Time is Spine
On 30 October 2020 I published an article in The Insurance Wire entitled 'Stem cells and spinal cord injury – Where are we now?'Most of the material for that article was taken from the ISCORE Conference which I attended in Barcelona in December 2019. One of the speakers at the conference was Dr Michael Fehlings.
In Barcelona Dr Fehlings gave a very interesting talk discussing a number of aspects in the acute treatment of SCI patients including:
- Neuroprotective Approaches
- Time is Spine
- Re-evaluation of the role of steroids
- Riluzole, minocycline, hypothermia
- Promoting plasticity of neural circuits
- Activation of latent circuits to rescue breathing
- Epidural stimulation for chronic SCI
- Bioengineered scaphoids
- Cellular therapies
- Neural stem cells
- Schwann cells
- Machine Learning to Assess Outcomes
As a gallop through some of the amazing work that is being done in SCI research it was, genuinely, a digestible overview of so many different areas and I will readily admit that it is an ambition of mine to one day interview Dr Fehlings as a guest on DWF's new podcast series ['A Slice of PI'] which will be going live very soon. For anyone interested in an early taste of how that might sound Dr Fehlings recently gave an interview to the Lancet Neurology podcast: 'Spinal cord injury and degenerative cervical myelopathy'.
The second half of the podcast is not particularly relevant to us. The first half, however, concerns early surgical intervention and, as Dr Fehlings sees it, the benefits of such treatment following spinal cord injury: his concept of 'time is spine' as discussed in Barcelona.
With apologies to those who read my article in The Insurance Wire it is worthwhile re-capping the stages of primary and secondary damage.
Following primary injury (often the tortious event which we tend to be concerned with) there is immediate structural damage to the spinal cord but, following that, a series of secondary damage occurs including haemorrhage, oedema, demyelination and axonal and neuronal necrosis. Fibrous glial scarring is formed by infiltrated inflammatory cells across the lesion. In layman's terms think of it as swelling, scarring and death of the surrounding tissue which in turn makes treatment that much more difficult. Neuroprotective therapy works by limiting secondary damage while neuro regenerative strategies are aimed at replacing the damage cells axons and circuits in the spinal cord.
My previous article concerned neuro regenerative strategies and in particular stem cells in their various different guises.
Time is spine is one of a number of potential neuroprotective strategies i.e. preserving as much of the spinal cord circuitry for future benefit.
In The Lancet Dr Fehlings argues for early surgical treatment for acute spinal cord injury. The study: The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data is published in The Lancet Neurology, Volume 20; Issue 2; P117 – 126; February 1, 2021.
Patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at one year after spinal injury. This was interpreted as meaning that surgical decompression within 24 hours of acute spinal cord injury is associated with improved sensory motor recovery. The first 24 to 36 hours after injury appears to represent a crucial time window to achieve optimal neurological recovery with decompressive surgery following acute spinal cord injury.
I appreciate that (and indeed The Lancet article makes reference to this) the topic remains one which is hotly debated and, whilst I accept that I am not qualified to express an opinion one way or another, what I can say is that uncertainty does nothing other than lead to confusion and lack of clear thinking with the patient being the one who is potentially losing out: one centre will treat differently to another when ultimately it seems to me that everyone is benefited if clarity can be obtained and proper treatment protocols put in place.
If the data regarding better AIS grades and less severe impairment [at one year post surgery] is correct then isn't it about time that this debate was brought to an end?
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