Re-inventing a Surgical Procedure
by Maryann Brinley
Robert F. Heary, MD
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he patient was experiencing numbness in his arms and a gradual loss of physical function that had been advancing ominously up his spine towards the brain. What complicated the case was the fact that here was a man, age 37 at the time, who had already been left paralyzed from the waist down by a traumatic car accident three years earlier. Now, a cyst-like syrinx, or syringomyelia, was threatening to cause complete quadriplegia and eventually brain infections that could kill him within two years.
“Try something. Give it a shot,” Tim Reynolds told Robert F. Heary, MD, a UMDNJ-New Jersey Medical School professor of neurosurgery, director of The Spine Center at NJMS, and the surgeon who first operated on his broken back in December 2000.
“In Tim’s case, when you’ve lost the use of your legs, your hands are everything. He had fought back energetically against this spinal cord injury and was at a point where he could conduct his entire life — an amazingly, energetic hard-working life using just his upper body.” A marathon runner before the accident and happily married father of three young children, Reynolds had even become strong enough during his recuperation to cover the same 26.2 miles competitively in a racing wheelchair.
“So we had to re-operate on him,” Heary says. But there were potential problems and unanswerable questions.
An uncommon surgical procedure did exist to stop the advance of this syrinx — a cyst within the spinal cord which can enlarge and expand — but the technique wasn’t well-suited for a trauma case and would have been more applicable in a pediatric setting or to remove a spinal tumor. Heary was also cautious because, “There’s no guarantee of what the results are going to be when you go back into a spinal cord surgically, particularly after a major injury disruption.” He discussed the case with Peter W. Carmel, MD, chair of the NJMS Department of Neurosurgery and a pediatric specialist. If he applied the same surgical principles used more often by Carmel in sick children to this adult trauma setting, would they work?
The very fact that Heary could put Tim into an MRI machine was a technological advantage that wouldn’t have been possible just 10 years earlier. In the old days, steel hooks and rods were commonly implanted for spinal repair but that kind of embedded instrumentation “didn’t allow us to use MRI for additional imaging later on,” Heary explains. Reynolds was lucky because his screws and rods were made of titanium, which weighs less than steel and is used extensively in many prosthetic devices including artificial heart pumps, valves, pacemakers, and joint replacements. Titanium, named after the mythological giant, Titan, doesn’t become magnetized and is almost magically immune to the acidity of human body fluids.
Back in 2000, Heary had spent five hours in complicated surgery to realign both the spinal cord and the canal in Reynolds’ back, using a combination of these newer titanium screws and rods along with spinal fusion. The goal then was “to give him the best opportunity for a good quality of life beyond his injury.” This patient had sustained a T-9, T-10 fracture subluxation. “We stabilized the spine from Thoracic number 7 to 12,” Heary explains. As any surgically repaired spine heals, usually
within two years, Heary explains, this titanium infrastructure will actually become unnecessary. “Once a solid fusion of the bones occurs, there is no force being felt by the screws and rods.” The bones have taken over the work of living.
Interestingly, smoking, diabetes, infections or being immune-compromised in any way will predispose a patient to spinal fusion failure. But Reynolds had been in good physical shape and had continued to follow physical therapists’ and doctors’ orders conscientiously. Using myelography, an imaging technique which combines X-rays with fluoroscopy to show the space around the spinal cord, Heary could almost pinpoint the spot where fluid was being cut off by the syrinx. “That’s when we made the determination to go back into the operating room, and into the dura around the spinal canal.”
Using a microscope, “I opened up the spinal canal, released membranes, cysts and scar tissue to free up the fluid and get it flowing properly again. I also put a short shunt in to drain excess fluid.” Because his spinal fusion had healed properly and was solid, Heary could actually remove the titanium hardware. “We didn’t need to put any metal back into him.” Almost immediately, Reynolds was “dramatically better. His upper body sensations went back to where they had been.” Later, a radiologist who did a follow-up MRI on Reynolds used adjectives like “miraculous” and “unbelievable” in his written report describing the surgical results. And, while this surgeon now adopts a matter-of-fact tone when recalling the re-invented procedure, his patient thinks otherwise, adding, “Frankly, I do believe he saved my life.”
The Reynolds family is so grateful to Heary that they have donated $2 million to fund the new Tim Reynolds Family Spinal Cord Injury Laboratory at NJMS, which will focus on real world scenarios in a search for a cure for paralysis. “Most research laboratory models of spinal cord damage cause an injury in a lab setting and then immediately begin the treatment. I’m a surgeon. It’s what I’ve been doing for a living for 12 years and I wish I could treat my patients right away but that doesn’t happen. I get them hours and days after the injury occurred. In reality, when people get hurt, there is almost always some degree of time lag so those types of laboratory efforts aren’t going to carry over to people in clinical settings.” This lab will be different from the others. Using human neural stem cells, glial-derived, neurotrophic growth factors, and biologically-engineered scaffolds, the Reynolds family translational research lab’s goal will be to reanimate injured spinal cords, “to bridge the injured segments so messages get through. If we find success over time in these areas, the next step will be to move into the clinical realm.”