I have two things that I want to communicate in the next 10 minutes. I'm going to give you my perspective on the management of spinal cord injury as it relates to the injured athlete, and it begins with the question, do you have a plan in place if someone under your care sustains a spinal cord injury? And then the second thing is about artificial discs, and we're starting to see artificial discs creep into the world of athletes, and is it appropriate for someone who plays football? This is a cervical spine session, but I'll talk about I took care of the last person in the National Football League to be paralyzed, Ryan Chazier, and although, in fact, he was a thoracic injury, it's a spinal cord injury, and so the principles are precisely the same. So on December 4, 2017, Monday Night Football, a pass comes across the middle, and number 50 leads with his head, with the crown of the helmet. That should have the forces exit the weakest part of the spine, which in basically virtually everyone in this room, that would be in the neck. However, this is an injury that's never been seen in football before. I hope it's the only one that any of us ever have to deal with, but all the right things happened on the field, but he was completely paralyzed. He was what's known as an Asia A, so no sensory or motor function. He was in spinal shock, and everybody understands the spinal stabilization and loading onto the cart, but what do you do next after you get to the hospital? So who's in charge? We were the away team. Who's the admitting primary service? What is the role of me or whoever is there? It turns out it was a fantastic collaboration. Bill Knight is someone who all of us have a lot of indebtedness towards, because not only did he help care for Ryan Shazier, but he is also the person who took care of DeMar Hamlin in the ICU, Monday Night Football, Cincinnati, both circumstances, so there's a little bit of PTSD associated with that for me, but here are the management decisions. We had to think about what pictures we were going to get, where we're going to operate, steroids, hypothermia, and all these things, and I'll just quickly run through these, but the real question is, do you have a protocol in place? We have protocols. We run through them. We train for the EAP of the person on the field, but that isn't the end. That's the beginning. What are you going to do next, and so what did we do to maximize this person's outcome? I didn't know at the time, but this is the scalp view of the CT scan in the trauma bay, and it turns out he has scoliosis. If you understand scoliosis, which I do for my day job, I correct scoliosis as part of my day job, the weakest point in the spine is the hypoplastic pedicle at the apex of the concavity, so when you lead with the crown of the head and the force exits the spine at the weakest spot, it is right at the apex of the concavity of the spine, and that is in fact where he had his fracture. We then quickly got an MRI, and he did not have significant neural element compression, so he didn't have an unstable injury, and he didn't have active neural element compression, and so we actually didn't operate immediately, which in 99% of the time in my world, if someone sustains, has a neurologic deficit referable to spinal column trauma, we go from the trauma bay to the operating room, but this was a very, very specific, unique, and rare situation where surgery in that moment wasn't indicated. He then proceeds to recover some strength in his left lower extremity over the next 24 hours, and on day two, on post-injury day two, he goes back out, and he's completely paralyzed again, and at that point re-imaged him, and at this point he was put in a helicopter and flown from Cincinnati to Pittsburgh, and when we landed in Pittsburgh, got a second MRI, and now he has active spinal cord compression and spinal cord edema, and in fact, what happened as you can see in the artist's illustration is that a hematoma had developed inside of ligamentum flavum and created spinal cord pressure that re-paralyzed him and someone who was beginning to recover, so at that point, he was taken to the operating room. I did a short segment fusion. I drilled down the pedicle, resected the hematoma, took away ligamentum flavum, and gave his spinal cord more room to breathe. So that was the steps towards surgery, but steroids. This is controversial, and theoretically, there is this new movement towards not using steroids in the spinal cord injury patient population, but if you actually understand where this data came from, which were these NASCS trials back in the early 1990s, before we even had the modern terminology of spinal cord injury, if you look carefully at the patients who benefited from steroids, it was young people who had incomplete injuries. Well, that is almost certainly what's going to happen in the world of football, so in my view, it doesn't make any sense whatsoever to withhold a potentially favorable treatment from someone when you think of the sum total of patients, when the data tells us that the patient most likely to benefit from steroids is the young patient with an incomplete spinal cord injury. So our protocol in Pittsburgh calls for the high-dose Bracken protocol of methylprednisolone, of IV methylprednisolone. The data surrounding hypothermia is a little bit less strong, however, there are both theoretical benefits to hypothermia and some early clinical indications, principally from our colleagues at the University of Miami, that spinal cord patients benefit from hypothermia. So in this patient, we gave him two liters of chilled saline in the trauma bay, and then in Cincinnati, they don't have intravascular cooling devices, they have the Arctic Sun, which is a surface cooling device, so we cooled him down to 33 degrees and gave him two liters of chilled saline in the trauma bay. This is sort of next level and probably outside of the scope of the people in this room, but there is another way of looking at spinal cord injury where you don't manage with hypertension directed at mean arterial pressure, you actually place a lumbar drain into the fecal sac, measure intrathecal pressure, and guide your management of oxygen delivery to the spinal cord with a lumbar drain. So that's a part of our protocol. And then we threw the kitchen sink at him. And so we used adjunctive therapies, including omega-3 fatty acids, which if you're going to do that, you have to understand the dosing, you also have to understand the laboratory values you need to track if you're going to use omega-3 fatty acids. And we did hyperbaric oxygen. And he did 29 dives in our hyperbaric oxygen chamber, which is an extraordinarily complicated practicality, but we managed to institute that. And then on top of everything, he got a limitless supply of rehab, which is why he started his foundation because what he was able to benefit from is not something that people in the general population can benefit from if they sustain a spinal cord injury. No one spends six weeks in inpatient rehabilitation anymore. And he had more than 130 outpatient therapy sessions. And then by two years, he is normal. So he went from paralyzed to normal. So he had excellent on-field management. There was not a protocol in place. If he had been in Pittsburgh, we have a protocol. There was not a protocol in place in Cincinnati. But it just so happens that the neurosurgeon in charge there is an old friend of mine. And we had a wonderful collaboration. And because of the mechanism of things now, and because we actually have a neurosurgeon on the sidelines of every game for the Steelers, I've gotten to know so many of you guys. And so the VTML was someone that I had worked with previously. And then I also just happened to know Bill Knight as one of the intensivists in Cincinnati. So we had an excellent collaborative approach to this. And they basically adopted the Pittsburgh protocol in Cincinnati, even though there wasn't a protocol in place. And like I said, Ryan has now written about this. I didn't talk about this for the longest time, because he asked us not to. But now he's perfectly content with his story being told. All right. And then in the last few minutes, we'll talk about cervical arthroplasty. So is this an option for elite contact sport athletes? You're starting to hear about this more and more. There was an NHL player whose franchise didn't want him to get cervical disc arthroplasty, an artificial disc. They wanted him to get a fusion. He insisted on it and orchestrated a trade to the Vegas Golden Knights because they would allow him to get an arthroplasty. He was demanding arthroplasty for treatment of his cervical disc disease. But there are now three NHL players, there's an MLB player, and then Nathan Jones is probably the most relevant to this conversation because he's an Aussie rules football player, which is a brutal sport in and of itself. And he played multiple years after having cervical disc arthroplasty. But there's really no evidence to support and help guide this concept and this decision. And so people have tried to amalgamate the experience out there in the world. But when you look through the world of athletes who have undergone cervical disc arthroplasty, it's actually a tiny, tiny number who have played contact sports or only two contact sport athletes. The NHL guys who did it, if you look through their statistics following their surgery, they did not have a drop-off in performance, which is one of the motivations for this. And even Nathan Jones had no drop-off in statistical performance in the four seasons following his cervical disc arthroplasty. There's one UFC fighter that Dan Rue at Columbia operated on. But when I look carefully at that x-ray and that lateral, I'm a little bit worried about the relationship of those two halves of the disc. And so this is the challenge. Are we actually going to do this in someone who plays football? Because what, in fact, are the risks? How long does it take that to incorporate? This is radically different from when Mike Rosner, who served in uniform for many years as a neurosurgeon, in the early days of OEF and OIF, he was operating on special forces guys and doing cervical disc arthroplasties and letting them return to fight, jump out of airplanes and go kill bad guys, a week later. Because the arthroplasty doesn't need all that time to fuse. So you start thinking to yourself, can you actually accelerate the return to play by choosing an arthroplasty over fusion? But how is alignment and motion altered? And then what about device migration and catastrophic failure? We all want these athletes to have a solid arthrodesis radiographically before we let them go back to a contact sport. What do you do with an arthroplasty where there will never be an arthrodesis and you're relying on that implant integrating into the vertebral bodies above and below? So when you look at failures, they classically will happen anteriorly. But there are failures of cervical disc arthroplasties where the implant migrates. And in this review of the literature, three out of the 18 patients had neurologic deficits. And then one of my former trainees published a case report recently of someone for whom he cared who had had a three level cervical disc replacement nine years prior, had a simple ground level fall. And if you look at that axial, that hyper intensity in the center of the canal is the wire that wraps around the implant that's now inside of this person's spinal cord. So I don't know about you, but I'm not quite ready to put a cervical disc arthroplasty into someone whose job it is to accelerate and have a hyperextension event over and over and over again as part of their professional existence. I'm not ready to do it, but I think someone is going to do it sooner or later. And we can all expect the athletes to start asking this question because of its creep into other sports. Thank you.

spinal cord injury

athletes

artificial discs

management

plan