Traumatic injuries of the spinal cord in the cervical segment

A group of 1000 patients treated for traumatic injuries to the spinal cord in cervical segment was analysed. These patients were hospitalized at the Department of Rehabilitation in Konstancin in 1967-1987. The most frequent causes of spine injuries, level and degree of lesions to the spinal cord, techniques of conservative treatment and surgeries and results of therapy are discussed. Significant neurological improvement was observed in 62% of the treated patients. An improvement depended on the degree of lesion to the spinal cord, time and method of therapy, mechanism of trauma, and to some extent patients' age. Finally, hospitalization duration was analysed which greatly depend on the degree of lesions to the spinal cord.     

Sequelae of injuries of thoracic vertebrae with spinal cord trauma in persons under the influence of alcohol

An analysis of 416 patients treated at the Department of Rehabilitation for the trauma to thoracic spine is presented. Analysed group included 178 patients who underwent trauma being drunk. Sequelae of the trauma, the results of neurological and functional treatment were compared in two groups of patients: admitted to the hospital under the influence of alcohol and sober. An analysis of the data indicates lower degree of the trauma to the spinal cord and markedly better neurological and functional results of therapy in patients being sober during the accident. Mortality rate is also lower in this group comparing to this in the group of patients being drunk during the accident. Statistical analysis of these date suggests high degree of the probability of interdependence of therapeutical results and sobriety of the victims.     

Missed injuries of the spinal cord.

Damage to the spinal cord had not been recognised initially in 15 patients out of a consecutive series of 353 admitted over a decade to the National Spinal Injuries Centre with paralysis due to trauma to the cord. In some patients the missed diagnosis led to mismanagement and a greater neurological deficit. Missed injuries of the spinal cord are seen in patients with multiple injuries and head injuries and in those without any paralysis. Various radiological errors contribute to the failure to recognise the vertebral injury. In addition to causing severe disability to the victim these missed and mismanaged injuries of the spinal cord cost the National Health Service large sums in compensation. A careful evaluation of the history of each accident, with greater awareness of the potential of certain types of accidents to cause spinal cord injury, should reduce the incidence of missed injuries of the spinal cord.     

脊髓损伤的病理变化及治疗进展

脊髓损伤是中枢神经系统严重的创伤,多为脊柱损伤的最严重并发症之一,常造成损伤平面以下的肢体运动、感觉及植物神经功能紊乱,不仅给患者本人带来常人难以想象的心理痛苦及生活障碍,给家庭及社会同样带来高额的负担。近年来,脊髓损伤呈现出高发病率、高耗费、高致残率及低龄化的"三高一低"的发病趋势,逐渐成为学术界急需攻克的重大医疗问题。随着脊髓损伤病理生理机制的深入研究,针对发病机制不同阶段进行阻断的新药研究成为热点,加上干细胞技术及生物工程的发展,均为脊髓损伤后的治疗提供了新的方向。     

An attempt to treat patients who have injured spinal cords with intralesional implantation of concentrated autologous bone marrow cells

Background aimsSpinal cord injury is common among young subjects involved in motor vehicle accidents. Mechanisms and attempts to reverse post-traumatic pathophysiologic consequences are still being investigated. Unfortunately no effective and well-established treatment modality has been developed so far. The regeneration capability of the human nervous system following an injury is highly limitedMethodsThe study involved four patients (two male, two female) who had suffered spinal cord injury as a result of various types of trauma. On neurologic examination, all the patients were determined to be in American Spinal Injury Association (ASIA) grade A. All patients were treated with decompression, stabilization and fusion for vertebral trauma anteriorly, as well as intralesional implantation of cellular bone marrow concentrates using a posterior approach 1 month after the first operation. The patients were then treated and followed-up in the physical rehabilitation clinicResultsAt the end of the post-operative 1-year follow-up, two of the patients were classified as ASIA C while one was classified as ASIA B. One patient showed no neurologic change; none of the patients suffered from any complications or adverse effects as a result of intralesional application of bone marrow cellsConclusionsThe results of this experimental study show the potential contribution of intralesional implantation of bone marrow to neuronal regeneration in the injured spinal cord, with neuronal changes. In light of the results of this experimental study, the potential for regenerative treatment in injuries of the human spinal cord is no longer a speculation but an observation.     

脊髓损伤后脊髓神经细胞膜PAF受体特性的变化

采用３ＨＰＡＦ放射配体结合试验方法测定脊髓神经细胞膜上ＰＡＦ受体的特异性位点,观察脊髓损伤后２、６ｈ、１、３周脊髓神经细胞膜ＰＡＦ受体结合特性变化。结果显示,脊髓神经细胞膜上存在ＰＡＦ高、低亲和力结合位点,脊髓损伤后２、６ｈ、１周组ＰＡＦ受体高、低亲和力位点Ｋｄ值和Ｂｍａｘ均有不同程度下降,与对照组比较,有显著性差异（Ｐ＜０．０５）。表明在伤后早期ＰＡＦ受体亲和力增加,结合位点减少。提示ＰＡＦ受体在脊髓损伤后继发性损害病理生理过程中起一定作用。     

Polytrauma in elderly

The aim of this study is to present certain particularities in treating polytraumatized patients age of 65 and above. All of the patients were treated in our hospital. 413 patients were included in this 4 year study (2006-2010). Injury severity score was 17 and above (ISS > 17). Patients aged above 65 were sub grouped. In this 4-year period, we treated 52 or 13% elderly patients. In this subgroup there were 30 (58%) males and 22 (42%) females, with mean age of 74 (max age 95 years old). Demographic factors, injury mechanisms, patients resuscitation protocols, imaging used, etc. were also included as variables. Mortality rate in elderly patients was 31%, while in patients below 65 years of age as 12%. Taking relevant data into consideration, a special emphasis was given to certain circumstances of intensive and surgical treatment of elderly patients. A large portion of polytraumatized patients are consisted of elderly. Patients aged 65 and above have higher mortality rate with lower ISS in the mortal group and falls are the most frequent mechanism of trauma. In this study, we tried to emphasize some clinical implications when treating those patients, as well as importance in continuous medical staff education in trauma principles to minimize mortality rates.     

Histophysiology of the microvascular bed in experimental trauma

1. Morphohistological changes in a focus of spinal cord trauma have a phasic character, with a period of primary lesions (5-30 min after traumatization) and a period of secondary lesions (1-23 h after traumatization). 2. Variation of transport enzyme activities in the walls of the microvessels of the traumatized spinal cord is characterized by an undulating course and by asynchrony of the peaks of Mg-dependent ATPase and alkaline phosphatase activity. 3. With reference to the rapid drop in the given enzyme activities and to progressive necrotic changes in the traumatized spinal cord, it is desirable that the cord circulation should be corrected within the first few hours after traumatization.     

L-NNA对大鼠急性脊髓损伤的影响

实验采用雌性 Wistar大鼠 41只 ,分为正常对照组、生理盐水对照组和 L - NNA治疗组 ,后两组制成不完全性(2 18克厘米力 )急性脊髓 (第 10胸髓 )损伤模型 ,于术后每天一次腹腔注射 L - NNA (2 0 m g/ kg)或等量生理盐水 ,连续四周 ,然后处死动物 ,行脊髓 NOS染色和超微结构观察。结果显示 ,L - NNA治疗组脊髓 NOS阳性神经元染色较生理盐水对照组浅 ,两组光密度比较 P<0 .0 5 ;超微结构观察 ,生理盐水对照组脊髓神经元胞质呈空泡样变 ,线粒体等细胞器变性 ,髓鞘严重变形 ,少数髓鞘呈线团状改变 ,常伴有高电子密度的块状沉积物。但 L - NNA治疗组脊髓神经元及大部分神经纤维的髓鞘结构清晰。因此我们认为 ,大鼠急性脊髓损伤可诱导神经元 NOS表达 ,L - NNA对其损伤修复起促进作用。     

The Expression of Nerve Growth Factor Receptor on Schwann Cells and the Effect of These Cells on Regeneration of Axons in Traumatically Injured Human Spinal Cord

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Dorsal root entry zone lesions for conus medullaris root avulsions

We have found dorsal root entry zone (DREZ) lesions to be an effective treatment of chronic deafferentation pain in patients who have had avulsions of the dorsal rootlets from the spinal cord. Eight patients were operated in whom chronic pain of the lower extremity resulted from dorsal root avulsions from the conus medullaris. In 7 of the 8 patients, the mechanism of injury was a motor vehicle accident; all 7 sustained severe pelvic trauma. Seven of the 8 patients remained pain-free, off all narcotics, with an average follow-up of 33 months. All patients had DREZ lesions of the conus performed by radiofrequency techniques.     

Mechanism of formation of intramedullary cavities and their role in the regeneration of the spinal cord

The spinal cord preparations of 38 dogs and 20 rabbits have been studied with the aim to investigate the influence of the cerebrospinal fluid on the spinal cord nervous tissue. The spinal cord preparations of 8 patients having trauma of the vertebral column with interruption of the spinal cord have also been studied. As demonstrate histological investigations, the cerebral tissue of the pieces, put into the flask with liquor, in the subarachnoidal space of the canine spinal cord, in diastasis between the ends of the cut spinal cord during 6 h up to 7 days, swells, becomes edematous. Cavities occupying about 30% of the area in the slices studied appear in it. At hemisection of the rabbit spinal cord without closure of the defect in the meninx vasculosa with the glue MK-6, the area of the cavity formation varies from 24 up to 35%, comparing the whole area of the preparation, while in rabbits with hemisection and successive gluing of the defect in the meninx vasculosa the area of the nervous tissue destruction makes 13-18%. It has been proved that the scar forming in the traumatized segment of the spinal cord does not present a continuous formation, but contains a large amount of cavities that prevent regeneration of nerve fibers. The experimental data concerning lysing effect of the cerebrospinal fluid on the traumatized nervous tissue are confirmed by the results obtained at investigating the preparations of the spinal cord of the patients died as the cause of the spinal cord trauma.     

低温在脊髓损伤治疗中应用的研究进展

脊髓损伤多由高空坠落、车祸、运动冲击等原因引起,是脊柱外科的一种常见疾病,至今仍是一个治疗难题。低温疗法是一种重要的物理治疗手段,以多种机制减少脊髓损伤后有害因素的产生,是一种有效的脊髓保护途径。其在脊髓损伤的研究中表现出很好的效果,为脊髓损伤的治疗提供了新的思路,然而也发现一些低温治疗导致的全身性或某些系统为主的不良影响,需要我们进一步研究和解决,以期达到更好的治疗效果。本文就低温治疗用于脊髓损伤应用中的研究进展进行综述。     

Posttraumatic Syringomyelia

Posttraumatic syringomyelia is becoming increasingly recognized as a sequel to major and minor spinal cord injury, paralleling the development and widespread availability of magnetic resonance imaging as a diagnostic modality for evaluating possible spinal pathologic lesions. Delayed, subacute, or progressive neurologic deterioration in victims of traumatic spinal injury with “fixed deficits” should raise the suspicion of posttraumatic syringomyelia. Alternatively, it may present as sensory or motor complaints occurring on a delayed basis after minor spinal trauma causing no initial neurologic impairment. At our institution, we have treated six of eight patients with this condition by shunting fluid from the intramedullary cyst to the peritoneal cavity by means of a simple valveless shunt, resulting in sustained neurologic improvement in five patients.     

Imaging Surrogates of Disease Activity in Neuromyelitis Optica Allow Distinction from Multiple Sclerosis

Inflammatory demyelinating lesions of the central nervous system are a common feature of both neuromyelitis optica and multiple sclerosis. Despite this similarity, it is evident clinically that the accumulation of disability in patients with neuromyelitis optica is relapse related and that a progressive phase is very uncommon. This poses the question whether there is any pathological evidence of disease activity or neurodegeneration in neuromyelitis optica between relapses. To investigate this we conducted a longitudinal advanced MRI study of the brain and spinal cord in neuromyelitis optica patients, comparing to patients with multiple sclerosis and controls. We found both cross-sectional and longitudinal evidence of diffusely distributed neurodegenerative surrogates in the multiple sclerosis group (including thalamic atrophy, cervical cord atrophy and progressive widespread diffusion and myelin water imaging abnormalities in the normal appearing white matter) but not in those with neuromyelitis optica, where localised abnormalities in the optic radiations of those with severe visual impairment were noted. In addition, between relapses, there were no new silent brain lesions in the neuromyelitis optica group. These findings indicate that global central nervous system neurodegeneration is not a feature of neuromyelitis optica. The work also questions the theory that neurodegeneration in multiple sclerosis is a chronic sequela to prior inflammatory and demyelinating pathology, as this has not been found to be the case in neuromyelitis optica where the lesions are often more destructive.     

Effect of Microcirculation Reserves on Spinal Cord Recovery after Injury

Local capillary blood flow was studied in and around the spinal cord compression focus in humans with spinal injuries in the acute and early periods of the trauma. The effect of the capillary blood flow in the perimedullary network in the region of spinal cord compression on the degree of motor and sensory disturbances was analyzed. The relationship of the increase in capillary blood flow after spinal cord decompression with increases in leg muscle strength and pain threshold was determined.     

Topical application of dynorphin A (1-17) antiserum attenuates trauma induced alterations in spinal cord evoked potentials,microvascular permeability disturbances,edema formation and cell injury: an experimental study in the rat using electrophysiological and morphological approaches

Summary.  Dynorphin is a neuropeptide that is present in high quantities in the dorsal horn of the spinal cord. The peptide is actively involved in pain processing pathways. However, its involvement in spinal cord injury is not well known. Alteration in dynorphin immunoreactivity occurs following a focal trauma to the rat spinal cord. Infusion of dynorphin into the intrathecal space of the cord results in ischemia, cell damage and abnormal motor function. Antibodies to dynorphin when injected into the intrathecal space of the spinal cord following trauma improve motor recovery, reduce edema and cell changes. However, influence of dynorphin on trauma induced alteration in spinal cord bioelectrical activity is still not known. Spinal cord evoked potentials (SCEP) are good indicator of spinal cord pathology following trauma. Therefore, in present investigation, influence of dynorphin antibodies on trauma induced changes in SCEP were examined in our rat model. In addition, spinal cord edema formation, microvascular permeability disturbances and cell injury were also investigated. Our results show that topical application of dynorphin antiserum (1 : 200) two min before injury markedly attenuated the SCEP changes immediately after injury. In the antiserum treated animals, a significant reduction in the microvascular permeability, edema formation and cell injury was observed in the traumatised spinal cord. These observations suggest that (i) dynorphin is involved in the altered bioelectrical activity of the spinal cord following trauma, (ii) the peptide actively participates in the pathophysiological processes of cell injury in the spinal cord trauma, and (iii) the dynorphin antiserum has potential therapeutic value for the treatment of spinal cord injuries. Received July 3, 2001 Accepted August 6, 2001 Published online July 31, 2002     

Imaging of specific activation of photodynamic molecular beacons in breast cancer vertebral metastases

Breast cancer is the second leading cause of cancer-related death in women. Approximately 85% of patients with advanced cases will develop spinal metastases. The vertebral column is the most common site of breast cancer metastases, where overexpression of matrix metalloproteinases (MMPs) promotes the spread of cancer. Current therapies have significant limitations due to the high associated risk of damaging the spinal cord. An attractive alternative is photodynamic therapy providing noninvasive and site-selective treatment. However, current photosensitizers are limited by their nonspecific accumulation. Photodynamic molecular beacons (PP(MMP)B), activated by MMPs, offer another level of PDT selectivity and image-guidance preserving criticial tissues, specifically the spinal cord. Metastatic human breast carcinoma cells, MT-1, were used to model the metastatic behavior of spinal lesions. In vitro and in vivo evidence demonstrates MMP specific activation of PP(MMP)B in MT-1 cells. Using a clinically relevant metastatic model, fluorescent imaging establishes the specific activation of PP(MMP)B by vertebral metastases versus normal tissue (i.e., spinal cord) demonstrating the specificity of these beacons. Here, we validate that the metastasis-selective mechanism of PP(MMP)Bs can specifically image breast cancer vertebral metastases, thereby differentiating tumor and healthy tissue.     

Altered levels of PGF in cat spinal cord tissue following traumatic injury.

Previous studies by others indicated that PGs were present in brain, spinal cord, and c.s.f. of several mammalian species. In the present study we compared levels of PGE and PGF by R.I.A. in spinal cord tissue from traumatized cats and cats pretreated with indomethacin prior to trauma to those of baseline and sham operated controls in order to assess for the first time, to our knowledge, whether meaningful changes in levels of PGE and PGF could be detected which might shed new light on the etiology of spinal cord trauma. Levels of PGF (nanograms/gram wet wt) in the cord segment immediately adjacent to the point of trauma were 8.05 +/- 1.50, and 13.13 +/- 1.38 for baseline and sham operated cats respectively. Spinal trauma led to more than a 100% increase in PGF levels to 29.26 +/- 3.58. Although pretreatment with indomethacin 30 min prior to trauma gave the expected blockade of the PGF response to trauma, a measurable level of PGF (2.55 +/- 0.17) was found in the cord after indomethacin. Cord levels of PGF declined after 3 hr in both sham operated and traumatized animals. PGF was maximally stimulated by trauma during the first 3 hr with little effect at 72 hr. Although carefully examined, PGE levels in cat spinal cord appeared to be virtually unaffected by trauma. These findings clearly demonstrate for the first time that traumatic injury to the spinal cord is accompanied by marked increases in PG levels at the site of trauma, and that the observed elevation in PGF in response to trauma can be blocked by indomethacin in vivo. Whether PGF changes are causally related to the etiology of spinal cord trauma, or merely represent a manifestation of PG release as a result of non-specific tissue injury, remains to be seen.     

The physiological basis of transplantation of fetal catecholaminergic neurons in the transected spinal cord of the rat

1. Fetal (E.17) rat locus coeruleus and mesencephalic dopaminergic neurons when implanted into the transected spinal cord of the young adult rat survive for periods of longer than four months. Axons of up to 15 mm in length are observed growing from the cell bodies of the implanted neurons. 2. Fluorescent catecholaminergic (presumably dopaminergic) cell bodies are found in the caudal region of the transected, non-implanted spinal cord. 3. After transection of the spinal cord at the middle thoracic region in rats, at different postnatal ages (PN. 0, 7, 14, 21 and 28), there is substantial recovery of motor coordination involving all four limbs in the PN. 0 and PN. 7 groups. Recovery is best in the PN. 7 group. There is almost no recovery in the PN. 28 group, and very little recovery in the PN. 14 and PN. 21 groups. 4. Spinal locomotor generators in rat can, therefore, display a substantial degree of functional autonomy, if the spinal cord is cut before a certain critical stage of development (before PN. 14). These results have interesting implications with regard to current efforts to understand the mechanisms that regulate the spinal locomotor generators in experimental animals, and perhaps in man as well.