Traumatic injuries to the spinal cord: Present and future

Traumatic injuries to the spinal cord: Present and future

Traumatic injuries to the spinal cord are among the most exciting frontiers in medicine. Improvements in treatment are helping many more people survive spinal cord injury. Yet most spinal cord injuries still cause lifelong disability.

Spinal cord

The normal spinal cord coordinates movement and sensation in the body. It is a complex organ containing nerve cells, supporting cells, and nerve fibers to and from the brain. The spinal cord is arranged in segments, with higher segments controlling movement and sensation in upper parts of the body and lower segments controlling the lower parts of the body.
The consequences of injury reflect this organization and importance of this structure as a whole.

Spinal cord injury

The types of disability associated with spinal cord injury vary greatly depending on the type and severity of the injury, the level of the cord at which the injury occurs, and the nerve fiber pathways that are damaged. Severe injury to the spinal cord causes paralysis and complete loss of sensation to the parts of the body controlled by the spinal cord segments below the point of injury. Spinal cord injuries also can lead to many complications, including respiratory limitations, incontinence and hypotension immediately after the injury and pressure sores and increased susceptibility to respiratory infections later.

Clinical management of spinal cord injury

Clinical management of spinal cord injury has advanced greatly in the last 50 years. Recent advances include improved imaging of damage to the spinal cord and vertebrae. The claim of development of the first effective drug therapy for use in the hours just after injury few years ago has been busted within a decade. Current management of acute spinal cord injury involves diagnosing and relieving gross misalignments and other structural problems of the spine, minimizing cellular-level damage, and stabilizing the vertebrae to prevent further injury. Once a patient is stabilized, supportive care and rehabilitation strategies promote long-term recovery.

Secondary Damage

Damage to the spinal cord does not stop immediately after the initial injury, but continues in the hours following trauma. These delayed injury processes present windows of opportunity for treatments aimed at reducing the extent of disability resulting from spinal cord injury.
Most types of immune cells (white cells) enter the spinal cord only rarely. However, when the spinal cord is damaged by trauma or disease, immune cells engulf the area, eliminating debris and releasing a host of powerful regulatory chemicals, both beneficial and harmful. Scientists know little about the role of these immune cells after spinal cord injury.
Following spinal cord injury, highly reactive chemicals called oxidants or "free radicals" are released. These chemicals attack the body's natural defences and critical cell structures. Trauma also causes release of excess neurotransmitters, leading to excite-toxicity, or secondary damage from overexcited nerve cells. Understanding how to block oxidative damage and excite-toxicity may provide avenues for reducing damage following spinal cord injury.
Insights about how cells die have affected many areas of disease research, including spinal cord injury. Until recently, most cell death in spinal cord injury was attributed to necrosis, the common, uncontrolled form of cell death in which cells swell and break open. Experiments have shown that some cells die as a result of apoptosis, a form of "cell suicide" in which damaged cells eliminate themselves with less harm to their neighbours. Blocking apoptosis appears to improve recovery after spinal cord injury in rodents.
Damage to axons causes most of the problems associated with spinal cord injury. Earlier it was assumed that the physical forces of spinal cord trauma immediately tear axons. New evidence suggests that many axons deteriorate more slowly because the vital transport of molecules and cell components to and from the ends of axons is disrupted. This delay in axon loss allows time for intervention.
Following injury, nerve cells in the spinal cord below the lesion may die; disrupting spinal cord circuits that help control movement and interpret sensory information.

Regeneration

For successful regeneration to occur following spinal cord injury, damaged nerve cells must survive or be replaced, and axons must regrow and find appropriate targets. Axons and their targets must then interact to construct synapses, the specialized structures that act as the functional connections between nerve cells.
Although conditions in the injured adult spinal cord are significantly different from those occurring during intrauterine development, the requirements for regeneration are similar. We are still learning how the cells specialize, how axons find their correct targets, and how synapses form in the developing spinal cord. Physicians may ultimately be able to manipulate developmental signals to control regeneration in future.
Central nervous system neurons require combinations of natural chemicals called trophic factors to survive and grow. Understanding which trophic factors are important and how cells respond to these molecules may enable researchers to use trophic factors to foster regeneration after spinal cord injury. Research on ways to administer these factors and avoid side effects will be necessary before they can be used for human spinal cord injury. Scientists are currently studying how nerve cells' innate ability to grow, and the environment that surrounds them, affect regeneration following injury. For example, investigators have discovered a gene that prevents nerve cells from growing in adults. Methods that control this innate ability to grow may eventually complement other therapies.
Researchers are beginning to apply new knowledge about regeneration in animal models of spinal cord injury. Strategies include grafting of peripheral nerve pieces and fetal tissue into the damaged spinal cord, administering growth factors, genetically manipulating cell death programs, and neutralizing or bypassing natural growth-inhibiting substances. Combinations of such therapies have produced the first evidence that some functional regeneration of completely severed spinal cords in adult mammals is possible.

Current Interventions

It would have been really heartening for the contemporary physicians when a supposed to be effective drug therapy for spinal cord injury first became a reality in 1990 with the finding that the steroid drug methylprednisolone can significantly improve recovery. Clinical trials of methylprednisolone demonstrated that there is an 8-hour window of opportunity for treatment after injury. This trial also showed that health care systems can provide the rapid treatment necessary in spinal cord injury, and it serves as a model for efficient clinical trials of other therapies. For almost a decade Methylprednisolone had become the standard of care worldwide when another clinical trial at Canada busted the myth. At present there is no medical treatment having evidence to prevent progression of the spinal cord injury cascade.
Neural prostheses present another approach for improving the quality of life after spinal cord injury. These electronic and mechanical devices, such as hand-grasp prostheses, connect with the nervous system to supplement or replace lost motor or sensory function. Devices such as prostheses to control bladder function and to help people stand are now in development or planning stages.
Rehabilitation can greatly improve patients' health and quality of life. New knowledge about the factors underlying spasticity, muscle weakness, and in-coordination may lead to innovative ways of reducing these problems. In some cases, drugs available for other purposes may be effective for treating problems associated with spinal cord injury.
Preclinical and Clinical Testing of New Therapies
Animal studies point to several avenues for developing new therapies for spinal cord injury, including drugs that promote regeneration and transplantation strategies. Each of the mechanisms of secondary damage offers targets for intervention.
Efficient preclinical tests can ensure that the most promising potential therapies proceed rapidly to clinical testing. New animal models, innovative approaches to testing, and reliable outcome assessments are essential to this process.
Randomized, controlled, clinical trials are the gold standard for revealing the benefits and drawbacks of a particular therapy, but practical and ethical constraints limit large-scale trials to the most promising therapies. Good preclinical data is essential so that researchers can predict which treatments and doses are most useful and which patients might benefit. Combination therapies present special challenges that must be overcome when designing clinical trials for promising therapies.

Conclusion

With accelerating progress in basic and applied research, there is renewed vitality and growing optimism among investigators that, with continued effort, the problems of spinal cord injury will be overcome. Findings from other fields, such as development, immunology, and stroke research, can be applied to the study of spinal cord injury. But "magic bullet" for curing spinal cord injury is yet to be found. And so a precautionary and preventive approach like reduction in the road traffic accident, industrial accidents and tuberculosis which are the major preventable/ controllable cause of spinal cord injuries, should be adopted.

Wikipedia fundraiser

Wikipedia has changed how we live. Almost half of my present history knowledge is based on it. Even for medicine, I do look at it as the minimum basic knowledge source . . . some times more than that. Last year when I saw the fundraising request, I immediately donated 5$. That was because I thought it was a stress call! I had never seen such a message on wikipedia earlier. Later I saw the thanks message on it and I felt, oh! even if I wouldnot have donated, it would have survived. This time I am seeing the message for along time . . . I am willfully holding myself. I want it to survive . . . want to see that happenning without me.

Dr. Binayak Sen: The blunders he made

No one could answer the issues raised by Dr. Binayak Sen when he was free and talking his mind and so they booked him under the charges which he would not have even imagined of - sedition.


And yes, if the "state" wants to give signal to the likes of Dr. Sen, that mockery of the state will not be tolerated any more, I will tolerate the pain as its not going to be given to my body but only to Dr. Sen's body . . . . which he will tolerate rather more happily to strengthen our nation; but then it must be "fully" backed by sensible actions.


Here is a man who has clearly stated that he doesn't condone Naxalites or approve of their violent methods. Yet, after being initially jailed for more than a year without trial, he has now been convicted, on the basis of an unsigned letter, of waging war against the government - we all know our police is the master of creating the cases - so I am not surprised. Last month "luckily" good thought prevailed the police constable (without bribe - but I had to prostrate before the 10th pass constable) I escaped the molestation charges or else one of my IPS friend had refused to help me if thats the case against me!


But Dr. Sen would have surely done something wrong. Lets look back at it.

Despite of looking for it ferociously and talking to people whom I had expected to know about him (probably they are afaraid that they too will be included in the sedition charges - joking, he passed MD in 1976 - too senior for anyone of us), I could not find anything of substance about his personal life. He was born in Raipur of erstwhile Madhyapradesh and now Chhatisgarh. Against usual tendency of doctors to move "forward" from village to towns and towns to cities and still bigger cities and to USA and UK . . . after he finished his studies of the superspecilisation in pediatrics from Christian Medical College Vellore, he went down the line to a more remote tribal area! That was his biggest mistake! And retrogressive too, specialy for his generation. At least he could have settled in Delhi when he had gone to work at JNU for 2 years!

But why did he do so? After staying in Tamilnadu for more than 20 years in close association with people from West Bengal and Bangaladesh (I did not want to call them as simply Bengali), I understand their craze towards Tamilnadu and Christian Medical College Vellore for health services. After working at the best coporate hospital in India, as I am working at a Christian missionary hospital, I am feeling the difference. So, I suspect, thses christian missionaries who are infested with the worm of service, would have infected this stupid namby - pamby Bangali! But here again, he did another blunder. He did not convert to Christianity! If he would have converted and done the same what he has been doing now and what has happened to him now, he would have become a god!

Are yaar, in a country, where AK 47 is dropped from the sky and the pilot is escorted to safety, thousands die in Bhopal and the killer company owner is escorted to the airport, terrorists are escorted to the foreign nations with minister as escort, man who cost the government lakhs of crores is raided by the CBI after ample notice that would've given him time to get rid of incriminating evidence; what is the use of establishing a hospital serving poor mine workers, founding a health and human rights organization supporting community health workers in 20 villages? He must be a maverick to do all this and then go around trying to convice people that what our contrators, buisenessmen and admionistrators are doing hand in glove with the politicians is wrong! This was the worst take.

And see the atom bomb - When the new state of Chhattisgarh was formed, he was appointed a member of the advisory group on Health Care Sector reforms, where he helped to develop the Mitanin programme, which in turn, became the role model for the ASHA of the National Rural Health Mission!


So, what else you want a 60-year-old to do to not to be an enemy of the nation? The fact that one of his patients was a Maoist ideologue!

Efforts of his fact-finding team in exposing the atrocities committed by the Salwa Judum!


You have been a citizen of this country far longer than the Chairperson of the coalition so your activities must be against the nation!


You dont know that you cannot speak against any action of the government unless you are a part of the state machinery. What other ignorance you want to have?

I am sure, only god can save him!


Just ending this none sense - please some one tell me - How far are we from turning into China or Iran or Sri Lanka, where most political prisoners are journalists and activists, held for criticising the government?

Can I say this to Dr. Binayak sen -


Those who call you mad.
Those who today occupy their seats of power,
puffed up in their pride,
Will descend from their thrones and bow their heads to you in love
Tomorrow morning.
Probably written by Rabindranath Tagore.

Hypocrites and Dr. Binayak Sen

Even hypocrites and selfish people who are totaly submerged in to their own sea of problems and happiness are sheding crocidile tears for Dr. Binayab Sen. I know its heartenning to do that as you feel yourself among the great people. Its human. But as a close associate and observer of the leftist movement in India, what I have felt is that leftist movement starting from thje mainstream CPI/ CPM to the extremists like naxals, suffer due to the selfish and hypocritic persons involved. What I have observed that people will get associated with the organisation due to requirement of their "buiseness" and leave it as soon as the purpose is over.

Moreover, people like Dr. Binayak Sen are above the usual activists among communists and naxals. I dont know him personaly or never talked to him, but whats is obvious is he was from a respectable family (born in a Brahmin family), studied the best profession from one of the world famous institution and could have easily joined the elite club in any metropolitan city of the WORLD! But he opted to work in the tribal area where even police doesnot want to go, politicians do the deals with their leaders only away from the area in the towns and cities! None of us including myself can compare ourselves with him. Though I agree that many people are having difficlut life and are struggling against the odds "bravely", But thats the situation in which they are and that makes the biggest difference. Dr. Binayak Sen opted for a hard life, difficult life though he could have easily avoided that!

Paralysis by Analysis

The term "Paralysis by Analysis" though popular in the soft ware companies, was not heard more earlier because ENGLISH people dont get traped into it ususaly (in my perception). But in India, its usual . . . Probably thats the reason thousands of years ago they had delacred even the outcome of this phenomenon - दीर्घ सूत्री विनश्यन्ती - Those who plan long . . . will meet destruction! Relatively english outcome very mild - only paralysis!

Analysis paralysis" or "paralysis of analysis" refers to over-analyzing (or over-thinking) a situation, so that a decision or action is never taken, in effect paralyzing the outcome. A decision can be treated as over-complicated, with too many detailed options, so that a choice is never made, rather than try something and change if a major problem arises. A person might be seeking the optimal or "perfect" solution upfront, and fear making any decision which could lead to erroneous results, when on the way to a better solution.

The phrase describes a situation where the opportunity cost of decision analysis exceeds the benefits that could be gained by enacting some decision, or an informal or non- deterministic situation where the sheer quantity of analysis overwhelms the decision-making process itself, thus preventing a decision. This is often phrased as paralysis by analysis, in contrast to extinct by instinct (making a fatal decision based on hasty judgment or a gut-reaction).

Software development
In software development, analysis paralysis typically manifests itself through exceedingly long phases of project planning, requirements gathering, program design and data modeling, with little or no extra value created by those steps. When extended over too long a timeframe, such processes tend to emphasize the organizational (i.e., bureaucratic) aspect of the software project, while detracting from its functional (value-creating) portion.
Analysis paralysis often occurs due to the lack of experience on the part of business systems analysts, project managers or software developers, as well as a rigid and formal organizational culture.
Analysis paralysis is an example of an anti-pattern. Agile software development methodologies explicitly seek to prevent analysis paralysis by promoting an iterative work cycle that emphasizes working products over product specifications.


Analysis paralysis can be used to describe the way that information affects workplace productivity. An overload of physical mail, email, internet websites, voicemails, instant messaging, telephone and cellphone calls, memos, faxes, and interpersonal communication can make it difficult or impossible for employees to make decisions.


In India, its our culture. And we are proud of it!

Naxalism and Adivasis: Are they rebels?

The history of the naxal movement is from that of an agrarian unrest to ideologically driven violence against the State. Naxals were not protagonists of liberal democracy. The naxalite leadership, which was mostly non-adivasi, had managed to superimpose their ideology on the disaffection of the tribal people. This succeeded because the insurgency had considerable support among the dalits and adivasis. And thats merely because of ignorance of the establishment! They have not only fueled it, they have allowed it to grow to this size.

Mainstream political parties had found it expedient to seek naxal support for narrow political gains by giving them concessions while in power and money during elections. Local construction contratcors and buisenessmen all have used them on and off for their narrow gains . . . Naxalism, if its a monster threatenning us, its we who have created them!

Policies
Despite considerable emphasis being placed on tribal rights and governance in the 5th and 6th schedules, there has been no serious effort in that direction. The national policy on tribals is still in its draft form and the cabinet committee on tribal affairs has been ineffective. The ministry of tribal affairs and its tribal area plans has been ignored at State and Central levels. The official and ministerial postings in the region or the ministry are considered as punishment postings with 40-50 % of the posts in these areas remaining vacant.The oversight of the Central government, which was to happen through Governors, has not happened and it has been a ’live and let live’ policy. The crucial role of the Governor to analyse and modify any relevant legislation to suit the tribal areas, and recommend changes has not been fulfilled. Annual reports has not been presented, and the Governor has not been provided with the wherewithal to discharge this responsibility. Despite co-opted tribal members in the parliament, there has been no directives or discussions. Article 275(2) makes reference to the powers of Central and State governments for tribal development and welfare, including provision of funds, but no funds has been provided. Section 4 of the Forest Act 1927 and the issue of eminent domain in land acquisition further are complicated. Model for development set in the country has multi national corporations exerting far too much influence on formulation of national policy.

Role of Corporates
Examples of several companies having forest based industries paying the naxalites for protection are obvious. National Mineral Development Corporation, a PSU, is a big confusion in itself. 100% of mineral oil rights are under tribal ownership in countries like Canada. In a stark contrast, in India 26% proposed by the Planning Commission in India was rejected by the CII.

And then few half baked people brand the menace of Naxal - tribal coperation as continuation of the Aryan - Dravidian struggle!

Tribes are simple straightforward people . . . easy to convince . . . they are patriots for sure. In fact they might not be even knowing what patriotism means. One of my journalist friend said that they did not know why and how a female becomes pregnant? How can they be a rebel?

Conviction of Binayak Sen

I am not able to understand conviction of Binayak Sen (a pediatrician, a CMC Vellore alumni) by the Raipur court. I respect court and Indian legal procedure. In fact though delayed, but judgments in the naxal cases in India has always been very favorable for the left wing people, one of the reasons for their boldness in past. Binayak Sen has been punished with other two people, Naxal ideologue Narayan Sanyal and Kolkata businessman Piyush Guha by a Raipur court for helping the Maoists in their fight against the state. They have been sentenced to life imprisonment by the court.

58-year-old Sen, had been accused by the prosecution of carrying messages and letters from Sanyal to the underground Maoists. Guha was also found involved in helping the Maoists establish a network. Binayak was arrested on May 14, 2007 from Bilaspur and was in jail for two years before being granted bail by the Supreme Court in May last year. Sen, who was freed on bail last year, has always maintained his innocence. "I have never condoned Maoist violence. It is an invalid and unsustainable movement," Dr Sen had said after his arrest in 2007. His wife Elina Sen said that she was sad for the "state of Indian democracy".


Though it’s only a lower court decision but still it has significance. As I have told above, earlier court decisions used to have very sympathetic approach towards left wing extremists. Is this overturn to indicate that establishment is no more going to tolerate! If so it should have been uniform. Not trying Arundhati Roy for her irresponsible statement on Kashmir was not a good indicator. More over there are more serious inflictions on the Indian nation from the corrupt top officials. And every one of us will accept that police atrocities hand in glove with corporate in the tribal areas is a serious cause of concern in long term. I also understand that recently Maoists have become more dangerous with liaison with terrorists. But for that also the establishment should look in to people within who have not only allowed it to grow, they have helped it; and it’s not people like Dr. Binayak Sen; its people like A. Raja, Mr. Kalmadi and Mrs. Neira Radia . . . Over all, its the perrenial ignorance, insesitivity of the administrators and greedy corporates who make criminal out of gentlemen.

I am sure Dr. Sen is not among those who will wantedly and knowingly cause harm to the Indian nation. If so, there must have been very serious reason for that or some other compulsion. Such verdicts will create wider waves of sympathy. I wish he will be released soon on bail. I understand that the laxity towards such people till date should be shed off. But it can’t start all of a sudden and it can’t be selective.

परशुराम उवाच PARASHURAM SAID

'रोक-टोक से नहीं सुनेगा, नृप समाज अविचारी है,
They will not listen to prohibitory suggestions and advices . . . rulers are insensitive and bankrupt at thought level
ग्रीवाहर, निष्ठुर कुठार का यह मदान्ध अधिकारी है।
Exploiter, unkind, blinded by their proud (and greed – from my side), they are to be punished rightfully.
इसीलिए तो मैं कहता हूँ, अरे ज्ञानियों! खड्‌ग धरो,
That’s why I say, oh! Laureates, take the sword!
हर न सका जिसको कोई भी, भू का वह तुम त्रास हरो।
Relieve the earth of the torture it is going through.
'जब-जब मैं शर-चाप उठा कर करतब कुछ दिखलाता हूँ,
Whenever I show the tricks with my bows and arrows,
सुनकर आशीर्वाद देव का, धन्य-धन्य हो जाता हूँ।
I get overwhelmed by the blessings of the gods
'जियो – जियो, अय वत्स; तीर तुमने कैसा यह मारा है,
Long live oh son! What a performance with your archery!
दहक उठा वन उधर, इधर फूटी निर्झर की धारा है।
There is fire in the forest on one side and water fall on the other!
About Parashuram
From “Rashmirathi” - Ramdhari Singh “Dinkar”
So

LAUREATES OF THE WORLD, TO PROTECT THE EARTH
Join politics.