The real weight of infections

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Spinal cord injuries have overwhelming consequences that affect more than just movements and sensation. Immediately after the injury, patients are often completely paralyzed below the level of injury. Most people will experience what is called a “spontaneous recovery” and will recover part of the functions they previously lost without any treatment whatsoever. For a few fortunate people the recovery can be dramatic - almost back to normal. The rate of recovery is greatest in the first three months, but recovery continues for a year or even more.

Unfortunately, the amount of recovery is nearly impossible to foresee, making any prediction with or without any potential treatment (clinical trial) a pure guess. One aspect that is puzzling all scientists is the fact that even when two patients have injuries with similar size and location, which in principle would make them identical, their amount of spontaneous recovery can still differ greatly. This means that other unknown elements must be influencing their spontaneous recovery.

The immune system
The spine injury somehow “disconnects” the brain and the body, and this disconnection goes further than the obvious loss of sensation and movement. It has been shown than the centers involved in the regulation of the immune system are affected as well, resulting in a condition known as spinal cord injury-induced immune deficiency syndrome (SCI-IDS). In simple terms, the immune system is somehow “silenced”, leaving the body more susceptible to catching diseases. In fact, respiratory infections are the main cause of death after spinal cord injuries and significantly reduces the overall life expectancy. Unfortunately, the last thirty years of clinical practice and research brought no real improvements for this specific issue.

New results of the study
Scientists working at the Charité Medical University of Berlin had a different approach to this problem. Their reasoning was quite simple: What happens when a healthy person with a scheduled surgery develops an infection? Well, if there is no immediate life-threatening situation, say for example a bursting appendix, the surgeons will systematically post-pone the operation because when the body is busy fighting an infection, there are greater risk of post-operative complications and a poorer wound healing quality. So, could this logic apply to spinal cord injuries as well? After all, the immune system plays a major role in the healing process after a spinal cord injury, both in the clearance of the cellular debris and the boosting of any natural regeneration. If so, having an infection could potentially influence the spontaneous recovery, leading for example two persons with similar injuries to have a very different recovery.

The team thoroughly analyzed the data of thousands of patients that were followed over a period of ten years after their initial injury. The study showed that almost half of the subjects developed an infection (mostly pneumonia) very early after their injury and that this infection resulted in a lower functional recovery. This lower functional recovery was still perceivable even years after the injury, showing that infections have a long lasting effect on the spontaneous recovery.

What will happen next?
This study has several consequences. First of all a strong attention should be given to preventing the development of such infections early after the injury in order to protect the functional recovery. Since so many patients seem to be affected by this problem, a good strategy could be to establish frequent screening for early signs of pneumonia, before the infection develops to a significant level.
In the case of a clinical trial, subjects that develop such infections should still be monitored but should be analyzed in a separate group. Finally, a more difficult strategy might be to somehow “boost” the immune system after the injury in order to promote repair mechanisms as well as keeping infections at bay.

This project was funded by Wings for Life.
“Long-term functional outcome in patients with acquired infections after acute spinal cord injury” Kopp MA, Watzlawick R, Martus P, Failli V, Finkenstaedt FW, Chen Y, DeVivo MJ, Dirnagl U, Schwab JM. Neurology, January 27, 2017.

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