A global perspective on spinal cord injury epidemiology

Nerve transfers for the restoration of hand function after spinal cord injury

Spinal cord injury (SCI) remains a significant public health problem. Despite advances in understanding of the pathophysiological processes of acute and chronic SCI, corresponding advances in translational applications have lagged behind. Nerve transfers using an expendable nearby motor nerve to reinnervate a denervated nerve have resulted in more rapid and improved functional recovery than traditional nerve graft reconstructions following a peripheral nerve injury. The authors present a single case of restoration of some hand function following a complete cervical SCI utilizing nerve transfers.

Traumatic spinal cord injuries--incidence, mechanisms and course

BACKGROUND

The primary purpose of this article is to provide an overview of demography, neurological level of injury, extent of lesion, incidence, prevalence, injury mechanisms as well as lethality and causes of death associated with traumatic spinal cord injuries.

MATERIAL AND METHOD

A literature search was carried out in PubMed, with the search words "traumatic spinal cord injury"/"traumatic spinal cord injuries" together with "epidemiology", and "spinal cord injury"/"spinal cord injuries" together with "epidemiology".

RESULTS

The reported annual incidence of traumatic spinal cord injuries varies from 2.3 per million in a study from Canada to 83 per million in Alaska. The prevalence is given as ranging from 236 per million in India to 1800 per million in the USA. The average age at the time of injury varies from 26.8 years in Turkey to 55.5 years in the USA. The ratio of men to women varies from 0.9 in Taiwan to 12.0 in Nigeria. The most frequent cause of injury is traffic accidents, followed by falls, violence and sports/leisure activity incidents. Patients with traumatic spinal cord injuries have a higher lethality than the normal population. The most frequent causes of death today are airway problems, heart disease and suicide.

INTERPRETATION

There are large geographical differences in reported incidence, prevalence and lethality. This is attributable to differences in definition, inclusion, classification and patient identification procedures in the various studies, together with geographical and cultural differences and differences in prehospital and hospital treatment.

High incidence of traumatic spinal cord injury in Estonia

STUDY DESIGN

Retrospective population-based cohort study.

OBJECTIVES

To provide national data on epidemiology of traumatic spinal cord injury (TSCI) among the population of Estonia from 1997 to 2007.

SETTING

All Estonian hospitals.

METHODS

Medical records of patients with TSCI from all regional, central, general and rehabilitation hospitals in Estonia were retrospectively reviewed. Epidemiological characteristics, etiology, neurological level and severity of injury, concomitant injuries were analyzed.

RESULTS

A total of 595 patients with TSCI from 1 January 1997 to 31 December 2007 were identified. The male to female ratio was 5.5:1. The mean age at injury was 39.0 years. The crude incidence rate was 39.7 (95% confidence interval: 36.6-43.0) per million population. The most frequent cause of TSCI was falls (41%), followed by traffic accidents (29%). Alcohol consumption preceded 43% of injuries. The lesion level was cervical in 59.4%, thoracic in 18.3% and lumbar/sacral in 22.3%.

CONCLUSION

Compared to recent studies from Europe, where the incidence of TSCI is between 15 and 30 per million population, the incidence of TSCI in Estonia is among the highest. The rates are significantly higher in men compared with women and especially among the youngest men. The leading cause of TSCI is falls. A significant proportion of injuries are related to alcohol consumption before trauma in Estonia.

Nanotechnology-novel therapeutics for CNS disorders

Research into treatments for diseases of the CNS has made impressive strides in the past few decades, but therapeutic options are limited for many patients with CNS disorders. Nanotechnology has emerged as an exciting and promising new means of treating neurological disease, with the potential to fundamentally change the way we approach CNS-targeted therapeutics. Molecules can be nanoengineered to cross the blood-brain barrier, target specific cell or signalling systems, respond to endogenous stimuli, or act as vehicles for gene delivery, or as a matrix to promote axon elongation and support cell survival. The wide variety of available nanotechnologies allows the selection of a nanoscale material with the characteristics best suited to the therapeutic challenges posed by an individual CNS disorder. In this Review, we describe recent advances in the development of nanotechnology for the treatment of neurological disorders-in particular, neurodegenerative disease and malignant brain tumours-and for the promotion of neuroregeneration.

An overview of published research about the acute care and rehabilitation of traumatic brain injured and spinal cord injured patients

Knowledge of the breadth, nature, and volume of traumatic brain injury (TBI) and spinal cord injury (SCI) research can aid in research planning. This study aimed to provide an overview of existing TBI and SCI research to inform identification of knowledge translation (KT), systematic review (SR), and primary research opportunities. Topics and relevant articles from three large neurotrauma evidence resources were synthesized: the Global Evidence Mapping (GEM) Initiative (129 topics and 1644 articles), the Acquired Brain Injury Evidence-Based Review (ERABI; 152 topics and 732 articles), and the Spinal Cord Injury Rehabilitation Evidence (SCIRE) Project (297 topics and 1650 articles). A de-duplicated dataset of SRs, randomized controlled trials (RCTs), and other studies identified by these projects was created. In all, 145 topics were identified (66 TBI and 79 SCI), yielding 3466 research articles (1256 TBI and 2210 SCI). Topics with KT potential included cognitive therapies for TBI and prevention/management of urinary tract problems post-SCI, which accounted for 17% and 18%, respectively, of the TBI and SCI yield. Topics that may require SR included management of raised intracranial pressure in TBI, and ventilation and intermittent positive pressure interventions following SCI. Topics for which primary research may be needed included pharmacological therapies for neurological recovery post-TBI, and management of sleep-disordered breathing post-SCI. There was a larger volume of non-intervention (epidemiological) studies in SCI than in TBI. This comprehensive overview of TBI and SCI research can aid funding agencies, researchers, clinicians, and other stakeholders in prioritizing and planning TBI and SCI research.

Spinal cord clinical trials and the role for bioengineering

There is considerable need for bringing effective therapies for spinal cord injury (SCI) to the clinic. Excellent medical and surgical management has mitigated poor prognoses after SCI; however, few advances have been made to return lost function. Bioengineering approaches have shown great promise in preclinical rodent models, yet there remains a large translational gap to carry these forward in human trials. Herein, we provide a framework of human clinical trials, an overview of past trials for SCI, as well as bioengineered approaches that include: directly applied pharmacologics, cellular transplantation, biomaterials and functional neurorehabilitation. Success of novel therapies will require the correct application of comprehensive preclinical studies with well-designed and expertly conducted human clinical trials. While biologics and bioengineered strategies are widely considered to represent the high potential benefits for those who have sustained a spinal injury, few such therapies have been thoroughly tested with appreciable efficacy for use in human SCI. With these considerations, we propose that bioengineered strategies are poised to enter clinical trials.

Engineering therapies in the CNS: what works and what can be translated

Engineering is the art of taking what we know and using it to solve problems. As engineers, we build tool chests of approaches; we attempt to learn as much as possible about the problem at hand, and then we design, build, and test our approaches to see how they impact the system. The challenge of applying this approach to the central nervous system (CNS) is that we often do not know the details of what is needed from the biological side. New therapeutic options for treating the CNS range from new biomaterials to make scaffolds, to novel drug-delivery techniques, to functional electrical stimulation. However, the reality is that translating these new therapies and making them widely available to patients requires collaborations between scientists, engineers, clinicians, and patients to have the greatest chance of success. Here we discuss a variety of new treatment strategies and explore the pragmatic challenges involved with engineering therapies in the CNS.

Bicycle injuries: a matter of mechanism and age

Bicycle riding is a popular form of recreation with positive health and environmental effects. These road users are vulnerable to serious injuries, especially when motor vehicles are involved. The goal of this study was to characterize cyclist-related injuries according to motor vehicle involvement for adults versus children. A retrospective study was carried out using data from 11 trauma centers in the Israeli National Trauma Registry (2001-2007). Injuries were classified according to whether a motor vehicle was involved, and differences in injury characteristics were assessed for adults (18+ years) versus children (1-17 years). A total of 5529 patients were hospitalized for bicycle injuries, of whom 1765 were adults and 3764 were children. Thirty percent (n=1662) of all bicycle injuries involved motor vehicles, although the rate of injuries resulting in hospitalization was 37% among adults and 27% among children. Injury characteristics and hospital resource utilization differed substantially by age group. Cyclists struck by a motor vehicle presented with more severe injuries requiring more hospital resources and resulting in poorer outcomes than those not involved with motor vehicles. The interaction effect between motor vehicle involvement and age was significant for torso injuries and need for medical imaging. We found that injury characteristics, hospital resource utilization and health-related outcomes for bicycle injuries are highly dependent on patient's age and mechanism of injury. Effect modification of motor vehicle involvement by age may in part reflect physicians' attitudes toward pediatric imaging. The risks identified in this study should be used for preparedness and management of trauma hospitalizations from bicycle injuries.

Análise radiográfica do tratamento cirúrgico da fratura cervical baixa por via posterior

OBJETIVO: Avaliação da evolução radiográfica da lesão da coluna vertebral cervical tratada pela fixação posterior isolada. MÉTODOS: De 2000 a 2008 foram selecionados 23 pacientes que atenderam aos critérios de inclusão do estudo. Eram masculinos 91,3% e a idade média foi de 34 anos e quatro meses. O tempo de seguimento médio foi de 82 meses. Foi avaliado no exame de imagem pré-operatório, pós-operatório imediato e após seis meses de evolução o tipo de implante, a consolidação da artrodese, se houve soltura do implante, perda de redução, cifose segmentar, degeneração de nível adjacente e pseudartrose. RESULTADOS: Em relação ao método de síntese, 60,8% dos pacientes foram submetidos ao amarrilho interespinhoso, 26% à placa com parafusos de massa lateral e 13% à barra com parafusos de massa lateral. Dos pacientes submetidos à fixação com parafusos, nenhum apresentou complicações radiográficas e 35,7% dos pacientes submetidos à artrodese com amarrilho interespinhoso tiveram complicação, sendo a mais frequente a cifose segmentar. CONCLUSÃO: As lesões da coluna cervical submetidas a artrodese com parafuso de massa lateral apresentaram uma evolução radiográfica melhor do que as submetidas a fixação com amarrilho interespinhoso, tendo este último apresentado maior incidência de complicações na artrodese.

Factors influencing acceptance of disability in individuals with spinal cord injury in Neiva, Colombia, South America

PURPOSE

The aim of the present study was to determine the level of acceptance of disability as measured by the Acceptance of Disability Scale (ADS) within a sample of individuals with spinal cord injury (SCI) from Neiva, Colombia and to examine the influence of sociodemographic variables, injury characteristics, and level of depression on ADS score.

METHODS

The ADS was administered to 40 adults with SCI from Nieva, Colombia who were recruited from an organization that connects individuals with disabilities to resources. Most (92.5%) participants were men, with a mean age of 34.75 years and approximately 12 years since injury. Fifty-five percent of subjects were diagnosed with paraplegia and the remainder with tetraplegia. Descriptive, linear model and multiple regression analyses were used to describe the relationship between the independent and dependent variables.

RESULTS

The mean total ADS score of this sample was 171.5, indicating overall low disability acceptance. After controlling for level of depression and time since injury, gender was significantly related to ADS score such that women reported higher acceptance of disability. After controlling for gender and time since injury, level of depression was significantly related to ADS score.

CONCLUSION

Acceptance of disability is a serious problem in this group of SCI survivors in Neiva, Colombia, especially among women and individuals with higher levels of depression. Because acceptance of disability is likely a problem for many individuals living with disability in the developing world, future researchers should investigate what interventions (e.g. counseling, pharmacological intervention, social service programs) can be implemented to improve acceptance of disability in this population.

Etiology of spinal cord injuries in Sub-Saharan Africa

STUDY DESIGN

Review.

OBJECTIVES

The aim is to highlight the epidemiology of spinal cord injuries (SCIs) in Sub-Saharan Africa in order to improve prevention strategies.

SETTING

University Hospitals Leuven, Belgium.

METHODS

Pubmed was searched over August and September 2010. A combination of the following MeSH-terms was used: 'Africa South of the Sahara', 'Spinal Cord Diseases', 'Paraplegia' and 'Spinal Cord Injuries'. Limits were set on articles published as from 1990. The World Health Organization database was also consulted.

RESULTS

We obtained 243 hits of which 13 articles were relevant to the case. These papers covered seven countries: Ethiopia, Ghana, Nigeria, Senegal, Sierra Leone, South Africa and Zimbabwe. In traumatic SCIs, motor vehicle accidents are the most frequent cause of injury followed by falling from a height and thirdly violence, being the most important cause of SCI in South Africa. In the Plateau State of Nigeria, collapsing tunnels in illegal mining are the most prevalent cause. For the non-traumatic SCIs, tuberculosis appeared to be the most important cause, followed by malignant illnesses. Human immunodeficiency virus (HIV) serology tests were only available in the article concerning Ethiopia. Relatively more men were involved in traumatic SCIs and the average age was higher in the non-traumatic than in the traumatic group.

CONCLUSION

Although literature on the subject is scarce, prevention should focus on road-safety, tuberculosis and HIV. Standardized registration of SCI is needed for prevention and further research. The use of the current International SCI core data set should be encouraged worldwide as a uniform classification method.

Epidemiology of traumatic spinal cord injuries in Iceland from 1975 to 2009

STUDY DESIGN

Retrospective population-based epidemiological study.

OBJECTIVES

To assess the nationwide, population-based incidence, causes, age, gender, extent and prevalence of spinal cord injuries (SCIs) in Iceland from 1975 to 2009.

SETTING

Landspitali University Hospital in Iceland, the single referral center for SCIs in Iceland.

METHODS

A retrospective review of hospital records on all admissions due to SCIs. Analysis of incidence, causes, age, gender, extent of injury and prevalence.

RESULTS

A total of 207 patients with traumatic spinal cord injury (TSCI) were admitted: males 72%, females 28%. The percentage of females with TSCI increased to 37% in 2000-2004. Mean age at injury was 38 years. Average incidence per million population per year was 30 in 1975-1979, 12.5 in 1995-1999 and 33.5 in 2005-2009. Thirty-day mortality was 6.3%. Causes of injury were road traffic accidents (RTA) in 42.5% of the cases; the majority did not use seatbelts. Falls amounted to 30.9%, with an increase of low falls among the elderly causing incomplete cervical lesions. Sport/leisure activities were the cause in 18.8%, of which 54% occurred after 2000. The main single cause of TSCI in sport/leisure were horse-riding accidents, followed by winter sport accidents, especially among women. Other causes constituted 7.7%. The injury was complete in 39%; cervical lesions were 57% and thoracic/lumbar lesions were 43%. In December 2009, the crude prevalence rate was 526 per million population.

CONCLUSIONS

The findings showed a significant increase of TSCI in 2005-2009, especially in sport/leisure accidents and incomplete cervical lesions due to falls among elderly. Prevention strategies need to focus on these risk groups and on seatbelt use.

Epidemiological profile of 239 traumatic spinal cord injury cases over a period of 12 years in Tianjin, China

STUDY DESIGN

Hospital-based retrospective review.

OBJECTIVE

To describe the epidemiological characteristics and trends of traumatic spinal cord injury in Tianjin, China.

SETTING

Tianjin Medical University General Hospital.

METHODS

Medical records of 239 patients with traumatic spinal cord injury admitted to a general hospital from 1998 to 2009 were reviewed. Variables included gender, age, marital status, occupation, etiology, time of injury, level, and severity of injury. Epidemiological characteristics of different countries were compared.

RESULTS

Over this period, the mean age of patients with traumatic spinal cord injury was 45.4 ± 14.1 years, and the male/female ratio was 4.6:1. In all, 86.2% were married. The leading cause was fall (52.3%), followed by motor vehicle collision (36.4%). The most common injury site was the cervical spinal cord, accounting for 82.0%. Incomplete tetraplegia made up for 59.4%, followed by complete tetraplegia (22.6%). Eight patients died after operation, six of whom died from respiratory complications.

CONCLUSION

The results of this study are in accordance with that of most other developing countries; falls and motor vehicle collisions were the two leading causes, but the mean age was older. Percentage of the aged with traumatic spinal cord injury was increasing. The low-falls group tended to expand over this period. All these data indicated that the preventive programs should focus on the traffic accidents and falls, and more attention should be paid to the aged for the vulnerability to low fall.

Volitional muscle strength in the legs predicts changes in walking speed following locomotor training in people with chronic spinal cord injury

BACKGROUND

It is unclear which individuals with incomplete spinal cord injury best respond to body-weight-supported treadmill training.

OBJECTIVE

The purpose of this study was to determine the factors that predict whether a person with motor incomplete spinal cord injury will respond to body-weight-supported treadmill training.

DESIGN

This was a prognostic study with a one-group pretest-posttest design.

METHODS

Demographic, clinical, and electrophysiological measurements taken prior to training were examined to determine which measures best predicted improvements in walking speed in 19 individuals with chronic (>7 months postinjury), motor-incomplete spinal cord injuries (ASIA Impairment Scale categories C and D, levels C1-L1).

RESULTS

Two initial measures correlated significantly with improvements in walking speed: (1) the ability to volitionally contract a muscle, as measured by the lower-extremity manual muscle test (LE MMT) (r=.72), and (2) the peak locomotor electromyographic (EMG) amplitude in the legs (r=.56). None of the demographics (time since injury, age, body mass index) were significantly related to improvements in walking speed, nor was the clinical measure of balance (Berg Balance Scale). Further analysis of LE MMT scores showed 4 key muscle groups were significantly related to improvements in walking speed: knee extensors, knee flexors, ankle plantar flexors, and hip abductors (r=.82). Prediction using the summed MMT scores from those muscles and peak EMG amplitude in a multivariable regression indicated that peak locomotor EMG amplitude did not add significantly to the prediction provided by the LE MMT alone. Change in total LE MMT scores from the beginning to the end of training was not correlated with a change in walking speed over the same period.

LIMITATIONS

The sample size was limited, so the results should be considered exploratory.

CONCLUSIONS

The results suggest that preserved muscle strength in the legs after incomplete spinal cord injury, as measured by MMT, allows for improvements in walking speed induced by locomotor training.

Gait analysis following treadmill training with body weight support versus conventional physical therapy: a prospective randomized controlled single blind study

STUDY DESIGN

Single-blind randomized, controlled clinical study.

OBJECTIVES

To evaluate, using kinematic gait analysis, the results obtained from gait training on a treadmill with body weight support versus those obtained with conventional gait training and physiotherapy.

SETTING

Thirty patients with sequelae from traumatic incomplete spinal cord injuries at least 12 months earlier; patients were able to walk and were classified according to motor function as ASIA (American Spinal Injury Association) impairment scale C or D.

METHODS

Patients were divided randomly into two groups of 15 patients by the drawing of opaque envelopes: group A (weight support) and group B (conventional). After an initial assessment, both groups underwent 30 sessions of gait training. Sessions occurred twice a week, lasted for 30 min each and continued for four months. All of the patients were evaluated by a single blinded examiner using movement analysis to measure angular and linear kinematic gait parameters. Six patients (three from group A and three from group B) were excluded because they attended fewer than 85% of the training sessions.

RESULTS

There were no statistically significant differences in intra-group comparisons among the spatial-temporal variables in group B. In group A, the following significant differences in the studied spatial-temporal variables were observed: increases in velocity, distance, cadence, step length, swing phase and gait cycle duration, in addition to a reduction in stance phase. There were also no significant differences in intra-group comparisons among the angular variables in group B. However, group A achieved significant improvements in maximum hip extension and plantar flexion during stance.

CONCLUSION

Gait training with body weight support was more effective than conventional physiotherapy for improving the spatial-temporal and kinematic gait parameters among patients with incomplete spinal cord injuries.

Emerging approaches to the surgical management of acute traumatic spinal cord injury

Traumatic, spinal cord injury (SCI) is a potentially catastrophic event causing major impact at both a personal and societal level. To date, virtually all therapies that have shown promise at the preclinical stage of study have failed to translate into clinically effective treatments. Surgery is performed in the setting of SCI, with the goals of decompressing the spinal cord and restoring spinal stability. Although a consensus regarding the optimal timing of surgical decompression for SCI has not been reached, much of the preclinical and clinical evidence, as well as a recent international survey of spine surgeons, support performing early surgery (<24 hours). Results of the multicenter, Surgical Trial in Acute Spinal Cord Injury Study (STASCIS), expected later this year, should further clarify this important management issue. The overall goal of this review is to provide an update regarding the current status of surgical therapy for traumatic SCI by reviewing relevant pathophysiology, laboratory, and clinical evidence, as well as to introduce radiologic and clinical tools that aid in the surgical decision-making process.

The epidemiological survey of acute traumatic spinal cord injury (ATSCI) of 2002 in Beijing municipality

STUDY DESIGN

Epidemiological survey.

OBJECTIVES

To study the incidence and epidemiology of acute traumatic spinal cord injury (ATSCI) of 2002 in Beijing municipality.

SETTING

Beijing.

METHODS

After quota sampling, data of all ATSCI patients who were injured in Beijing in 2002 from sample hospitals were collected for detailed investigation.

RESULTS

In all, 1079 patients were estimated to have ATSCI in 2002 in Beijing municipality and the annual incidence was 60.6 per million. The incidence increased more than ninefold compared with that of 6.7 per million between 1982 and 1986. The mean age of patients at the time of injury was 41 years. The male/female ratio was 3.1/1. The causes of injury were fall from height (37.5%), traffic accidents (26.9%), struck by object (16.3%) and fall on ground (8.3%), in that order. The mean expenditure of hospitalisation was 27819.3 RMB in 2002. The proportion of cervical, thoracic and lumbar injuries was 4.9, 28.0 and 65.9, respectively in 2002. The mean time of hospitalisation was 18.9 days and only 1.5% of the spinal cord injury (SCI) patients went to rehabilitation hospitals after their discharge. The severity of neurological impairment was not recorded in the majority of hospitals.

CONCLUSION

There was a rapid increase of the annual SCI incidence from 1982 to 2002 during an economic boom. Safety regulations are of primary importance in preventing the injury. Once happened, long-term health insurance is essential for the well-being of the victims. Although some improvement has been made since 2002, much remains to be done in this direction.

Lack of improvement after audit assessing the management of voiding dysfunction in patients with spinal cord injury: necessity for institutional guidelines

INTRODUCTION

Standard management guidelines for voiding dysfunction in patients with spinal cord injury (SCI) do not exist and these patients are managed on the basis of institutional protocols or individual judgment of managing physicians.

OBJECTIVES

To notice general trends and improvements over a five-year period, in the institutional practices related to management of voiding dysfunction in SCI patients.

METHODOLOGY

A retrospective cross-sectional study was conducted by Neurosurgery and Urology services together. A nine years (June 1995-June 2004) internal clinical audit of urological management of SCI patients was compared with a similar audit conducted five years later (January 2008-June 2010). Comparisons were made using chi-square test. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 146 patients were compared (89-pre-audit, 57-post-audit). The quality of documentation of examination findings worsened over the two study periods (p = 0.002). Although determination of baseline serum creatinine improved to statistically significant levels (p = 0.019), no imaging for the kidneys was performed as baseline in the post-audit period (p = 0.000). Similarly the number of urodynamic studies performed decreased from 11% to 1.75% (p = 0.045). The number of urological consultations, however, increased from 26% to 31.58% (p = 0.452). During follow-up, only 17 (19.1%) patients in the pre-audit study period and 6 (10.5%) in the post-audit study period were voiding spontaneously.

CONCLUSION

Our study of two eras clearly demonstrated a worsening trend in quality of patient management, which can be corrected by agreeing upon and implementing standard guidelines for management of SCI patients.

A global map for traumatic spinal cord injury epidemiology: towards a living data repository for injury prevention

STUDY DESIGN

Literature review.

OBJECTIVES

To map traumatic spinal cord injury (TSCI) globally and provide a framework for an ongoing repository of data for prevention.

SETTING

An initiative of the ISCoS Prevention Committee.

METHODS

The results obtained from the search of Medline/Embase using search phrases: TSCI incidence, aetiology, prevalence and survival were analysed. Stratification of data into green/yellow/red quality 'zones' allowed comparison between data.

RESULTS

Reported global prevalence of TSCI is insufficient (236-1009 per million). Incidence data was comparable only for regions in North America (39 per million), Western Europe (15 per million) and Australia (16 per million). The major cause of TSCI in these regions involves four-wheeled motor vehicles, in contrast to South-east Asia where two-wheeled (and non-standard) road transport predominates. Southern Asia and Oceania have falls from rooftops and trees as the primary cause. High-fall rates are also seen in developed regions with aged populations (Japan/Western Europe). Violence/self-harm (mainly firearm-related) was higher in North America (15%) than either Western Europe (6%) or Australia (2%). Sub-Saharan Africa has the highest reported violence-related TSCI in the world (38%). Rates are also high in north Africa/Middle East (24%) and Latin America (22%). Developed countries have significantly improved TSCI survival compared with developing countries, particularly for tetraplegia. Developing countries have the highest 1-year mortality rates and in some countries in sub-Saharan Africa the occurrence of a spinal injury is likely to be a fatal condition within a year.

CONCLUSION

Missing prevalence and insufficient incidence data is a recurrent feature of this review. The piecemeal approach to epidemiological reporting of TSCI, particularly failing to include sound regional denominators has exhausted its utility. Minimum data collection standards are required.

Stem cell therapies for spinal cord injury

Stem cell therapy is a potential treatment for spinal cord injury (SCI), and a variety of different stem cell types have been evaluated in animal models and humans with SCI. No consensus exists regarding the type of stem cell, if any, that will prove to be effective therapeutically. Most data suggest that no single therapy will be sufficient to overcome all the biological complications caused by SCI. Rationales for therapeutic use of stem cells for SCI include replacement of damaged neurons and glial cells, secretion of trophic factors, regulation of gliosis and scar formation, prevention of cyst formation, and enhancement of axon elongation. Most therapeutic approaches that use stem cells involve implantation of these cells into the spinal cord. The attendant risks of stem cell therapy for SCI--including tumor formation, or abnormal circuit formation leading to dysfunction--must be weighed against the potential benefits of this approach. This Review will examine the biological effects of SCI, the opportunities for stem cell treatment, and the types of stem cells that might be used therapeutically. The limited information available on the possible benefits of stem cell therapy to humans will also be discussed.

The development of electrically conductive polycaprolactone fumarate-polypyrrole composite materials for nerve regeneration

Electrically conductive polymer composites composed of polycaprolactone fumarate and polypyrrole (PCLF-PPy) have been developed for nerve regeneration applications. Here we report the synthesis and characterization of PCLF-PPy and in vitro studies showing PCLF-PPy materials support both PC12 cell and dorsal root ganglia (DRG) neurite extension. PCLF-PPy composite materials were synthesized by polymerizing pyrrole in preformed PCLF scaffolds (M(n) 7,000 or 18,000 g mol(-1)) resulting in interpenetrating networks of PCLF-PPy. Chemical compositions and thermal properties were characterized by ATR-FTIR, XPS, DSC, and TGA. PCLF-PPy materials were synthesized with five different anions (naphthalene-2-sulfonic acid sodium salt (NSA), dodecylbenzenesulfonic acid sodium salt (DBSA), dioctyl sulfosuccinate sodium salt (DOSS), potassium iodide (I), and lysine) to investigate effects on electrical conductivity and to optimize chemical composition for cellular compatibility. PCLF-PPy materials have variable electrical conductivity up to 6 mS cm(-1) with bulk compositions ranging from 5 to 13.5 percent polypyrrole. AFM and SEM characterization show microstructures with a root mean squared (RMS) roughness of 1195 nm and nanostructures with RMS roughness of 8 nm. In vitro studies using PC12 cells and DRG show PCLF-PPy materials synthesized with NSA or DBSA support cell attachment, proliferation, neurite extension, and are promising materials for future studies involving electrical stimulation.

Anti-alpha4beta1 integrin antibody induces receptor internalization and does not impair the function of circulating neutrophilic leukocytes

OBJECTIVE

A compelling strategy for treatment of spinal cord injury is the blockade of integrin-mediated leukocyte extravasation using a monoclonal antibody (mAb) against the alpha4 subunit of the alpha4beta1-integrin. However, little is known with respect to neutrophil function following anti-alpha4 mAb treatment. This study assessed the effects of anti-alpha4 mAb binding on neutrophil activation [reactive oxygen species (ROS) production], function (phagocytic activity) and anti-alpha4-mAb/alpha4beta1-integrin-complex internalization.

METHODS

Resting, primed or stimulated rat neutrophils were incubated ex vivo with anti-alpha4 mAb or isotype-control antibody. ROS production, phagocytic activity, and anti-alpha4-mAb/alpha4beta1-integrin-complex internalization were determined by flow cytometry using dihydrorhodamine (DHR1,2,3), fluorescent microspheres, and indirect immunolabeling, respectively.

RESULTS

Brief (0.5 h) incubation of resting, primed or activated neutrophils with anti-alpha4 mAb had no effect on ROS production and did not change neutrophil phagocytic activity. However, prolonged incubation (2 h), assessed only in resting neutrophils, increased ROS production. The anti-alpha4-mAb/alpha4beta1-integrin-complex was internalized after 1 h of anti-alpha4 mAb treatment and remained internalized up to 6 h.

CONCLUSION

Neutrophil ROS production and phagocytic function remain unaltered after brief anti-alpha4 mAb exposure, demonstrating that use of this mAb as a treatment should not adversely affect important beneficial roles of these cells.

Identification of problems in individuals with spinal cord injury from the health professional perspective using the ICF: a worldwide expert survey

STUDY DESIGN

Worldwide Internet survey.

OBJECTIVES

The specific aims of the study were (1) to identify problems of individuals with SCI in the early post-acute and the long-term context, respectively, addressed by health professionals and (2) to summarize these problems using the ICF.

SETTING

International.

METHODS

Physicians, nurses, physical therapists, occupational therapists, social workers and psychologists were asked for problems in the functioning and contextual factors of individuals with SCI using open-ended questions. All answers were translated ('linked') to the ICF based on established rules. Absolute and relative frequencies of the linked ICF categories were reported stratified by the context.

RESULTS

Out of 243 selected experts, 144 (59.3%) named 7.650 different themes, of which 78.8% could be linked to ICF categories. In the early post-acute context, 30.7% of the 88 categories belonged to the component Body Functions, 14.8% to Body Structures, 30.7% to Activities and Participation and 23.9% to Environmental Factors. In all, 16 ICF categories were unique for the early post-acute context. In the long-term context, 27.2% of the 92 categories belonged to the component Body Functions, 13.0% to Body Structures, 35.9% to Activities and Participation and 23.9% to Environmental Factors. A total of 20 ICF categories were unique for the long-term context.

CONCLUSION

Health professionals identified a large variety of functional problems reflecting the complexity of SCI. Unique aspects of functioning exist for the early post-acute and the long-term context, respectively. The ICF provided a comprehensive framework to integrate answers from different professional backgrounds and different world regions.

Transdifferentiation of bone marrow stromal cells into cholinergic neuronal phenotype: a potential source for cell therapy in spinal cord injury

BACKGROUND AIMS

Cholinergic neurons are very important cells in spinal cord injuries because of the deficits in motor, autonomic and sensory neurons. In this study, bone marrow stromal cells (BMSC) were evaluated as a source of cholinergic neurons in a rat model of contusive spinal cord injury.

METHODS

BMSC were isolated from adult rats and transdifferentiated into cholinergic neuronal cells. The BMSC were pre-induced with beta-mercaptoethanol (BME), while the induction was done with nerve growth factor (NGF). Neurofilament (NF)-68, -160 and -200 immunostaining was used for evaluating the transdifferentiation of BMSC into a neuronal phenotype. NeuroD expression, a marker for neuroblast differentiation, and Oct-4 expression, a marker for stemness, were evaluated by reverse transcriptase (RT)-polymerase chain reaction (PCR). Choline acetyl transferase (ChAT) immunoreactivity was used for assessing the cholinergic neuronal phenotype. Anti-microtubule-associated protein-2 (MAP-2) and anti-synapsin I antibodies were used as markers for the tendency for synptogenesis. Finally, the induced cells were transplanted into the contused spinal cord and locomotion was evaluated with the Basso-Beattie-Bresnahan (BBB) test.

RESULTS

At the induction stage, there was a decline in the expression of NF-68 associated with a sustained increase in the expression of NF-200, NF-160, ChAT and synapsin I, whereas MAP-2 expression was variable. Transplanted cells were detected 6 weeks after their injection intraspinally and were associated with functional recovery.

CONCLUSIONS

The transdifferentiation of BMSC into a cholinergic phenotype is feasible for replacement therapy in spinal cord injury.

Prevalence of spinal cord injury in Tehran, Iran

BACKGROUND/OBJECTIVE

To determine the prevalence of traumatic spinal cord injury (SCI) in Tehran, Iran.

METHODS

A population-based study was performed. In a random cluster sampling, 100 addresses were selected as the starting point of the survey for each cluster consisting of 25 households. To expand the geographic dimension of each cluster, the interviewers skipped 3 of 4 houses in gathering data for each study unit. Each person with traumatic SCI was evaluated initially by a nurse and then by a neurosurgeon by physical examination and spinal imaging at the hospital or at home.

RESULTS

Ninety-seven percent of all surveyed agreed to participate in the study (2425 households, or 9006 persons). Four cases of SCI were identified. The point prevalence of SCI was 4.4 [95% CI = 1.2-11.4] per 10,000 people. Over the 5-year period from january 2003 through January 2008, the reported incidence rate of SCI was 2.2 (95% CI = 0.27-8.00) per 10,000 people.

CONCLUSIONS

In this, the first published population-based study from Iran, the prevalence of traumatic SCI in Tehran ranged from 1.2 to 11.4 per 10,000 people. More research is required to determine the patterns and causes of SCI. Development of a nationwide SCI registry or surveillance system is fundamental to an understanding of the epidemiology, and hence the prevention, of this costly health problem.

A 50-year follow-up of the incidence of traumatic spinal cord injuries in Western Norway

STUDY DESIGN

Retrospective population-based epidemiological study.

OBJECTIVE

To assess the prevalence and temporal trends in the incidence of traumatic spinal cord injuries (TSCI), and demographic and clinical characteristics of an unselected, geographically defined cohort in the period 1952-2001.

METHODS

The patients were identified from hospital records. Crude rates and age-adjusted rates were calculated for each year. The multivariate relationship between cause of injury, age at injury, decade of injury and gender was examined using a Poisson regression model.

RESULTS

Of 336 patients, 199 patients were alive on 1 January 2002, giving a total prevalence of 36.5 per 100,000 inhabitants. The average annual incidence increased from 5.9 per million in the first decade to 21.2 per million in the last. Mean age at injury was 42.9 years and the male to female ratio 4.7:1. Fall was the most common cause of injury (45.5%), followed by motor vehicle accidents (MVA) (34.2%). The incidence of MVA-related injuries increased during the observation period, especially among men <30 years. The lesion level was cervical in 52.4%, thoracic in 29.5% and lumbar/sacral in 18.2%. The lesion was clinically incomplete in 58.6% and complete in 41.4%. The incidence of fall-related injuries and the proportion of incomplete cervical lesions increased during the observation period, especially among men >60 years.

CONCLUSIONS

The incidence of TSCI has increased during the past 50 years. Falls and MVA are potentially preventable causes. The increasing proportion of older patients with cervical lesions poses a challenge to the health system.

Forelimb locomotor assessment scale (FLAS): novel assessment of forelimb dysfunction after cervical spinal cord injury

We describe here a novel forelimb locomotor assessment scale (FLAS) that assesses forelimb use during locomotion in rats injured at the cervical level. A quantitative scale was developed that measures movements of shoulder, elbow, and wrist joints, forepaw position and digit placement, forelimb-hindlimb coordination, compensatory behaviors adopted while walking, and balance. Female Sprague-Dawley rats received graded cervical contusions ranging from 200 to 230 ("mild," n=11) and 250-290 kdyn ("moderate," n=13) between C5 and C8. Rats were videotaped post-injury as they walked along an alley to determine deficits and recovery of forelimb function. Recovery of shoulder and elbow joint movement occurred rapidly (within 1-7 days post-injury), whereas recovery of wrist joint movement was slower and more variable. Most rats in all groups displayed persistent deficits in forepaw and digit movement, but developed compensatory behaviors to allow functional forward locomotion within 1-2 weeks post-injury. Recovery of forelimb function as measured by the FLAS reached a plateau by 3 weeks post-injury in all groups. Rats with mild contusions displayed greater locomotor recovery than rats with moderate contusions, but exhibited persistent deficits compared to sham controls. Reliability was tested by having seven raters (three internal, four external) from different laboratories, independently and blindly score videos of all rats. The multivariate correlation between all raters, all animals, and all time points ranged from r(2)=0.88-0.96 (p<0.0001), indicating a high inter-rater reliability. Thus, the FLAS is a simple, inexpensive, sensitive, and reliable measure of forelimb function during locomotion following cervical SCI.

Spinal cord injury: the promise of translational research

Spinal cord injury (SCI) is a condition with devastating consequences for the patient, family, and society. Although effective treatments for SCI remain limited, there have been many advances in recent years, which have promise for the future from a clinical translational perspective. This issue of Neurosurgical Focus explores some of the current basic science, preclinical, and clinical research directed towards this goal. Clinical investigations are also discussed with regard to the treatment and management of different types of SCI and of SCI in different populations. The issue concludes with a review of the current, ongoing, and planned clinical trials, providing a glimpse of the promising new therapies being developed for the treatment of SCI.

A systematic review of the management of autonomic dysreflexia after spinal cord injury

OBJECTIVE

To review systematically the clinical evidence on strategies to prevent and manage autonomic dysreflexia (AD).

DATA SOURCES

A key word search of several databases (Medline, CINAHL, EMBASE, and PsycINFO), in addition to manual searches of retrieved articles, was undertaken to identify all English-language literature evaluating the efficacy of interventions for AD.

STUDY SELECTION

Studies selected for review included randomized controlled trials (RCTs), prospective cohort studies, and cross-sectional studies. Treatments reviewed included pharmacologic and nonpharmacologic interventions for the management of AD in subjects with spinal cord injury. Studies that failed to assess AD outcomes (eg, blood pressure) or symptoms (eg, headaches, sweating) were excluded.

DATA EXTRACTION

Studies were critically reviewed and assessed for their methodologic quality by 2 independent reviewers.

DATA SYNTHESIS

Thirty-one studies were assessed, including 6 RCTs. Preventative strategies to reduce the episodes of AD caused by common triggers (eg, urogenital system, surgery) primarily were supported by level 4 (pre-post studies) and level 5 (observational studies) evidence. The initial acute nonpharmacologic management of an episode of AD (ie, positioning the patient upright, loosening tight clothing, eliminating any precipitating stimulus) is supported by clinical consensus and physiologic data (level 5 evidence). The use of antihypertensive drugs in the presence of sustained elevated blood pressure is supported by level 1 (prazosin) and level 2 evidence (nifedipine and prostaglandin E(2)).

CONCLUSIONS

A variety of options are available to prevent AD (eg, surgical, pharmacologic) and manage the acute episode (elimination of triggers, pharmacologic); however, these options are predominantly supported by evidence from noncontrolled trials, and more rigorous trials are required.

Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study

STUDY DESIGN

This was a prospective cross-sectional study for people with chronic spinal cord injury (SCI).

OBJECTIVES

To (1) evaluate the intensity level and nature of physical activity in community-dwelling individuals living with SCI, and (2) explore the relation between descriptive individual variables (for example, lesion level), secondary complications and participation in physical activity.

SETTING

Urban community setting.

METHODS

A total of 49 subjects with SCI who used a manual wheelchair for primary mode of mobility (mean years since injury, 11.8; mean age, 43.7 years; 67% paraplegia) completed the physical activity recall assessment for people with SCI (PARA-SCI).

RESULTS

Approximately 50% of reported physical activity among individuals with SCI is due to activities of daily living. The amount of physical activity was not related to lesion level, age, body mass index or waistline size. Greater heavy-intensity activity was related to lower levels of pain and fatigue and higher levels of self-efficacy, whereas higher amounts of mild-intensity activity and total activity were related to less depressive symptoms.

CONCLUSIONS

Activities of daily living are a large component for physical activity among individuals with SCI. It appears that greater physical activity is associated with less secondary complications (pain, fatigue and depression) in individuals with SCI.

Involvement of acidic fibroblast growth factor in spinal cord injury repair processes revealed by a proteomics approach

Acidic fibroblast growth factor (aFGF; also known as FGF-1) is a potent neurotrophic factor that affects neuronal survival in the injured spinal cord. However, the pathological changes that occur with spinal cord injury (SCI) and the attribution to aFGF of a neuroprotective effect during SCI are still elusive. In this study, we demonstrated that rat SCI, when treated with aFGF, showed significant functional recovery as indicated by the Basso, Beattie, and Bresnahan locomotor rating scale and the combined behavior score (p < 0.01-0.001). Furthermore proteomics and bioinformatics approaches were adapted to investigate changes in the global protein profile of the damaged spinal cord tissue when experimental rats were treated either with or without aFGF at 24 h after injury. We found that 51 protein spots, resolvable by two-dimensional PAGE, had significant differential expression. Using hierarchical clustering analysis, these proteins were categorized into five major expression patterns. Noticeably proteins involved in the process of secondary injury, such as astrocyte activation (glial fibrillary acidic protein), inflammation (S100B), and scar formation (keratan sulfate proteoglycan lumican), which lead to the blocking of injured spinal cord regeneration, were down-regulated in the contusive spinal cord after treatment with aFGF. We propose that aFGF might initiate a series of biological processes to prevent or attenuate secondary injury and that this, in turn, leads to an improvement in functional recovery. Moreover the quantitative expression level of these proteins was verified by quantitative real time PCR. Furthermore we identified various potential neuroprotective protein factors that are induced by aFGF and may be involved in the spinal cord repair processes of SCI rats. Thus, our results could have a remarkable impact on clinical developments in the area of spinal cord injury therapy.

Dietary restriction started after spinal cord injury improves functional recovery

Spinal cord injury typically results in limited functional recovery. Here we investigated whether therapeutic dietary restriction, a multi-faceted, safe, and clinically-feasible treatment, can improve outcome from cervical spinal cord injury. The well-established notion that dietary restriction increases longevity has kindled interest in its potential benefits in injury and disease. When followed for several months prior to insult, prophylactic dietary restriction triggers multiple molecular responses and improves outcome in animal models of stroke and myocardial infarction. However, the efficacy of the clinically-relevant treatment of post-injury dietary restriction is unknown. Here we report that "every-other-day fasting" (EODF), a form of dietary restriction, implemented after rat cervical spinal cord injury was neuroprotective, promoted plasticity, and improved behavioral recovery. Without causing weight loss, EODF improved gait-pattern, forelimb function during ladder-crossing, and vertical exploration. In agreement, EODF preserved neuronal integrity, dramatically reduced lesion volume by >50%, and increased sprouting of corticospinal axons. As expected, blood beta-hydroxybutyrate levels, a ketone known to be neuroprotective, were increased by 2-3 fold on the fasting days. In addition, we found increased ratios of full-length to truncated trkB (receptor for brain-derived neurotrophic factor) in the spinal cord by 2-6 folds at both 5 days (lesion site) and 3 weeks after injury (caudal to lesion site) which may further enhance neuroprotection and plasticity. Because EODF is a safe, non-invasive, and low-cost treatment, it could be readily translated into the clinical setting of spinal cord injury and possibly other insults.

A select combination of neurotrophins enhances neuroprotection and functional recovery following spinal cord injury

Previously, we have shown that topical application of brain-derived neurotrophic factor (BDNF) or insulin-like growth factor 1 (IGF-1) given within 5 to 30 min after a focal trauma to the rat spinal cord attenuates spinal cord injury (SCI)-induced breakdown of the blood-spinal cord barrier (BSCB), edema formation, motor dysfunction, and cell injury. This investigation was undertaken to find out whether a combination of select neurotrophins (BDNF, glial cell line-derived neurotrophic factor [GDNF], neurotrophin 3 [NT-3], or nerve growth factor [NGF]) will further enhance the neuroprotective efficacy of growth factors in SCI. The neurotrophins (0.1-1 microg/10 microL in phosphate-buffered saline) were applied 30, 60, or 90 min after injury topically over the traumatized spinal cord either alone or in combination. The SCI was performed by making a unilateral incision into the right dorsal horn of the T10-T11 segment under Equithesin anesthesia. The rats were allowed to survive 5 h after trauma. Topical application of BDNF, GDNF, or NGF 30 min after SCI in high concentration (0.5 microg and 1 microg) significantly improved the motor functions and reduced the BSCB breakdown, edema formation, and cell injury seen at 5 h. These beneficial effects of neurotropins were absent when administered separately either 60 or 90 min after SCI. However, a combination of BDNF and GDNF (but not with NT-3 or NGF) given either 60 or 90 min after SCI significantly reduced the motor dysfunction and spinal cord pathology at 5 h. These novel observations suggest that a select group of neurotrophins in combination have potential therapeutic value for the treatment of SCI in clinical situations.

The impact of neurotrauma on society: an international perspective

Neurotrauma, in many countries and particularly in the younger age group kills more people than AIDS or cancer but unlike these diseases the causes are known and it is preventable. The costs to communities in terms of suffering and economics are enormous. The common causes are road traffic accidents, falls and violence. Neurotrauma affects particularly the developing world where it consumes already over stretched health resources. In the developed world steps to reduce the incidence of neurotrauma and to treat the victims have had some effect nevertheless it stills remains an endemic problem which does not receive the public awareness or the political support it deserves. For the victims there is general agreement on the principles of clinical management but often difficulties in applying early and effective care in countries with the greatest need because of shortage of facilities and expertise. To reduce the overall burden of neurotrauma demands actions which extend from the political to basic patient care. There have been remarkable advances in the understanding of acute brain and spinal cord injury and encouraging possibilities for effective neuroprotection, repair and regeneration but in the broader context prevention of neurotrauma is the urgent imperative. In this endeavour the neuroscientist has knowledge which informs and encourages policy makers to take the steps necessary to reduce injury. These steps require political will and community support for hard decisions which impact on the way people conduct their daily lives. The WHO predicts that unless there are changes in present policies and if there are no additional road safety countermeasures put in place, there will be a major increase in road traffic fatalities over the next 20 years and beyond (World Health Organisation. (2004). www.who.int).

Guanosine reduces apoptosis and inflammation associated with restoration of function in rats with acute spinal cord injury

Spinal cord injury results in progressive waves of secondary injuries, cascades of noxious pathological mechanisms that substantially exacerbate the primary injury and the resultant permanent functional deficits. Secondary injuries are associated with inflammation, excessive cytokine release, and cell apoptosis. The purine nucleoside guanosine has significant trophic effects and is neuroprotective, antiapoptotic in vitro, and stimulates nerve regeneration. Therefore, we determined whether systemic administration of guanosine could protect rats from some of the secondary effects of spinal cord injury, thereby reducing neurological deficits. Systemic administration of guanosine (8 mg/kg per day, i.p.) for 14 consecutive days, starting 4 h after moderate spinal cord injury in rats, significantly improved not only motor and sensory functions, but also recovery of bladder function. These improvements were associated with reduction in the inflammatory response to injury, reduction of apoptotic cell death, increased sparing of axons, and preservation of myelin. Our data indicate that the therapeutic action of guanosine probably results from reducing inflammation resulting in the protection of axons, oligodendrocytes, and neurons and from inhibiting apoptotic cell death. These data raise the intriguing possibility that guanosine may also be able to reduce secondary pathological events and thus improve functional outcome after traumatic spinal cord injury in humans.