A radical method for treating spinal cord injuries

Analynne Salas has regained almost all of her normal function, thanks to Dr. Fehlings’ surgery. (Photo: Mike Watier)

By Tamar Satov

In November 2017, Analynne Salas and her partner, Domingo Blanquera, pulled into a parking lot in Toronto’s east end, on their way to an appointment to discuss their mortgage.

Blanquera helped Salas out of the car, as she’d been experiencing numbness and weakness in her limbs for months. But as they walked hand in hand, Salas suddenly lost sensation in one leg and fell onto her back before he could catch her. “I was conscious, but I couldn’t move anything except my eyes and my mouth,” recalls Salas, who’s now 46. “I was scared. I thought I was going to die.”

Blanquera called 911, and tests performed at a nearby hospital determined that her spinal cord was badly injured, leaving her paralyzed with no movement from the shoulders down. The cord’s bruising and internal bleeding were a result of not just the fall but also a pre-existing condition called degenerative cervical myelopathy (DCM), which is the most common cause of spinal cord injury in the country. The disorder, which affects two per cent of Canadians and leads to a 1,000-fold increased chance of spinal cord injury (SCI), turned the ligaments in her upper and middle spine into bone. That ossified tissue then squeezed her spinal cord, which caused the numbness and unstable gait that precipitated her fall.

To have any hope of using her arms and legs again, Salas needed immediate spinal decompression surgery, a delicate procedure in which those ossified ligaments would be removed, preventing further damage to blood vessels and nerve cells.

Her healthcare team made a key decision that would vastly improve the trajectory of her recovery: they transferred her to University Health Network’s (UHN’s) Toronto Western Hospital under the care of Dr. Michael Fehlings, a neurosurgeon and senior scientist at the Krembil Brain Institute and the Gerry and Tootsie Halbert Chair in Neural Repair and Regeneration, who is also part of the Sprott Department of Surgery at UHN.

Time is spine

Dr. Fehlings was among the first clinician-researchers to identify the benefits of early decompression surgery. A study he published in 2012 compared patient outcomes among 313 SCI patients in six centres across North America. It showed that the odds of having significant neurological improvement six months after injury was three times higher for those who had spinal decompression surgery within the first 24 hours, compared to those who had surgery later. “The approach I took was considered to be very radical at the time,” he says.

Dr. Fehlings then undertook a more detailed study, published last December, which analyzed data from four previous studies that included 1,548 SCI patients after surgery. At one year

post-injury, patients who had the procedure within 24 hours showed greater improvement in all motor scores tested. Plus, the earlier patients received surgery, the better their recovery. “The study definitively showed for the first time that ‘time is spine,’” says Dr. Fehlings. “Providing surgical decompression early, within 24 hours, is mission critical.”

Dr. Michael Fehlings performs early spinal decompression surgery to improve patient outcomes. (Photo: UHN).

Putting research into practice

When Salas arrived at Toronto Western around midnight, Dr. Fehlings had to act fast. He rushed in to assess her at 2 a.m. and had her in the operating room by 6 a.m. – a mere 16 hours after her fall.

He cut into her back to remove the thickened tissue and bone that was narrowing her spinal canal. The compression on her cord was so severe he had to take out much of the arch of her upper spine and reconstruct it with screws and rods made of titanium. “She’s now the bionic woman,” quips Dr. Fehlings, underplaying the remarkable achievement of the painstaking six-hour surgery.

After initially recovering in the intensive care unit, Salas was admitted to the general ward for spinal patients under the care of a specialized team of nurses, occupational therapists, social workers, physiotherapists, spine fellows and residents, in addition to Dr. Fehlings. “Almost every organ system is affected with spinal cord injury, so a multidisciplinary team approach is required,” he says.

Advance practice nurse Rosalie Magtoto collaborates with the multidisciplinary team in the unit and ward, which provides care for patients. She’s been working with the spine team, part of the neurosurgical group, for the past 17 years – attending interdisciplinary rounds and family meetings to fulfil the care needs of patients and their families.

Importantly, she is a reassuring support for those whose lives have been upended. “When you have a spinal cord injury, there is a fear of the unknown. You don’t know if you’re going to walk again or if you’ll be able to return to your job, and the quality of a patient’s life is affected,” she says.

Rosalie Magtoto collaborates with the multidisciplinary team to meet each patient’s care needs. (Photo: UHN).

Recovery milestone

After spending about two weeks in the unit, Salas managed a slight stir in one of the fingers in her right hand when Dr. Fehlings held it. “He said to his nurse, ‘This is very promising progress. Let’s get her to rehab!’” recalls Salas.

Magtoto also remembers that moment: “When she started showing improvement, it was very gratifying for all the participants in her care.”

Salas then went to Toronto Rehab’s Lyndhurst Centre and was upright and standing within three weeks. By the time she left in February 2018, she was on the move with a walker, and she continued physiotherapy as an outpatient for six more months.

Today, Salas has regained nearly all of her normal function, aside from not being able to move her neck fully from side to side. And while it’s possible she may someday require surgery on her lower (lumbar) spine – as do 20 per cent of patients who have DCM – research into new therapies and medications offers additional hope for those with an SCI.

For example, Dr. Fehlings recently completed a Phase 3 randomized control trial to see if Riluzole, a sodium channel blocker, can improve the recovery of patients with a traumatic SCI when given within 12 hours of injury. He expects to publish the results later this year.

“I can’t believe what science can do. I thought that was the end for me,” says Salas, who is grateful to be there for her family, including her three kids, aged six, 17 and 20. “I appreciate what Dr. Fehlings did for me. His team is amazing.”

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