvement in the NASCIS/American Spinal Cord Injury Association motor scores that were documented in NASCIS III 1 year after SCI, and the models are applied to the extent of motor recovery demonstrated in NASCIS II. The models predict improvement in FIM that would be expected from the motor function recovery observed in NASCIS II. Estimates are provided overall and for patients with complete and incomplete neurological loss at time of injury. The authors review recent evidence obtained from randomized studies documenting adverse effects that may result from high-dose MP therapy. The relationship between motor function and FIM is strongly nonlinear and dependent on initial level of injury and degree of injury severity. In the best statistical model, the expanded motor score could be used to explain 77.2% of the variability in the FIM. Based on the mean MP-related 3.6-unit improvement in the motor score for patients with complete injuries and 7.3 for those with incomplete injuries owed to MP in NASCIS II, 18.6% of patients would improve six or more FIM points and 9% nine or more points, respectively. In those with complete neurological injury, the mean motor improvement of 3.6 predicted that 63.9% of the patients would improve three or more FIM points and 12.1% six or more points to a maximum of eight points. Of those with incomplete neurological injury, a 7.3 mean improvement in motor function predicted that 27.4% would gain six or more FIM points and that 21% would gain nine or more points to a maximum of 15 points. Analysis of the current best evidence from SCI and other randomized surgical trials in which high-dose MP has been administered provides no grounds for concern about commonly studied adverse effects. CONCLUSIONS: The extent of MP therapy-related motor function recovery observed in NASCIS II predicted clinically important recovery in the FIM. Reasons to be cautious with regard to this prediction include the lack of robustness in statistical modeling, some loss of validity in the FIM, and considerable heterogeneity in the SCI population. Whatever functional activity is ascribed to high-dose MP therapy, it is does not appear to be associated with risk of adverse outcomes.

Activities of Daily Living↗
PubMed1999

Changes in neuronal receptive field characteristics in caudal brain stem following chronic spinal cord injury.

Chronic spinal cord injury pain is poorly understood and, thus, not effectively relieved by traditional treatments. In the present study, a variety of partial, severe and sham chronic spinal lesions were made in 31 male rats at spinal level T8. During routine care/handling and brief behavioral testing of the animals throughout the 30-day recovery period, the majority of those with severe contusion injuries (verified histologically) showed signs of mechanical hypersensitivity on the dorsolateral trunk just rostral to the level of injury (i.e., upper thoracic territory). Terminal electrophysiological experiments were performed on all rats (urethane anesthesia). Single unit recordings were made at two supraspinal locations within the caudal brainstem, the nucleus reticularis gigantocellularis and nucleus reticularis gigantocellularis pars alpha. Neurons in these areas normally receive bilateral nociceptive somatovisceral inputs from many parts of the body. Seventy-three percent of the animals with severe contusion injuries developed novel low-threshold neuronal responses to stimulation of the dorsolateral trunk (upper thoracic territory). This amount was significantly greater than for animals with more moderate spinal lesions (dorsal or lateral hemisection; 29% and 25%, respectively) or sham controls (0%). These data suggest (1) that the spinal contusion is a reliable model for studies of the neural mechanisms that underly central spinal cord injury-related pain and (2) that the caudal brainstem is one supraspinal location where neurons undergo significant changes in responsiveness following severe chronic spinal cord injury. The observed plasticity is likely part of the central reorganization producing the multitude of sensory disturbances that surface following spinal cord injury.

Afferent Pathways↗
PubMed2006

Recurrent asystole resulting from high cervical spinal cord injuries.

Cervical spinal cord injury is a highly morbid condition frequently associated with cardiovascular instability. This instability may include bradyarrhythmias, as well as hypotension, and usually resolves in a relatively short time. However, over a 3-year period (January 2003-December, 2005), 5 of 30 patients with complete cervical spinal cord injuries seen at our Level I trauma center required placement of permanent cardiac pacemakers for recurrent bradycardia/asystolic events. Strong consideration for pacemaker placement should be given for those spinal cord-injured patients with symptomatic bradyarrhythmic events still occurring 2 weeks after injury.

Adult↗
PubMed2003

Assessment of disability in spinal cord injury.

PURPOSE: Spinal cord injury (SCI) implies a drastic change in the quality of life of an individual, and this fact must be considered by the physiatrist. The aim of this study was to assess the degree of disability shown by patients with spinal cord injury at 5 years post-SCI. For this purpose we used the Craig Handicap Assessment and Reporting Technique (CHART) scale which included the evaluation of occupation, physical independence, mobility, social integration and economic self-sufficiency. METHOD: A questionnaire was mailed to 243 patients who were admitted over a one-year period to the Hospital Nacional de Parapléjicos in Toledo, Spain. From these, we received 90 answers. No significant differences were observed when they were compared to the 90 patients who answered the questionnaire. RESULTS: 30% of the patients had less than 333 points on the scale, meaning that they could be considered severely disabled, while a score higher than 438 points was seen in 46.7% of the patients: most of these individuals were younger than 18 and had less severe neurologic injuries. CONCLUSIONS: Despite the enormous impact of SCI, according to the scale used most patients have scores above the disability level.

Adolescent↗
PubMed2003

Critical care and perioperative management in traumatic spinal cord injury.

Traumatic spinal cord injury is frequently associated with brain injury and with alterations in respiratory and cardiovascular function that require critical care management. Complications include respiratory failure, atelectasis, pneumonia, neurogenic shock, autonomic dysreflexia, venous thromboembolism, and sepsis. While complications may be managed with supportive care, the goal of ameliorating neurologic outcome has proved elusive. Methylprednisolone, when instituted <8 hours after traumatic spinal cord injury, was associated in two clinical trials with statistically significant improvements in motor scores at 6 months and 1 year; however, critical reappraisal of these data raises questions about their validity and clinical relevance. Until more evidence of clinically effective therapies is available, acute management must be driven by pathophysiologic principles, with emphasis on interventions that attenuate secondary neurologic injury; these include the rational use of immobilization, cautious airway management, and promotion of cord perfusion and oxygenation with the appropriate level of hemodynamic and respiratory support. Clinical trials of pharmacologic neuroprotection have yielded disappointing results, but the ongoing elucidation of spinal cord repair and regenerative mechanisms suggests new therapeutic prospects.

Critical Care↗
PubMed1990

Intrathecal injection of a specific enzyme in rats as a model for chemically induced spinal cord injury.

A spinal cord injury model is described using chymopapain as a neurotoxic agent in rats. The trauma was evaluated by neurophysiological and morphological methods. Electrically evoked compound action potentials were used to quantify the neurophysiological effects caused by the injection of chymopapain into the lumbar dural theca in rats. A branch of the sciatic nerve was stimulated with voltage impulses of constant amplitude (40 V) and duration (0.1 ms) at the right external malleolus. The responses were recorded at the dorsal root entry zone L1. We used different doses of the enzyme (1000 i.u./ml; 2500 i.u./ml; 5000 i.u./ml). A total amount of 0.1 ml was injected into the rats' lumbar spinal canal intrathecally (n = 18). The control rate (n = 8) were subjected to exactly the same stimulus and recording procedures but the test solution was a corresponding volume of isotonic saline. Two hours after injection the animals were examined clinically and then sacrificed for histology. The prolongation of the latency of the electrically evoked potentials caused by the enzyme was very clear at the doses of 2500 i.u. and 5000 i.u. being about 10-15% relative to the mean latency before administration of the drug. The histological evaluation showed hemorrhage, vascular damage and indirect signs of myelin edema of the lumbar nerve tissue. Our study indicates that chymopapain injections into the lumbar spinal canal can be used as a reproducible model for spinal cord injury research.

Animals↗
PubMed1994

Current trends in the management of acute spinal cord injury.

Acute spinal cord injury is a traumatic event that affects more than 10,000 individuals each year. Rapid diagnosis and treatment are imperative. The critical care practitioner who can provide early intervention to prevent anticipated complications, as well as provide appropriate therapy, may significantly reduce the mortality and/or morbidity for these patients. This article describes the classification of, as well as current research regarding the pathophysiologic processes that occur during spinal cord injury. Furthermore, trends in the surgical and pharmacologic treatment, and therapies to prevent complications, are discussed. Finally, research horizons are articulated.

Acute Disease↗