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Thread: a Dr. Young: concerened with level of injury question

  1. #1
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    a Dr. Young: concerened with level of injury question

    On one hand I was thankful that my injury was low, a T-12/L-1. Now I'm hearing that this level of injury is least likely to respond to any therapies down the road. I think I'm going to be sick!! Say, with a conus injury, Dr. Young, remylenation is not enough? Does a complete t-12/l-1 have the reality that sensory and motor function are not likely to regrow due to the death of neurons in the grey matter?

    sherman brayton

  2. #2
    Sherman, much depends on the severity of the injury and the extent of gray matter damage. I believe that there will be solutions for neuronal replacement but it will simply take longer because research on this problem did not begin until several years ago. Regeneration has now been worked on for over 10 years. At the present, we really don't know whether adult stem cells will do the job or that embryonic stem cells are necessary. That is one of the reasons why I am quite concerned with the progressive closure of the embryonic stem cell door and am trying to keep it open until more evidence is available showing that adult stem cells will be able to produce replacement neurons in the spinal cord. If you had asked me 3 years ago whether or not motoneuronal replacement was possible with any existing technology, I would probably have shaken my head. Now, I am nodding and hoping that the research would just go faster.

    Please note that there are several other options besides stem cells. One of them is the human neuronal teratoma (HNt) cell line that has been transplanted into some people with stroke. These cells were derived from a tumor cell line that produces neurons. Another possibility is fetal neurons (which they have been transplanting into Parkinson's patients) but work has to be done to isolate acetycholine neurons.

    Wise.
    Wise.

  3. #3
    Senior Member Josh's Avatar
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    I have a question similiar to this. I need someone to explain something to me like I'm a 3rd grader. I'm a T-11 complete, 17 months post. I have no spasams or movement or feeling below the injury. The other day, however, I did notice that I could move my legs in the pool a little. Anyway, my question is what kind of therapies am I going to need to get me out of this chair. What needs to happen for me to get up? Do I need the nuerons relaced. Please, someone help me with this. Thanks

  4. #4
    Joshua, there is no generic answer to your question. Everybody is different. The fact that you are recovering something means that you have neurons in your lower cord. The absence of spasticity or spasms indicate that there is not much activity coming from your lower spinal cord. The motoneurons that innervate the muscles of your legs are located between T10 to L1 vertebral levels. Below L1, there is mostly cauda equina. An experienced physical therapists or doctor should do a careful neurological examination to see what reflexes you have for each major muscle group in your legs. If you have reflexes (they don't have to be spastic), that means the motoneurons for those muscles are still excitable. A careful sensory examination should also tell you where your level is.

    There is only so much that exercise and training can do. Recent studies suggest that locomotor training can indeed restore function to people, particularly in people who are incomplete and did not train to walk again after spinal cord injury. German studies suggest that as many as 40% of people who have never walked after spinal cord injury can regain independent walking after intensive locomotor training, if they have some movement or sensation in their legs. Note that this study was carried out in the early 1990's in Europe where they may have been less aggressive about standing and walking their patients after injury and therefore they have more "learned non-use".

    It is not the end of the world if you have motoneuronal damage. That is after all why we are fighting so hard for stem cell research and what the excitement is all about. For the people who have neuronal loss after spinal cord injury, cell replacement therapy is necessary. At the present time, the most promising approach to do this is through implantation of stem cells. Although nobody has really proven that this works in animals or humans, we know that stem cells can produce new neurons. I believe that neuronal replacement therapy is possible, just as I believe the regenerative therapies is possible. But remember that stem cell therapeutic studies began only 2 years ago whereas regenerative studies have been going on for over 10 years. Also, almost every with spinal cord injury may benefit from regenerative therapies.

    Wise.

  5. #5
    Senior Member Josh's Avatar
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    Thank you Dr. Young, that was very helpful.One more question, should my doctor be able to tell me exactly what's wrong with my cord by looking at an MRI? I ask questions like what's my cord look like and what happened to it exactly, they never really give me a straight answer. The way my Doctor talks it almost seems like it really doesn't matter what kind of damage I have to the cord because it's not going to get any better. This is my rehab doctor who specilizes in SCI, Should I find a Neurosurgen? Thanks for the help.

  6. #6
    Joshua,

    Even the highest resolution MRI image gives only a rough picture of the spinal cord. It can detect objects that are about a mm in diameter or are very different from the surrounding tissues in terms of magnetic resonance. An MRI cannot see individual cells (which are about a tenth to hundredth of a mm in width) or axons (which are about hundredth to a thousandth of a mm).

    What an MRI can tell is whether there is something that is indenting the spinal cord or whether it is smaller than usual or before (if there was a previous MRI for comparison), whether there is increased water content in the tissue (which may show up early after injury but diminishes with time), whether there is a cyst (an fluid filled cavity) in the cord. It can distinguish between white matter and gray matter, because myelin in white matter has a stronger signal. It can detect large areas of demyelination, abnormal areas that have had significant cell loss.

    Thus, if the MRI shows something, it may provide some information about the extent and location of damage. However, it often may show little or no change that could explain loss of spasticity. In that case, a good neurological examination coupled with detailed electrophysiological studies (electromyographic or EMG, somatosensory evoked potentials, and motor evoked potentials) will give more and better information.

    A lot of people ask me whether they should get an MRI study, an EMG study, or whatever because they want information that might give them hope that they will recover. I suggest that the tests should not be used for that purpose because they usually cannot tell you whether or not you will or will not recover. The tests will simply confirm what a good neurological examination can show.

    On the other hand, an MRI and detailed neurological assessment is important to provide a documentation of where you are, so that if there if there are any changes, you can ascertain why. I recently posted an article in the Research Forum where a doctor recommended that everybody with spinal cord injury should get an MRI every two years, so that you and your doctor know whether you are changing.

    Finally, regarding who would be best at reading MRIs. Most doctors who take care of people with spinal cord injury have some working knowledge of MRI. However, the people who would have the most expert knowledge would be neurosurgeons and orthopedic surgeons who use the MRI as a daily tool for planning surgery and who often see the actual spinal cord after having seen the MRI. Frequently an experienced neuroradiologist in an academic center should also be a good person to interpret the MRI but note that many radiologists who read MRI do not see sufficient spinal cord injury to be able to interpret the images adequately.

    Wise.

  7. #7
    Senior Member Jeff's Avatar
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    Wow...

    That was a million dollar explanation of MRIs. I've read a lot and never gotten that much insight, before. Thanks, Dr. Young.

    ~See you at the SCIWire-used-to-be-paralyzed Reunion ~

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