Protocol/Rationale – SCIR

Dr Bansal has designed a MRI based staging system to assess severity of injury.

Type 1-Pure contusion

  1. less then 50%
  2. more then 50% but not complete
  3. Complete

Type 2-Laceration

  1. less then 50%
  2. more then 50% but not complete transaction and
  3. complete transaction

Type 3- Maceration with obvious Gap

  • *Patients are also classified clinically with ASIA system.
  • #Borderline A/B patients will be screened  on the basis of MRI .
  • #only ASIA A will be taken up for treatment in acute phase .
  • #ASIA B and C will be treated only in chronic phase when all the possibility of natural recovery is exhausted.

According to the time window eligible patients will be further divided into three groups:

  • acute (< 2 weeks),
  • sub- acute (2-8 weeks) and
  • chronic > 8 weeks

In Acute Phase:

All Acute Patients of ASIA A, MRI type 1a and 1 b will undergo  spinal cord decompression and Stabilization, and Omentum transposition as early as possible .
All Acute ASIA A Patients other then MRI type 1a and 1 b will undergo spinal cord decompression and Stabilization only without omentum transposition.
No other active surgical treatment is needed in acute phase. Few of these patients show improvement. Those patients who still demonstrate persistent complete paralysis below the level of injury will be taken up for further treatment in subacute phase.

In subacute phase as the pathological entity to be tacked are

*slow down scar formation,
*provide growth facors which enhance neuronal sprouting.
*fasten wallerian degeneration as in Peripheral Nervous System

Amongst available promising approach is intravenous/intraarterial/intrathecal/epidural/caudal injection of autologous stem cells without any manipulation before scar formation occurs.
Presence  of natural occurring growth factors boosts the regenerative process
Few of these patients show improvement. those patients who still demonstrate persistent complete paralysis below the level of injury are taken up for further treatment in chronic  phase.

In chronic phase therapy is directed towards:

*remyelination of intact axons
*addressing the Scar at the injury site.

Patient’s characteristics like age, duration of injury, psychological status and the possibility of aggressive rehabilitation influence the outcome.Treatment depends on

presence of a rim of intact cord tissue extent & Type of scar

##Since scar has already formed by now unless we get rid of it regeneration can’t occur. Therapies tried in chronic phase without removing scar still help  by reactivation of intact but dormant/demyleinated axons.

myelomalacic changes in grey matter distal and proximal to cord.

**myelomalacic changes due to slow and prolonged wallerian degeneration in white matter are of less significance. What are more important are myelomalaciac changes in grey matter.

Available promising approaches:

Non invasive therapy (without surgical intervention) treatment consisting of conventionalintravenous/intraarterial/intrathecal/epidural/caudal injection of autologous stem cells

## it is aimed for Reactivation of intact axons in chronic phase Indicated only  if some rim of intact tissue present around lesion.

Minimal invasive option of intraspinal/intralesional injection of autologous stem cells

*has recently yielded very good results probably both by virtue of reactivation & regeneration.

 Invasive procedure includes Duroplasty and scar reduction implantaion  of stem cells /olfactory tissue with or without omentum transposition.

*Scar reduction with autologous olfactory tissue transplantations +/- omental transposition

*Scar reduction with intraspinal injections autologous stem cells transplantation +/- omental transposition

**With advanced neurosurgical techniques and skills Possibility of damage to intact neural  tissue during scar reduction is practically nil

** All procedures are from autologous tissue (i.e obtained from patient ). The stem cells being used for the therapeutic protocol are autologous (patient’s own) stem cell harvested either from the bone marrow,adipose tissue ,dental pulp or olfactory tissue.

IN SUBACUTE PHASE

IN CHRONIC PHASE