SCI Forum Reports
A Brief History
June 1, 1999
Until the early 20th century, spinal cord injuries were considered untreatable, said Robert Goodkin, MD, associate professor in the UW Department of Neurological Surgery. This attitude began to change during the world wars, when surgical intervention was attempted in hopes of reversing the catastrophic injury. But since the results were initially unsuccessful, some adopted the credo of "do no harm and do no surgery." Instead, the main course of treatment was to non-surgically stabilized the spine as it healed to avoid further damage. During the Korean War a more aggressive surgical paradigm was established.
The 1960s were years of active SCI research in the U.S. Drs. Robert White and Maurice Albin experimented with cooling of the injured spinal cord in an animal model showing efficacy of induced hypothermia directly to the spinal cord. At New York University, Goodkin also used animal models to experiment with cooling the spinal cord and, in addition, studied the effect of systemic steroids and/or myelotomies immediately following injury, on the theory that this would slow or halt the damage. In some of these cases, Goodkin said, the progressive damage to the spinal cord was altered and many of the animals were able to walk eventually, while the injury if not treated would have rendered the animal permanently paralyzed. The results of cooling and myelotomies, however, could not be replicated in humans.
At the same time, Goodkin's research using cats documented the sequential changes that occur in the spinal cord at specific intervals from 2 minutes to weeks after injury. These studies showed that there is a critical period - between 3 and 8 hours after injury - in which treatment must occur in order to be effective.
This research dovetailed nicely with experiments using steroids in the late 1960s. At the time, steroids were used successfully to treat brain tumors. While similar doses were not effective in reversing the neurological deficit from spinal cord disorders, massive doses - four times the amounts given to brain tumor patients - were found to improve neurological deficit in these patients. "Now it's the standard to give massive doses of steroids within the first eight hours after injury," Goodkin said.
Neurosurgeons today have a better understanding of when to operate - and when not to operate - to stabilize the spine or decompress the spinal cord than they did 20 years ago. Yet in spite of huge advances in neurological and orthopedic spine surgery, a surgical cure for the permanently spinal cord injured patient is still a dream. Claims of such cures periodically surface in the public media. Patients often travel distances to receive these treatments at great personal expense - but none of these claims so far has survived close scrutiny.
Currently, there are several avenues of SCI research that show some promise, Goodkin said. Based on the theory that scarring from injury adversely affects recovery, drug treatments that prevent scarring are being investigated.
Fetal cell transplants to treat syringomyelia (a secondary complication of spinal cord injury that can cause increased weakness and pain) are in the pilot phase now and may enter phase II soon. "Everything looks good in phase 1," Goodkin cautioned. "First results are sometimes the best."
The progress of SCI research often seems frustrating and slow, Goodkin admits. Consumers frequently wonder why treatments that prove successful in animals aren't automatically attempted in human subjects. "In experiments, the animal you use has a lot to do with the results you get," Goodkin said. "So far humans do not appear to follow what works in other animals in the case of spinal cord injury." Although monkeys and chimpanzees may be genetically similar to humans, these animals are difficult to use in long term SCI studies because they may mutilate the extremity that is paralyzed, Goodkin said. Furthermore, the researcher is able to control the injury in animal studies, whereas in humans, each injury is unique. Thus it is problematic to compare treatment effects, especially when treatment involves surgical intervention.
While the drug Sygen successfully reduced the severity of paralysis in animal studies, for example, it didn't show any long-term benefits in human trials. "Much works in the lower animals that doesn't work in humans," Goodkin said. "We just do not know enough. Hopefully, a breakthrough will occur that will allow us to extrapolate to humans."
Goodkin cautioned consumers to investigate carefully when they hear about new treatments through the popular media. "Read the articles, not the headlines," he said. Although he was reluctant to predict where SCI treatments are going, recalling the advances of the past 40 years shows that improvements in SCI treatment have indeed occurred. "Remember," he said, "in World Wars I and II life expectancy was guarded for people with a spinal cord injury."