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).