Recent trends in spinal trauma management and research

It has been an exciting decade with recent trends in spinal trauma management and research having unlocked many breakthroughs in prevention, diagnosis, comprehensive care and post-treatment support worldwide.¹ As a result, many new techniques and cutting-edge technologies have surfaced, changing the scenario for a condition that was once considered as an ailment not to be treated and which still poses a major challenge to society since it is amongst the most devastating ailments.² Researchers are currently looking into different innovative strategies which have the potential to greatly transform the way spine trauma is managed.

Of note, mounting evidence has emerged with regard to the timing and effectiveness of surgery for spinal cord injuries (SCI). This evidence has been recently summarized in systematic reviews and guidelines that support the idea of “Time is Spine”.³ Based on this work, a strong recommendation has emerged that surgical intervention for SCI be undertaken within 24 h after injury.⁴ Many knowledge gaps remain to be addressed, however, which include the role of ultra-early surgery, the role of expansile duroplasty, the optimal management of mild central cord injury and the practical aspects of implementing a “Time is Spine” protocol in developing countries.⁴

Recent evidence suggests spinal cord perfusion pressure (SCPP) correlates better with the recovery of neurologic functions following traumatic SCI than mean arterial pressure (MAP),⁵ although the evidence to support SCPP monitoring remains somewhat controversial. The evidence for optimal hemodynamic management of patients with acute SCI has been summarized in recent systematic reviews and guidelines.^6,7 Several knowledge gaps have emerged which include the role of SCPP optimization vs. MAP-directed management and the best physiological targets to target.⁷

Diffusion Tensor Imaging (DTI) promises to be a powerful MRI tool supporting an objective, non-invasive assessment of SCI. It works on the principle of measuring the magnitude and direction of the diffusion of water molecules in the structures being scanned to assess their integrity.⁸ Tractography uses data collected from DTI to create a visual representation of nerve tracts in 3D.⁹ The latest tractography algorithm can accurately produce up to 90 % of the actual nerve bundles.¹⁰

Enhanced recovery after surgery (ERAS) protocols are pre-operative care plans that aim to expedite the process of post-operative recovery. The goal is to preserve pre-operative organ function as well as lower the overwhelming stress response after surgery.¹¹ Fundamental principles include pre-operative counselling, proper pre-operative nutrition, refraining from pre-operative fasting and loading of carbohydrates before a certain period, use of standardized anaesthetic agents, analgesics and early ambulation.¹² The introduction of ERAS protocols has led to a substantial reduction in the days spent at the hospital and similar morbidity in patients compared to the traditional approach.¹³

Machine learning and artificial intelligence are very recent developments for management and research in spinal cord injury. Machine learning algorithms find complex, non-linear relationships within large datasets, which would otherwise be less amenable to analysis with traditional logistic regression.¹⁴ These have applications in clinical diagnosis, prognostication, decision-making, planning out surgeries and post-surgical recovery and rehabilitation. Algorithms are developed by feeding a plethora of complex data to train the artificial intelligence/machine learning models and develop artificial neural networks with fine-tuned parameters considering every possible outcome. They have huge potential applications in SCI, ranging from predicting the extent of traumatic SCI from imaging to predicting independent walking ability post-traumatic SCI at discharge.^15,16

3D printing is a technique that helps manufacture customized and life-size implants, braces, etc. Its application in the development of personalized assistive devices/orthoses is a promising avenue today. It significantly reduces the cost of production, with high-speed fabrication, when compared to traditional orthoses.¹⁷ Although 3D-printed lower limb orthoses, including AFOs, have been around for a while, more complex 3D-printed upper limb orthoses, such as the myoelectric hand, are now being developed.¹⁸ Furthermore, with the development of neural tissue engineering, 3D bioprinting is receiving huge attention as it is a powerful tool that can accurately print complex structures.¹⁹ Significant research is underway in the field of reconstruction of the injured spinal cord using 3D printed ideal biomimetic scaffolds.²⁰

Sacral neuromodulation using an implantable electrical stimulator allows on-demand micturition with low post-void residual urine and lower rates of urinary tract infections.^21,22 It needs to be performed at specialized centres and needs team efforts of spine specialists, urologists and rehabilitation experts. Future studies analysing the efficacy of spinal cord stimulation (SCS) as compared to sacral neuromodulation of sacral nerve roots will establish definitive bladder management guidelines in SCI individuals.²³

Epidural SCS has exhibited improved motor function in chronic SCI in animal and human trials.^{24, 25, 26} Transcutaneous SCS is also a promising tool to enhance the functional outcome in patients with SCI, principally while being paired with synchronous rehabilitation.²⁴ It allows ease of application and lower costs. Various studies have demonstrated multi-fold benefits of SCS reducing autonomic and metabolic issues in SCI subjects, improvement in bladder function with improvement in voluntary voiding.^{27, 28, 29, 30, 31, 32, 33} Lower thoracic spinal cord stimulation activates the expiratory muscles and allows peak end expiratory pressure augmenting coughing efforts in SCI patients.^32,34,35 Further multicentre trials to explore the efficacy and reproducibility of various effects of SCS are the need of the hour to establish protocols for rehabilitation and define outcomes. Moreover, the role of brain-spinal cord computer interfaces represents an emerging area of translational research which shows promise.³⁶

Even though there have been substantial advancements in spine trauma management and research, there is still much that we don't know about this complex issue to effectively meet the existing challenges. One of the significant areas of concern is our limited understanding of the barriers to spinal cord regeneration and the most effective strategies to overcome them. This not only presents a significant challenge for healthcare professionals and researchers alike, it also highlights the need and scope for continued investigation and innovation in this field.

The aim of this Virtual special issue is to familiarize healthcare professionals and translational researchers with some of the recent trends in the management and research of spinal trauma. We encourage readers to incorporate recent trends in the management of their spine trauma patients and to do everything possible within their resources to find innovative solutions to enhance the quality of lives of individuals with SCI such that ‘life after spine trauma can be joyous, fulfilling and worth living’.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.