Among the alleged wisdoms of Yogi Berra is “Nobody misses the plate like a pitcher that isn’t looking for it.” That may be the case in SCI outcomes.

The majority of evidence supporting surgical decompression blindly gropes at a suggestive Class-III evidentiary level, a scientific nostrum for none at all (J Neurosurg, 1999). There is similarly no consensus on the optimal timing of such surgery, and what of scientific scrutiny. If traditionalists insist alternative methods pass “scientific scrutiny,” should they be allowed less?

If trauma is the cause of SCI, what is the value of adding more trauma, which the cautery, retractors, bone ronguers, chisels, and sutures assuredly are.  If ischemia/reperfusion is to be avoided, what is the effect of hypotension at surgical levels of anesthesia in a cord-compromised patient? Are we doing surgery just to be doing something if proof is lacking as to result, a “practice option” that is erratically timed? Perhaps, as suggested in Current Opinions in Neurology 2003, we should question its use, along with methylprednisolone, until it meets some standard beyond tradition and fiat declaration.

The “missing-the-plate” metaphor may equally apply to how certain mechanisms of SCI damage are understood. Contemporary articles cite cytokines, which although players in SCI inflammation and neuronal cell death, are clearly not the first. Guzik (J Physiol Pharm, 2003) notes constitutive phase free radicals, such as nitric oxide and reactive oxygen species, “affect virtually every step of the development of inflammation, while low levels of nitric oxide and reactive oxygen species INHIBIT cytokine synthesis and leukocyte activation (transcriptive phase).” We may thus have the opportunity to INHIBIT cytokines and other inflammatory compounds if we can affect these first responders, free radicals and nitric oxide. Today we can measure the effectiveness of therapies against these events in measuring F-2 isoprostanes, one of the most reliable measures of oxidative stress in vivo.

When a cord is compressed, or rarely cut, the pia mater is immediately involved as it tightly invests the cord in its mesh of blood vessels and ordinary connective tissue. Any swelling or laceration involving the pia immediately creates hypoxia which alters the time-varying equilibrium critical to homeostasis in the vascular bed, and free radical concentrations rise instantly. Effective therapy should bolster the native antioxidants at the site to mute this small change in concentration that activates multiple inflammatory mediators. Once activated, they cause neuronal cell death. I see nothing in surgery that could possibly do other than add more hypoxia to this delicate balance, a direct contravention to the axiom “primum non nocere” (i.e., first do no harm), and a jackhammer approach to polishing a diamond.

The drug industry is looking for meaningful interventions, but I suggest pulsed-electromagnetic field technology of specific pulse design has already demonstrated it can assist the cord and pia to prevent further decay in the delicate time varying equilibrium between antioxidants and free radicals. In contrast to drugs, pulsed-electromagnetic fields are known for their freedom from adverse side effects. Lastly, in a watershed paper completed for NASA, scientists clearly demonstrated the ability to upregulate “classes of growth and restoration genes” leading to correctly integrated, mature human brain tissue, a feat never previously accomplished with any drug or technology.

If the chemical avalanche never starts, neuronal cell death can be minimal as a result of trauma or focal laceration, an important distinction in what really constitutes injury, the limited anatomic insult or several days of expanding chemical degradation. Only when inflammation is stopped can healing hope to begin, which NASA placed inside our horizons.  

Author: A Vietnam veteran and former fellow of the National Institutes of Health, Dr. Gordon is an expert on the use of pulsed-electromagnetic field technology, especially its sports-medicine applications (see www.em-probe.com).