STEM CELLS

1) Geron Corporation (USA)has initiated a preliminary study evaluating the safety of transplanting hESC-derived cells in 8-10 individuals who had sustained thoracic T3-T10 injuries within 7-14 days of enrollment.

Before transplantation, the hESCs will be induced to differentiate into oligodendrocyte progenitor cells (OPCs), which, as discussed in the stem-cell introduction, can evolve into oligodendrocytes, a myelin–producing neuronal support cell. Basically, myelin insulates the neuron, controlling signal-propagating ion flow in and out of the cell. After injury, many neurons remain intact but have lost their insulating myelin sheath and, hence, are dysfunctional. The goal of Geron’s approach is to restore function by remyelinating and turning on these neurons.

The cells will be injected into the cord’s area of injury. To prevent potential immunological rejection of the transplanted cells, the patients will take anti-rejection drugs for several months, which some believe could be a potential risk in itself during this sensitive recovery phase. Although the study’s primary endpoint is safety, functional improvements in the trunk or lower extremities will also be assessed.

For awhile, the US Food and Drug Administration (FDA) blocked the study from proceeding because rat studies suggested that the transplanted cells form microcysts in the spinal cord. After FDA lifted this regulatory block, recruitment started in the fall of 2010.

In June 2011, Geron staff presented preliminary data on the first two patients to be recruited, both who possessed neurologically complete thoracic injuries. Two million cells were injected into the injury site between 7 and 14 days after injury. As indicated before, to prevent potential rejection of the transplanted cells, an immune-suppression drug was administered for 60 days. At the time of the report, one patient had been followed for 180 days and the other for seven days. Overall, no surgical complications were noted, and, in the longer-observed patient, there was no evidence of immune rejection of the transplanted cells 30 days after immune-suppression-drug administration had been stopped.

The proposed trial is built upon a foundation of animal research carried out by Dr. Hans Keirstead and colleagues (USA), who have transplanted hESC-derived OPCs into rats with a contusion injury, the sort of injury most commonly observed in humans. To compare the effectiveness of such transplantation in acute and chronic injury, 1.5-million OPCs were injected into rats seven days and 10 months after injury (i.e., acute and chronic injury phase, respectively). All animals received an anti-rejection drug (cyclosporine A) starting a day before transplantation and proceeding to the end of the study.

In both the seven-day and 10-month rats, the transplanted cells survived, differentiated into oligodendrocytes, and migrated short distances in the cord. However, the seven-day, acutely injured rats showed significant remyelination and improved locomotor ability, while the 10-month, chronically injured rats had no such improvement. Apparently, the formation of injury-site scar tissue over time inhibits the remyelination potential of the transplanted cells. These results are the reason why Geron’s trial will include only individuals with acute and not chronic injury.

2) In 2010, TCA Cellular Therapy (USA) announced the initiation of a phase-1 study evaluating the safety and tolerability of an intrathecal infusion (i.e., lumbar puncture) of bone-marrow-derived, mesenchymal stem cells. The cells will be isolated from the patient’s bone marrow (i.e., autologous), purified, and amplified in culture before being transplanted back into the patient. Recruited subjects must have ASIA-A complete injuries below the cervical C5 level and been injured between two weeks and 60 months before recruitment.

3) In 2010, investigators associated with Medistem, Inc (USA, Panama, Costa Rica) reported the results of treating a 29-year-old male with an ASIA-A complete injury (see appendix) at the T12-L1 level with several umbilical-cord-associated stem cells. Cells were transplanted into the intrathecal space surrounding the spinal cord in three cycles 5, 8, and 14 months after injury. During the last cycle, the cells were also injected intravenously. At the time of his final assessment a half year after the last treatment cycle, the patient had improved to an ASIA-D incomplete-injury classification (see appendix), had recovered some bowel, bladder, and sexual function, and had less neuropathic pain. No adverse effects were observed.

SOUTH AMERICA, MEXICO

1) Dr. Tarcisio Barros et al (Sao Paulo, Brazil) have infused bone-marrow-derived stem cells into the spinal artery closest to the injury site in 32 subjects with clinically complete injuries (2-12 years post injury). The stems cells were isolated from the patient’s own blood after treatment with a drug that stimulates the bone-marrow production of these cells and, in turn, their spillover into the blood. After one-year follow-up, 18 patients have shown improvement in electrophysiological neuronal conduction, which, in some cases, has been translated into functional improvement. (Photo: Drs. Erika & Tarcisio Barros).

The results of the completed study were reported in a 2009 article. Cumulatively, these University of San Paulo investigators had infused such stem cells into the spinal-cord-serving arteries of 39 patients between 2002 and 2004. Of these patients, 11 were women, and 28 were men. Six had injuries between the cervical C2-C4 vertebral level, eight between the C5 and thoracic T1 level, and 25 between the T2 and lumbar L1 level. Injuries were caused by motor vehicle accidents (24), sports (7), and motorcycle/aircraft accidents (2). All patients were at least two years post injury. In other words, they all had chronic injuries, in which little additional recovery is routinely expected and, as a result, any improvements accruing are most likely due to the intervention.

After treatment, the patients were followed at six-month intervals for 2.5 years using electrophysiological measurements of nerve conduction. With these measurements, the lower limbs would be stimulated and any ensuing response measured in the brain. Although no patient could generate such a response before stem-cell treatment, 26 were able to do so afterwards. On average, this renewed nerve-conduction started nine to ten months after treatment.

2) Dr. Gustavo Moviglia et al (Argentina) has treated two individuals with bone-marrow-derived mesenchymal stem cells that have been transformed into neural stem cells by culturing with patient-derived autoimmune cells (Cytotherapy 8 2006). Compared to other programs, the science behind this program has an additional, more-difficult-to-understand dimension. Specifically, it combines a stem-cell approach with some of the immunological principles that underlie Dr. Michal Schwartz’ “activated macrophage” program for acute SCI discussed later.

In this program, mesenchymal stem cells were obtained from the marrow of the patient’s iliac crest (i.e., hip) bone, a location where a large quantity of marrow is concentrated. Called the jack-of-all-trades stem cell, mesenchymal stem cells have the potential to differentiate into a wide variety of cell types. After further purification, these stem cells were transformed into neural stem cells by culturing them with autoimmune cells previously isolated from the patient. Because all cells are from the patient (i.e., autologous), there is little rejection potential when implanted back into the patient.

Before stem-cell implantation, the previously isolated autoimmune cells were intravenously infused into the patient. This infusion primes the injury site by generating an inflammation response, creating a more receptive microenvironment for the introduced stem cells. Two days later, the processed mesenchymal/neural stem cells were infused into an artery serving the injury-site area.

The first patient treated was a 19-year-old male who had sustained a thoracic T-8 injury eight months before treatment from a car accident. He received two stem-cell infusions separated by three months. Electrophysiological measurements suggested improved nerve conduction through the injury site, and MRI (magnetic resonance imaging) evaluations indicated increased spinal-cord diameter. After the second treatment, his coordination and walking ability improved. Reportedly, he regained function to the sacral S-1 level.

The second patient was a 21-year-old woman with a cervical C3-5 injury cause by a car accident 30 months before implantation. After one treatment, both electrophysiological and MRI assessments suggested improvements, and the patient regained upper body strength and control, including hand function. Reportedly, she regained function to the thoracic T1-2 level.

Building upon this research, in 2009, Moviglia and associates reported the results of treating eight patients with chronic, complete injuries with three different cell therapies. Although details were sketchy, the process seemed to be similar to that discussed above except an additional preparatory cell therapy was added.

First, to enhance the all-important growth and development of new blood vessels (called angiogenesis) to the injury site, angiogenesis-promoting bone-marrow-derived stem cells were infused through an artery servicing the area. Second, 18-days later, spinal-cord-specific immune cells were introduced into the patients, the purpose of which was to open the blood-brain barrier and generate a microenvironment more suitable for the implantation of reparative stem cells. Third, autologous (i.e., isolated from the patient) neural stem cells were infused into an artery servicing the injury area. These cell transplantations were followed by neuro-rehabilitation programs designed to maximize functional recovery.

After treatment, five patients progressed from complete ASIA-A to incomplete ASIA-D injuries (see glossary) and regained, to varying degrees, standing and walking ability. Two others patients showed some motor and sensory improvements. One patient was not evaluated. No serious side effects were observed.

3) Reported at the 13^th Annual Meeting of the International Society for Cellular Therapy (June 2007), Dr. Luis Geffner (Ecuador) and colleagues have treated 25 patients with stem cells isolated from the patients’ own bone marrow (i.e., autologous). The time elapsing from injury to treatment ranged from 0.5 months to 22 years (average 4 years). Because considerable functional improvement may accrue without any intervention in the first year post-injury, any improvement of subjects treated soon after injury confounds overall results. Approximately, 1.2-million stem cells per kilogram body weight were implanted, and four to seven days later, a long-term rehabilitation program was started. Improvement was assessed by a variety of means, including electrophysiological evaluations of nerve conduction, MRI imaging of the spinal cord, urinary function, spasticity, walking ability, and ASIA impairment scales. According to the investigators: “Patients demonstrated improvements in sensitivity, motility, bladder sensation, even controlling sphincters, erection, and ejaculation. Fifteen patients (60%) could stand up, 10 (40%) could walk on the parallels with braces, 7 (28%) could walk without braces, and 4 (16%) could walk with crutches.” Although it is unclear how this data compares to pretreatment function, the ASIA scores improved considerably after the intervention. No adverse effects were observed, and no patient deteriorated due to treatment.

In 2008, Geffner et al reported that they had cumulatively treated 52 patients with SCI with autologous bone-marrow stem cells isolated from the patient’s iliac bone (largest bone of the pelvis). The investigators specifically discussed eight cases (7 men), who had been followed for the longest time periods. Four individuals had more acute injuries sustained 5 days, 13 days, 1.5 months, and 7 months before treatment; and four had chronic injuries sustained 6, 6, 7, and 22-years prior to treatment. Injuries ranged from the thoracic T4 to T12 level and were caused by gunshots (4), falls (3), and a car accident (1).

Before transplantation, a laminectomy was performed to expose the spinal cord, the scar tissue was carefully removed, and the cord detethered. Cumulatively, 90-million cells were implanted into each patient. To increase the likelihood that they would reach their target, the cells were introduced into each patient by three different routes. Specifically, 1) 20 milliliters of cell suspension were injected in numerous locations in and around the injury site; 2) after suturing shut the dura membrane surrounding the exposed cord, another 30 milliliters was infused into the spinal canal; and 3) a final 30 milliliters administered intravenously.

Patients were evaluated before treatment and 6-months, 1-year, and 2-years afterwards using a variety of assessments, including the commonly used ASIA or Frankel impairment scales, spasticity assessments, quality-of-life evaluations, bladder function, and MRI imaging. To varying degrees, all patients recovered some function, even the four with long-term injuries in which additional functional recovery is considered unusual.

The researchers emphasize the potential importance of the angiogenesis-promoting properties of these stem cells. They hypothesize that improved blood flow and oxygen supply within the injury area may have contributed to the functional improvements seen in these patients.

4) Dr. Fernando Callera’s team (Brazil) assessed the safety of transplanting patient-derived, bone-marrow stem cells into 10 patients via lumbar puncture. Seven had paraplegia and three had quadriplegia; mean age was 24; and the time lapsing since injury averaged three years. To stimulate stem-cell production by the bone marrow, patients were given granulocyte macrophage-colony stimulating factor (GMCSF) for five days. On day six, 100 milliliters of bone-marrow tissue were aspirated from the pelvic bone’s iliac crest (see illustration above), and the stem cells isolated. Four hours after aspiration, ~100-million cells were transplanted via lumbar puncture. After following the patients for 12 weeks, the investigators concluded the “procedure was feasible, safe, and well tolerated.”

5) Dr. Emilio Jacques (Mexico) has transplanted umbilical cord stem cells into the injury area. Based on limited information, Jacques’ procedures apparently removed the scar tissue by laser, decompressed the spinal cord, injected stem cells into the injury area, and placed patient-derived fatty tissue over the injury area to minimize scar-tissue formation. The procedure is followed by monthly stem-cell injections into surrounding muscles. Sources indicate that Jacques has also started transplanting embryonic stem cells.

One patient who sustained a T5-9 injury about a year and half before treatment briefly described to this report author some of the functional improvement that accrued three months after surgery. Specifically, he feels touch two inches below the T9 level and pressure all the way down to his waist. Furthermore, he can peddle a bike on his own for over 30 minutes, move his hips, push 25 pounds with his legs, and using a harness and treadmill, swing his legs forward.

Jacques’ stem-cell procedures were summarized in a 2005 talk at the 2005 International Congress of Surgeons in Acapulco, Mexico. The submitted abstract indicated that he implanted the undefined stem cells “exactly in the spinal cord injured zone, combined with post-operative use of neuro-muscular rehabilitation, electro-acupuncture, infrared laser, and 4AP.” (A conduction-enhancing drug)

Of the 59 treated patients (average age 21), 51% and 49% were male and female, respectively; 50 and 9 had incomplete and complete injuries, respectively; and 52%, 38%, and 10% sustained cervical, thoracic, and lumbar/sacral injuries, respectively. Jacques reported that 68% “gained sensory and motor levels; 16% gained only motor level and the remaining 16% were still the same.” Patients who had sustained lower level injuries, who were younger, and who had less time elapsing since injury did the best.

6) Medra, Inc./Stem Cell of America under Dr. William Rader’s medical direction, provides a fetal stem-cell program for a wide range of neurological and other disorders, including SCI. Although headquartered in Malibu, California, the surgeries are carried out in the Dominican Republic and Mexico. Very few specifics relevant to SCI-related procedures are available. Derived from elective abortions, fetal hematopoietic stem cells are apparently administered intravenously and fetal neuronal stem cells subcutaneously into the lymph nodes. The program claims that these cells will migrate to the location where they are needed and also release function-restoring growth factors. The program states that the key advantage of using fetal stem cells over, for example, bone-marrow stem cells is that the undifferentiated nature of the former minimizes immunological rejection. This claim, however, ignores the fact that a number of emerging SCI-related stem-cell programs (see above) use autologous stem cells (i.e., isolated from the patient) which are even more immunologically compatible than fetal cells. When contacted several times by the author of this report, the company did not respond.

EUROPE

1) Dr. Eva Sykova and colleagues (Prague, Czech Republic) have implanted autologous, bone-marrow stem cells harvested from the iliac bone (i.e., pelvis) into 20 patients. Eight were subacute, receiving treatment within 10-33 days of injury; and 12 were defined as chronic, receiving treatment 2-18 months after injury. Soon after harvesting, about 150-million cells cells were reintroduced into the patient through the vertebral artery or intravenously. With the subacute patients, four were treated by each route; with the chronic patients, two and 10 received cells via the artery and intravenous route, respectively.

Patients were assessed periodically by various electrophysiological measurements and ASIA-impairment scales. Improvements were noted in 1) all subacute patients receiving the cells via the vertebral artery but only one receiving the cells intravenously, and 2) one of the two chronic patients receiving the cells via the vertebral artery. Of the patients who improved their ASIA grades, most advanced from grade A to B, and one from grade B to D (i.e., scale ranging from A, most paralyzed, to E, complete recovery). Although Sykova is cautious in over-interpreting these preliminary results, she believes more benefits accrued when the treatment was done sooner after injury and using the vertebral artery route, which introduces cells closer to the injury site.

In a 2009 update, the number of patients treated by these procedures had grown to 36.

2) Dr. Cornelis Kleinbloesem created a stem-cell oriented company Cells4Health with headquarters in Netherlands but using Turkish surgeons and facilities. The C4H program collected bone-marrow cells from the patient through a puncture in the iliac crest bone (pelvis) in which a large quantity of bone marrow is concentrated. The isolated stem and other bone-marrow cells were processed through a proprietary process.

The cells were then injected into the patient’s spinal cord at the lesion area through 20-40 microinjections. Cumulatively, about two-milliliters of the stem-cell preparation, corresponding to about 10-20 million cells, were injected above, below, and around the injury site using an insulin needle. In some later cases, cells were also intrathecally (into the spinal canal) or intravenously injected.

At least 18 patients with SCI had been treated under this C4H program. Of the first nine patients with chronic SCI treated, eight reportedly had positive results. In three of the first four treated in February, 2005, MRI imaging indicated that the lesion size was reduced by half three months after surgery, data suggesting the creation of new neural cells and supporting structure.

Reportedly, cell transplantation restored some function and sensation in three of these four initial patients. Two to three months after transplantation, the first patient, who sustained a T6-complete injury four years earlier from a car accident, reportedly recovered function to the T12- L1 level and was able to move legs, walk a few steps using a walker, and stand. The second patient, who had sustained a complete cervical-level C5-6 injury seven months earlier, a month and half after surgery was said to be able to move legs and fingers and feel toes, and regained rectal and bladder sensation. Several months after transplantation, the third patient, who sustained a complete C5-6 injury nine months earlier from a surgical complication, reportedly regained his ability to stand, ambulate using a walker with leg braces, and write. Also, his sensation returned to near normal, and he regained rectal control. The fourth patient accrued no benefit, perhaps because his spinal cord turned out to be transected not compressed.

Many of the results were reported by C4H. Independent sources have portrayed a less promising picture with many patients not gaining and some even losing function.

More recently, Kleinbloesem and colleagues have created the XCell-Center located in Germany, which appears to carry out many similar procedures for a variety of disorders including SCI. Specifically, stem-cell-rich bone marrow is obtained from the patient’s hip bone, the stem cells are processed from this marrow, and transplanted back into the patient’s injured cord after exposure by a surgical laminectomy or through a less invasive lumbar puncture into the spinal fluid. The program claims a 60% success rate in restoring some function.

According to Xcell-Center follow-up data of 162 patients with SCI (March 2010), ~57% reported improvements after stem cells were transplanted by lumbar puncture. Of these patients, ~38%, 36 %, and 30% reported improved bladder, bowel, and sexual function, respectively; and 53% and 51% reported decreased neurogenic pain and muscle spasticity, respectively. In the 46 patients who completed pre- and post-treatment ASIA motor and sensory examinations, the average motor score increased by six points and the average sensory score by 11 points.

In April 2011, Xcell Center ceased operations in response to changes in German regulatory policy on stem cells. Kleinbloesem has now relocated operations to Lebanon.

3) Dr. Venceslav Bussarsky et al (Bulgaria) have treated 115 patients with chronic SCI with autologous stem cells and growth factors isolated from the patient’s bone marrow. Patient age ranged from 18 to 65 (average 43) years. Approximately, 40-million cells were intrathecally infused into the space surrounding the spinal cord, a procedure repeated nine months later. Various MRI, neurological, and psychological tests were done before and three months after each treatment. Although the study lacked a control group for comparison, improvements in sensory and motor function was noted in 105 patients.

4)Dr. Robert Trossel (Netherlands) has treated individuals with SCI with umbilical stem cells. Although specifics are scanty, one press report briefly described Trossel’s treatment of a woman with a high-level injury. In this case, 1.5-million stem cells were intravenously injected at the base of her skull where she was injured and at five other locations down each side of her neck. Trossel’s therapy has generated controversy.

5) Dr. Armin Curt (Switzerland) has initiated a phase I/II clinical trial transplanting human central nervous system stem cells into individuals with complete and incomplete thoracic injuries who became injured three to twelve months earlier. Although taking place in Switzerland, the trial it is being sponsored and the stem cells provided by StemCells, Inc headquartered in California, USA. The trial will use stem cells derived from aborted fetuses. Unlike embryonic stem cells, these cells have already differentiated into central nervous system cells. Preliminary results reported at the 2012 meeting of the International Spinal Cord Society indicated that two of the first three study subjects had regained some sensation below the level of their injuries.

RUSSIA

1) Dr. Andrey Bryukhovetskiy (Moscow, Russia), former director of the Russian Navy’s Neurology Department, has transplanted both embryonic/fetal stem cells and autologous (i.e., from the patient) adult stem cells into patients with chronic SCI. In addition in some patients, Bryukhovetskiy has transplanted autologous olfactory ensheathing cells (OECs) using procedures developed by England’s Dr. Geoffrey Raisman. Although not technically stem cells, as discussed above, OECs have considerable regeneration potential and have been the focus of much attention in the SCI research community.

Bryukhovetsiy no longer uses embryonic/fetal stem cells due to the ethical controversy surrounding their use, their rejection potential, and, most importantly, his belief that autologous, adult stem cells are more effective.

Basically, Bryukhovetskiy's transplantation procedures can be categorized as follows:

Embryonic Cells: In 1996, the Russian Health Ministry authorized Bryukhovetskiy to carry out limited clinical trials in SCI. In these early trials, stem cells, neurons, and glia obtained from a various tissues, including 12-week-old human fetuses, were transplanted into the spinal cord/fluid of 17 patients with SCI. Their ages ranged from 16-52 (average 30) years, and the time interval between injury and transplantation ranged from 1-20 (average 5) years. Six, ten, and one had cervical, thoracic, and lumbar injuries respectively. In addition to cell transplantation, all had a variety of other procedures performed depending upon their unique injuries.

Before treatment, 14 subjects were ASIA grade A and three were grade B. After transplantation (0.5 - 3-year follow-up period), four were grade A, five grade B, and seven grade C. Fifteen had some sensory improvement, seven had motor improvement, and 12 had improved bladder function.

SpheroGel & Autologous Cells: Bryukhovetskiy’s team has implanted SpheroGel (a biodegradable polymer matrix) with embedded cells in six patients who required reconstructive surgeries. In three, hematopoietic stem cells were embedded, and, in the three others, olfactory cells. At follow-up (3-8 months), two grade-A patients had improved to grade C, and one had advanced to grade B. In one patient (grade B initially), there was no improvement.

Intrathecal Stem-Cell Transfusion: The intrathecal transfusion of autologous hematopoietic stem cells is the procedure most currently used. Basically, in this relatively straight-forward procedure involving no surgery, the patient’s stem cells are collected without anesthesia and stored with viability until they are transfused back into the patient.

To stimulate hematopoietic stem-cell production and, in turn, cell accumulation in the blood, patients typically received eight subcutaneous injections over four days of granulocytic colony-stimulating factor, a drug also called Neupogen^® or Filgrastim. On day five, the patient is hooked up to a blood separator. Over 3-4 hours, blood is drawn from a vein, processed by the separator, which isolates the stems cells, and returned through another vein.

The collected stem cells are concentrated by centrifugation and slowly frozen in liquid nitrogen (-170^o centigrade) in the presence of dimethyl sulfoxide (DMSO), a cryopreservative that allows cells to be frozen with minimal damage. Care is taken to check for infections so that they will not be later introduced behind the protective blood-brain barrier during transfusion.

At the time of transfusion, the stem-cell suspension is thawed and about 5.3-million cells injected intrathecally into the subarachnoid space (i.e., into the spinal fluid) through a L3-L4 lumbar puncture using a local anesthetic (photo). The procedure, which I observed, is quick and straightforward. The patient can repeat the transfusion in two months. Bryukhovetskiy believes multiple transfusions enhance functional recovery.

In contrast to hematopoietic stem cells, positive results have been limited with the intrathecal transfusion of olfactory cells, previously isolated and cultured from the patient’s nasal tissue.

Although Bryukhovetskiy’s team has collected stem cells from about 120 patients, for a variety of reasons, including the presence of latent infections, only about 60 have had cells reintroduced. Of these 60, 18 have had the recommended multiple transfusions. In turn, 61% of the 18 showed some functional recovery, in some cases dramatic.

Because most patients’ transfusions were relatively recent at the time of this report, it is too early to assess long-term benefit. Early improvements are unlikely caused by comparatively slow neuronal regeneration or remyelination processes and are probably triggered by altering the injury site’s environment through the secretion of growth factors and other molecules.

Bryukhovetskiy hypothesizes that the stem-cells’ regenerative effects are mediated through an important growth factor called ciliary neurotrophic factor (CNTF) and its interaction with a key transmembrane receptor called gp130. This interaction, in turn, influences cell differentiation.

In 2012, Dr. Bryukhovetskiy reported the electrophysiological outcomes of treating 20 individuals with injuries at the cervical C4-8 level with autologous (i.e., from the patient) hematopoietic stem cells. These hematopoietic stem cells have the potential to differentiate into myelin-producing cells which, in turn, have the capability to replace the insulating myelin that is often lost in injury-damaged neurons.

Of the 20 patients, 15 were men and 5 were women; age ranged from 18 to 55 (average 32) years; and the time lapsing since injury varied from 1 to 9 (average 3) years. Patient stem cells were obtained as described above. Specifically, after several days of dosing with a stem-cell-stimulating drug, stem cells were isolated from the patient’s blood and frozen until it was ready to transfuse them back into the patient. The cells were injected intrathecally into the spinal fluid (i.e., lumbar puncture) twice over an 8-day period. After 3-5 months, the next two stem-cell doses were given, and the cycle repeated. The duration of treatment varied from 1.5 to 2.5 years.

Periodically, electrophysiological measurements were performed on the patients, including somatosensory and motor evoked potentials (defined in appendix). Basically, these measurements assessed the amount of signal getting through the injured spinal cord. More conduction after stem-cell therapy would suggest some restoration of neuronal function. Indeed, the results indicated that many of the patients accrued some improvement in conduction after treatment.

2) Dr. Samuil Rabinovich and colleagues (Novosibirsk, Russia) have transplanted various combinations of fetal OECs, cells from nervous and hematopoietic tissues, and spinal cord fragments into the injury site of 15 patients (Biomed Pharmacother 57(9), 2003). Ranging in age from 18 to 52, patients were one-month to six-years post injury and had complete, Frankel grade-A injuries (Frankel classification evolved into today’s ASIA scale). Each patient received one to four cell transplantations at various times, and was followed at least 1.5 years. Improvements were noted in 11 of 15 patients. Six improved to grade-C, incomplete level, and five were able to walk with crutches. In general, patients who had the transplantations sooner after injury accrued the most benefit.

According to an updating report posted on the investigators’ website www.transplantation.ru, 122 patients have been treated with a procedure in which the injury site is filled with a gel containing fetal stem cells. The initial transplantation is followed later by one or more additional transplantations of the cells underneath the spinal-cord membrane (i.e., subarachnoid). The time between injury and surgical transplantation ranged from several months to five years.

The outcomes for these patients are reported in the table below. As can be seen, many patients regained some function, although some were treated in a period after injury in which additional functional recovery is not uncommon.

Neurological status in terms of ASIA definition before transplantation	Neurological status after transplantation
	A	B	C	D
A (73 patients)	31%	48%	18%	3%
B (49 patients)	-	78%	22%	-

In 2010, Dr. Rabinovich and colleagues reported the long-term recovery results of fetal cell transplantation in 43 patients with SCI. Of these patients, 11 were men and 32 were women; and 22, 12, and 9 had cervical, upper thoracic, and lower thoracic/lumbar injuries, respectively. Three patients were less than 20 years old, 23 were 20-29 years old, 13 were 30-39 years old, and 4 were older than 40. The time from injury to transplantation was two to five years in 37 patients (also 3 < 1 year; 3 > 5 years).

The transplanted fetal cells were isolated from the brain and liver of 16-22-week aborted fetuses and were composed of both fetal nervous and hematopoietic (see glossary) cells. These cells were repeatedly transplanted into the patient’s cerebrospinal fluid by lumbar puncture. In spite of the concerns surrounding the use of fetal cells for transplantation, these investigators actually believe that their use has advantages over autologous cells (i.e., isolated from the patient) because these fetal cells contain “the whole spectrum of brain cells at different stages of differentiation…with high growth potential capable of integrating into the neuronal networks of recipient."

Improvements were primarily measured using the FIM scale (Functional Independence Measure), which evaluates everyday functional independence. Using this assessment, 49% of patients who were followed for at least three years reported improvements. Greater benefits were observed in patients receiving cell transplantation within the first two years after injury and in younger recipients.

3) Dr. Helena Chernykh and colleagues (Russia) transplanted autologous bone-marrow stem cells into the spinal cord of 18 patients with SCI undergoing a surgery to treat cystic development in the cord. Isolated from the patient’s bone marrow the day before the surgery, a portion of the stem cells were injected into the cystic cavity during surgery and the rest infused intravenously. These patients were compared to 18 control patients with SCI, who received the surgery only. Changes in motor function, sensation, ability to carry out “activities of daily living,” and spasticity were evaluated on average 9 months after surgery. Significant improvements were noted in 12 of the 18 stem-cell-treated patients but only 5 of the 18 controls.

ASIA - CHINA, KOREA, & JAPAN

1) Dr. K-S Kang et al. (South Korea) injected stems cells isolated from umbilical cord blood (UCB) into the injury area of a 37-year old woman who had sustained a T-10 complete injury 19 years earlier from a fall (Cytotherapy, 7(4), 2005). Unlike their embryonic counterparts, umbilical stem cells are not controversial. They also have less rejection potential than most other allogeneic donor tissue except embryonic tissue; i.e., some, but not strict, matching between donor and recipient is needed.

In this case, human UCB was obtained from the Seoul Cord Blood Bank, and the UCB cells isolated within 24 hours and, in turn, cultured in media. The investigators indicated that when grown in a neurogenic medium, the cells demonstrated features characteristic of neurons and neuronal support cells (i.e., glia).

With this patient, after a laminectomy, one milliliter containing one-million cells was injected “into the subarachinoid space of the most distal part of the normal spinal cord.” An additional one million stem cells were injected “diffusely into the intradural and extradural space of the injured cord.”

The investigators reported that the patient regained additional lower-limb function within 41 days of the transplantation, including, according to other press reports, some walker-assisted ambulatory ability. Various electrophysiological measurements supported these observations. The investigators suspected that injecting the cells directly into the spinal cord is more effective than infusing them into the fluid surrounding the cord. They do not exclude the possibility that functional improvement was due to laminectomy-related, spinal-cord decompression.

Unfortunately, according to more recent press reports, after her a second stem-cell treatment, her condition greatly deteriorated. She is now unable to sit erect for long time periods and spends most of her day in bed. According to her, “the improvements disappeared quickly. I underwent another treatment, and this is the result. I was unable to move and suffered from extreme pain.”

Doctors suggested she contracted an infection the second time due to either procedural aspects or bacterial contamination of the transplanted cells. As a result, the surrounding tissues have hardened.

2) Dr. Yoon Ha et al (South Korea) has transplanted bone-marrow cells (BMCs) into the injury site of patients with acute SCI (7-14 days post injury) in conjunction with granulocyte macrophage-colony stimulating factor (GMCSF), a factor that stimulates stem-cell production. The bone-marrow cells were aspirated from the patients’ iliac (i.e., hip) bone and further processed. Because these autologous cells are isolated from the patient, there is no rejection potential. After a laminectomy from one vertebra above to one below the contusion site, a total of 1.8 milliliters of bone-marrow cell paste were injected into six points near the injury site.

All patients were men, ranging in age from 17 to 51 years. Five and one had cervical and thoracic injuries, respectively, and all had ASIA-A complete injuries. Five received both bone-marrow cells and GMCSF, and one received only GMCSF.

GMCSF was subcutaneously injected for first five days of each month over five months. In addition to stimulating bone-marrow stem-cell proliferation, animal models suggest that it may also 1) activate macrophages (immune cells) to remove myelin debris that inhibit axonal regeneration, and 2) inhibit post-injury cell death through a process called apoptosis.

Although sensory improvements were noticed immediately after the procedure, sacral-region sensory recovery and significant motor improvements were observed three weeks to seven months afterwards. Four patients, including the one that received only GMCSF, improved from ASIA-A complete to ASIA-C incomplete injuries, one from ASIA-A to B, and one remained at ASIA-A. MRI assessments 4-6 months after injury showed slight enhancement.

Other than GMCSF-associated fever, the investigators concluded that this BMC-transplantation procedure has no serious complications, the study’s goal. Because this intervention and follow-up assessments were performed during a period relatively soon after injury in which some functional improvement is not uncommon, the investigators were careful to avoid conclusions concerning overall efficacy; however, they did quote studies indicating that only a relatively small number (~6%) of patients improve from ASIA-A complete to ASIA-B incomplete injuries.

3) Dr. Yongfu Zhang and colleagues (China) have transplanted autologous (i.e., isolated from the patient) bone-marrow stem cells into 90 patients with both acute and chronic SCI (1^st International SCI Treatments & Trials Symposium, Hong Kong, December 2005). Of these patients, 10 had cervical injuries, 62 thoracic injuries, and 18 lumbar injuries. The elapsed time from injury ranged from three days to six years. “The injection site was in the upper and lower area between injury and normal spinal cord.”

Thirty-three and 11 patients had improved sensory and muscular ability, respectively after cell transplantation as measured by Frankel assessments (which evolved into today’s ASIA standards). All patients with clinical improvements sustained their injuries within a year of the transplantation procedure. Treatment sooner after injury was associated with better outcomes. The investigators suggested that the bone-marrow stem cells improved blood circulation and inhibited glial scar formation at the injury site.

4) In 2008, Dr. Fukuki Saito et al (Japan) reported the treatment of an acutely injured patient with autologous, bone-marrow stem cells. A 35-year-old male, the patient sustained a cervical C4-5 complete injury from a fall at a construction site. Three days after injury, stem-cell-containing, bone-marrow tissue was collected from the patient’s ilium (i.e., pelvis’ largest bone), and the stem cells grown and amplified in culture for 10 days. Thirteen days after injury, 31-million stem cells suspend in about two milliliters of saline were transplanted into the cerebrospinal fluid via lumbar puncture. Motor and sensory improvements were noted one and three months after transplantation. Afterwards, little further improvement was observed. Because some improvement is not uncommon in this post-injury phase, it is difficult to ascertain how much of the restored function is attributable to the stem cells and how much would have accrued anyway.

In 2012, Saito’s investigative team reported safety and feasibility results of treating five patients with cervical injuries with autologous bone-marrow-derived stem cells. The patients were all men with age ranging from 23 to 59 years. Four sustained injuries from falls and one from a traffic accident. Bone marrow was isolated from the iliac crest within 72 hours of injury at the time when the patients were undergoing surgery for spinal stabilization, a procedure which required the isolation of an iliac bone segment. Stem cells were isolated from the bone marrow and cultured. The cells were intrathecally transplanted back into the patient by lumbar puncture within three weeks of injury. Patients were followed for one to four years. During this period, no adverse responses due to cell transplantation were observed. The investigators concluded the procedure was safe. Although it is difficult to attribute to the transplantation procedure due to the nature of the study, significant functional recovery was observed in several patients.

5) Beike Biotechnology Company (China) was founded in 2005 with funding from Beijing University, Hong Kong University of Science and Technology, and Shenzhen City (near Hong Kong), and nurtured with Chinese government grants. The company has established collaborations with 60+ scientists at leading Chinese universities. Building upon a base of research starting a decade ago, Beike-affiliated doctors treated their first patient in 2001; and in several years, had treated hundreds with a variety of disorders. As confidence grew, they established Beike to treat patients with stem cells on a commercial scale.

By the end of 2008, they had treated ~3,900 patients at about 30 clinics in China and one in Thailand, about 800 of which came from 35 other countries. Over a third of the patients had spinal-cord dysfunction, including SCI (1176), MS (103), and ALS (194); and 77 had traumatic brain injury.

Technically, however, Beike does not treat patients. Through their 18 laboratories located throughout China, the company provides stem cells to collaborating hospitals. It is the hospitals who have been granted the authority from the China Ministry of Health to treat patients in Beike-established clinics. Although many Chinese hospitals provide stem-cell therapy, Beike is the country’s largest stem-cell source. To make the therapy more internationally accessible, Beike will be establishing laboratories and treatment centers in India, Europe, Middle East, and either Panama or Mexico.

Beike transplants a variety of stem cells by different routes. Frequently, the company uses umbilical cord stem cells, in part, because cord blood is commonly collected after birth by Chinese blood banks. Beike also transplants stem-cells obtained from the patient’s bone marrow. Cells are usually transplanted either intravenously or by lumbar puncture, the latter which introduces the cells directly into the CNS. Occasionally, cells have been implanted directly into the spinal cord.

After testing for diseases, the cord blood is transferred from the blood bank to a Beike laboratory and retested. Stem cells are separated from blood cells and platelets through centrifugation and then cultured in a media containing growth factors, which enhance rejuvenation potential. The growth media is washed away, leaving the desired stem cells. To ensure viability, all stem-cell preparations are fresh and not frozen for later use.

Typically, patients receive 4-7 stem-cell injections over a 25-35 day period. This treatment regimen is supplemented with individually tailored, rehabilitation programs.

Many Beike-treated patients with SCI have regained life-enhancing benefits, ranging from the subtle to fairly dramatic. Although improvements with some disorders may fade over time, SCI gains seem to be enduring. Consistent with more long-term physiological mechanisms, benefits often slowly kick-in after stem-cell treatment and returning home.

In general, Beike prefers treating individuals with incomplete injuries. According to Beike founder Dr. Sean Hu: “Spinal cord injuries are very interesting as they seem to go against the earlier-is-better rule. We have found that some of our best cases have been the patients who have had injuries for over 20 years…We have discovered a better response in these patients compared to those with an injury sooner than six months. As a result… we generally do not allow the hospitals to accept patients whose injuries have happened in the last six months.”

Study: Beike scientists have evaluated the effects of treating 500 patients with umbilical-cord-blood stem cells (465 completed the study). Patients were 18-65 years old, 78% were men, and all had been injured 1-10 years before treatment (C4-T10 injuries). Patients received 4-5 intrathecal injections containing 10-30 million stem cells at one-week intervals and followed for a year using several evaluation parameters, including commonly used ASIA assessments (American Spinal Injury Association) for motor function and sensation. Statistically significant, modest improvements were documented which continued after the final injection. No serious side effects observed.

Many patient experiences are posted at www.stemcellschina.com, including before-and-after-video documentation, including the following case. The patient was a 30-year-old Romanian male, who sustained a C5-6 incomplete injury in 1995 from a diving accident. After three sets of stem-cell injections, he posted the following [English edited]:

“My hand movements are much better. I have more power in my hands and body, and new sensations all the way down to my feet, almost 90% … I feel my hands 100% now.”

“I’ve started to move my fingers a little and can feel pain in my first two fingers. I also can feel a lot of heat in my legs, and…can move my feet, but only 1-2 times. Now, I can contract my stomach muscles. I can stay on my feet 30-50 minutes, but with assistance and support on my knees. I have more stability than before, and when I’m on my feet I can move my hands and body more because my abdominal and back muscles are stronger.”

When lying in bed, I can move my feet a little … I can hold my urine for 5-10 minutes before I have to go. My sensation is much improved; I can feel better my legs and all my body for temperature, as well as pain and touch (skin) sensation…My stability is much better than before, I can sit on the bed without support, and if my mother pushes my legs forward, I can move them back. So, now I have started to move my legs; even if it is a little, it’s a start. My triceps have started to work too.”

6) Doctors at Tiantan Puhua Hospital, Beijing, China have established a stem-cell center for treating a variety of neurological disorders, including SCI. Stem cells from various sources have been transplanted into the patients via a number of routes. The center’s program has also incorporated a “self stem-cell activation and proliferation” component in which an individually customized cocktail of “neurotrophic medicine” is intravenously administered daily to the patient. It is claimed that this cocktail stimulates the patient’s own stem cells to differentiate into nerve precursor cells and migrate to where they are needed. The treatment experiences of several patients are posted on the center’s website www.stemcellspuhua.com.

The center has reported transplanting bone-marrow-derived stem cells into patients with SCI, five with chronic injuries sustained at least a year before treatment. Because the cells are isolated from the patient’s own bone marrow (i.e.,autologous), they will not be immunologically rejected when transplanted back into the patient. Considering the injury-site “glial” scar as a barrier to regenerating neurons, the doctors ablate (remove) the scar by “medicine” before the cells are transplanted. The cells are grown and amplified in culture for about 3-4 weeks to obtain about 4,000,000 cells, which are then transplanted back into the patient in 3-4 injections spaced two weeks a part. The cells are either implanted into the patient’s spinal cord fluid by lumbar puncture or surgically implanted directly into the injured cord.

7) As discussed elsewhere, a network of Chinese SCI centers have been established to carry out clinical trials on promising therapies. Initial network studies focus on the use of lithium and umbilical-cord-blood-derived stem cells (see “Pharmaceutical Approaches”). These two approaches are being considered together because evidence suggests that lithium stimulates these cells to proliferate and to generate beneficial neuronal growth factors.

After evaluating lithium’s safety in individuals with SCI, a phase-2 trial was initiated assessing the effects of implanting increasing amounts of umbilical-cord-blood-derived stem cells into the cord above and below the injury site in individuals with chronic SCI combined with lithium treatment. Finally, in a phase-3 trial, the investigators intend to implant the stem cells into 400 subjects randomized to receive either placebo or lithium for six weeks. Similar studies are being planned in the United States and India.

ASIA - INDIA & OTHER

1) Dr. Geeta Shroff (New Delhi, India) has used human embryonic stem cells (ESC) to treat over 300 patients, including 70 with SCI. Impressive results have accrued, and especially important given the theoretical risks of ESC, no adverse side effects have occurred.

All cells that have been transplanted into the many patients numerous times were derived from a single, surplus fertilized egg from Shroff’s in-vitro-fertilization (IVF) program. Developed with donor permission, this fertilized egg would have been disposed of under normal circumstances. Clearly, Shroff’s success was facilitated by her extensive experience working with embryonic cells as a fertility doctor. Her 70% success-rate in making women pregnant through IVF is quite high compared with most other programs. Apparently, the skills she acquired in developing healthy embryos translated well into the creation of robustly therapeutic stem cells. Her cells are prepared with “Good Manufacturing Practice (GMP)” and “Good Laboratory Practice (GLP)” quality-control standards.

Shroff’s key breakthrough is that she has grown ESC without using any animal products, including animal feeder cells often used by other researchers. By keeping the cells purely “human” in nature, she makes them more amenable to transplantation. The cells from her “mother culture” are further adapted or primed to create daughter cultures targeting specific disorders. Hence, a more specialized cell line will be used to treat individuals with SCI, stroke, diabetes, etc. According to Shroff, the transplanted cells will home into the tissue where they are needed. Thus, even when introduced by more remote intravenous or intramuscular routes, the cells’ physiological affinity for the target tissue will cause them to migrate where they are needed.

Shroff’s ESC use is allowed under Indian stem-cell guidelines if the condition or disorder is considered incurable. Given the snail-pace development of real-world stem-cell therapies in many countries, these are insightful guidelines.

Countering criticism she’s using the vulnerable and disadvantaged as guinea pigs, Shroff notes that 30% of her patients are physicians or have family members who are physicians. In other words, highly educated medical professionals who appreciate underlying issues have chosen to avail themselves of the treatment. In addition, a number of senior government officials have been treated and, based on their comments to me, are delighted with the benefits. Documenting interest in her program at the highest levels, Shroff has briefed the Indian President and Prime Minister. Finally, showing that her program is more than just a profit-making venture, many of her indigent patients have been treated without charge.

Shroff has treated over 100 persons with SCI. Although she believes that treatment would be optimal when started close to injury, most of her patients have been injured for at least a year. Basically, she decided not to treat the more acutely injured patients because critics would dismiss improvements as something that would have occurred anyway during a period in which functional gain is not uncommon.

Patients often visit the clinic several times for a series of transplantations. The cells are introduced through a variety of routes, including intravenous or intramuscularly injections, and more infrequent intrathecal transplantations directly into the spinal-cord region. The number of transplanted cells increases over time. All patients are carefully followed to document progress.

One of Shroff’s more well-known patients was Ajit Jogi, a 60-year-old Indian parliament member and former chief minister of an Indian state, who sustained a cervical injury from a 2004 auto accident. After injury, Jogi was unable to sit up and had difficulty breathing and even writing. Since treatment, he can walk about 10 steps with braces, has regained significant bowel and bladder function, has full sensation down to his toes, and, with the renewed, very-evident energy has resumed a politician’s busy life style.

2) Dr. Satish Totey and colleagues (India) initiated a pilot study evaluating the effectiveness of transplanting bone-marrow-derived, mesenchymal stem cells isolated from the patient (i.e., autologous) back into the patient. The cells were extracted from the hip bone and cultured several weeks before being transplanted back into the patient. Twenty-two subjects with complete (ASIA A), C4-T10 injuries sustained within the previous half year were to be recruited into the study. Approximately, one-million stem cells per kilogram of body weight were injected by relatively non-invasive lumbar puncture into the spinal-cord fluid. To evaluate potential improvements or changes, various electrophysiological, imaging, and clinical assessments were carried out before and three months after transplantation.

At the time this information was collected, 12 subjects had been recruited, of whom one had completed the three-month assessments. This individual, a 32-year-old male, initially received two stem-cell transplantations nearly two weeks apart. In addition to improvements noted by various electrophysiological assessments, the patient reported improved bowel-and-bladder function; increased sensation; improved muscle function and strength, including some ambulation and toe wiggling, and overall enhanced strength.

In 2009, Dr. Totey and his associates reported the results of treating 30 patients with SCI with autologous, bone-marrow-derived mesenchymal stem cells. All but three of the patients were men, and age ranged from 21 to 56 years. Twenty had injuries of between one-month and six-months duration, and 10 had injuries of greater than six-months duration. Bone marrow was isolated from the iliac crest of the pelvis bone and processed in culture to obtain the stem cells. The cells were intrathecally reintroduced into the patient by lumbar puncture.

Patients were evaluated using a variety of assessments, including the ASIA scale (see appendix), a measurement of patient independence and quality of life, and electrophysiological tests for nerve conduction. At the time of publication, 3, 10, and 10 patients had completed three years, two years, and one year of follow-up, respectively. Five patients were lost to follow-up.

The results indicated that the procedure caused no serious adverse effects. According to the investigators, two patients “showed significant clinical and functional recovery… and the rest of the patients have shown variable patterns of recovery,” including bladder function. One year after transplantation, improvements were noted in patient independence for those with thoracic injuries who had been injured for less than six months at the time of transplantation. However, no such change was noted for those with cervical injuries and those who had been injured more than six months at transplantation.

3) Dr. R. Ravi Kumar and colleagues (India) have transplanted autologous (i.e., obtained from the patient) stem cells into over 120 patients with SCI. Stem-cell preparation was done in association with the Nichi-In Center for Regenerative Medicine, a Japanese laboratory located in India that specializes in the preparation of autologous - no-rejection - stem cells. Stem cells were extracted from 100 ml of bone marrow obtained from the patient. The concentrated preparation, containing about 2-4 million cells, was injected into the lumbar spinal fluid (i.e., intrathecal).

According to presentations at 2007 stem-cell meetings, 120 patients who received stem cells in this fashion were followed for six months. Of these patients, 85 were male and 35 female; age ranged from 8-55 years; and time lapsing from injury varied from three months to 11 years. Nine patients had cervical injuries, 38 upper thoracic (T1-T7) injuries, 60 lower thoracic (T7-T12), and 12 lumbar injuries.

Six months after transplantation, 12 and 8 patients improved at least two or one grade(s) of motor power, respectively (greater improvement noted for lower-level injuries); three could walk independently; 14 had sensory improvement or pain reduction; and 18 had improved bladder control. No significant adverse side effects were noted.

In 2009, the investigators reported the results of treating 297 patients with autologous, bone-marrow-derived stem cells obtained from the patient’s iliac crest of the pelvis (8). Of these patients, 215 had traumatic paraplegia, 49 had traumatic quadriplegia, and 33 had various other forms of spinal cord dysfunction. The isolated cells were transplanted back into the patient through a lumbar puncture (i.e., into the cerebrospinal fluid). The patients were followed in three-month intervals for cumulative periods ranging from 18.4 to 20.5 months. The investigators concluded that the transplantation of autologous, bone-marrow-derived cells through a lumbar puncture is safe, and that one third of the patients had “perceptible improvements in neurological status.” Improvements appeared to be greater for more recently injured individuals.

4) Dr. Adeeb Al-Zoubi and colleagues (Jordan) reported their experience transplanting purified stem cells into eight patients (6 males and 2 females) with complete thoracic level injuries. The stem cells were isolated from the blood of the patient (i.e., autologous) after treatment with granulocytic-colony-stimulating factor, a drug that promotes stem-cell production. On average, 51-million stem cells were implanted into the injury site’s cyst cavity or subarachinoid space (a space between the spinal-cord membranes filled with cerebrospinal fluid). After nine months of patient follow up, no adverse side effects were observed. Four patients demonstrated sensory improvement and two motor-function improvement.

In 2010, Al-Zoubi discussed the results of transplanting bone-marrow-derived, purified stem cells into ~50 patients with SCI. Isolated from the patient’s bone marrow – not the blood as above - these cells were reintroduced into the patient’s spinal cord. Although some improvements were noted, he believed the results to be “suboptimal.” As such, Al-Zoubi is researching ways to better prepare, process, and differentiate these and other bone-marrow-derived cells into more neurologically oriented stem cells with, in turn, a greater potential to treat SCI.

5) Dr. Haluk Deda and colleagues (Turkey) have transplanted autologous, bone-marrow-derived stem cells into nine patients (5 males and 4 females) with ASIA-A complete injuries. Age ranged from 17 to 40 years, and the time lapsing from injury varied from two to 17 years. Six and three patients had cervical and thoracic injuries, respectively. Approximately 100-150 milliliters of stem-cell-endowed bone marrow was aspirated from the pelvis’ iliac crest, sent to a company in Michigan for stem-cell processing and purification, and returned to the hospital for implantation. The injured spinal cord was exposed by a laminectomy and carefully cutting of the covering membranes. Any bone fragments and adhesions around the injury area were removed. Stem cells were implanted by several mechanisms, including: 1) multiple injections directly into the cord at different depths, 2) covering the exposed cord by a stem-cell-containing gel foam, 3) injection into the subarachnoid space (i.e., the space that contains cerebrospinal fluid) after membrane closure, and 4) intravenous injection. Functional improvements were noted in all patients as early as three weeks after the procedure. A year after transplantation, seven of the nine patients had improved from ASIA-A complete injuries to ASIA-C incomplete injuries (i.e., regaining some motor and sensory function), and two had improve to ASIA-B incomplete injuries (i.e., some sensory recovery).

6) Dr. Himanshu Bansal (India) has used several procedures in an effort to restore some post-injury function, including, as discussed here, stem-cell transplantation and, as reviewed later, omental transposition. In preliminary investigations, Bansal has transplanted bone-marrow-derived stem cells into 11 patients with motor-sensory complete injuries (i.e., ASIA-A) sustained at least a year earlier from contusion or laceration. Nine possessed cervical injuries and two thoracic injuries, and all except one were men. Although most were younger than 30, age ranged from 20 to 52.

The stem cells were obtained by aspirating ~120 milliliters of bone marrow from the patient’s iliac crest, a bone-marrow abundant area of the pelvis bone, and then obtaining a stem-cell rich concentrate by centrifugation. To maintain their fundamental nature, as well as the presence of regenerative-enhancing growth factors, no further physical, chemical, or biological processing of the cells was carried out before transplantation.

In some patients, cells were directly injected into the area around the spinal-cord injury site and, in other cases, into the cord’s surrounding intrathecal space. Although the post-transplantation follow-up time period has been limited, results suggest that some improvement accrued for the six patients who had cells directly implanted into their injured cords. Bansal noted that two of them “had a 100% improvement in bladder control, one had good improvement in motor scores, and one had improved coordination and walking ability with sensory improvement.” With higher level injuries, he observed recovery of trunk control and decreases in spasticity. Because the five patients who received stem cells intrathecally had little improvement, Bansal no longer uses this route of administration. He believes post-transplantation aggressive physical rehabilitation is especially important in promoting the development of function-restoring nervous-system connections.

7) Dr. Sunil Waghmare and colleagues at the Spectrum Cell Clinic (India) have used either umbilical-cord-blood or autologous bone-marrow stem cells to treat a wide variety of disorders, including SCI. In the case of SCI, the cells have been implanted into patients by several routes, including 1) via a blood vessel that supplies the front area of the spinal cord (anterior spinal artery), 2) intrathecally into the space surrounding the cord, and 3) directly into the injury-site area. In general, the clinic prefers employing less invasive techniques using local anesthesia

At the time of this report, the clinic had treated about 30 individuals with varying degrees of injury completeness as determined by the commonly used ASIA impairment scale (see appendix). Waghmare notes that in the case of incomplete injuries, the therapeutic response is ~75-80% with improvement of more than two grades on the ASIA scale. With complete injuries, treatment often results in a one-grade improvement. In an anecdotal case described on the clinic’s website, a 42-year-old male, who had sustained a C5-6 incomplete injury 13 years earlier, reported significant functional improvements after three stem-cell treatments, including 1) regaining bowel and bladder control, 2) increasing muscle bulk and coordination, and 3) a lessening of spasticity.

8) Dr. Alok Sharma and associates at the NeuroGen Brain and Spine Institute (India) have transplanted bone-marrow-derived, autologous (i.e., from the patient stem cells into many individuals with diverse neurological disorders, including SCI. Routinely, several days after treatment with a drug that stimulates stem-cell production, bone marrow is aspirated from patient’s iliac crest bone of the pelvis area. The stem cells are then separated from the bone marrow and stem cells intrathecally transplanted back into the space surrounding the patient’s spinal cord. To maximize post-transplantation functional return after transplantation, patients are encouraged to undertake physical rehabilitation either at the clinic or at home. According to the NeuroGen website, patients have regained life-enhancing function relatively soon after treatment.

9) In 2011, Dr. Ayhan Attar and colleagues (Turkey) reported the results of treating two men and two women with autologous (i.e., from the patient) bone-marrow-derived stem cells. Patient age ranged from 19 to 25, and all had ASIA-A complete injuries (see appendix) sustained approximately one month before transplantation. Bone marrow was obtained from the patient’s pelvis bone ilium, which, in turn, was processed and the resulting stem cells reintroduced into the spinal-cord injury lesion. All patients underwent six-months of rehabilitation and were periodically followed with a variety of assessments. At the end of one year, two patients had improved to ASIA-C (some sensory and motor recovery), one had improved to ASIA-B (some sensory improvement), and one had not demonstrated any improvement.

AFRICA

1) Dr. Nirmeen Kishk and colleagues (Egypt) transplanted autologous (i.e., isolated from the patient) bone-marrow-derived mesenchymal stem cells into 43 subjects with chronic SCI. Mesenchymal stem cells have the potential to 1) differentiate into a variety of tissue types (see figure) depending upon the unique signals from the local physiological environmental, and 2) detect and migrate toward injured tissues.

The treatment group was composed of 36 men and seven women with an average age of 32 and average time lapsing since injury of 3.6 years. Eighty-six and 6% had thoracic and cervical injuries, respectively, and 12 injuries were labeled complete and 31 incomplete as determined by MRI assessments (i.e., magnetic resonance imaging). The treatment group was compared to a similarly composed control group of individuals who had refused stem-cell transplantation.

Procedurally, 10-20 milliliters of bone marrow was isolated from the patient’s pelvis’ iliac bone. After processing, the mesenchymal stem cells were isolated and injected intrathecally into the patient’s lumbar region (i.e., lumbar puncture) once a month for six months. All subjects, including controls, participated in thrice weekly rehabilitation sessions composed of a variety of training and strengthening exercises.

Twelve months after completion of the six-month stem-cell intervention, functional recovery was evaluated using a number of assessments. Although stem-cell treated patients demonstrated slight improvements in motor, bladder, and bowel function, overall, little difference was observed between treated and control subjects. Furthermore, any improvements were counterbalanced by a number of safety concerns, including an increased incidence of both neuropathic pain and spasticity, which was not observed in control subjects. The investigators concluded that given adverse side effects, more controlled studies should be carried out before these stem cells “should be offered to patients.”

OTHER

1) Advanced Cell Therapeutics (ACT) According to the company’s website, ACT, registered in the Caribbean Turks and Caicos with connections in South Africa, provides “access to cord blood stem-cell therapy in locations where the treatment is lawful...” According to ACT-generated resources, their cord-blood stem-cell protocols have been used over 700 times for over 80 conditions, including SCI. There has been much adverse publicity concerning ACT operations, and the true nature of the cells.

ACT claimed to have enhanced the therapeutic effectiveness of their stem-cell preparations through a number of procedures. First, white and red blood cells were removed, minimizing rejection potential. Second, key CD133+ stem cells were amplified from the normal 10% of cord-blood stem cells to an elevated 70-80% level. These CD133+ as well as standard CD34+ cells are considered especially powerful stem cells due to their enhanced ability to zero in on a target tissue, differentiation, and engraftment. Third, ACT developed procedures to differentiate cord-blood stem cells into more specialized lines, such as neuronal stem cells for brain and spinal-cord regeneration or pancreatic stem cells for diabetes. Finally, the company supposedly developed freezing techniques that enhanced cell viability after thawing.

ACT reported treating eight patients with chronic SCI with cord-blood stem-cell preparations. Patient age range from 18 to 43; five and three had quadriplegia and paraplegia, respectively; and most injuries were incomplete. About 1.5-million stem cells were introduced into the patient by intravenous and/or subcutaneous injection. After a relatively short follow-up period, most patients reported some functional improvements, including increased sensation, ambulatory ability, and bowel-and-bladder function.

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