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Recent Update on Basic Mechanisms of Spinal Cord Injury

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Recent Update on Basic Mechanisms of Spinal Cord Injury Neurosurgical Review https://doi.org/10.1007/s10143-018-1008-3 REVIEW Recent update on basic mechanisms of spinal cord injury Syed A. Quadri1,2 & Mudassir Farooqui3 & Asad Ikram3 & Atif Zafar3 & Muhammad Adnan Khan1,2 & Sajid S. Suriya1,2 & Chad F. Claus4 & Brian Fiani5 & Mohammed Rahman6 & Anirudh Ramachandran7 & Ian I. T. Armstrong1,2 & Muhammad A. Taqi1,2 & Martin M. Mortazavi1,2 Received: 8 May 2018 /Revised: 20 June 2018 /Accepted: 6 July 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Spinal cord injury (SCI) is a life-shattering neurological condition that affects between 250,000 and 500,000 individuals each year with an estimated two to three million people worldwide living with an SCI-related disability. The incidence in the USA and Canada is more than that in other countries with motor vehicle accidents being the most common cause, while violence being most common in the developing nations. Its incidence is two- to fivefold higher in males, with a peak in younger adults. Apart from the economic burden associated with medical care costs, SCI predominantly affects a younger adult population. Therefore, the psychological impact of adaptation of an average healthy individual as a paraplegic or quadriplegic with bladder, bowel, or sexual dysfunction in their early life can be devastating. People with SCI are two to five times more likely to die prematurely, with worse survival rates in low- and middle-income countries. This devastating disorder has a complex and multifaceted mechanism. Recently, a lot of research has been published on the restoration of locomotor activity and the therapeutic strategies. Therefore, it is imperative for the treating physicians to understand the complex underlying pathophysiological mechanisms of SCI. Keywords Spinal cord injury . Mechanism of spinal cord injury . Primary phase . Secondary phase . Chronic phase Introduction sports injuries are the leading causes with road traffic acci- dents being the most common etiology [1, 2, 5–10]. The inci- Traumatic spinal cord injury (SCI) is a life-shattering neuro- dence is two- to fivefold higher in males as compared to fe- logical disorder, which affects between 250,000 and 500,000 males, with a peak in younger adults. Studies have reported individuals each year [1–4]. Trauma to the spinal cord second- annual economic burden of billions of dollars on the federal ary to motor vehicle accidents (MVAs), falls, violence, and healthcare systems [11–13]. Since it predominantly affects the younger adult population, the psychological impact of adap- tation of a healthy individual to a paraplegic or quadriplegic in * Syed A. Quadri their early life can be devastating [14–17]. Moreover, it is [email protected] reported that people with an SCI are two to five times more likely to die prematurely than people without an SCI, with 1 California Institute of Neuroscience, 2100 Lynn Road, Suite 120, worse survival rates in low- and middle-income countries [1, Thousand Oaks, CA 91360, USA 18–20]. 2 National Skull Base Center, Thousand Oaks, CA, USA Multiple medical specialties are involved in the manage- 3 Department of Neurology, University of New Mexico, ment and treatment of patients with SCI. Such specialties in- Albuquerque, NM, USA clude neurosurgery, trauma surgery, neurology, psychiatry, 4 Department of Neurosurgery, St. John Providence Hospital and pain management, and rehabilitation [16]. Recently, extensive Medical Centers, Michigan State University, Southfield, MI, USA research and attention have been focused on the restoration of 5 Department of Neurosurgery, Desert Regional Medical Center, Palm locomotor activity and therapeutic strategies for SCI, includ- Springs, CA, USA ing cell transplantation, surgical neurostimulation, and drug 6 Department of Neurology, Desert Regional Medical Center, Palm administration. Therefore, it is essential for physicians inter- Springs, CA, USA ested in SCI research to understand the underlying mecha- 7 – College of Osteopathic Medicine of the Pacific, Western University nisms of injury of this devastating condition [21 25]. of Health Sciences, Pomona, CA, USA Though the subject is quite vast, in this article, the authors Neurosurg Rev provide a glance into the complex and multifaceted mecha- usually causing contusion of the spinal cord, followed by a nism of SCI. secondary phase, characterized by destructive and self- propagating biochemical changes in neuronal and glial cells that lead to increased dysfunction and eventual cell death over Different levels and severity of SCI hours to weeks after the initial insult [13, 34–38]. The spatial extent of secondary injury events spread rostrally and caudally from the site of the impact causing structural and functional SCI is characterized by a wide array of symptoms including disturbance along the spinal cord [37, 38]. Cell death begins paralysis, paresthesia, spasticity, pain, and cardiovascular, locally and centrally, ultimately leading to the destruction of bowel, bladder, or sexual dysfunction [26]. It has been shown the central gray matter along with the partial or complete loss to cause substantial autonomic dysfunction, with neurogenic of adjacent white matter tracts [39–42]. The primary phase of shock being one of the leading causes of death following the SCI is usually unexpected and could lead to significant traumatic SCI [19, 27–29]. The amount of disability depends delay in the management. In contrast, the secondary phase of on the severity and the level of spinal cord injury. SCI is subacute and can be manageable [39]. A proper under- The International Standards for Neurological Classification standing of the mechanisms underlying the secondary phase of Spinal Cord Injury (ISNCSCI) developed by the American of SCI may help the physician manage it promptly with a Spinal Injury Association (ASIA) is used commonly to assess measure to decrease this secondary reaction and optimize the the severity of injury [30, 31]. The severity of the injury is treatment, limiting the extent of the spinal cord injury [43]. classified into different grades in the ASIA Impairment Scale The mechanism of SCI is summarized in Fig. 1. (Table 1). Various epidemiological studies have demonstrated that SCI occurs more at the cervical levels, being the most mobile segment of the spine and limited by two stable segments at its Primary SCI phase two ends being the cranium superiorly and the thorax inferi- orly, although the distribution varies substantially based on the The spinal cord can be contused or transected. A contu- geographic location of the studies [1, 2, 6]. sion is the most frequent finding [44–46]. Persistent com- pression after the impact triggers a cascade of events lead- ingtodisabilityaftertheSCI[47–50]. Primary injury Mechanism of SCI occurs at the time of the initial impact. An example is compression from a retropulsed component of a burst It is well established that the pathophysiology of acute SCI fracture [35, 51, 52]. Hallmarks of primary injury are occurs in two stages: the initial, immediate mechanical injury local hemorrhage, edema, and ischemia that progress caused by a permanent or temporary compression [32, 33] and initiate the secondary phase [53]. The mechanisms Table 1 The American Spinal Injury Association (ASIA) Grade Degree of spinal cord dysfunction Impairment Scale A Full dysfunction • Complete loss of motor and sensory function below the level of SCI • Includes S4–S5 loss, leading to perianal numbness (anal area, see Fig. 1) B Partial dysfunction • Complete loss of motor function below the level of SCI • Variable loss of sensory function below the level of SCI, sparing S4–S5 sacral innervation (anal sensations intact, see Fig. 1) C Partial dysfunction • Partial: more than 50% loss of motor function below the level of SCI • Motor movements cannot be made against the gravity of affected muscles (grade 1/5 or 2/5) D Partial dysfunction • Partial: less than 50% loss of motor function below the level of SCI • Motor movements can be made against the gravity in affected muscles (grade 3 or more out of 5) E Normal neurologic examination • Complete neuronal recovery • No motor or sensory loss Neurosurg Rev Fig. 1 The mechanism of spinal cord injury (SCI). Demonstration of various phases of SCI after trauma to the spinal cord of injury can be compression, distraction, or translation of theory, the gray matter is irreversibly damaged during the the spinal column [54]. Disruption of local vascular struc- first hour after the SCI, but the white matter may survive tures at the site of insult often leads to localized hemor- theinsultupto72haftertheSCI[61]. rhages within the spinal cord tissue [55–58]. Since the spinal cord tissues are located within a confined space, framed by vertebral bodies, clotting and edema shift the Secondary SCI phase position of the neuronal and glial tissues within its con- fined area, increasing local pressures on the tissues, thus The primary injury causes delayed damage and death to adja- enhancing ischemia. All of the blood flow to the injury cent cells that survive the original trauma. This biological and site decreases so that local neurons and glial cells are self-propagating response to SCI is known as the secondary deprived of oxygen and glucose. The ischemia and mem- injury phase and is characterized by multiple cascades of bio- brane damage in surviving cells initiate the secondary chemical events that cause further tissue loss and dysfunction. phase of spinal cord injury. Edema is common among These cascading events [33, 36, 57, 58, 62] can be divided spinal cord injuries and is a significant proponent of the into three distinct yet often continuous sequences: acute, sub- development of secondary injury. The initial traumatic acute, and chronic phases. impact increases the permeability of the blood-spinal cord barrier and can induce both vasogenic and cytotoxic fac- Acute phase tors, all of which can cause osmotically active substances to enter and contribute to the injury edema [39, 40, 59, In the acute phase, the damage is a direct result of the primary 60].
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