CHAPTER
Elena Okon
136
Novel Approaches to Neural Repair
and Regeneration After Spinal
Cord Injury
INTRODUCTION
The past few decades have witnessed much progress in the
clinical management of individuals who have suffered an acute
injury to their spinal cord. Early in-field immobilization, adher-
ence to acute trauma resuscitation protocols, surgical and med-
ical stabilization, and subsequent long-term rehabilitation have
dramatically improved the overall care of these patients. These
factors, coupled with improved public awareness and industry
standards to increase motor vehicle, occupational, and recre-
ational/athletic safety have likely contributed to increased
long-term survival and the observed trend over time in which
the proportion of incomplete paraplegia has increased with a
concomitant decrease in complete tetraplegia.
Despite these improvements, the prognosis for neurologic
recovery remains grim for those individuals who suffer injuries
that initially render them with complete motor and sensory
loss. In addition to this sobering fact, the annual injury inci-
dence of approximately 10,000 in the United States alone, the
enormous societal costs connected with the acute and long-
term care of these patients, and the incalculable personal loss
and devastation associated with acute paraplegia all contribute
to making spinal cord injuries (SCIs) a public health issue of
considerable significance.
The bleak neurologic prognosis that follows SCI has gener-
ated intense research activity to better understand the biologic
obstacles to recovery. A brief review of what happens within the
spinal cord after it has sustained an injury is useful to provide a
framework for how the various streams of neuroscientific
research are targeted at the problem of maximizing function
after SCI. In the context of nonpenetrating spinal cord trauma,
as the osseous and ligamentous structures of the spinal column
give way, the spinal cord is subjected to a variety of biomechani-
cal forces, which cause mechanical deformation of the neural
tissue. This mechanical injury results in the interruption of
axons, damage of their myelin sheaths, and is responsible for
the immediate primary damage to local neurons, glial cells,
vasculature, and surrounding parenchyma. The initial tissue
destruction caused by mechanical forces is rapidly followed by a
series of pathophysiologic insults related to such things as
1474
LWBK836_Ch136_p1474-1484.indd 1474
Jessica Hillyer
Brian K. Kwon
inflammation and ischemia, which lead to further secondary
damage. The recognition that the targeting of these biologic
events might reduce tissue loss and hence optimize neurologic
function has stimulated a large body of basic science research
focused at developing neuroprotective strategies, which will be the
focus in this chapter. Testing such treatments in various animal
models of SCI has confirmed that improved neurologic out-
comes can be achieved by limiting secondary damage, although
the reproduction of such an effect in acute human SCI has been
historically very challenging, as evidenced by the many acute,
neuroprotective treatments (including methylprednisolone),
which have failed to show convincing efficacy in human trials.29
Over time, the site of SCI matures and is characterized by
disrupted white matter tracts, glial scarring, and central cavita-
tion. The chronic pathology that is established after the acute
pathophysiologic processes have quiesced presents significant
impediments to the regrowth of axons across and around the
injury site. With such established neural damage, the neurobio-
logic challenge is to develop strategies to promote the regen-
eration and sprouting of disrupted and spared axon, and to
remyelinate demyelinated axons to potentially improve signal
conduction across the injury site. A number of elements within
the injured spinal cord such as myelin-associated inhibitors and
the glial scar are recognized as being barriers to such axonal
regeneration. Many strategies have emerged to try to overcome
these inhibitory factors within the cord and to also improve the
intrinsic growth properties of neurons within the central ner-
vous system (CNS).
PATHOPHYSIOLOGY OF ACUTE
SPINAL CORD INJURY
Animal models of acute SCI in which the spinal cord is subjected
to a blunt, contusive force have revealed a number of interre-
lated pathophysiologic mechanisms such as vascular disruption,
inflammation, excitotoxicity, and programmed cell death (apop-
tosis). Interest in better understanding these mechanisms is
motivated by the possibility of reducing secondary damage and
improving neurologic function by attenuating them.
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 Chapter 136 Novel Approaches to Neural Repair and Regeneration After Spinal Cord Injury
VASCULAR DISRUPTION AND ISCHEMIA
Traumatic injury to the spinal cord disproportionally disrupts
the intramedullary microvasculature much more than the large
surface arteries on the spinal cord. Initial microvascular abnor-
malities include hemorrhage, vasospasm, the release of vasoac-
tive molecules, and the loss of pressure autoregulation; all of
which ultimately contribute to ischemia. Ischemia is thought to
be one of the most important aspects of the secondary injury,
although quantifying it at a tissue level within the spinal cord
remains unclear.
Ischemia has particular importance in the pathophysiology
of acute SCI for one simple and practical reason: it is the one
pathophysiologic mechanism that clinicians potentially may be
able to influence. The microvascular abnormalities described
above can be exacerbated by systemic hypotension, and there-
fore it is crucial to prevent dramatic decreases in systemic blood
pressure after SCI. Sustained hypotension was found by Harrop
et al13 to be a significant factor in cord-injured patients who
sustained a deterioration in neurologic function after admis-
sion to the hospital. It has been suggested that mean arterial
pressure be maintained at or above 85 to 90 mm Hg, although
institutions may have individualized protocols for the hemody-
namic management of this patient population.
EXCITOTOXICITY AND IMPAIRMENT
OF IONIC HOMEOSTASIS
Following the trauma of acute SCI, the ability of various cellular
components of the cord to maintain a tight regulation of intrac-
ellular concentrations of such ions as calcium, sodium, and
potassium across their plasma membranes is severely and dan-
gerously compromised. Within minutes after cord injury, gluta-
mate is released and accumulates to dangerously high levels at
the injury site. This excess glutamate causes an overactivation of
NMDA and non-NMDA glutamate receptors, which can lead to
the excitotoxic death of neurons, astrocytes, and oligodendro-
cytes, in large part due to the loss of calcium homeostasis. As one
would expect, the recognition of the important role of glutamate
excitotoxicity after neurologic injury has prompted much inter-
est in the pharmacologic blockade of NMDA and non-NMDA
receptors as a means of protecting the susceptible spinal cord
tissue, and enthusiasm over promising laboratory results spurred
the initiation of a prospective randomized human clinical trial of
an NMDA receptor antagonist called gacyclidine (Beaufour
Ipsen Pharma, Paris, France).17 This drug was evaluated in
France and, unfortunately, the results of this study (unpublished
at this time) did not reveal any neurologic benefit.
The loss of sodium homeostasis is also significant after neu-
rotrauma and can lead to edema and other cytotoxic events.
Consistent with this, animal studies have revealed, both histo-
logically and functionally, the neuroprotective effects of sodium
channel blockade after SCI.
OXIDATIVE STRESS
Free radicals can disrupt biologic systems through the oxida-
tion of essential cellular elements. Oxidation of lipids (lipid
peroxidation) can alter crucial properties of cellular mem-
branes contributing to membrane malfunction and ultimately
apoptotic or necrotic cell death. The extent of lipid peroxida-
tion appears to correlate with the severity of tissue damage.
LWBK836_Ch136_p1474-1484.indd 1475
1475
Reactive oxygen species are commonly observed within bio-
logic systems as a result of an inefficient electron transport
chain during energy metabolism within the mitochondria.
Given the relevance of oxidative stress in secondary damage
and a plethora of available compounds that act as antioxidants,
there has been significant interest in applying such antioxi-
dants as neuroprotectants in acute SCI. The attenuation of
lipid peroxidation was, for example, one of the primary bio-
logic rationales behind the use of high-dose methylpredniso-
lone as a neuroprotective agent after SCI. Innumerous
compounds have shown promise at reducing lipid peroxida-
tion and improving neurologic recovery in animal models of
SCI.
INFLAMMATORY/IMMUNOLOGIC RESPONSE
Injury to the spinal cord initiates an acute inflammatory and
immunologic response that is thought to be an important
component to secondary damage. While it is evident that the
aforementioned pathophysiologic mechanisms that mediate
secondary damage are interrelated, the central role of inflam-
mation after SCI is highlighted in a recent review of the topic,
in which Popovich and colleagues14 state that most (if not
all) of these secondary degenerative processes can be initiated
and/or coordinated by cellular and humoral components of
post-traumatic inflammation. Given that inflammation is an
important aspect of secondary damage after SCI, and the
technology currently exists to pharmacologically influence it
(as evidenced by the wide assortment of anti-inflammatory
drugs available at the local pharmacy), it is only logical that a
significant amount of scientific interest would be directed at
developing therapies to inhibit posttraumatic inflammation
after SCI, with the hopes of minimizing its deleterious
effects.
The cellular aspects of the inflammatory and immune
response include microglia and circulating macrophages, neu-
trophils, and lymphocytes, and their activities are regulated by
a barrage of cytokines, chemokines, growth factors, and other
soluble molecules. Neutrophils are the first cells to migrate into
the injured spinal cord, and express reactive oxygen and nitro-
gen species (contributing to oxidative stress) and matrix metal-
loproteinases (MMPs) (contributing to degradation of adjacent
extracellular matrix). An injurious role to their activity is indi-
cated by the fact that blocking neutrophil activation and migra-
tion into the cord appears to be neuroprotective in animal
models. The activation of microglia (resident CNS mac-
rophages) and the invasion of blood-borne macrophages occur
primarily between 3 and 7-days postinjury, and both contribute
to local phagocytosis, in addition to expressing multiple cytok-
ines that influence neutrophil and T cell activity. The activation
and invasion by these inflammatory and immune cells occur
over the first week postinjury suggest that a potential time win-
dow for therapeutic intervention may exist.
The complexity of the neuroinflammatory response to SCI
makes it impossible to adequately cover, but it should be noted
that not all aspects of inflammation are considered to be dele-
terious to the spinal cord (and hence in need of being inhib-
ited). The inflammatory response is indeed the bodys response
to injury, and some constituents of it are evidently beneficial
for neurologic recovery. Delineating these differences will be
critical in our development of therapies that influence this neu-
roinflammatory response.
8/25/11 10:17:09 PM
 1476 Section XII Trauma
ANIMAL MODELS OF SPINAL
CORD INJURY
The field of spinal cord regeneration research has been
extremely dependent on the use of animal models for gaining
insight into the underlying pathophysiology of acute spinal
cord trauma and for providing settings in which to evaluate
potential therapies.16 While a large variety of animal species
have been employed in such models, rat and mouse models are
most commonly used, and it is generally felt that the pathologic
changes that occur after SCI in these animal models are reason-
ably representative of what occurs in humans. Given that none
of the therapies that have emerged from these animal SCI mod-
els have been found to have convincing efficacy in humans, it
could be argued that the validity of the models as being accu-
rate biologic representations of the human SCI condition has
yet to be demonstrated. Nonetheless, it is widely believed that
these models are an acceptable place to start.
A broad spectrum of injury paradigms has also been used,
ranging from sharp transections to blunt contusions. While the
clinical community is quick to dismiss sharp transection models
as being clinically applicable to the vast majority of patients
who present with nonpenetrating injuries, it is worth noting
that different information can be obtained from these different
injury paradigms, and thus each has its own advantages and
disadvantages. Sharp injury paradigms allow one to evaluate
strategies that promote axonal regeneration and sprouting,
because one can be more confident that the axons in question
were indeed cut during the injury. On the other hand, contu-
sion models more realistically simulate the forces applied to the
spinal cord in blunt injuries and are therefore valuable for eval-
uating neuroprotective interventions that target the resultant
acute pathophysiologic processes. However, because it is diffi-
cult to know exactly what axons have been cut in these contu-
sion injuries, it is extremely difficult (if not impossible) to know
how much axonal regeneration has occurred. This simply
points out that different injury models are useful for answering
different questions regarding the biology of SCI and the effect
of a particular treatment.
OUTCOMES ASSESSMENT IN ANIMAL MODELS
Experimental interventions in animal SCI models are most
commonly evaluated histologically, biochemically, and func-
tionally, although there is general agreement that functional/
behavioral recovery is a critical determinant in whether to pro-
ceed to human testing with a particular treatment. As func-
tional recovery plays such an important role in interpreting
therapeutic efficacy, numerous methods have been developed
to perform assessments of motor, sensory, and autonomic func-
tion in animals after SCI. Many tests of varying degrees of
sophistication have been described for assessing locomotion
and fine motor control, with the most widely used being the
BBB locomotor rating scale, described by Beattie, Basso, and
Bresnahan in 1995 as a measure of motor performance in rats.1
This is a 21-point scale (0 to 21) in which hindlimb joint move-
ment is achieved in the lower third (1 to 8), hindlimb weight
support of varying degrees is achieved in the middle part of the
scale (9 to 14), and animals in the upper third (15 to 21)
achieve varying degrees of coordination between the forelimbs
and hindlimbs. The BBB score has been correlated to the
LWBK836_Ch136_p1474-1484.indd 1476
degree of tissue injury after spinal cord contusion. Its wide-
spread use has been extremely valuable for allowing the stan-
dardized comparison and communication of results from
different institutions. Recently, a second locomotor rating scale
has been developed, which was created precisely for scoring
open field locomotion in mice. Other tests, including the lad-
der, pegboard, beam, and swim test, can be used for the evalu-
ation of more particular locomotor behaviors.
In interpreting these behavioral outcome measures, it
should be recognized that the neural control of locomotion in
rodents and mice is not the same as in humans, and as such, it
is still difficult to predict what, for example, a three-point
improvement on the BBB scale would actually mean to a human
(it also depends in part on where in the scale that three-point
improvement occurs). Nonetheless, these behavioral tests have
facilitated the preclinical development of several treatment
options, which have been encouraged into human testing based
in large part on their capacity to enhance recovery in animals.
BLUNT SPINAL CORD INJURY PARADIGMS
As this chapter will focus on acute neuroprotective strategies, a
brief review of the blunt, nonpenetrating injury paradigms in
which such treatments are typically evaluated is provided here.
In an effort to reproduce the biomechanical forces and subse-
quent neuropathology relevant to the typical nonpenetrating
human SCI, a number of blunt injury models have been devel-
oped in various animals. In these animal models, it is felt that
the pathophysiologic processes initiated acutely after injury
bear reasonable resemblance to those occurring in humans,
therefore providing a setting to evaluate neuroprotective strate-
gies. Also, as in nonpenetrating human injuries, blunt injury
models ultimately result in a central cystic-like lesion with a
spared rim of intact neuronal tissue at the periphery, the quan-
tity of which is correlated with residual locomotor function.
In order to produce nonpenetrating injuries of consistent
pathologic and functional severity, the biomechanical forces
applied to the cord and the injury conditions must be tightly
controlled. A number of blunt injury models have been com-
mercially developed with these considerations in mind, all of
which impart a force onto the dorsal aspect of the midthoracic
spinal cord in rats. The contusion SCI devices include the New
York University (NYU) weight drop impactor, which drops a
weight onto the cord from varying heights; the Ohio State
University (OSU) electromechanical impactor, which drives
the impactor a specified distance into the cord; and, more
recently, the Infinite Horizon Impactor, which drives the
impactor into the cord with a specified force.22 Also described
for rats and mice is a clip compression model of SCI in which
a modified aneurysmal clip of varying occlusion forces is closed
around the spinal cord for variable durations. While this model
provides both a ventral and dorsal compressive force to the
cord, and allows for the application of compression for a sus-
tained period of time, it does not reproduce the dynamic bio-
mechanical forces imparted by the rapidly dislocating verte-
bral column (which is more closely simulated with contusion
devices). As of yet, no consensus exists as to which the most
clinically relevant blunt injury model is. Recognizing that cer-
vical quadriplegia is the most prevalent human injury (and
that the biology of thoracic injuries may be distinct in impor-
tant ways), cervical contusion models of SCI have also been
developed.
8/25/11 10:17:09 PM
 Chapter 136 Novel Approaches to Neural Repair and Regeneration After Spinal Cord Injury 1477

NOVEL TREATMENT APPROACHES
The intense interest in developing new therapeutic interven-
tions for SCI has generated a plethora of scientific papers that
have enhanced our understanding of the biology of this injury
and ways to potentially treat it. As a basic illustration of this, a
PubMed search of SCI limited to animals generated more
than 3800 articles that were published in the year 2007 alone
a rate of 10 new papers per day. Clearly, there is no meaningful
way to cover every therapy that has been recently studied. This
chapter will therefore focus on a series of novel treatments that,
while diverse in their nature, they are related by the fact that
they are (1) currently being evaluated in human clinical trial
for acute SCI; (2) about to begin human clinical trials for acute
SCI; (3) in late stages of preclinical development with propos-
als to begin clinical trials in acute SCI; or (4) in early stages of
preclinical development, but has appeal due to the fact that its
safety in humans has already been confirmed by its routine
clinical use in some other unrelated indication.
PHARMACOLOGIC INTERVENTIONS
Minocycline
Minocycline is a semisynthetic tetracycline antibiotic, which
possesses, in addition to its antimicrobial activity, significant
anti-inflammatory and antiapoptotic properties. Minocycline
has been shown to attenuate the activation of microglia, inhibit
inducible nitric oxide synthase (iNOS), and reduce caspase
activation, each of which is thought to contribute to secondary
damage after acute SCI. Minocycline treatment causes inactiva-
tion of the RhoA pathway, which is involved in the programmed
cell death and the axonal growth cone collapse.
The utility of minocycline in animal models of acute SCI
has been confirmed by numerous independent authors (Table
136.1). For instance, in a mouse model of thoracic SCI, intra-
peritoneal minocycline, given 1 hour after injury and contin-
ued for 6 subsequent days, effectively reduces lesion size in
the spinal cord, spares rubrospinal axons, and significantly
improves both hindlimb function and strength.31 In rat mod-
els, minocycline administration started during the early post-
traumatic period and continued for days after limits the
expression of stress-responsive p38 mitogen-activated protein
kinase (MAPK) and RhoA, reduces apoptosis of oligodendro-
cytes, lessens axonal loss, and ultimately leads to improved
neurologic outcomes. Other researchers have shown that
acute minocycline treatment decreases lesion size, proinflam-
matory cytokine expression, release of cytochrome C from
mitochondria; facilitates survival of motoneurons; protects
oligodendrocytes; and inhibits microglial activation.
Functional assessments in these studies have indicated that
minocycline treatment results in behavioral recovery superior
to that seen in control animals. More important is the finding
that the effectiveness of minocycline is not affected by a treat-
ment delay of 24 hours. In addition, minocycline may have a
role in a more chronic SCI setting, as its administration 4
weeks after injury in a rat SCI model suppresses microglia acti-
vation and leads to the normalization of mechanical and ther-
mal nociceptive thresholds.
Minocycline is a good example of the bench to bedside
translation of scientific discovery, in that its efficacy in a num-
ber of models of acute SCI in 2003 and 2004 prompted investi-
gators at the University of Calgary to initiate a prospective,
randomized, placebo-controlled clinical trial in acute human
SCI (led by Drs. John Hurlbert and Steven Casha). At the time
of this writing, the results of this single-center clinical trial were
not available.
Atorvastatin
The rate-limiting step in de novo cholesterol synthesis is the
conversion of hydroxymethylglutaryl coenzyme A (HMG-CoA)
to mevalonate by HMG-CoA reductase. The statins are a
group of drugs that potently inhibit this enzyme and as such
are commonly prescribed as cholesterol-lowering agents that
have become household names such as lovastatin (Mevacor),

TABLE 136.1 Minocycline in Animal Models of SCI

Paper Histologic/Biochemical/Physiologic Outcome Functional Outcome

Wells J, Brain, Vol 126:1628, 2003
Lee S, J Neurotrauma, Vol 20:1017, 2003
Stirling D, J Neurosci, Vol 24:2182, 2004
Teng Y, PNAS, Vol 101:3071, 2004
Festoff B, J Neurochem, Vol 97:1314, 2006
Zhao P, J Neurosci, Vol 27:2357, 2007
Zhao P, J Neurosci, Vol 27:8893, 2007
Yune T, J Neurosci, Vol 27:7751, 2007
Reduced tissue damage
Reduced cavitation and apoptosis
Reduced apoptosis; reduced dieback and
lesion size
Spared white matter, protected neurons, and
oligodendro
Reduced tissue damage and apoptosis
Reduced microglia activation and TNF-
levels
Delayed 4 wk: Reduced microglial activation
and prostaglandin E2 levels
Delayed 4 wk: Reduced microglial activation
Reduced inflammatory signaling and
apoptosis
Improved animal survival and locomotor
recovery
Improved locomotor recovery
Improved coordination and reduced angle
of rotation
Improved locomotor recovery
Improved locomotor recovery
Not reported
Normalize mechanical and thermal
nociceptive thresholds
Improved locomotor recovery

TNF-, tumor necrosis factor-alpha.

LWBK836_Ch136_p1474-1484.indd 1477 8/25/11 10:17:09 PM

 1478 Section XII Trauma

atorvastatin (Lipitor), pravastatin (Pravachol), and simvastatin Erythropoietin

(Zocor). It has been recently recognized that the statins addi-
tionally have powerful immunomodulatory and anti-inflamma-
tory effects through the decreased isoprenylation of Ras and
Rho GTPases, inhibition of nuclear factor kappa B (NF-
kappaB), and prevention of cell stimulationinduced secretion
of iNOS and interleukin-6 (IL-6).28 As mentioned previously,
the Rho-ROCK pathway plays a central role in axonal growth
cone signaling, and the inhibition of Rho-ROCK promotes
axonal growth and plasticity after SCI. Hence, the statins may
play a role not only in attenuating some of the acute inflamma-
tory response to acute SCI, but also in promoting plasticity in
the more subacute and chronic stages.
The neuroprotective and neurorestorative potential of
atorvastatin in acute SCI models has been reported in two
widely cited articles by Pannu et al.23,24 In the first of these
studies, pretreatment with atorvastatin in addition to daily
postinjury treatment reduced the expression of inflammatory
mediators like iNOS, tumor necrosis factor-alpha (TNF-),
and IL-1, significantly decreased secondary damage at the
injury site, and promoted remarkable locomotor recovery. In
the second of these studies, even with a delay in treatment
administration of up to 6 hours postinjury, the authors
reported significant locomotor recovery in association with a
variety of histologic and biochemical improvements such as
reduced MMP-9 expression in the cord. An independent con-
firmation of the rather phenomenal locomotor recovery
reported in these two studies had not yet been published at
the time of this writing.
In addition to its well-documented hematopoietic activity, eryth-
ropoietin (EPO) has antiapoptotic, neurotropic, antioxidant,
and angiogenic properties.27 Like minocycline and atorvastatin,
EPOs long history of safety in humans gives it appealing poten-
tial as a neuroprotective agent for SCI. Local production of EPO
and its receptor in the brain and spinal cord increases as a
response to injury, and importantly, recombinant human EPO
(rhEPO) is able to cross the bloodbrain barrier and enter the
injured CNS when administered systemically.
In 2002, Gorio et al12 reported on series of rat SCI experi-
ments in which EPO promoted significant neuroprotection
and functional recovery. Since then, he and other authors have
reported on the neuroprotective properties of EPO in animal
models of SCI (Table 136.2). For instance, EPO started 1 hour
postinjury was found to increase tissue sparing and decrease
the levels of certain proinflammatory cytokines (macrophage
inflammatory protein [MIP]-2, TNF-, IL-1, and IL-6). EPO
was reported to slow neutrophil invasion, limit apoptosis and
axonal damage, and facilitate Schwann cell infiltration while
also increasing the volume occupied by microvasculature of the
spinal cord. Improved behavioral recovery has also been
reported by multiple authors.
While these results on EPO in acute SCI are certainly very
encouraging, the experience with it is not universally positive.
We conducted a comparison of the neuroprotective effects of
EPO and its derivative darbepoetin in a standard thoracic con-
tusion SCI model using doses of each drug that were reported

TABLE 136.2 Erythropoietin in Animal Models of SCI

Paper Histologic/Biochemical/Physiologic Outcome Functional Outcome

Gorio A, PNAS, Vol 99:9450, 2002
Brines M, PNAS, Vol 101:14907, 2004
Kaptanoglu E, Neurosurg Rev, Vol
27:113, 2004
Gorio A, PNAS, Vol 102:16379, 2005
Boran B, Restor Neurol Neurosci,
Vol 23:341, 2005
Cetin A, Eur Spine J, Vol 15:1539,
2006
Grasso G, J Neurosurg Spine,
Vol 4:310, 2006
Arishima Y, Spine, Vol 31:2432, 2006
Vitellaro-Zuccarello L, Neuroscience,
Vol 144:865, 2007
Okutan O, J Clin Neurosci,
Vol 14:364, 2007
King V, Eur J Neurosci, Vol 26:90,
2007
Vitellaro-Zuccarello L, Neuroscience,
Vol 151:452, 2008
Mann C, Exp Neurol, Vol 211:34,
2008
Pinzon A, Exp Neurol, Vol 213:129,
2008
Reduced secondary damage Improved locomotor recovery and
swimming scores
Effect mediated independent of hematopoietic actions Improved locomotor recovery
of EPO
Reduced lipid peroxidation Not reported
Reduced secondary damage and expression of Improved locomotor recovery
proinflammatory cytokines
Not reported Improved scores on swimming test
Reduced secondary damage Improved scores on swimming test
Reduced astrogliosis Improved locomotor recovery
Reduced apoptotic cell death and secondary damage Not reported
Reduced secondary damage Improved locomotor recovery
Reduced lipid peroxidation and apoptotic cell death Improved locomotor recovery
Reduced apoptotic cell death, axonal damage, and Not reported
secondary damage
Increased microvasculature, decreased astrogliosis Improved locomotor recovery
No reduction in secondary damage No locomotor recovery
No reduction in secondary damage No locomotor recovery

EPO, erythropoietin.

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 Chapter 136 Novel Approaches to Neural Repair and Regeneration After Spinal Cord Injury 1479

by others to be neuroprotective.19 We found no evidence of his-
tologic or functional improvement in either the erythropoietin-
or darbepoetin-treated animals. Recently, a National Institutes
of Health (NIH)-funded reproduction of the initial study by
Gorio and colleagues12 also found no improvement in EPO-
treated animals.25 Such discrepancies give one pause when con-
sidering the potential translation of this therapy into human
clinical trials.
Nonsteroidal Anti-inflammatory Agents
Prostaglandins have been shown to be quickly produced within
the injured spinal cord, and as potent inflammatory mediators
they have been implicated in the pathophysiology of secondary
damage.26 Prostaglandins are produced by the oxidation of
arachidonic acid by cyclooxygenase 1 and 2 (COX-1 and COX-
2), both of which are found in increasing levels within the spinal
cord within hours of injury. Naturally, this has generated interest
in the use of various nonsteroidal anti-inflammatory drugs
(NSAIDs), which inhibit COX-1 and/or COX-2 (Table 136.3).
Nonselective COX-1/2 inhibitors, including indomethacin
and ibuprofen, alleviate edema, reduced the number of neu-
rons experiencing cytologic changes, normalize bloodspinal
cord barrier permeability, limit changes in spinal cord blood
flow, stabilize spinal cord evoked potentials, and improve loco-
motor recovery. Similar improvements in locomotor recovery
have been demonstrated with specific COX-2 inhibitors as well.
Interestingly, a growing body of evidence has implicated these
arachidonic acid metabolites in the pathogenesis of neuro-
pathic pain after SCI, suggesting that the inhibition of their
production may not only improve locomotor function but also
reduce the burden of the frequently intractable neuropathic
pain that these patients suffer. More recently, it was also dem-
onstrated that over-the-counter NSAIDs, through the inhibition
of RhoA signaling, may also promote sprouting of corticospinal
and serotonergic axons. While the easy accessibility of drugs

TABLE 136.3 NSAIDs in Animal Models of SCI

Histologic/Biochemical/Physiologic
Paper Outcome
Fujita Y, Paraplegia, Vol 23:56, 1985 Prevented decreases in the activity of
Na/K-ATPase, reduced
thromboxane B levels
Faden A, Brain Res, Vol 463:63, 1988 Reduced tissue thromboxane B levels, but
did not lower water (edema) or cation
content
Simpson R, Jr., J Spinal Disord, Vol 4:420, 1991 Reduced histopathologic changes
Sharma H, Neuroscience, Vol 57:443, 1993 Reduced edema and microvascular
permeability
Sharma H, Muscle Nerve Suppl, Vol 11:S83, 1993 Reduced edema and histopathologic
changes
Winkler T, Neuroscience, Vol 52:1057, 1993 Reduced edema, normalized spinal cord
evoked potentials
Guth L, PNAS, Vol 91:12308, 1994 Decreased cavitation in combination with
pregnenolone or LPS vs. these
compounds alone
Resnick D, J Neurotrauma, Vol 15:1005, 1998 Not reported
Guven M, Pediatr Neurosurg, Vol 31:189, 1999 Indomethacin increased lipid
peroxidation
Resnick D, Spine J, Vol 1:437, 2001 Reduced prostaglandin E2 and TxB2
levels
Hains B, J Neurotrauma, Vol 18:409, 2001 Increased tissue sparing; reduced
prostaglandin E2 levels
Sharma H, Muscle Nerve Suppl, Vol 11:S83, 2002 Reduced edema; restore BSCB and spinal
cord evoked potentials
Schwab J, Glia, Vol 47:377, 2004 Decreased the number of RhoA+ cells;
increased GAP-43 neurites
Pantovic R, Spinal Cord, Vol 43:519, 2005 Reduced free fatty acid elevation
Fu Q, J Neurosci, Vol 27:4154, 2007 Enhance axon sprouting; reduced Rho
activation
Harada N, J Neurotrauma, Vol 23:1739, 2006 Increased MPO activity and TNF
expression; decreased prostacyclin
levels (indomethacin)
Functional Outcome
Improved locomotor recovery (aspirin)
Improved locomotor recovery
Improved locomotor recovery, but not
sensory recovery, SSEP, or corticomotor
evoked potentials
Not reported
Not reported
Not reported
Improve locomotor recovery in
combination with pregnenolone or LPS
vs. these compounds alone
Improved locomotor recovery
Not reported
Not reported
Improved locomotor recovery; attenuated
the development of mechanical
allodynia.
Not reported
Not reported
Improved locomotor recovery
Improved locomotor recovery
(ibuprofen only)
Decreased motor performance
(negative results)

BSCB, bloodspinal cord barrier; LPS, lipopolysaccharide; MPO, myeloperoxidase; SSEP, somatosensory evoked potential; TNF, tumor
necrosis factor.

LWBK836_Ch136_p1474-1484.indd 1479 8/25/11 10:17:10 PM

 1480 Section XII Trauma

such as ibuprofen or indomethacin makes them appealing can-
didates for human translation, there is also active interest in the
neuroprotective properties of other anti-inflammatory agents
that influence arachidonic acid metabolism.
Anti-CD11 d Monoclonal Antibodies
Invasion of inflammatory cells is one the most potent mecha-
nisms of secondary damage. After spinal cord trauma, immune
cells penetrate the injured area, eliminating debris and releas-
ing a variety of beneficial and harmful regulatory compounds.
The recruitment of neutrophils and macrophages into the spi-
nal cord begins within the first hours and continues for days
following injury in both humans and animal models.7 The pro-
tein CD11 d/CD18 integrin facilitates the extravasation of leu-
kocytes into the injury site by binding them to intercellular
adhesion molecule 1 (ICAM-1) on the vascular wall, and there-
fore, blocking this cellular interaction may reduce this inflam-
matory response into the injured cord.
This strategy of limiting neutrophil extravasation into the
spinal cord by disrupting this integrin interaction with a CD11
d monoclonal antibody has been pioneered by Lynne Weaver
and colleagues in London, Ontario (Table 136.4). They have
demonstrated that administration of this antibody decreases
the invasion of neutrophils and monocyte/macrophages into
the lesion site, promotes significant neuroprotection with
reductions in reactive oxygen species and proinflammatory
enzymes, and improves both locomotor function and measures
of neuropathic pain. Importantly, these positive effects appear
to be achievable even when the treatment is delayed by up to 6
hours postinjury. This biologic therapy would require the
infusion of a monoclonal antibody, which is quite different
from the previously described therapies such as minocycline,
which have a long track record of human usage. Nonetheless,
the substantial body of preclinical data on the anti-CD11 mono-
clonal antibody approach has prompted recent discussion of
developing this into a human therapy.
Riluzole
Riluzole, or Rilutek (Sanofi-aventis, Bridgewater, NJ), is a
benzothiazole anticonvulsant, which blocks voltage-sensitive
sodium channels and antagonizes glutamate release. It has
been investigated extensively in human patients with amyo-
trophic lateral sclerosis (ALS), and is currently approved by the
Food and Drug Administration (FDA) for this indication, with
evidence that it has a modest (2 to 3 months) effect on slowing
the progression of this fatal neurodegenerative disease.20 Given
that glutamate-mediated excitotoxicity and the loss of sodium
homeostasis are relevant processes in the acute postinjury
phase, riluzole has been studied by a number of authors in ani-
mal models of acute SCI (Table 136.5). These studies have
demonstrated that riluzole decreases calpain activation, inhib-
its oxidative stress and lipid peroxidation, and decreases the
lesion size of the spinal cord at the site of injury. Riluzole has
been tested in conjunction with methylprednisolone and
appears to be additive or synergistic when administered
together. It has also been found to be efficacious in ischemic
models of SCI. Based on these findings and the fact that rilu-
zole is widely used clinically, a human clinical trial for acute SCI
has been proposed and, at the time of this writing, is about to
be initiated through the North American Clinical Trials Net-
work (NACTN). This study will utilize the orally administered
form of riluzole that is commercially available in doses.

TABLE 136.4 Anti-CD11 Monoclonal Antibodies in Animal Models of SCI

Paper Histologic/Biochemical/Physiologic Outcome Functional Outcome

Mabon P, Exp Neurol, Vol 166:52,
2000
Saville L, J Neuroimmunol,
Vol 156:42, 2004
Bao F, J Neurochem, Vol 90:1194,
2004
Bao F, J Neurochem, Vol 88:1335,
2004
Bao F, J Neurochem, Vol 94:1361,
2005
Gris D, J Neurosci, Vol 24:4043, 2004
Gris D, Exp Neurol, Vol 194:541,
2005
Oatway M, J Neurosci, Vol 25:637,
2005
Weaver L, J Neurotrauma,
Vol 22:1375, 2005
Ditor D, J Neurosurg Spine,
Vol 5:343, 2006
Reduced macrophage and neutrophil infiltration Not reported
Reduced macrophages and neutrophils in lesion site Not reported
Decreased COX-2 expression, RNA and DNA oxidation, Not reported
and protein nitration and carbonylation.
Reduced macrophages and neutrophils in lesion site, Not reported
lipid peroxidation and iNOS
Reduced oxidative stress and apoptosis Not reported
Increased tissue sparing, myelin, and neurofilament; Improved locomotor recovery and
decreased necrosis reduced neuropathic pain
Decreased lesion area, increased CGRP-immunoreactive Decreased autonomic dysreflexia at 2 wk
fibers (which was attributed to decreased lesion but not 6 wk after injury.
progression)
Increased projections below the injury; compact myelin Improved locomotor recovery and
within and adjacent to lesion center reduced mechanical allodynia
Increased areas of neurofilament and myelin close to Improved locomotor recovery and
the lesion center (better than MP). reduced mechanical allodynia (better
than Methylprednisolone (MP))
Decreased oxidative enzymes (gp91phox, COX-2, Improved locomotor recovery; attenuated
iNOS), DNA, and protein oxidation the autonomic dysreflexia.

CGRP, calcitonin generelated peptide; COX-2, cyclooxygenase 2; iNOS, inducible nitric oxide synthase, MP, methylprednisolone.

LWBK836_Ch136_p1474-1484.indd 1480 8/25/11 10:17:10 PM

 Chapter 136 Novel Approaches to Neural Repair and Regeneration After Spinal Cord Injury 1481

TABLE 136.5 Riluzole in Animal Models of SCI

Paper Histologic/Biochemical/Physiologic Outcome Functional Outcome

Stutzmann J, Neuroreport, Vol 7:387, 1996
Springer J, J Neurochem, Vol 69:1592, 1997
Mu X, J Neurotrauma, Vol 17:773, 2000
Mu X, Brain Res, Vol 870:66, 2000
Schwartz G and Fehlings M, J Neurosurg,
Vol 94:245, 2001
McAdoo D, Brain Res, Vol 1038:92, 2005
Ates O, J Clin Neurosci, Vol 14:658, 2007
Reduced hemorrhage and necrosis Improved locomotor recovery and
recover SSEPs
Reduced the loss of microtubule-associated protein Not reported
2 (MAP-2)
Combination with MP increased spared tissue Combination with MP improved BBB
scores
Reduced oxidative stress, synergistic with MP Not reported
Reduced tissue loss, preserved integrity of Improved locomotor recovery
descending axons
Did not decrease glutamate release Not reported
Reduced oxidative stress, edema, and lesion area; Improved locomotor recovery
retained more myelin tissue and neurons

SSEP, somatosensory evoked potential.

The Peroxisome ProliferatorActivated
Receptor Agonists
The peroxisome proliferatoractivated receptors (PPARs) are
ligand-activated transcription factors (PPAR, PPAR/, and
PPAR) that have been extensively studied for their role in regu-
lating genes involved in lipid and glucose metabolism.15 In addi-
tion, however, they have potent anti-inflammatory and antioxidant
effects, which has stimulated interest in their potential for neu-
roprotection in animal models of stroke, brain injury, and neu-
rodegenerative diseases such as Alzheimers and Parkinsons
disease. The clinical interest in the neuroprotective properties of
PPARs stems from the fact that agonists for these receptors such
as rosiglitazone (Avandia) and pioglitazone (Actos) (both are
PPAR agonists) are currently available for the treatment of dia-
betes, and so their safety in humans is well established.
In animal models of SCI, the pioglitazone and rosiglitazone
administration within 30 minutes of injury enhances white and
gray matter sparing; decreases lesion size, astrogliosis, and micro-
glial activation; and attenuates myelin and motor neuron loss,
both rostral and caudal to the injury epicenter. Pioglitazone, spe-
cifically, restrains the activation of inflammatory genes 6 hours
after SCI, including IL-6, IL-1, monocyte chemotactic protein-1
(MCP-1), and ICAM-1. Pioglitazone also significantly enhances
the post-SCI production of neuroprotective heat shock proteins
and antioxidant enzymes. In both of these studies, the PPAR ago-
nists, results in improved functional recovery, including higher
BBB scores, more proficient toe clearance, earlier stepping, and
paw positioning closer to parallel. PPAR also appears to play an
important role in SCI pathophysiology, as the PPAR knockout
mouse has worsened recovery after SCI, and PPAR agonists have
improved locomotor recovery. While interest in PPAR agonists
for acute neuroprotection in SCI is at its early stages (Table 136.6),
the fact that they may regulate genes involved in attenuating
inflammation and oxidative stress, and that they are clinically
available, make them attractive candidates for further study.
BIOLOGIC THERAPIES DIRECTLY APPLIED
TO THE SPINAL CORD
Anti-Nogo Antibodies
Unlike in the peripheral nervous system, injury to the CNS is
not accompanied by significant axonal regeneration (this is, for

TABLE 136.6 PPAR Agonists in Animal Models of SCI or PPAR Knockouts with Acute SCI

Paper Histologic/Biochemical/Physiologic Outcome Functional Outcome

Park S, J Pharmacol Exp Ther, Vol 320:1002,
2007
McTigue D, Exp Neurol, Vol 205:396, 2007
Kerr B, Glia, Vol 56:436, 2008
Genovese T, Exp Neurol, Vol 194:267, 2005
Genovese T, J Pharmacol Exp Ther,
Vol 326:12, 2008
PPAR agonist: reduced lesion area, motor
neuron and myelin loss, microglial activation,
inflammatory response, and oxidative stress
PPAR agonist: spared tissue, increased motor
neurons
PPAR agonist: improved neuron survival, 5-HT
fiber innervation, reduced inflammatory
response
PPAR knockout: increased edema, neutrophil
infiltration, apoptosis, inflammatory response
PPAR agonist: reduced edema and tissue
damage, inflammatory and oxidative response,
apoptosis
Improved locomotor recovery,
decreased thermal hyperalgesia
Accelerated locomotor recovery
Improved locomotor recovery,
returned sensory thresholds to
normal
Worsened locomotor recovery
(suggesting that PPAR is beneficial
for recovery)
Accelerated locomotor recovery

PPAR, peroxisome proliferatoractivated receptors; SCI, spinal cord injury.

LWBK836_Ch136_p1474-1484.indd 1481 8/25/11 10:17:10 PM

 1482 Section XII Trauma
the most part, the essence of the problem in SCI). The failure
of axons to regenerate after SCI is related in part to the rela-
tively low intrinsic growth propensity of CNS neurons and in
part to the inhibitory environment of the injured CNS. A great
deal has been done to try to identify those components of the
injured spinal cord, which inhibit axonal growth. In general,
the nonpermissive nature of the injured spinal cord can be
attributed to inhibitors within CNS myelin and the glial scar
that develops after injury.
Pioneering work by Martin Schwab and colleagues in the
1980s led to the identification of two protein constituents of rat
CNS myelin with molecular weights of 35 and 250 kDa that
potently inhibited neurite outgrowth.3 These were named neu-
rite growth inhibitors NI-35/250. A monoclonal antibody named
IN-1 was raised against NI-250, and subsequently has been shown
to promote axonal regeneration within the inhibitory CNS envi-
ronment, the induction of sprouting of intact axons, and sub-
stantial functional recovery after experimental SCI.
Despite the repeated demonstrations throughout the 1990s
of the inhibitory activity of NI-35/250 and the positive influ-
ence of the IN-1 antibody on axonal regeneration, the actual
identity of NI-35/250 and NI-220 remained elusive until the
year 2000, when the cloning of the largemolecular-weight
fragment was achieved and reported by three independent lab-
oratories and called Nogo. An anti-Nogo antibody therapy was
subsequently developed, which was reported to promote axonal
sprouting and functional improvements even in primate mod-
els of SCI.8
The anti-Nogo therapy has been commercialized by Novartis,
(Basel, Switzerland) and a clinical trial for acute SCI has been
initiated in Europe and more recently in North America.
Unfortunately, in the studies that developed the IN-1 therapy, the
IN-1 was produced by hybridomas, which were then implanted in
the animals. The subsequent anti-Nogo antibody requires intrath-
ecal administration, which, in the first iteration of the clinical
trial, required an indwelling intrathecal lumbar catheter for up to
4 weeks. Concerns regarding the length of time that such a cath-
eter can be maintained in place prompted consideration of repeat
bolus injections through individual lumbar puncture. Given that
the therapy is meant to induce axonal regeneration/sprouting,
such a mode of delivery (via the intrathecal space) is feasible. If it
were an acute neuroprotective therapy, the time required to get
intrathecal access might limit its utility. At the time of this writing,
the preliminary anti-Nogo trial was still ongoing.
The identification of the Nogo receptor (NgR) was
reported a year after the cloning of Nogo, and this has led
to the development of a number of different approaches for
overcoming myelin inhibition of axonal growth. The role of
the Nogo receptor is particularly important given that it
appears to mediate the inhibitory effects of not only
Nogo, but also myelin-associated glycoprotein (MAG) and
oligodendrocyte-myelin glycoprotein (OMgp). One approach
utilizes residues 1 to 40 of the Nogo-A protein (NEP140) to
competitively block the interaction between Nogo and its
receptor. Using an osmotic minipump to deliver the NEP140
directly onto the spinal cord immediately after injury,
Strittmatter and colleagues reported the stimulation of axonal
sprouting (especially through the gray matter) and increased
locomotor function on BBB scores. Importantly, unlike the
anti-Nogo antibody, the NEP140 treatment can be adminis-
tered systemically and additionally has been found to be effec-
tive when delivered a week postinjury. Another therapeutic
LWBK836_Ch136_p1474-1484.indd 1482
approach to overcoming this myelin inhibition is a soluble
Nogo-66 receptor (NgR(310)ecto-Fc), which is intended to
interact with a number of myelin inhibitors and prevent them
from interacting with the Nogo receptor. This approach was
shown to enhance 5-HT fiber sprouting and locomotor recov-
ery even when given 3 days postinjury. The Nogo receptor
therapeutic approaches are not as far along in their preclini-
cal development as the anti-Nogo antibody (which is currently
in clinical trial) but are mentioned here to point out a very
active area of ongoing research and interest in the SCI
community.
Cethrin
Cethrin (BA-210) is an Rho antagonist that underwent a phase
I/IIa clinical trial in acute human SCI, completing enrolment
in the summer of 2006. The strategy of Rho antagonism devel-
oped from an interest in the intracellular pathways that were
activated at the tip of the injured CNS axon in the spinal cord.
It was recognized that if there were many different myelin
inhibitory proteins present in the injured CNS, that it would
take many different and unique treatments to block each of
them individually. However, if multiple inhibitory proteins acti-
vated the same intracellular pathways within the growing axons
to signal them to stop, then a single treatment that targeted
that pathway might be effective at overcoming the inhibitory
effects of many proteins. The actual movements of the axonal
tip (called the growth cone) are mediated by dynamics of the
cytoskeleton, which in turn appears to be regulated by the Rho
family of guanine triphosphatases (GTPases). These GTPases,
which include Rho, Rac, and Cdc42, are small proteins that
cycle between an active state when bound to GTP and an inac-
tive state when bound to guanosine diphosphate (GDP). It is
this interchange between active and inactive states that regu-
lates the actin cytoskeleton and cell motility. Rho, Rac, and
Cdc42 have several downstream targets that mediate actin
polymerization and actinmyosin interaction.
Rho and its downstream activation of Rho kinase (ROCK)
have particular importance in the complex intracellular path-
ways, as they have been implicated in, amongst other things,
the induction of growth cone collapse. RhoA, mRNA, and pro-
tein expression increase significantly after SCI. Lisa McKerracher
and colleagues18 demonstrated that the in vitro inhibition of
neurite extension from retinal ganglion cells by myelin and
MAG could be overcome by pretreating the neurons with an
Rho inhibitor, the C3 exoenzyme from Clostridium botulinum.
Subsequent to this, they reported that this C3 transferase treat-
ment was associated with axonal regeneration and improved
functional recovery in a mouse model of SCI,5 and that it inhib-
ited Rho-mediated apoptotic cell death at the injury site.6
Interestingly, Fournier et al10 found that C3 transferase treat-
ment did not stimulate axonal growth and in fact appeared to
increase tissue damage in a rat model of SCI.
With further work to characterize more membrane-perme-
able forms of C3 transferase, McKerracher commercialized a
form of C3 with enhanced tissue-penetration properties under
the name Cethrin, and a human clinical trial was initiated by
a Canadian biotechnology company, BioAxone Therapeutique.
The protein was mixed in Tisseel and applied onto the dura at
the time of surgical decompression, with the expectation that it
would penetrate the dura and permeate through the spinal
cord locally. This trial enrolled approximately 37 complete,
8/25/11 10:17:10 PM
 Chapter 136 Novel Approaches to Neural Repair and Regeneration After Spinal Cord Injury
American Spinal Injury Association (ASIA) A cervical and tho-
racic SCI patients across North America. A high percentage of
patients in this trial were reported to improve neurologically,
but being a nonrandomized, open-label study, the extent to
which the recovery was mediated by the treatment is difficult to
interpret. At the time of this writing, a randomized, placebo-
controlled trial for Cethrin was being planned but had not
been initiated by Alseres Pharmaceuticals, who acquired
Cethrin from BioAxone shortly after the phase I/IIa trial was
completed.
Chondroitinase ABC
One of the important aspects of acute SCI pathophysiology is the
eventual establishment of a glial scar around the injury site. Such
a glial scar is likely necessary to contain the neuroinflammatory
process that is initiated during the acute injury phase, but the
molecular and physical barrier that it creates and leaves chroni-
cally is considered to be an important impediment to axonal
regeneration. Major extracellular matrix components of this scar
are chondroitin sulfate proteoglycans (CSPGs), and these are
potent inhibitors of growth in the injured CNS. Recognizing this,
there has been great interest in methods of degrading this scar.
The most substantive therapy in this regard is chondroitinase
ABC (ChABC), a bacterial enzyme that cleaves the glycosamino-
glycan (GAG) side chains of chondroitin.
ChABC has been found by numerous investigators to pro-
mote axonal sprouting in animal models of SCI. In a rat model
of cervical crush injury, ChABC leads to the growth and
sprouting of corticospinal tract (CST) axons.2 In thoracic
injury models of both rats and cats, the enzyme generates
neuron regrowth and sprouting, increases the level of neuron
growth-associated protein 43 (GAP-43) in the lesion center,
and facilitates the sprouting of serotonergic fibers into the
rostral portion of the lesion site. Finally, in rats with T8
transections, anterograde tracing shows neurons crossing the
transection site. In most of these studies, functional recovery
in the form of improved locomotion or even bladder control
were reported, and such functional recovery was also recently
reported in a cat model of SCI.30 Combining ChABC with lith-
ium provides additive benefits for both neuron labeling and
locomotor recovery. Some studies show that the drugs effects
on contact placing, stride length, and axon regeneration do
not change when treatment is delayed up to 7 days; however,
acutely treated animals still recovered better functioning in
the skilled paw reaching task.
Because of its role in manipulating the glial scar, ChABC is
frequently tested in conjunction with other therapies that
might induce axonal growth, such as cell transplants. One
could envision a treatment paradigm in the future where, in
the chronic injury setting, ChABC would be administered to
break-up the scar to facilitate the migration of subsequently
transplanted cells, or to facilitate the growth of new axons in
association with another growth-promoting therapy such as
anti-Nogo antibodies or Cethrin. As a proof of this principle,
the combinational therapy of ChABC with Schwann cells was
found to encourage significant axonal growth beyond the cell
transplant.4 Another study demonstrates that the combination
of a Schwann cell bridge, olfactory ensheathing glia, and
ChABC is more beneficial than grafts alone, where animals
exhibit not only improved locomotion and coordination, but
also heightened levels of myelinated axons and serotonergic
LWBK836_Ch136_p1474-1484.indd 1483
1483
fibers in the bridge.9 ChABC is currently undergoing late-stage
preclinical development by Acorda Therapeutics with the
hopes of bringing it to clinical trial.
CONCLUSIONTHE TRANSLATION
FROM BENCH TO BEDSIDE
The chapter describes a number of novel SCI therapies that are
either in clinical trial, are about to go to clinical trial, are in late
stages of preclinical development, or are imminently translat-
able due to well-established human safety. A decade ago, a
chapter describing such therapies would be very short. A decade
from now it will likely be three times as long. The pace at which
new treatments of SCI are being reported from preclinical
models is clearly accelerating. This creates substantial excite-
ment in the SCI community, which has been hoping for a
cure for many decades now. It is only natural for clinicians
and scientists to be excited and enthusiastic about therapies,
which show promise in these animal models of SCI. Indeed, a
tremendous amount has been learned about the biology of SCI
and a growing number of treatments have been found to pro-
mote significant recovery.
The translation of these results into human reality, however,
requires a great deal of caution. Firstly, the biology and physiol-
ogy of the rodent SCI is quite likely to have important distinc-
tions from the human conditionand yet, almost all therapies
for SCI are developed in these models. In addition, for the
most part, such promising therapies make the jump into human
clinical trials straight from the results obtained in these rat or
mouse models. Cethrin is a good example of this phenomenon,
as it was a treatment approach that was commercialized for a
human clinical trial based on the efficacy demonstrated in a
single study that utilized a mouse model of SCI (with contrary
results observed by other investigators in a rat model). This
step from rodent to human is, in part, related to the fact that
the SCI community lacks a well-validated large animal model
that would be a suitable intermediary between rodent and
human. It is, however, also attributable to the great sense of
urgency that we all feel in bringing new treatments to the
patients who suffer this devastating injury. Nonetheless, the SCI
community would be wise to heed the lessons learned from the
dismal experience of our stroke colleagues, who have witnessed
more than 1000 promising therapies in animal models of cere-
bral ischemia fail to materialize into a single effective treatment
in human stroke, a fact that was painstakingly documented by
OCollins et al.21
Beyond the biologic differences between animals and
humans, the methodology with which we study SCI in preclini-
cal models is quite variable amongst laboratories and, again,
may fall short of being adequately representative of the human
condition. Although a number of contusion and compression
injury models have been developed in animals, these injuries
will never be identical to clinical injuries because of differences
in mechanical parameters, such as the size and speed of the
mechanical impact. Many treatments are also tested by being
administered at the time of injury, which is obviously a clinically
inapplicable time to evaluate the efficacy of any treatment.
While this is widely recognized in the SCI field, it is relatively
unusual for investigators to analyze therapies with a delay in the
intervention of more than 1 to 2 hours. How this is to translate
into the reality of clinical practice is unclear. Currently, we do
8/25/11 10:17:10 PM
 1484 Section XII Trauma
not have good data to indicate how the time postinjury in rat
compares to the time postinjury in a human. In general, we
believe that the processes in rodent models occur quite a bit
faster than in humans, and as such, a less than 8-hour time
window in humans may in fact be represented by a 1- to 2-hour
time window in rats. This, however, is speculative.
Methodological differences between laboratories are likely
to be partly responsible for the varying results that appear in
the literature on a given therapy. EPO is a good example of
this. As described earlier, many authors reported substantial
neuroprotection with EPO, while we and the investigators at
the Miami Project commissioned by the NIH to reproduce
these findings did not observe any histologic or functional ben-
efits with this drug. Unfortunately, while the scientific commu-
nity may attribute these differences in outcome to subtle meth-
odological differences between laboratories, such as animal
strain, gender, weight, anesthetic protocols, injury severity, type
of impactor, and the impact characteristics, these differences
pall in comparison to the variability seen in human patients
with SCI. Ultimately, if a drug cannot remain effective amongst
differences in rat strain, weight, gender, and anesthetic proto-
col, then the chances that it would be effective in the inevitably
variable condition of human SCI are probably very low. These
issues are difficult ones to deal with in trying to determine what
is worth translating into human trials.
Finally, beyond these issues of preclinical testing, the actual
execution of clinical trials needed to validate these novel thera-
pies for acute SCI is an extremely difficult process. The inci-
dence of SCI is relatively low as compared to traumatic brain
injury and stroke, for example. Many SCI patients have associ-
ated injuries that make them impossible to evaluate clinically
and hence they are ineligible for clinical trials. The spontane-
ous variability in recovery that occurs amongst patients of the
same ASIA grade is quite high, even for ASIA A complete
patients. This imposes the necessity to recruit large numbers of
patients in order to be sufficiently powered to detect a small
improvement in functional recovery (and it is now recognized
that our treatments are likely to achieve just thatsmall
improvements). As an example of how difficult this process is,
the Sygen clinical trial11 that enrolled nearly 800 SCI patients
took 28 neurotrauma institutions across North America nearly
5 years just to complete the recruitment. With this in mind, one
is reminded of the preclinical considerations just described. If
it is so challenging to actually run a clinical trial for a novel
therapy, then it behooves us in the scientific community to
ensure that the preclinical optimization and refinement of the
therapy has been performed as comprehensively as possible.
Unfortunately, this fact is easy to overlook in the rush to bring
new treatments to clinical trial.
This closing statement is not meant to be overly pessimistic,
but rather, a commentary on the challenges that we currently
face in the ongoing struggle to achieve a better neurologic out-
come for patients whose lives are irretrievably altered by SCI.
The pace of discovery in SCI gives good reason for scientists,
clinicians, and patients to have optimism. However, as we learn
more about both animal and human SCI we have discovered
some unique pitfalls that have hindered progress in translating
therapies from the former to the latter. Our recognition of
LWBK836_Ch136_p1474-1484.indd 1484
these pitfalls will undoubtedly help us in the future develop-
ment of new therapies.
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