Management of Acute Spinal Cord Injury: Where Have We Been? Where Are We Now? Where Are We Going?

Abstract

The strides that have been achieved in the realm of spinal cord injury (SCI) management are remarkable. It is likely that 90 percent of what has been recognized to date about SCI pathophysiology and treatment has emerged over the past three decades. As such, the field of SCI research has experienced an enormous evolution with preclinical studies significantly facilitating our comprehension of the pathobiologic mechanisms underlying SCI. For instance, results from pivotal basic science studies have emphasized the importance of the secondary injury mechanism, which promoted successful translation of neuroprotective interventions such as early decompressive surgery, blood pressure augmentation, and the potential use of steroids in certain types of SCI, especially cervical lesions. Yet, despite timely implementation of neuroprotective measures in the setting of acute SCI, regaining lost neurologic function continues to be a major challenge. Failure of spontaneous regeneration after SCI has been associated with the loss of multipotent progenitor cell populations, ongoing neuroglial degeneration and the inhibitory properties of the post-injury microenvironment, including the chronic astroglial scar. Our understanding of this concept has given rise to the exciting field of neuroregenerative SCI research, with a multitude of promising strategies currently on the cusp of clinical translation. Despite advances in the management of acute SCI, patients with similar pathologies demonstrate variable extents of recovery, thus indicating an increasing need to consider patient heterogeneity. Personalizing SCI management to stratify patients with the greatest potential to benefit from neuroprotective and/or neuroregenerative strategies will aid in maximizing treatment outcomes.