Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study

A review of the pathophysiology of cervical spondylotic myelopathy with insights for potential novel mechanisms drawn from traumatic spinal cord injury

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction. Despite advances in diagnosis and surgical treatment, many patients still have severe permanent neurologic deficits caused by this condition. An improved understanding of the pathophysiology of cervical spondylotic myelopathy, particularly at a cellular and molecular level, may allow improved treatments in the future. A detailed review of articles in the literature pertaining to cervical spondylotic myelopathy was supplemented by an analysis of relevant mechanisms of spinal cord injury. The pathologic course of cervical spondylotic myelopathy is characterized by early involvement of the corticospinal tracts and later destruction of anterior horn cells, demyelination of lateral and dorsolateral tracts, and relative preservation of anterior columns. Static and mechanical factors and ischemia are critical to the development of cervical spondylotic myelopathy. Free radical-and cation-mediated cell injury, glutamatergic toxicity, and apoptosis may be of relevance to the pathophysiology of cervical spondylotic myelopathy. To date, research in cervical spondylotic myelopathy has focused exclusively on the role of mechanical factors and ischemia. Fundamental research at a cellular and molecular level, particularly in the areas of glutamatergic toxicity and apoptosis may result in clinically relevant treatments for this condition.

Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials

The National Acute Spinal Cord Injury Study (NASCIS) 2 and 3 trials are often cited as evidence that high-dose methylprednisolone is an efficacious intervention in the management of acute spinal cord injury. Neither of these studies convincingly demonstrate the benefit of steroids. There are concerns about the statistical analysis, randomization, and clinical end points. Even if the putative gains are statistically valid, the clinical benefits are questionable. Furthermore, the benefits of this intervention may not warrant the possible risks. This paper comments on these two clinical trials.

Brown-Sequard syndrome due to isolated blunt trauma

Blunt trauma without associated fracture or ligamentous injury is a rare cause of Brown-Sequard syndrome. We report a case of Brown-Sequard syndrome after a direct blow to the cervical spine that did not cause injury to adjacent bone or ligaments. Characteristic neurologic findings, including a unilateral hemiparesis with associated contralateral sensory findings, were noted at the time of presentation. High-dose steroids were instituted after recognition of the patient's injury, and magnetic resonance imaging of the cervical spine revealed a unilateral cord contusion with no associated fractures. After 1 month, the patient had recovered much of his function and was able to ambulate unassisted.

Predicting neurologic recovery in traumatic cervical spinal cord injury

OBJECTIVE

Traumatic spinal cord injury (SCI) affects 8,000 to 10,000 individuals per year in the United States. One of the most difficult tasks confronting the clinician is the discussion of neurologic recovery and prognosis with the patient and/or family. Our objective is to provide a guide for practitioners to accurately predict neurologic outcome in acute traumatic cervical SCI (tetraplegia).

DATA SOURCE

Published reports obtained through MEDLINE search, texts, and studies presented at national conferences.

STUDY SELECTION

Peer reviewed studies, in English language, that discussed prognosis after traumatic SCI.

CONCLUSION

A comprehensive physical examination of the acute SCI patient is essential in determining the initial level and classification of the injury and is the most accurate method to predict neurologic recovery. Other diagnostic tests, including somatosensory evoked potentials, magnetic resonance imaging, and transcranial magnetic stimulation, may be helpful in further determining outcome when used in association with the clinical examination. The understanding of neurologic recovery should help predict ultimate functional capability and potential needs.

Oxidative injury in the nervous system

A free radical is a highly reactive chemical species that can react with organic macromolecules leading to cell and tissue damage and consequent functional disruption. Free radical or oxidative injury is increasingly recognized as an important factor in the pathophysiology of many human diseases, including those that affect the nervous system. This review summarizes important evidence implicating oxidative injury in the pathogenesis and progression of many important neurological disorders, including cerebrovascular disease, epilepsy, amyotrophic lateral sclerosis, and Huntington's disease. Results of controlled clinical trials of various antioxidant therapies in neurological disease performed to date are also highlighted.

A crash course in spinal cord injury

The complex management issues related to spinal cord injury traditionally have been the purview of physical medicine and rehabilitation specialists. However, changes in the healthcare system now offer primary care physicians an expanded role in helping affected patients live a healthier and more functional life. With proper understanding of the mechanisms of spinal cord injury, primary care physicians can become important members of the medical management team. Dr Yu presents a comprehensive overview of medical care issues and common complications in spinal cord injury.

Cervical spine disorders in infants and children

The evaluation of children with cervical spine disorders requires an understanding of the anatomic and developmental features that are particular to the pediatric spine. In this article, cervical spine developmental anatomy is briefly reviewed, along with common radiographic features of the pediatric cervical spine. The epidemiology, clinical presentation, and management of congenital cervical anomalies are considered. The evaluation and management of pediatric cervical trauma are also reviewed. Other disorders with common cervical spine involvement, such as skeletal dysplasias, connective tissue disorders, inflammatory arthritides, and storage disorders, are discussed.

Biology of neurological recovery and functional restoration after spinal cord injury

OBJECTIVE

This article reviews the anatomic and pathophysiological bases for recovery of neurological function after experimental or clinical spinal cord injury (SCI).

METHODS

Current knowledge regarding the recovery of neurological function after experimental or clinical SCI was reviewed to determine the biological basis of neurological recovery.

RESULTS

There is a great propensity for recovery after clinical or experimental SCI. An examination of the anatomic basis of recovery indicates that there is a potential for both root and cord recovery, with the latter involving recovery of both gray and white matter of the cord. Resolution of acute injury events, such as hemorrhaging, and resolution of secondary pathophysiological processes, such as ischemia and excitotoxicity, can each account for recovery. The third recovery mechanism involves regrowth or regeneration of nervous tissue, resulting from either inherent or induced processes.

CONCLUSION

During the Decade of the Brain, there has been a profusion of very promising in vitro and in vivo studies that have shown enhanced neurological recovery after experimental or clinical SCI.