A chill down the spine
Buffalo Bills tight end Kevin Everett’s remarkable progress after a recent spinal injury has ignited hopes that one component of his treatment -- therapeutic hypothermia -- could represent a breakthrough for other victims of spinal cord injuries.
But while promising, rapidly cooling the body following catastrophic spine injury may not become standard practice. The treatment has yet to be proven effective in clinical trials, and it appears to increase the risk of infection and cardiac arrhythmias.
In fact, many physicians believe that it was the quick action of the response team, rather than the cooling, that made the difference in Everett’s case.
The initial word on Everett -- who crumpled to the ground after making a seemingly routine tackle in the Bills’ season opener two weeks ago against the Denver Broncos -- was grim.
Tests would reveal a catastrophic, and potentially life-threatening, fracture and dislocation of his spine at the third and fourth cervical vertebrae, known as C3 and C4. The third cervical vertebra had gotten shoved over the front of the fourth cervical vertebra -- like boxcars buckled up on a track -- and locked into place, causing a serious compression on the spinal cord. The higher up the injury, the greater the loss of movement on the body, says Dr. Mark Spoonamore, director of USC’s Center for Spinal Surgery.
The vertebrae are numbered sequentially, from C1 at the top to C7 at the bottom. “Christopher Reeve was a C2, and you saw what happened to him,” Spoonamore says. “At C3 to C4, you still are looking at possible quadriplegia,” as well as paralysis of the diaphragm, which would mean being dependent on a ventilator to breathe.
But the Bills’ medical team worked fast. Within 15 minutes of the injury, Everett was in an ambulance, where Bills orthopedic surgeon Dr. Andrew Cappuccino administered steroid methylprednisolone and cold saline, intravenously, to reduce inflammation and swelling in the injured area and to induce moderate hypothermia, lowering his temperature by 4 to 5 degrees. Within six hours of the injury, Everett was in surgery.
The surgical process
The four-hour operation that Cappuccino and Dr. Kevin Gibbons, a neurosurgeon, performed on Everett at Millard Fillmore Gates Hospital, in Buffalo, is fairly standard for Everett’s type of injury.
With Everett on his back, the physicians performed what is known as an anterior cervical discectomy and realignment of C3 and C4, which involved removing the disc between the vertebrae, and realigning and stabilizing the spine with placement of a bone graft and metal plate.
Then they turned Everett over, made an incision in the back of his neck, placed screws into the affected vertebrae on both sides and connected them by small rods. They also performed a laminectomy, removing some bone from the affected vertebrae to provide more room for the cord. Two days after the operation, in what some say was a miracle, Everett started moving his arms and legs.
Therapeutic hypothermia is used for certain types of heart surgery and brain injuries, but its efficacy in the treatment of spinal injuries has not been established.
Continuing research by the Miami Project to Cure Paralysis, a renowned spinal-cord-injury research center at the University of Miami, on effects of hypothermia on spinal cord injuries, suggests that cooling the nervous system may decrease spinal cell damage.
Hypothermia reduces inflammation, free radical formation, swelling, and cell death, says Dalton Dietrich, scientific director for the project. “Mild hypothermia is protective because it targets multiple injury processes [not just one].” And often it’s the aftermath of a spinal injury that determines the fate of the injured.
“We know that within the first hours after a spinal cord injury, there’s a wave of degenerative processes that are triggered, and if blocked early enough, the severity can be reduced,” says Oswald Steward, director of the Reeve-Irvine Research Center at UC Irvine.
“Cells designed to protect the body against bacteria enter the spinal cord,” he says, “and as a consequence of releasing chemicals to kill bacteria, they also cause ‘bystander’ injuries to the nerve cells.” These toxic chemicals can damage nerve cells. “It’s part of the wave of devastation that occurs,” he says. Preventing further damage in the secondary phase “allows cells that are traumatized, but not actually dead, to recover their function.”
Although researchers such as Dietrich and his colleagues at the Miami Project have been studying the effects of hypothermia for decades, clinical data is scant because of the inherent difficulties in conducting randomized clinical studies with spinal injuries.
In addition to not fully understanding the effect of cooling on humans, researchers are still in the dark in terms of such basic questions as whether the entire body -- or just the injured portions -- should be cooled; how long the cooling should last; how quickly the body should be warmed afterward; and even whether cooling might have unexpected long-term effects. And simply getting the patient cooled is problematic, as hypothermia has to be initiated quickly, Dietrich says.
Even the rapid administration of the steroid methylprednisolone may not have been all that beneficial, suggest some researchers. “Administering steroids following a traumatic injury became standard practice years ago, believing that it reduces secondary injury, but now some researchers are questioning its value,” says Jerry Silver, professor of neurosciences at Case Western Reserve University School of Medicine in Cleveland.
“In experiments on rats, it showed some effect, and in clinical trials it was suggested there was a minor effect,” he says, but there’s also debate whether the side effects are worth the risk. Side effects include increased risk of immune problems down the road. Regardless, it may not have been any of these things individually that helped Everett regain movement.
“I think the critical thing they did,” Spoonamore says, “was they immediately got him on a backboard, got him to the hospital, immediately identified the problem and immediately treated him and took the pressure off the spinal cord with the surgery.”
Pushing science forward
It’s also possible, Spoonamore says, that Everett’s injury didn’t bruise the spinal cord as seriously as originally thought, and he was destined to recover regardless of the treatment.
“I’ve treated a number of patients who’ve been totally [paralyzed] on the initial examination,” he says, “and you start the steroids and treat them very quickly, and then miraculously they do recover” over the following days and weeks as the swelling dissipates. Because of all the things done for Everett, it’s almost impossible to determine which intervention was most important.
“The big difference [in this case],” Steward says, “was that the level of care Everett received was extraordinary. If someone injures their spinal cord in an auto accident, it may take hours to even get them out of the car, much less take them to the hospital.”
Everett’s extraordinary treatment is a remarkable boon for science, adds Dr. Larry Khoo, co-director of the UCLA Comprehensive Spine Center.
“Sometimes it takes an event like this to push science forward,” he says. “Kevin Everett was the perfect candidate for this. He was in perfect health and received this treatment by a spinal surgeon who was fully prepared. It doesn’t get any better than that.” As of Thursday, 11 days after the injury, Everett was able to move his legs with 80% to 90% normal strength and was moving his shoulders and biceps with 50% to 60% normal strength. Friday he was transferred from Millard Fillmore Gates Circle Hospital in Buffalo to the Institute for Rehabilitation and Research at Memorial Hermann hospital in Houston to begin a rehabilitation program, according to a spokesman from the Bills. Everett’s hands were still weak but improving. His doctors believe he will walk again -- either a testament to medical technology, miraculous intervention, blind luck, or a bit of all three.