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Debenham MIB, Franz CK, Berger MJ. Neuromuscular consequences of spinal cord injury: New mechanistic insights and clinical considerations. Muscle Nerve 2024; 70:12-27. [PMID: 38477416 DOI: 10.1002/mus.28070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 03/14/2024]
Abstract
The spinal cord facilitates communication between the brain and the body, containing intrinsic systems that work with lower motor neurons (LMNs) to manage movement. Spinal cord injuries (SCIs) can lead to partial paralysis and dysfunctions in muscles below the injury. While traditionally this paralysis has been attributed to disruptions in the corticospinal tract, a growing body of work demonstrates LMN damage is a factor. Motor units, comprising the LMN and the muscle fibers with which they connect, are essential for voluntary movement. Our understanding of their changes post-SCI is still emerging, but the health of motor units is vital, especially when considering innovative SCI treatments like nerve transfer surgery. This review seeks to collate current literature on how SCI impact motor units and explore neuromuscular clinical implications and treatment avenues. SCI reduced motor unit number estimates, and surviving motor units had impaired signal transmission at the neuromuscular junction, force-generating capacity, and excitability, which have the potential to recover chronically, yet the underlaying mechanisms are unclear. Furthermore, electrodiagnostic evaluations can aid in assessing the health lower and upper motor neurons, identify suitable targets for nerve transfer surgeries, and detect patients with time sensitive injuries. Lastly, many electrodiagnostic abnormalities occur in both chronic and acute SCI, yet factors contributing to these abnormalities are unknown. Future studies are required to determine how motor units adapt following SCI and the clinical implications of these adaptations.
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Affiliation(s)
- Mathew I B Debenham
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colin K Franz
- Biologics Laboratory, Shirley Ryan AbilityLab, Chicago, Illinois, USA
- Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael J Berger
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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2
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Kjell J, Svensson M. Advancing Peripheral Nerve Graft Transplantation for Incomplete Spinal Cord Injury Repair. Front Cell Neurosci 2022; 16:885245. [PMID: 35573831 PMCID: PMC9097274 DOI: 10.3389/fncel.2022.885245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Peripheral nerves have a propensity for axon growth and regeneration that the central nervous system lacks (CNS). However, CNS axons can also grow long distances if introduced to a graft harvested from a peripheral nerve (PNGs), which is the rationale for using PNGs as repair strategy for injuries of the spinal cord. From a clinical perspective, PNGs provide interesting possibilities with potential to repair the injured spinal cord. First, there are numerous options to harvest autologous grafts associated with low risk for the patient. Second, a PNG allow axons to grow considerable distances and can, by the surgical procedure, be navigated to specific target sites in the CNS. Furthermore, a PNG provides all necessary biological substrates for myelination of elongating axons. A PNG can thus be suited to bridge axons long distances across an injury site and restore long tracts in incomplete SCI. Experimentally, locomotor functions have been improved transplanting a PNG after incomplete injury. However, we still know little with regard to the formation of new circuitries and functional outcome in association to when, where, and how grafts are inserted into the injured spinal cord, especially for sensory functions. In this perspective, we discuss the advantages of PNG from a clinical and surgical perspective, the need for adding/repairing long tracts, how PNGs are best applied for incomplete injuries, and the unexplored areas we believe are in need of answers.
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Affiliation(s)
- Jacob Kjell
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
- Neurosurgery, Karolinska University Hospital, Solna, Sweden
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3
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Moneo J, Kramer JLK, Nightingale TE, Berger MJ. Can Magnetic Resonance Imaging Reveal Lower Motor Neuron Damage after Traumatic Spinal Cord Injury? A Scoping Review. Neurotrauma Rep 2021; 2:541-547. [PMID: 34901947 PMCID: PMC8655802 DOI: 10.1089/neur.2021.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Restoring muscle function to patients with spinal cord injuries (SCIs) will invariably require a functioning lower motor neuron (LMN). As techniques such as nerve transfer surgery emerge, characterizing the extent of LMN damage associated with SCIs becomes clinically important. Current methods of LMN diagnosis have inherent limitations that could potentially be overcome by the development of magnetic resonance imaging (MRI) biomarkers: specific features on MRI that are indicative of LMN integrity. To identify research on MRI biomarkers of LMN damage in the acute phase after SCI, we searched PubMed, EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials for articles published from inception to April 27, 2021. Overall, 2 of 58 unique articles screened met our inclusion criteria, both of which were small studies. We therefore identify MRI biomarkers of LMN damage overlying SCI as a notable gap in the literature. Because of the lack of existing literature on this specific problem, we further our discussion by examining concepts explored in research characterizing MRI biomarkers of spinal cord and neuronal damage in different contexts that may provide value in future work to identify a biomarker for LMN damage in SCI. We conclude that MRI biomarkers of LMN damage in SCI is an underexplored, but promising, area of research as emerging, function-restoring therapies requiring this information continue to advance.
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Affiliation(s)
- Jethro Moneo
- MD Program, Faculty of Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - John L K Kramer
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada.,School of Kinesiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas E Nightingale
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Michael J Berger
- International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada.,School of Kinesiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Yoshida R, Tomita K, Kawamura K, Setaka Y, Ishii N, Monma M, Mutsuzaki H, Mizukami M, Ohse H, Imura S. Investigation of inspiratory intercostal muscle activity in patients with spinal cord injury: a pilot study using electromyography, ultrasonography, and respiratory inductance plethysmography. J Phys Ther Sci 2021; 33:153-157. [PMID: 33642691 PMCID: PMC7897523 DOI: 10.1589/jpts.33.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/25/2020] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The respiratory function in patients with cervical spinal cord injury is
influenced by inspiratory intercostal muscle function. However, inspiratory intercostal
muscle activity has not been conclusively evaluated. We evaluated the inspiratory
intercostal muscle activity in patients with cervical spinal cord injury by using
inspiratory intercostal electromyography, respiratory inductance plethysmography, and
ultrasonography. [Participants and Methods] Three patients with cervical spinal cord
injury were assessed. The change in mean amplitude (rest vs. maximum inspiration) was
calculated by using intercostal muscle electromyography. Changes in intercostal muscle
thickness (resting expiration and maximum inspiration) were also evaluated on
ultrasonography. The waveform was converted to spirometry ventilation with respiratory
inductance plethysmography, and the waveform at the xiphoid was considered to determine
the rib cage volume. Each index was compared with the inspiratory capacities in each case.
[Results] Intercostal muscle electromyography failed to measure the notable myoelectric
potential in all the patients. The rib cage volume was higher at higher inspiratory
capacities. The changes in muscle thickness were not significantly different between the
patients. [Conclusion] The rib cage volume (measured with inductance plethysmography) was
greater in the patients with cervical spinal cord injury when inspiratory intercostal
muscle activity was high. Respiratory inductance plethysmography can capture inspiratory
intercostal muscle function in patients with cervical spinal cord injury.
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Affiliation(s)
- Ryo Yoshida
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ibaraki 300-0394, Japan
| | - Kazuhide Tomita
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ibaraki 300-0394, Japan
| | - Kenta Kawamura
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Japan
| | - Yukako Setaka
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, Japan
| | - Nobuhisa Ishii
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ibaraki 300-0394, Japan
| | - Masahiko Monma
- Department of Radiological Sciences, Ibaraki Prefectural University of Health Sciences, Japan
| | - Hirotaka Mutsuzaki
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ibaraki 300-0394, Japan.,Center for Medical Sciences, Ibaraki Prefectural University of Health Sciences, Japan
| | - Masafumi Mizukami
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ibaraki 300-0394, Japan
| | - Hirotaka Ohse
- Graduate School of Health Science, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ibaraki 300-0394, Japan
| | - Shigeyuki Imura
- Graduate School of Health Care, Takasaki University of Health and Welfare, Japan
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Santamaria AJ, Benavides FD, Saraiva PM, Anderson KD, Khan A, Levi AD, Dietrich WD, Guest JD. Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia. Front Neurol 2021; 11:514181. [PMID: 33536992 PMCID: PMC7848788 DOI: 10.3389/fneur.2020.514181] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic “motor level.” Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.
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Affiliation(s)
- Andrea J Santamaria
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Francisco D Benavides
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Pedro M Saraiva
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Kimberly D Anderson
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - Aisha Khan
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,Miller School of Medicine, The Interdisciplinary Stem Cell Institute, The University of Miami, Miami, FL, United States
| | - Allan D Levi
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - W Dalton Dietrich
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
| | - James D Guest
- The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.,The Department of Neurological Surgery, Miller School of Medicine, The University of Miami, Miami, FL, United States
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Frostell A, Mattsson P, Svensson M. Guiding Device for Precision Grafting of Peripheral Nerves in Complete Thoracic Spinal Cord Injury: Design and Sizing for Clinical Trial. Front Neurol 2018; 9:356. [PMID: 29872421 PMCID: PMC5972322 DOI: 10.3389/fneur.2018.00356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/01/2018] [Indexed: 01/08/2023] Open
Abstract
Background In an effort to translate preclinical success in achieving spinal cord regeneration through peripheral nerve grafts, this study details the design and sizing of a guiding device for precision grafting of peripheral nerves for use in a clinical trial in complete (AIS-A) thoracic spinal cord injury (SCI). The device’s design and sizing are compared to a simulation of human spinal cord sizes based on the best available data. Methods Spinal cord segmental sizes were generated by computer simulation based on data from a meta-analysis recently published by our group. Thoracic segments T2–T12 were plotted, and seven elliptical shapes were positioned across the center of the distribution of sizes. Geometrical measures of error-of-fit were calculated. CAD modeling was used to create cranial and caudal interfaces for the human spinal cord, aiming to guide descending white matter tracts to gray matter at the caudal end of the device and ascending white matter tracts to gray matter at the cranial end of the device. The interfaces were compared qualitatively to the simulated spinal cord sizes and gray-to-white matter delineations. Results The mean error-of-fit comparing simulated spinal cord segments T2–T12 to the best elliptical shape was 0.41 and 0.36 mm, and the 95th percentile was found at 1.3 and 0.98 mm for transverse and anteroposterior diameter, respectively. A guiding device design was reached for capturing the majority of corticospinal axons at the cranial end of the device and guiding them obliquely to gray matter at the caudal end of the device. Based on qualitative comparison, the vast majority of spinal cord sizes generated indicate an excellent fit to the device’s interfaces. Conclusion A set of SCI guiding devices of seven sizes can cover the variability of human thoracic spinal cord segments T2–T12 with an acceptable error-of-fit for the elliptical shape as well as guiding channels. The computational framework developed can be used with other medical technologies involving the human spinal cord where exact sizes and positioning are of importance.
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Affiliation(s)
- Arvid Frostell
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Per Mattsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Breast, Endocrine and Sarcoma Tumors, Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
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Feitosa MLT, Sarmento CAP, Bocabello RZ, Beltrão-Braga PCB, Pignatari GC, Giglio RF, Miglino MA, Orlandin JR, Ambrósio CE. Transplantation of human immature dental pulp stem cell in dogs with chronic spinal cord injury. Acta Cir Bras 2017; 32:540-549. [PMID: 28793038 DOI: 10.1590/s0102-865020170070000005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 06/05/2017] [Indexed: 12/15/2022] Open
Abstract
Purpose: To investigate the therapeutic potential of human immature dental pulp stem cells in the treatment of chronic spinal cord injury in dogs. Methods: Three dogs of different breeds with chronic SCI were presented as animal clinical cases. Human immature dental pulp stem cells were injected at three points into the spinal cord, and the animals were evaluated by limb function and magnetic resonance imaging (MRI) pre and post-operative. Results: There was significant improvement from the limb function evaluated by Olby Scale, though it was not supported by the imaging data provided by MRI and clinical sign and evaluation. Conclusion: Human dental pulp stem cell therapy presents promising clinical results in dogs with chronic spinal cord injuries, if used in association with physical therapy.
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Affiliation(s)
- Matheus Levi Tajra Feitosa
- Fellow PhD degree, Postgraduate Program in Anatomy in Domestic and Wild Animals, Department of Surgery, Faculty of Veterinary Medicine and Animal Science, Universidade de São Paulo (USP), Brazil. Intellectual and scientific content of the study; conception and design of the study; acquisition, analysis and interpretation of data, manuscript preparation
| | - Carlos Alberto Palmeira Sarmento
- Fellow PhD degree, Postgraduate Program in Anatomy in Domestic and Wild Animals, Department of Surgery, Faculty of Veterinary Medicine and Animal Science, Universidade de São Paulo (USP), Brazil. Intellectual and scientific content of the study; conception and design of the study; acquisition, analysis and interpretation of data, manuscript preparation
| | - Renato Zonzini Bocabello
- Fellow Master degree, Postgraduate Program in Anatomy in Domestic and Wild Animals, Department of Surgery, Faculty of Veterinary Medicine and Animal Science, USP, Sao Paulo-SP, Brazil. Intellectual and scientific content of the study; conception and design of the study; acquisition, analysis and interpretation of data; manuscript preparation
| | - Patrícia Cristina Baleeiro Beltrão-Braga
- Assistant Professor, Department of Surgery, Stem Cell Laboratory, USP, Sao Paulo-SP, Brazil. Intellectual and scientific content of the study, acquisition of human stem cells, analysis and interpretation of data, manuscript writing
| | - Graciela Conceição Pignatari
- PosDoc Fellow, Department of Surgery, Faculty of Veterinary Medicine and Animal Science, USP, Sao Paulo-SP, Brazil. Intellectual and scientific content of the study, acquisition of human stem cells, analysis and interpretation of data, manuscript writing
| | - Robson Fortes Giglio
- Assistant Professor, Department of Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida, USA. Intellectual and scientific content of the study; conception and design of the study; acquisition, analysis and interpretation of data; manuscript preparation and writing
| | - Maria Angelica Miglino
- Researcher, CNPq Grant Level 1A - CA VT, Professor, Chairwoman, Department of Veterinary Medicine, Faculty of Animal Science and Food Engineering, USP, Pirassunung-SP, Brazil. Conception and design of the study, manuscript writing, critical revision, final approval
| | - Jéssica Rodrigues Orlandin
- Fellow Master degree, Postgraduate Program in Animal Bioscience, Laboratory of Stem Cell and Gene Therapy, Veterinary Medicine Department, Faculty of Animal Science and Food Engineering, USP, Pirassununga-SP, Brazil. Manuscript preparation
| | - Carlos Eduardo Ambrósio
- Researcher, CNPq Grant Level 1A - CA VT, Associate Professor III, Head, Department Veterinary Medicine, Laboratory of Stem Cell and Gene Therapy, Veterinary Medicine Department, Faculty of Animal Science and Food Engineering, USP, Pirassununga-SP, Brazil. Conception and design of the study, manuscript writing, critical revision, final approval
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Krishna V, Andrews H, Varma A, Mintzer J, Kindy MS, Guest J. Spinal cord injury: how can we improve the classification and quantification of its severity and prognosis? J Neurotrauma 2014; 31:215-27. [PMID: 23895105 DOI: 10.1089/neu.2013.2982] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The preservation of functional neural tissue after spinal cord injury (SCI) is the basis for spontaneous neurological recovery. Some injured patients in the acute phase have more potential for recovery than others. This fact is problematic for the construction of clinical trials because enrollment of subjects with variable recovery potential makes it difficult to detect effects, requires large sample sizes, and risks Type II errors. In addition, the current methods to assess injury and recovery are non-quantitative and not sensitive. It is likely that therapeutic combinations will be necessary to cause substantially improved function after SCI, thus we need highly sensitive techniques to evaluate changes in motor, sensory, autonomic and other functions. We review several emerging neurophysiological techniques with high sensitivity. Quantitative methods to evaluate residual tissue sparing after severe acute SCI have not entered widespread clinical use. This reduces the ability to correlate structural preservation with clinical outcome following SCI resulting in enrollment of subjects with varying patterns of tissue preservation and injury into clinical trials. We propose that the inclusion of additional measures of injury severity, pattern, and individual genetic characteristics may enable stratification in clinical trials to make the testing of therapeutic interventions more effective and efficient. New imaging techniques to assess tract injury and demyelination and methods to quantify tissue injury, inflammatory markers, and neuroglial biochemical changes may improve the evaluation of injury severity, and the correlation with neurological outcome, and measure the effects of treatment more robustly than is currently possible. The ability to test such a multimodality approach will require a high degree of collaboration between clinical and research centers and government research support. When the most informative of these assessments is determined, it may be possible to identify patients with substantial recovery potential, improve selection criteria and conduct more efficient clinical trials.
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Affiliation(s)
- Vibhor Krishna
- 1 Department of Neurosciences, Medical University of South Carolina , Charleston, South Carolina
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