Friday, January 25, 2013

Spinal Injuries and Quadraplegia  

How life can change in a split second with velocity and impact.

Bravery, Courage and Sheer Determination needed.

Rapid response is required.


Often called"the BIG ONE, this common cervical injury usually means  that 
the patient will only be able to turn head, shrug shoulders, spontaneously breathe 
and talk. Paralysis usually sets in below the insulted area and a permanent  life change occurs.  

January, 2013
An email from a friend . . .
"My son broke his neck this afternoon Big Beach surfing. He told me in his words that he thought he was going to drown so he's lucky to not have. I'll meet with the neurosurgeon tomorrow but he's going to have to have surgery and hopefully the paralysis will come undone."


  • Bruising and swelling were now acting as a strangulation point for the cord below the insulted area and Ischemia (none or little amounts of oxygen are getting down past the fracture point).
  • Steroids were given in vast amounts to reduce bruising and swelling.

   The patient underwent surgery, three days after his accident. Another email, ten days later where the neurosurgeon said that they do not use scans (PET, SPECT, fMRI) to make a prognosis but the time between the accident and intervention. The prognosis - this 21 year old had "less than a 5% chance of ever walking again."

 Sandsie's Comment  January 2013.


   It has taken thirty years working with hyperbaric oxygen therapy (“HBOT”) to thread a string of beads about Coma Arousal, Spinal Injuries, Strokes,  and Near-Drowning.   Now in retirement in Hawaii, the last two beads fell into place within a 10 day period -- the month of January 2013. I should begin thirty years ago to my introduction to Australia's (and the World's) top specialist in spinal injuries,  Dr.  John Yeo.
http://www.spinalcure.org.au/a/100.html

   At that time, I was in the "R" period of Research and Development.In 1984 Sydney only had two hyperbaric chambers, one at School of Underwater Medicine (HMAS Penguin) and another at Royal Prince Alfred Hospital ("RPAH"). Both were large chambers that could take many casualties at one time. The Prince Alfred Chamber was working with spinal injuries. The medicine and research from both centers was fascinating but not the chambers that I had in mind. 



By the time I met John Yeo M.D., I already had the transport envelope of the system worked out . . .  small enough to fit a U.H. Series Bell Chopper, light enough to retrieve a casualty on a 2,000 mile flight in a Beechcraft Queen Air "B." Now for the needs of the patients . . .


1983 C of A Department of Science  & Technology
commissioned Sands  to develop advanced HBOT
 transportable chamber.


In 1984 Sydney only had two hyperbaric chambers, one at School of Underwater Medicine (HMAS Penguin) and another at Royal Prince Alfred Hospital ("RPAH"). Both were large chambers that could take many casualties at one time. The Prince Alfred Chamber was working with spinal injuries. The medicine and research from both centers was fascinating but not the chambers that I had in mind. Then I found out that Dr. John Yeo had a little British Vickers chamber at the Royal North Shore Hospital ("RNSH"). He readily agreed that I should come visit. While spending time with this gracious man, "Happenstance" threaded the first bead for me.  friendly man, so ready to share his knowledge with the World.



   

RNSH is  three miles from "the Bridge" on historic
Gore Hill  with stunning views of the City of Sydney.  
RNSH  with  740 beds is one of Australia's (and the World's)
Premier Medical  Schools and Medical Research Centers.
While at RNSH with Dr. John, a young man, less than eight hours from a Rugby football accident, was carried in -- crushed C4 but with an intact spinal cord and in full quadriplegia  -- , strapped down to a litter. Dr. John and his team gently slid him into the little chamber and, 90 minutes later, hauled the casualty out. WOW! The young man could wriggle his toes.

Four 90 minutes sessions in the chamber at 2.5 ATA over a two day period, the "spinal shock" had evaporated. Two weeks later, the young radiologists was back at work on light duties.
    I was so excited . . . "are you going to tell the world about this?" I asked. Dr. Yeo replied, "probably not yet." 
In the next six months I understood his reluctance. 

   I mentioned the two other Sydney chambers. School of Underwater Medicine where I lectured visiting physicians on dynamic lung function. RPAH -- breaking the backs of sheep with spinal research by Dr. Ian Unsworth -- well, even as a business partner, (Mercator Pty. Ltd.) we did not get on well at all. I told Unsworth of Dr. John Yeo's miracle two day rehab' of the spinal patient. There was a pause and Unsworth muttered "there is a lot of luck in hyperbarics."


A month later I was in Honolulu. Professor Ed' Beckam, M.D., Robert Overlock (shortly after my visit, Bobby became an M.D.) Frank farm, legendary Hawaiian deep-diver and others. Dr. Ed was as gracious as Dr. Yeo back at  RNSH in wanting to share knowledge. 
   At the time, the Hawiian crew were working with short-hair Fox Hound (the dogs loved them) on spinal accidents. All were so excited about the rapid recovery of the Sydney footballer. This was the first time that I had heard the term "Golden Window" (time from trauma to treatment and success probability) from Dr. Ed'. At the time, a Los Alamos atomic physicist was also visiting -- Tom Kunkle, Ph.D. He agreed with the concept of rapid response with HBOT to reduce edema and bruising and the additional oxygen that would keep paralysis contained.

South Carolina, USA.
    Three weeks later I was at Duke University. Buoyed along by the open-minds of Dr. John Yeo and Dr. Ed Beckman and the spontaneous change in Sydney casualty, I was beaten back down to reality, when the Director of the Center, Peter Bennett Ph.D. made the same comment as Unsworth at RPAH in Australia . . . "there is a lot of luck in hyperbarics." Pete simply did not want to hear about it. 

In January of this year, a young man -- the son of a friend of  mine -- fractured his C4 while surfing near my home in Maui. I called Dr. John Yeo (who remembered me and the incident of thirty years earlier) told me "The problem is ischemia. The sooner that you treat a spinal patient in a chamber, the better his chances. After you left Australia, I did a small research paper with fifty-six patients of recovery. I had great Golden Window success with  five of them but the other fifty were not matched in age or duration. Consequently the local specialist derided the results and we abandoned the use of HBOT  with spinal injury."


1993 -- A gentle voice on the telephone to my home in California introduced himself as Richard Neubauer and asked "can you design a chamber for me that will treat stroke and other neuro' patients?"  "Yes," says I. Then I asked him "Does it work with these?"
   "Come see for yourself."  His work and discoveries made at his center were jaw-dropping. No wonder that even today Dr, Neubauer is known as the Father of Hyperbaric Medicine in the U.S.

More beads to thread "Uncle Dick" Neubauer, '"Gus" Miale and "Shelly" Gottleib -- all high-end health scientists and physicians. One of them (I forget which one) told me twenty years ago "Sandsie, because of PET and SPECT scans, we know know about the ischemic Penumbra. This is no longer 'anecdotal.' Life for stroke, spinal and head injured patients is about to change. " Sadly, it did not.


Clin Nucl Med. 1992 Jun;17(6):477-81.

Identification of hypometabolic areas in the brain using brain imaging and hyperbaric oxygen.

Source

Ocean Hyperbaric Center, Lauderdale-by-the-Sea, Florida 33308.

Abstract

Current neurologic assessments consider idling neurons and ischemic penumbras to be metabolically lethargic and electrically nonfunctional or nonviable. Diagnosis, prognosis, and therapeutics of central nervous system dysfunctions require differentiation between viable and nonviable neurons. It is necessary to develop and document efficacious and safe techniques for reactivating idling neurons. The authors present a case study of a near drowning 12 years earlier. Areas of cortical hypometabolism were identified by using SPECT imaging in conjunction with hyperbaric oxygen therapy (HBOT). Delayed imaging after HBOT (1 hour, 1.5 atm abs) suggested viable but metabolically lethargic neurons. After HBOT (80 1-hour treatments, monoplace chamber, 1.5 atm abs), marked improvements in cognitive and motor functioning were demonstrated. The data support the hypothesis that idling neurons and ischemic penumbras, when given sufficient oxygen, are capable of reactivation. Thus, changes in tracer distribution after a single exposure to HBOT may be a good prognostic indicator of viable neurons. HBOT may be valuable not only in recovery from anoxic encephalopathy but also from other traumatic and nontraumatic dysfunctions of the central nervous system, including stroke. HBOT in conjunction with physical and rehabilitative therapy may help reactivated idling neurons to remain permanently active.


Neuroimaging in Traumatic Spinal Cord Injury: An Evidence-based Review for Clinical Practice and Research

Report of the National Institute on Disability and Rehabilitation Research Spinal Cord Injury Measures Meeting 2007

Positron Emission Tomography (PET): Five Class IV articles on PET imaging in patients with SCI were reviewed. A single Class IV PET imaging article was found that assessed PET of the spinal cord in the assessment of patients with compressive myelopathy. This study utilized high resolution fluorodeoxyglucose-positron emission tomography (FDG-PET) to evaluate the metabolic characteristics of the spinal cord in myelopathy patients and concluded that the standardized uptake values for FDG-PET in the cervical spinal cord correlated better than MRI with pre- and postoperative neurological scores in these nontraumatic subjects. Four Class IV articles were found describing PET assessment of the brain in persons with SCI. One of the articles utilized PET scanning to assess brain metabolism after sensory stimulation of the vagina and foot to elucidate the sensory pathways which convey genital stimulation to the brain in women with SCI  Two articles studied regional brain response to unilateral hand movement in persons with SCI determined by PET, showing changes in activation patterns compared to uninjured control subjects. One additional article assessing resting brain metabolism showed alterations in the distribution of PET glucose utilization in persons with SCI compared to uninjured control subjects (90). These studies suggest that PET may be used to assess the metabolism of spinal cord and brain in patients with SCI.

Richard Neubauer would groan and ask "Don't these young specialist physicians ever keep up with their reading?"


Sandsie's Comment. 
TIME TO CHANGE CHAMBERS

Since the little transportable recompression chamber system that I designed for the Australian Government and now in fleetwide use by the United State Navy was unsuitable for spinal patients, I designed a chamber that was/is perfect for spinal patients.

Thanks Dr. Neubauer, Dr. Yeo, Professor Beckman (M.D.) -- none of this would have happened without your input. In the last sixteen years, my centers have aroused numerous coma patients and treated many quad' and para' spinal patients.




 Sandsie's Comment. 
TIME TO CHANGE
   During those three decades I had the privilege of owning my own HBOT centers, charging affordable prices, and being able to skirt the constraints of vested interest groups such as the Undersea and  Hyperbaric Medicine Society (UHMS). Their  "approved" guidelines are in reality "approval for payment by the U.S. Government MEDICARE program (keeps the prices at around $2,000.00 per 90 minute session in a HBOT chamber). 
   The UHMS justification is that "there are no double-blinded studies for such trauma as a broken spine."  With objective scanning, there is no need.
   What a load of self-serving rubbish. Below is just one of the latest studies on brain damage less than ten days  after the accident. . . . and the same grey and white matter are included in a  spine. Mind you, at $2,000.00 per HBOT Tx. in an expensive hospital environment, and with the patient possibly needing 200 sessions, the costs of rehab' of a single spinal injury would "break the bank."
The solution is simple -- do not warehouse spinal casualties  or make them into statistics, condemning them to  reduced quality of life. Move the chambers out of hospitals and DROP THE PRICES per Tx. to less than $200.00 per session -- one tenth of hospital charges.   
In actual fact, such adjunct use of hyperbaric oxygen reduces the overall lifetime costs of the casualty -- usually carried by medical insurance or by State and Federal programs.

Yes, it is "disruptive medical technology" but the movement has commenced.

Meet a CHANGER 
          Dr. Grady Anderson, Orthopedic Surgeon

Grady and I became friends in 2003. He was fond of saying "no back operation is successful if you can still feel pain a year later . . . there are often other ways of mending bones. An extremely smart man. I remember one time he said that to a group of orthopedic and neurosurgeeons at a conference in San Diego, and the moderator  spoke up in a loud voice "Thank you Dr. Anderson, we have heard enough."

Grady stopped speaking and climbed from behind the microphone.  I was enraged on his behalf. "No need to be Sandsie," Grady said. "You have to understand that if you are a surgeon of any sort, if you don't cut,  you do not go to the bank."

Here's to you, Grady Anderson, M.D., Don Quixote of Orthopedics with the courage of tilting at the largest of windmills.

TIME TO CHANGE

In an elegant study -- mostly from Israel Universities comes ths:

Hyperbaric Oxygen Induces Late Neuroplasticity in Post Stroke Patients - Randomized, Prospective Trial

Abstract
Background: Recovery after stroke correlates with non-active (stunned) brain regions, which may persist for years. The current study aimed to evaluate whether increasing the level of dissolved oxygen by Hyperbaric Oxygen Therapy (HBOT) could activate neuroplasticity in patients with chronic neurologic deficiencies due to stroke.

Methods and Findings: A prospective, randomized, controlled trial including 74 patients (15 were excluded). All participants suffered a stroke 6–36 months prior to inclusion and had at least one motor dysfunction. After inclusion,patients were randomly assigned to "treated" or "cross" groups. Brain activity was assessed by SPECT imaging; neurologic functions were evaluated by NIHSS, ADL, and life quality. Patients in the treated group were evaluated twice: at baseline and after 40 HBOT sessions. Patients in the cross group were evaluated three times: at baseline, after a 2-month control period of no treatment, and after subsequent 2-months of 40 HBOT sessions. HBOT protocol: Two months of 40 sessions (5 days/week), 90 minutes each, 100% oxygen at 2 ATA. We found that the neurological functions and life quality of all patients in both groups were significantly improved following the HBOT sessions while no improvement was found during the control period of the patients in the cross group. Results of SPECT imaging were well correlated with clinical improvement. Elevated brain activity was detected mostly in regions of live cells (as confirmed by CT) with low activity (based on SPECT) – regions of noticeable discrepancy between anatomy and physiology.

Conclusions: In any case, the observed reactivation of neuronal activity in the stunned areas imply that increasing the plasma oxygen concentration with hyperbaric oxygenation is a potent means of delivering to the brain sufficient oxygen for tissue repair: HBOT might initiate a cellular and vascular repair mechanism and improve cerebral vascular flow 8,13,16,17]. At the cellular level, HBOT can improve mitochondrial function (in both neurons and glial cells) and cellular metabolism; improve BBB and inflammatory reactions; reduce apoptosis; alleviate oxidative stress; increase levels of neurotrophins and nitric oxide, and up-regulate axon guidance agents [13,16,17,20]. Moreover, the effects of HBOT on neurons can be mediated indirectly by glial cells, including asrocytes [18]. HBOT may also promote neurogenesis of the endogenous neural stem cells [19]. The major limitation of the above-mentioned data is that it has been tested in different types of models and includes different protocols of HBOT. However, it is well noticed that there is at least one common  enominator to all repair/regeneration mechanisms: they are all energy/oxygen dependent. It might be possible that HBOT enables the metabolic change simply by supplying the missing  energy/oxygen needed for those regeneration processes.

To conclude, in this study we provide, for the first time, convincing results demonstrating that HBOT can induce significant neurological improvement in post stroke patients. The neurological improvements in a chronic late stage demonstrate that neuroplasticity can be operative and activated by HBOT even long after acute brain insult. 
Thus, the findings have important implications that can be of general relevance and interest in neurobiology. Although this study focused on stroke patients, the findings bear the promise that HBOT may serve as a valuable therapeutic practice in other neurological disorders exhibiting discrepancy between the anatomical and functional evaluation of the brain.

When was this published? January 15, 2013  - about ten days ago from writing this blog. 
So the contemplation of the 1750  observation of spinal shock and loss of sensation and paralysis below the injury prognoses about many spinal injuries could possibly be changed if specialist physicians kept up with the latest science.  

 Sandsie's Comment:
"Mike Schwass was a friend of mine."
YES, YOU CAN DEFY THE PROGNOSIS
Mike was an historical figure and the first quadriplegic who showed that steely grit and determination could push past the spinal shock. It is worth spending a moment on his YouTube story "Don't Blame the Game," a full quad' at the age of sixteen. 
http://www.youtube.com/watch?v=so4_VVqSA_8



R.I.P. Michael.  Your death was predicted at  22 but you made
it all the way to 51 -- and enriched so many lives. thanks Mate.

"Mike Schwass spent most of his life paralyzed but he never gave up on his dream – every day he envisioned himself walking, free from the confinement of his wheelchair and the aides constantly at his side.  At 16-years-old, Schwass became a quadriplegic after an opposing hockey player checked him into the boards during a game.
Schwass also traveled the country as a motivational speaker. He co-wrote the book “Don’t Blame the Game,” an autobiography of his life, his injury and courage to beat the odds. As a counselor, many of his clients were also quadriplegics – he didn’t charge them because he knew from personal experience how costly their bills were, family said.
Nearly everyone that met him walked away inspired. But as he grew older, his body became weaker, bills stacked up and things were harder for Schwass.
His family put together a fundraiser called “Mike-a-palooza” in August to raise money to buy a new van for Schwass and pay some of his medical expenses."

   Mike came to my San Diego Center for numerous HBOT sessions and told me "I wish that I had known about hyperbaric oxygen when I was sixteen."  My wish for him also. Notice that, even with insurance and damages, Mike eventually ran out of money and fund-raisers were needs. It was a privilege to treat this cheerful man and, when offered payment by him I always told him "Mike, you paid me by just coming through the door of the clinic."


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