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Spine Neurosurgery Comes to Rescue When Injury Threatens Spinal Cord

06.01.2011

Matthew Ryan had been an athlete all his life before a big Pacific Ocean wave slammed him under water with a violent shock. "Ironically, I'd been backing off. I'd already stopped doing contact sports," he said. "I was just doing a little bit of bike riding and swimming and golf."

Ryan had played serious contact sports college football and rugby and playground basketball. "I beat my body up quite a bit," he said. Nearing 50, and veteran of three Iron Man competitions, he was still strong, "but internally my body was breaking down."

Ryan had followed his youthful interest in the mechanics of the body and trained in biomechanics and athletic training. He was also coaching a high school track team in Santa Cruz. He was married, the father of two.  In January 2009, with a third child about to be born, he and his mother-in-law decided to take the kids to the beach and give his wife Sara a bit of a break. It was a warm Sunday afternoon and Ryan asked his son if he'd like to see his dad do some boogie-boarding.

I was looking up and could see the sun through the water and I thought, 'This is it.'

-Matt Ryan, patient, Stanford Hospital & Clinics

Ryan paddled out into the waves and prepared. The wave he saw coming for him gave him barely enough time register what was about to happen. "I knew I was about to be thrown, and when you know you're going to be underwater for a while, you take a deep breath," he said. "I've done that in bodysurfing a thousand times."

For decades, Ryan has coached young athletes, using his knowledge of biomechanics and athletic training to make sure they do well without injury.

A surreal vision

As the wave flipped him down onto the ocean floor, he took a hit against it so hard that he didn't really know what had happened. "I took a second to check and that's when I knew I couldn't feel my body. It was surreal. I was looking up and could see the sun through the water and I thought, 'This is it.' I started thinking that if I lived, I would be a quadriplegic and a big burden to my family. I started thinking about Christopher Reeve and another friend who broke his neck."

Somehow, he got his face up out of the water and took a huge gulp of air and someone saw him—a surfer who had been a lifeguard ran to grab Ryan and haul him up onto the beach.

"My little girl was there, crying," Ryan said, "and I called my wife as they were loading me into the ambulance and told her, 'It's going to be all right.'  Later, she told me she'd been thinking, 'The baby can't come until he's back.'"

Three days later, Ryan was at his wife's side as she gave birth to their second daughter, Charlotte, at a hospital in Santa Cruz. And, he could stand to cut her umbilical cord, as he had done for the couple's other children.

Ryan, a lifelong athlete who'd competed two Ironman competitions, is still physically active golfing, swimming and cycling. Now, he's added martial arts to a routine that keeps him active without stress on his spine.

The only reason he could do that, Ryan said, is because of what happened for him at Stanford Hospital & Clinics, under the care of Jon Park, MD, Director of Stanford's Comprehensive Spine Neurosurgery.

The best in the world

"He came in to see me in the ICU and I could tell right away he was extremely bright and well-educated. He had a great bedside manner, very personal and very professional at the same time," Ryan said. "Here I am, I don't know what's going on, how badly damaged I was going to be, but I'd been told he was the best in the world. I just gave myself to him and said, 'Do everything that you do and I'm good with that.'"

What Park saw in the CT and MRI images was a mess. Ryan had multiple fractures of his spine at the sixth and seventh vertebrae, leading down from his skull. One of the damaged vertebrae was pushing the other one out of position and both were pushing against Ryan's spinal cord. The images also tracked nerve activity and found abnormal spinal cord signals at higher vertebrae and a cord compression at the sixth. The ligaments supporting the muscles around those sixth and seventh vertebrae were also injured and pushing them out of place.

The spine is a joint and when you're treating a joint, you have to be careful. It's not like a liver or an appendix.

-Jon Park, MD, Director, Stanford Hospital Comprehensive Spine Neurosurgery

Ryan, a physical therapist, is back at his job with no signs of the injury that nearly took his life or the surgery that saved it.

For seven hours, Park carefully maneuvered through Ryan's vertebrae, first going in through the front-facing side of Ryan's neck to reset the dislocated vertebrae. Then, he turned Ryan over and made an incision to get directly at the spine to pick out fragments of cartilage, finishing off the surgery by putting a protective cage around the injured vertebrae. The cage is made out of titanium, a metal noted for its strength and light weight. Park told Ryan later he was very surprised that the sixth vertebrae had not gone right through the cord, which would have left Ryan without feeling or the ability to move his body below his neck.

"What he also saw was a lot of instability that wasn't part of my neck fracture, from earlier injuries," Ryan said. "It also helped that I have a very long neck so he could move things around to put in the titanium cage to stabilize everything."

Park is modest about the surgery he did on Ryan. "Knowing I have made a difference for someone is what rewards me at the end of the day," he said.

A PAIN IN YOUR BACK
  • Nine out of 10 people in the United States will experience low back pain at least once during their lives. It's the most common reason people go to the doctor or miss work.
  • Most back pain resolves itself with nonsurgical treatment and self-care.
  • Many forms of nonsurgical therapies, such as physical therapy, can help, especially in the short term.
  • While a small minority of chronic back pain patients have a physical abnormality, like a large bone spur, scoliosis or significant disc degeneration, many people will have no obvious anatomic cause for the pain.
  • Spinal stenosis, the most common surgical need in the United States for people over 50, can often be treated with physical therapy or by using a cane before surgery is required.
  • The vast majority of back pain patients do not need surgery, said Stefan Mindea, MD, Director of Minimally Invasive Spinal Surgery in Stanford's Comprehensive Spine Neurosurgery program. “Back surgery does not work if you are not the right candidate,” he said.
  • A comprehensive care team can include a spine neurosurgeon, pain anesthesiologist, rehabilitation psychiatrist, and a neuropsychiatrist to manage surgical and nonsurgical disorders of the spine and peripheral nerves.
  •  Injuries like Matt Ryan's require specialized trauma care that may involve spine reconstruction.

Tricky territory

He is very serious about the complex geometry of the spine and the spinal cord. "The spine is a joint," Park said, "and when you're treating a joint you have to be very careful it's a mechanical area, not like a liver or an appendix."

Park, who also directs Stanford's Spine Research Laboratory, heads a team that includes Stefan Mindea, MD, Director of Minimally Invasive Spinal Surgery and Larry Shuer, MD, a professor of neurosurgery at the Stanford School of Medicine.  Shuer is also past president of the California Association of Neurological Surgeons.

The Stanford spine neurosurgery team's research includes work on artificial disc technologies, regenerative spinal technologies, radiosurgery for spinal cancers and degenerative spine disease.

Surgery on the spine has improved in many important ways, Park said. What has had the greatest impact are those diagnostic and treatment techniques that mean large incision surgery is not necessarily required to care for spinal trauma, disease and deformities. Minimally invasive procedures, sometimes accomplished through incisions as small as 1 centimeter, are now possible, guided by video and robotic instrumentation developed especially to work in the spine.  Stanford's neurosurgery spine physicians have been pioneers in such minimally invasive techniques.

Research has also found alternatives to major surgery, Park said. "Many spine problems we can treat without surgical intervention – like degenerative disc disease. We can selectively choose an area and do a minimally invasive procedure or something non-invasive that will improve a patient's condition. Putting in hardware is an end stage treatment."

In Ryan's case, it made sense. And it was so effective that he was up and about, although moving slowly, the day after the surgery when Park came to talk with him again. "He told me I'd been very, very hurt and that I was very, very lucky."

A few hours later, Ryan's mother-in-law called. Sara Ryan was in labor. Ryan asked if he could leave. Park said yes, and off Ryan went. His wife's physicians, who knew what had happened to him, were so surprised to see him arrive that they all came over to exclaim over him. "She's saying, 'Excuse me, I'm giving birth here!' But I stood up, shuffled over and cut the cord and little Charlotte came into the world."
 

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