Paraplegia: Research with backbone

7. April 2014
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Spinal cord injury often means for those affected a life with severe disability. However quick and effective action can prevent things being worse – and could in the future perhaps even repair the cross sectional nerve tear.

Around twenty times each day someone in Germany severely injured his or her spine. For one in five the damage caused to the nervous system remains. Even when the patient escapes paralysis, in most cases he or she continues to suffer from the consequences of his or her accident.

… to make life bearable …

In a bad case of paralysis not only the extremities but also quite normally unnoticeable physiological functions, which affect life, are left without sensory and motor control. Without the control of the central nervous system, the intentional periodic emptying mechanism involving the bladder does not work anymore. Alongside the presence of a bladder catheter, the risk of infection however greatly increases. In addition, bedsores also occur when those who do the nursing do not regularly shift the non-independent body. “Doctors write off the spinal cord”, laments neurologist James Fawcett of England’s Cambridge University, “and focus on what’s possible in order to make life bearable”. Compared to the hopelessness of a few decades ago, approaches exist for preventing paralysis using appropriate treatments when done in time, or when done in the future to even reverse the paralysis in part.

Time is Spine

One of the most important factors in treatment here is the time between the injury and its care. “Time is spine” is a common saying heard from neurosurgeons. It has long been known that a timely operation significantly improves chances for the patient. This concerns not so much the mechanical damage to the spine as it does the spinal cord. An international prospective study involving more than 300 patients injured in the cervical spine showed that rapid action by surgeons – within 24 hours – relieves the pressure on the affected regions and increases the chances of neurological recovery three-fold. The strategy of quickly doing an operation is based on the fact that the patient can be mobilised as soon as the spine is stabilised. This reduces the possibility of complications and the length of stay in the ICU. However, the study is probably true only for injuries in the upper part of the spine, whereas with damage in the central region the facts are less clear. Despite all the time pressure present here, there is a need, especially while recording and establishing the nature of the injury, for very special care. Radiographically, an age-related arthritis or osteoporosis can conceal a vertebral fracture. In the neck area a false finding is then often life-threatening.

Neural stem cells against paralysis?

In the treatment of spinal cord injuries, as many experts are convinced, new opportunities are opening up with the help of stem cell technology. One study from 2011 examined seven patients with paralysis in the thoracic vertebrae area. These patients received 20 million allogenic neural stem cells. In two out of three patients the “fresh cells” resulted in neural improvements within a year. One patient, who had previously complained of complete numbness in the legs, even managed slight movements. According to the plans of the sponsor “StemCells Inc.”, this study at the Balgrist Clinic in Zurich will soon be followed by studies in the U.S. and Canada. Something similar is also intended by their competitor “Neuralstem” from Rockville, USA. A phase I study involving eight thoracic vertebrae-paralysed patients should bring further results later this year. Its use on humans is to all appearances possible without there being serious side effects, as previous studies in ALS patients have shown.

Embryonic and induced stem cells

Both companies are convinced that the use of stem cells is then also worth the effort even if the injection does not take place in the very first days after the accident. For up to two years after the injury the two companies will be prepared to recruit patients for their studies, even if they admit that with increasing time intervals the chance of a recovery decreases. In addition to neural stem cells, less differentiated embryonic stem cells are also of particular interest in America when the subject is spinal injuries. The Californian company “Geron” has however taken itself out of the picture due to legal restrictions when working with these cells. “Asterias”, another company located close by, however wants to continue Geron’s research program, even if the cellular all-rounders used carry the risk of teratomas after implantation. In the first experiments, done by Geron, it seems that the scientists however have managed to control this risk.

In addition to the hope that newly formed neurons can overcome the scar tissue at the injury site, thereby creating new conduits, stem cell technicians are also placing hopes in the differentiation of virgin cells to oligodendrocytes. In many cases the nerves are not completely broken through but only chipped and have lost, for instance, their myelin insulation. Newly formed glial cells could then refabricate this myelin and also ensure that new blood vessels are formed at the injury site. Corresponding factors for the regeneration of the neurons might also be provided by the differentiated former stem cells. The clinical trials however are for the time being still in phase I. A little further away from being in routine medical use are the ethically “more acceptable” induced pluripotent stem cells. A Japanese study is currently investigating its potential application in the macular degeneration of the eye. With promising results here, spinal neurologists could also come into the game.

Neuropathic pain

More than half of all patients with spinal injuries suffer from neuropathic pain. However, even to specialists it is still not entirely clear what is the origin of this pain. Perhaps it originates from hyper-active nerves at the site of the nerve injury or beneath it. Hence many patients with injuries to the sacral vertebra complain of pain in the foot. Other neurologists shift the theoretical starting point of the pain to being one occurring in the brain. Originally developed as an anticonvulsant for epileptics, gabapentin helps in about one third of instances of spine injury, in that it increases the neurotransmitter GABA. Similar effects also come from the successor product pregabalin.

Online education for spine physicians

In order that a patient’s chances after spinal injuries can be made to avoid the fateful path ending in a more or less movement-restricted life in a wheelchair, the many cogs making up treatment and care need to be integrated quickly and in a friction-free manner. For new knowledge to make its way without long delay to the patient, regular training is a prerequisite. Alongside the courses conducted by the specialist communities, the International Spinal Cord Society has created its own training portal. Elearnsci.org is a self learning platform for physicians, nurses, therapists and others who are involved in such care. The American professional society ASIA offers free learning modules (InSTeP) and online learning software for examining children (WeeSTeP).

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Dr. med. Safwat Alani
Dr. med. Safwat Alani

Excellent up-dating Herr Lederer!!

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