Dr Tanya Gurevich, Professor of Clinical Neurology at Tel Aviv University; Director of Movement Disorders Unit, Parkinson’s Foundation of North America Center of Excellence; Head, Parkinson’s and Autonomic Service; Israeli Huntington’s Disease Center; Institute of Neurology, Tel Aviv Sourasky Medical Center, Israel.
The management of spinal cord injury (SCI) is a complex and multifaceted challenge in modern medicine. Beyond the initial trauma, patients face a lifelong journey that demands careful attention to a wide spectrum of physical, psychological, and neurological symptoms. Effective symptom control – particularly of pain, spasticity, and autonomic dysfunction – is central to improving quality of life for these individuals. As understanding of SCI deepens, multidisciplinary care approaches that unite pharmacological treatment, rehabilitation, and psychological support are increasingly recognized as essential.
At the recent GAMS conference in Tbilisi, we had the opportunity to speak with Dr. Tanya Gurevich, a distinguished neurologist and expert in movement disorders and autonomic disturbances. In this interview, she shares her perspective on the often-overlooked factors shaping symptom control in SCI and emphasizes the importance of treating the whole person behind the diagnosis. Her patient-centered philosophy and extensive clinical experience offer valuable guidance for navigating the complexities of spinal cord injury care.
What are the most underappreciated factors influencing variability in symptom control outcomes among spinal cord injury patients that clinicians should pay more attention to?
I think the most important ones are pain and autonomic dysreflexia. You know, we don’t have many options for improving weakness, tetraparesis or paraparesis. But spasticity is very disturbing for patients – and so is pain, which often causes autonomic dysreflexia.
If we want to improve quality of life, we have to focus on what is modifiable. And the main modifiable factors are pain and autonomic disturbances . If the patient is in pain, autonomic disturbances are much more prominent and vice versa – autonomic disturbances often contribute to the pain.
Therefore, pain management is essential. We need to be aggressive in treating pain – offering a wide range of medications, even intrathecal baclofen, botulinum toxin injections. We usually prefer to avoid the opioids, but they could be an option for the short time in the patient with severe intractable pain.
How do current symptom control strategies address the interplay between physical symptoms and psychological or neuropathic pain components in spinal cord injury patients?
The connection between physical symptoms, psychological status, and neuropathic pain is very strong. The patient’s psychological state greatly influences pain perception.
If a patient learns how to control his pain, and how to strengthen his own “barriers” against the pain, he will feel better – but it is very difficult work. I spoke in my lecture about CBT (cognitive behavioral therapy), virtual reality, and imagery-based techniques aimed at increasing the pain-tolerance barrier. These are very important.
Also, patients are often physically tight and stressed after a spinal cord injury. So we must treat not only the pain itself but also the psychological condition. There is a very close connection between the two.
You mentioned stem cell therapy but had limited time to discuss them. I know it’s still early stages but what aspects are you most optimistic about when it comes to stem cells or other innovative therapies?
I can say I’m optimistic. There are different companies developing neural implants derived from stem cells. Stem-cell therapy is becoming very active. But we still don’t have results of large scale clinical trials. I can’t say anything evidence-based yet unfortunately.
Spinal cord injury (SCI) causes many systemic, complex complications that require integrated management. Could you place special emphasis on future therapeutic directions that are rapidly evolving and have the potential to significantly change clinical outcomes?
Yes, that is true, including sodium channel blockers, KCC2 modulation, and anti-RGMa targeted interventions, which are aimed at preserving neural circuits and restoring function. This approach combines already established clinical practice and contemporary scientific innovation – demonstrating how new biological targets, neuromodulatory strategies, and technological progress can help patients with spinal cord injury improve function, increase independence, and enhance quality of life. This is the task for the coming decades.
I am optimistic and I view it as my responsibility to share this optimism with my patients. Patients are eager to hear that new therapies are emerging for their disease, that there is significant innovation in the field, and that many dedicated professionals are actively working to better understand their symptoms and improve their quality of life. Physicians should share with patients their knowledge about ongoing research, novel medications, and clinical trials, and – when appropriate – encourage participation in such trials or refer patients to specialized centers within the country.
You’ve often spoken about your guiding principle of “listening first, then treating,” and about tailoring each approach to the person behind the diagnosis – not just symptoms. How do you apply this approach in clinical practice, especially in spinal cord injury?
First of all, as we were taught in medical school, you must find the diagnosis and etiology – and then treat. Unfortunately, that doesn’t always happen in practice.
So first, as you said, you must see the patient – all of his problems. There are no unimportant complaints. If a patient complains, it is important. You cannot say, “It’s nothing, don’t worry.” If he has drooling, or excessive sweating – it matters. Pay attention to everything, and try to address everything you can.
Most importantly, explain to the patient what is causing the distressing symptom. Even if we have no treatment for it, you must show that you want to treat it. Never dismiss it as unimportant. I’ve heard people say, “You won’t die from that, so don’t pay attention to it.” Yes, maybe there is no mortality – but it is very unpleasant.
Sometimes, treatment of a symptom may lead to unwanted side effects. Therefore, it is important to discuss this openly with the patient – not simply to say, “this treatment is not for you,” but to explain clearly why you believe it may not be the optimal option in their specific case. It is essential to give every patient the clear feeling that they are respected, heard, and truly seen – that we are thinking about them as human beings, not only as medical cases. This is especially crucial for patients who are severely injured or living with profound disability, whose suffering is often physical, emotional, and deeply personal. We must always strive to do our very best and remember to see the person behind the diagnosis. A paternalistic approach no longer serves our patients; instead, they are our most important collaborators. When we walk this path together – physicians and patients side by side – we create hope, dignity, and real progress. Together, we can.
