Latest in Spinal Cord Injury Management

Podcast Transcript

Intro: Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Each year, approximately 17,000 individuals suffer a debilitating spinal cord injury, which takes lifelong care by a multidisciplinary team to manage. In this episode of Neuro Pathways, we're discussing the latest advances in spinal cord management, including care, education, technology, and research. I'm your host, Glen Stevens, Neurologist, Neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to have Dr. Greg Nemunaitis join me for today's conversation. Dr. Nemunaitis is a Physiatrist and Medical Director of Spinal Cord Injury Rehabilitation in Cleveland Clinic's Department of Physical Medicine and Rehabilitation. Greg, welcome to Neuro Pathways.

Greg Nemunaitis, MD: Thank you.

Glen Stevens, DO, PhD: So, Greg, first off, who is the typical spinal cord injured patient? If I was to look at the typical patient, who is that?

Greg Nemunaitis, MD: Well, it depends if you're talking about traumatic or non-traumatic. The traumatic individual would be a 19 year old male who was involved in a motor vehicle accident, and usually associated with substance use. The non-traumatic spinal cord injury would be an older individual in their 40s and 50s, and may include infection or other autoimmune associated problems.

Glen Stevens, DO, PhD: So when I was thinking about spinal cord injury, and I was driving to work in March and April of 2020, I was kind of on the road by myself, and I'm kind of curious if the traumatic spinal cord injury group decreased in 2020, or do we not have that data or stayed the same?

Greg Nemunaitis, MD: The data is not available for 2020. It is for 2019, and there was not a decline in 2019. They'll collect that data each year, and that primary data that goes to the model of Spinal Cord Injury Statistical Center in Alabama, and they'll look at that information. It'll be about a year before we know if anything changed in 2020. The big changes tend to be etiology of injury. One of the interesting things as our population is aged, we're seeing a lot more elderly individuals falling and breaking their spine.

Glen Stevens, DO, PhD: So Greg, we know the spinal cord injuries are some of the most complex to manage. Can you start off by discussing some of the major medical issues that lead to loss of independence, morbidity, mortality, for these poor patients, and help our audience better understand the factors that go into management of this complex patient population?

Greg Nemunaitis, MD: The biggest issue with spinal cord injury is they got multi-system involvement, with generally normal brain and cognitive functioning. I mean, if you had a stroke or a brain injury, you may have similar complexity of medical issues. But the spinal cord injury is an injury below the brain, and so these kids are basically locked in with normal cognitive functioning, which adds a whole another problem with medical issues, that being depression, suicide, post-traumatic stress disorder. But the issues with spinal cord injury relate not only to the loss of motor and sensory function, resulting in paraplegia and tetraplegia, but all the autonomic dysfunctions you don't see. It's easy to see somebody in a wheelchair because they can't walk, but we really don't see the other critical issues like bowel and bladder dysfunction, pulmonary dysfunction, skin dysfunction, endocrine issues that are related to the autonomic nervous system. So these patients individually got to be managed from each system on an ongoing basis for the rest of their life to enhance their health and wellness, so they can provide the most they can for their situation.

Glen Stevens, DO, PhD: So how are early interventions evolving to improve the effect of short and long-term medical issues for spinal cord injured patients?

Greg Nemunaitis, MD: Early interventions are really closely aligned with early education, not only of the patients as their own advocates, but also the medical staff, the nursing staff, the therapy staff. A lot of early studies, the big study with the STASCIS study, looking at early surgery and showing improved outcomes if people went to the OR within the first 24 hours. And studies coming out on early rehabilitation, instead of starting rehab once they leave the hospital, you start right there in the acute care hospital. And then of course, post-acute rehabilitation therapies to assess enhanced function. And then finally some interesting surgical procedures down the line with nerve transfers, tendon transfers, electrical stimulation of enhanced significant function for these people as well.

Glen Stevens, DO, PhD: Delving, a little more specific on this you and I both have gray hair and been around a long time. Steroids come and go, what's the role of steroids now as spinal cord injured patients?

Greg Nemunaitis, MD: There was a meta-analysis about 2013 that disproved any additional assistance in the recovery with spinal cord injury and the contraindication or the problems that were associated with the steroids were worse than any potential for recovery. So that no longer deemed a need in the acute care hospital.

Glen Stevens, DO, PhD: So I'm curious when you see patients come in, maybe from other locations, are other places still using it, or have people followed the guidelines?

Greg Nemunaitis, MD: People are following the guidelines, it's no longer used.

Glen Stevens, DO, PhD: A comment about a stem cells, complex topic of course.

Greg Nemunaitis, MD: It is a complex topic and stem cells are out there and preclinical studies are great, but preclinical studies are animal models. And a lot of times they don't translate to improve function in humans, but there are several studies that are out there and I was involved in one of them, SUN13837 study, which showed some improvement in phase I and phase II clinical trials. However, the problem with phase I and phase II clinical trials, these are small numbers of patients and phase III clinical trials are necessarily really assessed the full potential for the treatment.

Glen Stevens, DO, PhD: What are some of the latest innovations in technology and patient assistive devices?

Greg Nemunaitis, MD: Well, a system device is really where it's at. I mean, 20 years ago people were locked in their homes unable to do anything. I mean, if we can at all imagine what COVID has done to us magnify that by 10 times. And if you had a spinal cord injury and he couldn't drive, he couldn't walk, you couldn't ride a bike, it really puts you behind in life. So the redesign of wheelchairs, assistive devices for driving for standing for walking have been remarkable and really improve the health and wellness and participation of our patients with spinal cord injury.

Glen Stevens, DO, PhD: So what about current research, anything exciting in the field that you guys are involved with or you'd like to discuss that's breaking some ground.

Greg Nemunaitis, MD: We did a pretty interesting study in 2018 using direct current stimulation of the brain to enhance motor function of people with spinal cord injury. It was a small study with eight patients, but it clearly showed some improvement in motor function. Along with therapy but at this time are involved in a phase II clinical trial with three different centers, looking at a larger volume of patients to assess the effectiveness of this direct brain stimulation, to improvement of motor functioning person who would spinal cord injury.

Glen Stevens, DO, PhD: The cause of death of patients has that changed over time?

Greg Nemunaitis, MD: It has evolved in certain areas. Back in the fifties, you died from renal failure, from direct damage, from infection and amyloidosis as a result of chronic pressure wounds that has gone. And by the seventies that was no longer an issue with the institution of good intermittent catheter programs and good wound care and mooned education. And then pulmonary embolisms became one of the leading causes of death. And after clinical practice guidelines were produced and set out and people change their habits, that's no longer an issue. Right now with pneumonia and sepsis as being number one and two causes of death after spinal cord injury. And unfortunately that hasn't changed and they've been the leading causes of death for 50 years.

Glen Stevens, DO, PhD: And maybe it's again too early to know, but as COVID increased amongst the quad and patients?

Greg Nemunaitis, MD: It's interesting, I've been looking at that and then involved with the United Spinal Association. And we have monthly meetings with about 30 or 40 community individuals with spinal cord injury and really haven't notice anything significantly different than the non- spinal cord injury population. I mean, they get in they don't seem to have any significant issues other than what the standard person would have.

Glen Stevens, DO, PhD: So the thing that always concerned me with patients in terms of the cost of care, how would a patient pay for their care? It must be extraordinary.

Greg Nemunaitis, MD: Cost of the care for persons with spinal cord injury is huge. The state carries most of the burden of costs, the Medicare and Medicaid programs. Most people cannot afford the costs. If I can give you an example of the lifetime costs of somebody that had a paraplegic injury at age 20, it would be about 2.5 million. And if this 20 year old individual had a high tetraplegia, its direct lifetime costs would be 5 million. And this doesn't include the indirect cost in terms of loss of wages from working in that.

Glen Stevens, DO, PhD: So let's `go back to research for a minute. Let's say I have a drug A that I'm really hopeful that it's going to be something to help these patients. What's the average time that it's going to take me to get that through that if it actually turns out to be a good drug.

Greg Nemunaitis, MD: Well, the execution of the COVID vaccine was just amazing because looking at the data, it takes an average of 10 or 15 years before a therapeutic goes from the lab to the street. And then 2010, the Pharmaceutical Research Manufacturers of America produced an article about the cost and the number of drugs that came out in 2010, only 22 new drugs came out at a cost of $50 billion.

Glen Stevens, DO, PhD: I'm really glad you mentioned that about the vaccine and how fast it went through. And I'm not sure how you feel about it, but it actually gives me hope that maybe we'll look at things differently and how we do studies and how things are put through is going to change. And some of this malaise in the system will get better. Any thoughts on that? Are you hopeful or?

Greg Nemunaitis, MD: Extremely hopeful. I think everybody's seen it from the FDA on down and I think it's their responsibility to enhance the approval of these new therapeutics for the improvement of life and health and wellness for all of us.

Glen Stevens, DO, PhD: So Greg, talk to me about education of not only providers but also patients.

Greg Nemunaitis, MD: In this computer age we all live in including the COVID environment, the development of queue computer system education has been traumatic and it's helped not only our medical students to learn our physicians and therapists, nurses, but also the patients themselves. I mean the spinal cord population are pretty wise individuals that have lived life with spinal cord injury and often know more than the average clinician. These education programs go on through multiple avenues from the American Spinal Injury down to the community organizations, has assisted and not only reduction of injury, but also prevention of injury and complications as a result of spinal cord injury.

Glen Stevens, DO, PhD: Well, Greg, thank you so much for joining me today. This has been a very insightful conversation. I appreciate your time.

Greg Nemunaitis, MD: Thank you, sir.

Outro: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word and thank you for listening.