What are the latest advances in treating spinal cord injuries and restoring movement to paraplegic or quadriplegic patients?

Latest Advances in Spinal Cord Injuries and Restoring Movement

The most significant advance in spinal cord injury management is early surgical decompression within 24 hours of injury, which produces superior neurological recovery compared to delayed surgery, combined with emerging neuroprotective agents currently in clinical trials including riluzole, glyburide, and minocycline. 1, 2

Critical Acute Management: "Time is Spine"

The concept of "time is spine" has revolutionized SCI management by emphasizing rapid intervention to prevent secondary injury cascades. 2, 3

Early Surgical Decompression:

• Decompression within 24 hours results in superior neurological recovery compared to delayed surgery and is strongly recommended for all incomplete spinal cord syndromes. 4, 2
• Only 20-50% of SCI patients currently arrive at specialized centers within this critical 24-hour window, representing a major systems-level failure. 4
• Immediate transfer to specialized SCI units reduces both morbidity and mortality. 4, 2

Hemodynamic Management:

• Maintain strict blood pressure targets using invasive monitoring in intensive care settings to prevent secondary ischemic injury from hypoperfusion. 4, 2
• Cervical and high thoracic injuries cause loss of sympathetic innervation leading to profound hypotension that compounds ischemic insult to the cord. 2
• CSF drainage can improve spinal cord perfusion by reducing CSF pressure, which is critical for maintaining optimal spinal cord perfusion pressure. 2

Pharmacological Advances

Methylprednisolone is NOT Recommended:

• Methylprednisolone is explicitly not recommended for acute spinal cord injury based on 2013 Congress of Neurological Surgeons and American Association of Neurological Surgeons guidelines. 1, 4
• NASCIS trials showed no long-lasting neurological benefit, high complication rates including 3-times higher wound infection rates, and relied on flawed post-hoc analysis. 1
• Despite 30 years of research, no pharmacologic agent has been shown to improve neurological outcomes in acute SCI. 1

Emerging Neuroprotective Agents in Active Clinical Trials:

• Riluzole (RISCIS trial): Sodium channel blocker that reduces excitatory neurotransmitter release. 1, 2, 3
• Glyburide (SCING trial): Blocks upregulated sulfonylurea receptor 1-regulated nonselective cation channels to prevent secondary injury. 1, 2
• Minocycline (MASC trial): Anti-inflammatory agent with potential neuroprotective effects. 1, 2
• VX-210 (SPRING trial): Novel agent under investigation. 1

Regenerative and Restorative Strategies

Neuro-Spinal Scaffold (INSPIRE Trial):

• Intradural scaffold placement in patients with thoracic ASIA complete injuries showed encouraging early results in the first 8 patients. 1
• This represents one of the most promising nonpharmacologic interventions currently under investigation. 1

Cell-Based Therapies:

• Stem cell transplantation strategies are actively in clinical trials, though no definitive efficacy data yet available. 3
• Multiple approaches being investigated including mesenchymal stem cells, neural stem cells, and olfactory ensheathing cells. 1

Functional Electrical Stimulation (FES):

• Activity-based therapy using robotic exoskeletons and walking in suspension leads to significant gains in strength perceived by patients. 1
• However, electrical stimulation orthoses have not shown efficacy on recovery of grip capacity. 1

Comprehensive Rehabilitation Approach

Immediate Rehabilitation Initiation:

• Comprehensive rehabilitation must begin from the first days of injury and continue through all phases of care. 4
• Early vigorous rehabilitation maximizes neurological recovery through enhanced neurotrophic factor elaboration that promotes axonal regeneration. 4
• Stretching should be performed for at least 20 minutes per zone, completed by simple posture orthoses and bed/chair positioning. 1

Respiratory Management:

• Upper cervical injuries (C2-C5) commonly require ventilatory support. 2
• Early tracheostomy within 7 days (after anterior cervical approach surgery) may reduce ICU hospitalization times and laryngeal complications. 1
• Vital capacity is often reduced by more than 50% in upper level spinal cord injuries. 1

Functional Outcome Measures

Patient-Centered Outcomes:

• Patients report that bowel, bladder, and sexual function recovery are of equal or greater importance than walking. 1
• Walking Index in Spinal Cord Injury and Spinal Cord Independence Measure are validated functional outcome measures that address patient priorities. 1
• Functional Independence Measure (FIM) assesses general independence including eating, grooming, and ambulation. 1

Advanced Imaging:

• High-resolution MRI can serve as both inclusion criterion and outcome measure in clinical trials. 1
• Magnetic resonance spectroscopy evaluates metabolic state of injured spinal cord and response to treatment. 1

Bladder Management Advances

Intermittent Catheterization Protocol:

• Intermittent urinary catheterization is the reference method for urine drainage, associated with long-term reduction in urinary tract infections, urolithiasis, and increased probability of continence. 1, 5
• Remove indwelling catheters as soon as the patient is medically stable to minimize urological risks. 1, 5
• Use micturition calendar to adapt frequency and schedule of intermittent catheterization. 1, 5

Critical Pitfall:

• Do not treat asymptomatic bacteriuria with antibiotics as this creates antimicrobial resistance without benefit. 5
• Pyuria is common in catheterized patients and has no predictive value for symptomatic UTI. 5

Pain Management

Neuropathic Pain Control:

• Introduce multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during surgical management to prevent prolonged pain. 1
• Introduce oral gabapentinoid treatment for more than 6 months to control neuropathic pain, in association with tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient. 1

Spasticity Management

Pharmacological Options:

• Baclofen is FDA-approved for alleviation of spasticity resulting from spinal cord injuries, particularly for relief of flexor spasms, pain, clonus, and muscular rigidity. 6
• Tizanidine demonstrated statistically significant reduction in Ashworth scores at 1,2, and 3 hours after treatment in multiple sclerosis and spinal cord injury patients, with greatest reduction 1-2 hours post-treatment. 7

Common Pitfalls to Avoid

• Delayed transfer to specialized centers: Most patients arrive outside the critical 24-hour window for optimal surgical intervention. 4
• Using outdated methylprednisolone protocols: Based on flawed NASCIS trials with high complication rates and no functional benefit. 1, 4
• Failure to maintain adequate blood pressure: Leads to secondary ischemic injury that is potentially preventable. 4, 2
• Delayed removal of indwelling catheters: Increases urological risks unnecessarily. 1, 5
• Treating asymptomatic bacteriuria: Creates antimicrobial resistance without clinical benefit. 5

Follow-Up Requirements

• Minimum 12-month follow-up is recommended for most interventions. 4
• 24-month follow-up is preferable when regeneration strategies are evaluated. 4
• All patients with symptomatic spinal cord injuries should be discussed in multidisciplinary meetings. 4