Download PDF
CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2017; 75(06): 387-393
DOI: 10.1590/0004-282X20170048
REVIEW

Traumatic spinal cord injury: current concepts and treatment update

Traumatismo raquimedular: conceitos atuais e atualizações terapêuticas
Carolina Rouanet
1   Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil.
,
Danyelle Reges
1   Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil.
,
Eva Rocha
1   Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil.
,
Vivian Gagliardi
1   Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil.
,
Gisele Sampaio Silva
1   Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brasil.
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

ABSTRACT

Spinal cord injury (SCI) affects 1.3 million North Americans, with more than half occurring after trauma. In Brazil, few studies have evaluated the epidemiology of SCI with an estimated incidence of 16 to 26 per million per year. The final extent of the spinal cord damage results from primary and secondary mechanisms that start at the moment of the injury and go on for days, and even weeks, after the event. There is convincing evidence that hypotension contributes to secondary injury after acute SCI. Surgical decompression aims at relieving mechanical pressure on the microvascular circulation, therefore reducing hypoxia and ischemia. The role of methylprednisolone as a therapeutic option is still a matter of debate, however most guidelines do not recommend its regular use. Neuroprotective therapies aiming to reduce further injury have been studied and many others are underway. Neuroregenerative therapies are being extensively investigated, with cell based therapy being very promising.

RESUMO

O traumatismo raquimedular (TRM) afeta 1.3 milhão de norte americanos, sendo mais da metade secundário a trauma.No Brasil, pouco estudos avaliaram sistematicamente a epidemiologia do TRM, mas estima-se uma incidência de 16 a 26 por milhão por ano. A extensão final do dano medular é resultante de mecanismos primários e secundários, que começam no momento do evento e prosseguem por dias e até semanas seguintes. Há fortes evidências de que a hipotensão contribua para danos secundários pós TRM. A cirurgia descompressiva visa a aliviar a compressão mecânica sobre a microcirculação, assim reduzindo isquemia e hipóxia. O papel da metilprednisolona no tratamento de pacientes com TRM é controverso, não sendo recomandada pela maior parte das diretrizes atuais. Terapias neuroprotetoras visando a reduzir injúria adicional foram e vêm sendo estudadas. Terapias neurorregenerativas estão sob investigação ampla, sendo a terapia celular uma forte promessa.

spinal cord injuries - spinal cord compression - neurosurgery - spinal cord regeneration - cell- and tissue-based therapy
traumatismos da medula espinhal - compressão da medula espinal - neurocirurgia - regeneração da medula espinal - terapia baseada em transplante de células e tecidos


Publication History

Received: 11 January 2017

Accepted: 14 March 2017

Article published online:
05 September 2023

© 2023. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Revinter Publicações Ltda.
Rua do Matoso 170, Rio de Janeiro, RJ, CEP 20270-135, Brazil

 

  • References

  • 1 Wilson JR, Forgione N, Fehlings MG. Emerging therapies for acute traumatic spinal cord injury. CMAJ. 2013;185(6):485-92. https://doi.org/10.1503/cmaj.121206
  • 2 Ahuja CS, Martin AR, Fehlings MG. Recent advances in managing spinal cord injury secondary to trauma. F1000 Research. 2016;5(F1000 Faculty Rev):1017. https://doi.org/1010.12688/f1000research.7586.1
  • 3 Resnick DK. Update guidelines for the management of acute cervical spine and spinal cord injury. Neurosurgery. 2013;72(suppl 3):1.. https://doi.org/10.1227/NEU.0b013e318276ee7e
  • 4 Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34(6):535-46. https://doi.org/10.1179/204577211X13207446293695
  • 5 Le CT, Price M. Survival from spinal cord injury. J Chronic Dis. 1982;35(6):487-92. https://doi.org/10.1016/0021-9681(82)90063-7
  • 6 Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. N Engl J Med. 2000;343(2):94-9. https://doi.org/10.1056/NEJM200007133430203
  • 7 Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-8. https://doi.org/10.1001/jama.286.15.1841
  • 8 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(3):215-27. https://doi.org/10.1089/neu.2013.2982
  • 9 Vazquez RG, Sedes PR, Farina MM, Marques AM, Velasco EF. Respiratory management in the patient with spinal cord injury. BioMed Res Int. 2013;2013:168757. http://dx.doi.org/10.1155/2013/168757
  • 10 Choi HJ, Paeng SH, Kim ST, Lee KS, Kim MS, Jung YT. The effectiveness of early tracheostomy in cervical spinal cord injury patients. J Korean Neurosurg Soc. 2013;54:220-4. https://doi.org/10.3340/jkns.2013.54.3.220
  • 11 Hagen, EM. Acute complications of spinal cord injuries. World J Orthop. 2015;6(1):17-23. https://doi.org/10.5312/wjo.v6.i1.17
  • 12 Casha S, Christie S. A systematic review of intensive cardiopulmonary management after spinal cord injury. J Neurotrauma. 2011;28(8):1479-95. https://doi.org/10.1089/neu.2009.1156
  • 13 Ploumis A, Yadlapalli N, Fehlings MG, Kwon BK, Vaccaro AR. A systematic review of the evidence supporting a role for vasopressor support in acute SCI. Spinal Cord. 2010;48(5):356-62. https://doi.org/10.1038/sc.2009.150
  • 14 Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2008;31(4):403-79. https://doi.org/10.1080/10790268.2008.11760744
  • 15 Readdy WJ, Whetstone WD, Ferguson AR, Talbott JF, Inoue T, Saigal R. Complications and outcomes of vasopressor usage in acute traumatic central cord syndrome. J Neurosurg Spine. 2015;23(5):574-80. https://doi.org/10.3171/2015.2.SPINE14746
  • 16 Readdy WJ, Dhall SS. Vasopressor administration in spinal cord injury: should we apply a universal standard to all injury patterns? Neural Regen Res. 2016;11(3):420-1. https://doi.org/10.4103/1673-5374.179051
  • 17 Inoue T, Manley GT, Patel N, Whetstone WD. Medical and surgical management after spinal cord injury: vasopressor usage, early surgeries and complications. J Neurotrauma. 2014;31(3):284-91. https://doi.org/10.1089/neu.2013.3061
  • 18 Altaf F, Griesdale DE, Belanger L, Ritchie L, Markez J, Ailon T et al. The differential effects of norepinephrine and dopamine on cerebrospinal fluid pressure and spinal cord perfusion pressure after acute human spinal cord injury. Spinal Cord. 2017;55(1):33-8. https://doi.org/10.1038/sc.2016.79
  • 19 Jacobs WB. Mean arterial blood pressure treatment for acute spinal cord injury (MAPS). Clinical Trials.gov. NCT 02232165. 2016 [cited 2016 Aug 16]. Available from: https://clinicaltrials.gov/ct2/show/NCT02232165?term=NCT+02232165&rank=1
  • 20 Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012;7(1):e32037. https://doi.org/10.1371/journal.pone.0032037
  • 21 Wilson JR, Singh A, Craven C, Verrier MC, Drew B, Ahn H et al. Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study. Spinal Cord. 2012;50(11):840-3. https://doi.org/10.1038/sc.2012.59
  • 22 AOSpine Europe. Surgical treatment for spinal cord injury (SCI-POEM). Clinical Trials.gov. NCT 01674764. 2012 [cited 2016 Sep 13]. Available from: https://clinicaltrials.gov/ct2/show/NCT01674764?term=NCT+01674764&rank=1
  • 23 Bracken MB, Collins WF, Freeman DF, Shepard MJ, Wagner FW, Silten RM et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA. 1984;251(1):45-52. https://doi.org/10.1001/jama.1984.03340250025015
  • 24 Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury: results of the Second National Acute Spinal Cord Injury Study. N Engl J Med. 1990;322(20):1405-11. https://doi.org/10.1056/NEJM199005173222001
  • 25 Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. JAMA. 1997;277(20):1597-604. https://doi.org/10.1001/jama.1997.03540440031029
  • 26 Evaniew N, Belley-Cçté EP, Fallah N, Noonan VK, Rivers CS, Dvorak MF. Methylprednisolone for the treatment of patients with acute spinal cord injuries: a systematic review and meta-analysis. J Neurotrauma. 2016;33(5):468-81. https://doi.org/10.1089/neu.2015.4192
  • 27 Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ, Resnick DK, Ryken TC. Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 2002;50(2 Suppl):S1.
  • 28 Geisler FH, Coleman WP, Grieco G, Poonian D. The Sygen multicenter acute spinal cord injury study. Spine. 2001;26(24 Suppl):87-98. https://doi.org/10.1097/00007632-200112151-00015aa
  • 29 Petitjean ME, Pointillart V, Dixmerias F, Wiart L, Sztark F, Lassié P et al. [Medical treatment of spinal cord injury in the acute stage]. Ann Fr Anesth Reanim. 1998;17(2):115-22. French. https://doi.org/10.1016/S0750-7658(98)80058-0
  • 30 Wang J, Pearse DD. Therapeutic hypothermia in spinal cord injury: the status of its use and open questions. Int J Mol Sci. 2015;16(8):16848-79. https://doi.org/10.3390/ijms160816848
  • 31 Levi AD, Green BA, Wang MY, Dietrich WD, Brindle T, Vanni S et al. Clinical application of modest hypothermia after spinal cord injury. J Neurotrauma. 2009;26(3):407-15. https://doi.org/10.1089/neu.2008.0745
  • 32 Dididze M, Green BA, Dietrich WD, Vanni S, Wang MY, Levi AD. Systemic hypothermia in acute cervical spinal cord injury: a case-controlled study. Spinal Cord. 2013;51(5):395-400. https://doi.org/10.1038/sc.2012.161
  • 33 Grossman RG, Fehlings MG, Frankowski RF, Burau KD, Chow DS, Tator C et al. A prospective, multicenter, phase I matched-comparison group trial of safety, pharmacokinetics, and preliminary efficacy of riluzole in patients with traumatic spinal cord injury. J Neurotrauma. 2014;31(3):239-55. https://doi.org/10.1089/neu.2013.2969
  • 34 AOSpine North America Research Network. Riluzole in spinal cord injury study. (RISCIS). 2016 [cited 2016 Jul 13]. Clinical Trials.gov. NCT 01597518. Available from: https://clinicaltrials.gov/ct2/show/NCT01597518?term=NCT+01597518&rank=1
  • 35 Casha S, Zygun D, McGowan MD, Bains I, Yong VW, Hurlbert RJ. Results of phase II placebo-controlled randomized trial of minocycline in acute spinal cord injury. Brain. 2012;135(4):1224-36. https://doi.org/10.1093/brain/aws072
  • 36 Rick Hansen Institute. Minocycline in acute spinal cord injury (MASC). Clinical Trials.gov. NCT 01828203. 2014 [cited 2014 Oct 16]. Available from: https://clinicaltrials.gov/ct2/show/NCT01828203?term=NCT+01828203&rank=1
  • 37 Daiichi Sankyo Inc. Study to evaluate the efficacy, safety, and pharmacokinetics of SUN13837 injection in adult subjects with Acute Spinal Cord Injury (ASCI). Clinical Trials.gov. NCT01502631. 2016 [cited 2016 Aug 11]. Available from: https://clinicaltrials.gov/ct2/show/NCT01502631?term=NCT01502631&rank=1
  • 38 Kamiya K, Koda M, Furuya T, Kato K, Takahashi H, Sakuma T et al. Neuroprotective therapy with granulocyte colony-stimulating factor in acute spinal cord injury: a comparison with high-dose with methylprednisolone as a hystorical control. Eur Spine J. 2015;24(5):963-7. https://doi.org/10.1007/s00586-014-3373-0
  • 39 Takahashi H, Yamazaki M, Okawa A, Sakuma T, Kato K, Hashimoto M et al. Neuroprotective therapy using granulocyte colony-stimulating factor for acute spinal cord injury: a phase I/IIa clinical trial. Eur Spine J. 2012;21(12):2580-7. https://doi.org/10.1007/s00586-012-2213-3