my brother had a C6 sci before 5 months and at present is on rehab.last week we had an MRI and the doctors said it looks like there is a scar in his injured site.will this affects his chances of recovery.also i like to know what happens if there is myelomalacic changes.
12-17-2004, 06:33 AM
It would be quite unusual to NOT see scar formation at the injury site in a serious SCI. Myelomalacia is also common. Unfortunately we do not know how to prevent this at this time. In spite of these findings, many people do continue to get some return. I hope that Dr. Young can give you more information on this.
12-18-2004, 02:41 AM
The word scar is often loosely used to describe change at the injury site. To me, a scar means the presence of fibrous scar tissues. These usually develop between the spinal cord and the meninges and dural covering of the spinal cord. In magnetic resonance imaging (MRI) and computerized tomography scans (CT scans), such scar tissues are often not directly visible and is inferred by adhesion of the spinal cord to the dura. Normally, the spinal cord is completely surrounded by cerebrospinal fluid (CSF). If the spinal cord is consistently contacting the dura at one or more points, this suggests the presence of adhesive scars between the spinal cord and the membrane. In CT scans with contrast or myelograms (where dye is injected into the cerebrospinal fluid), patterns of dye at and around the injury site may suggest presence of such adhesive scars.
Adhesive scars between the spinal cord or spinal roots and the coverings of the spinal cord result in a condition called "tethering" of the spinal cord. As the word implies, the spinal cord is adherent to its surrounding membranes. It is possible to operate and expose the spinal cord, meticulously remove adhesive scars, and "untether" the spinal cord. Since surgery itself may also lead to adhesions and tethering, most neurosurgeons are reluctant to operate unless a patient is showing progressive worsening or pain. Such procedures sometimes may prevent worsening and may even restore function but often has little or no effect.
Myelomalacia is simply a Latin word suggesting that white matter (myelinated spinal tracts) looks bad. When applied to spinal cord around the injury site, the word implies narrowing of cord and abnormal MRI signals suggestive of white matter loss. Since spinal cord injury interrupts spinal tracts containing descending motor axons from neurons in the brain or ascending sensory axons from neurons in the lower spinal cord and dorsal root ganglia, the spinal tracts that have been cut off from the neurons degenerate, resulting in myelomalacia in the surrounding cord. Typically, this is most prominent in the dorsal (posterior) spinal cord above the injury site containing most of the sensory tracts and in the ventral (anterior) part of the spinal cord below the injury site containing most of the descending motor tracts.
Does the presence of scar and myelomalacia affect recovery? The presence of scar and myelomalacia suggest severe spinal cord injury. There may have been some hemorrhage (bleeding) at the injury site that led to the scar formation. As pointed out above, damage to white matter tracts at the injury site will usually cause myelomalacia in the spinal cord above and below the injury site. So, both indicate significant spinal cord injury. It is of course better not to have either of these signs but I have also seen patients with both scar at the injury site and myelomalacia recovering function. The best predictor of substantial functional recovery is the presence of some motor or sensory function below the injury site, particularly far below the injury site (in the anal region) within the first 24-48 hours after injury. Most such patients will recover an average of 75% or more of the motor and sensory function that they have lost, if they have received a drug called methylprednisolone early after injury. People who have no neurological function below the injury level, particularly in the anal region, tend not to recover about 21% of the motor and sensory function they have lost, mostly in the regions just below the injury site. However, 5-10% of patients with such so-called "complete" spinal cord injury do recover substantial function. Thus, while complete recovery from severe spinal cord injury is rare, it can happen.
The recovery takes a long time. Most of the recovery occurs during the first year after injury but some motor and sensory function continues to recover for years after injury. Such recovery initially occurs in the segments just below the injury site. I have known some patients to get back sensation and some movement far below the injury site many years after injury. Because prolonged paralysis itself tends to impede recovery, intensive physical therapy and exercise of the body below the injury site sometimes helps accelerate and even improve recovery. Incidentally, many people have spasticity (increased reflexes and tone below the injury site). They may also have spasms (spontaneous movements of the limbs below the injury site). Such changes of reflex activity and excitability of the spinal cord result from reorganization of the spinal cord adapting to the loss of connections with the brain.
I suggest that you read some of the articles that I have written in the http://carecure.org web site affiliated with these forums to understand more about the kinds of changes and patterns of recovery that occur after injury. There are therapies that stimulate regeneration of axons in the spinal cord and many scientists, including myself, are hopeful that these therapies will also restore function to people with spinal cord injury. The first generation therapies are already in clinical trial and being tested in people. The second generation therapies and also combination therapies in animals suggest that even more effective therapies are on their way. It is important that we start testing these therapies in people. Unfortunately, most of the clinical trials are now occurring overseas. I hope that clinical trials will start soon in the United States and Canada. Almost all the latest advances in clinical trials around the world are reported in the Cure Forum and you may wish to follow the progress in the field there.
Would administering steroids (like methylprednisolone) at the time of untethering surgery possibly prevent retethering?
"Was it over when the Germans bombed Pearl Harbor?"
12-20-2004, 12:41 AM
alan, it is a possibility. We, however, have now developed a new biodegradable biomaterial that appears to be quite effective in preventing adhesion of the spinal cord to surrounding tissues. I am hoping that we can get it into clinical trial soon. Wise.