Paul Rand: It wasn’t that long ago that spinal cord injuries were considered fatal, with most people not living beyond the first year. But what if doctors can not only give patients a chance at survival, but help them regain the ability to move their limbs or maybe even walk again?

Tape: We’re going to turn now to a stunning medical breakthrough, helping a man who was paralyzed for over a decade walk again.

Tape: You are watching a medical milestone. Several people who were paralyzed after devastating spinal cord injuries are now walking with minimal assistance.

Paul Rand: Dr. Mohamad Bydon, the Stahl Professor of Neuroscience in the Wallman Society of Fellows and Chair of the Department of Neurological Surgery at the University of Chicago, is a pioneer in treating spinal cord injuries. In his research, he has studied the benefits of stem cell therapy, which helped one paralyzed patient walk again, as well as the use of robotics to perform minimally-invasive surgery.

Mohamad Bydon: But I think it’s the future and it’s something that I believe will continue to be there, and it’ll be for the betterment of patients because it’ll make surgery safer.

Paul Rand: These kinds of technological advancements are giving patients new hope for recovery. Last year, Bydon and his team at UChicago made global headlines for saving the life of a 2-year-old named Oliver, whose spine was severed from his skull following a car accident.

Mohamad Bydon: And it was a very severe and significant and substantial injury. They went to experts in Germany and in Europe, and they were told very appropriately, “This is a catastrophic case and there’s no hope for him.”

Paul Rand: Bydon and doctors at UChicago Medicine performed a harrowing surgery to reattach his severed spinal cord. In the weeks that followed, Bydon said Oliver didn’t just survive, he started to show remarkable signs of life.

Mohamad Bydon: His hand moving, his foot, his arm. I mean, it was very, very strange. Initially we thought, “These are reflexes,” but it was to command. You would say, “Oliver, squeeze my hand.” He would squeeze your hand. It was, “How could this be?”

Paul Rand: From the University of Chicago Podcast Network, welcome to Big Brains, where we explore the groundbreaking research and the discoveries that are changing our world. I’m your host, Paul Rand. Join me as we meet the minds behind the breakthroughs. On today’s episode, the future of spinal surgery and new hope for patients.

Today’s episode of Big Brains is supported by the Court Theatre, Hyde Park’s Tony Award-winning theater located on the University of Chicago campus. Here, timeless stories speak to today’s world, from Sophocles to Tom Stoppard, Caryl Churchill to Anton Chekhov, and August Wilson to Tennessee Williams. When you’re at Court Theatre, you’re going to see something bold and provocative, something that will move you and make you think. You know you’re going to get a great theatrical experience unlike anything else, one that only could happen on the south side of Chicago. Reimagine what classic theater can be. Visit courttheatre.org.

So what I want to dig into right out of the gate, because I think it really brings to light all of the advances medicine has made, and it’s with a case that UChicago shared publicly a short while ago, and it was a 2-year-old child that had a catastrophic injury where the junction with the skull and the spine, I think it separated. I wonder if you could talk a little bit what that actually means and what is the usual outcome of such an injury and what did you do about it?

Mohamad Bydon: Yeah, so this was really a catastrophic case. This was a young boy whose father is from Germany, his mother is from Mexico. They lived in Germany and they were vacationing in Mexico when a very significant car accident caused a really catastrophic spinal cord injury to the young man, Oliver, himself. And that included essentially severing of the spinal cord, but also the spinal column connecting the head and the cervical spine.

It was a very severe and significant and substantial injury to the point that when I received the records, the parents had been trying to reach me and didn’t know how to contact me, and they went to experts in Germany and in Europe, and they were told very appropriately, “This is a catastrophic case and there’s no hope for him.” When I received the file, I get requests a few times from families where they just want to know that everything that could have been done was done. And learning that he was alive was a big surprise. The hospital essentially stabilized him, put him in a brace, and sent him on his way. But he was highly unstable in that situation and he unbelievably survived on a ventilator and in that situation for months.

Paul Rand: What made it really particularly dangerous, both from a neurological and a structural standpoint? What really stood out about case?

Mohamad Bydon: Well, this was a high cervical injury, complete paralysis, a complete injury, and a case where both the spinal cord, meaning both the nerves and the ligaments, and the bones were just shattered. These kinds of surgeries are risky in an adult. Now imagine in a child for whom a little bit of blood loss could result in catastrophic cardiac or other injuries. And so this was a very high-risk procedure without any guarantees of success. In fact, with the odds against success.

Paul Rand: As simply as possible, describe ultimately what you did and then the outcome of the surgery.

Mohamad Bydon: Yeah. So our goal was multifold in tackling this problem and in tackling this condition. One goal that I’d set for our team and that I wanted to make sure that we accomplished was obviously the reconstruction, from a bony perspective, of the connection between the skull and the spine. And that’s something that occurred over two phases. One phase, so the skull, the bottom part of the skull is called the occiput, and that upper part of the spine is called the cervical spine.

Paul Rand: Okay.

Mohamad Bydon: So what we did posteriorly was an occipito-cervical fusion, and that was one element in order to hold, we put a plate on the base of the skull and we put screws into that plate, and then we put screws on both sides of the spine to hold the head and the spine together.

Now, we did that from the back, but this was such a severe injury that that’s not going to be enough. So then we had to go in from the front, and this is a high cervical injury, so that adds its own level of complications and difficulties. And we came in from the front and performed a drilling of the bone that was moved forward, and then placement of a cage, a cage to recreate the bony lining of the anterior part of the spinal column, also known as the vertebral body. And so we placed a cage between those vertebral bodies to hold that together. And so that’s on the bony reconstruction side. So now the head’s connected to the spine again.

Paul Rand: Okay. Is the idea that he will grow into this or this has to be repeated at different stages of growth?

Mohamad Bydon: Generally he will be able to grow into that, but now we haven’t dealt with the spinal cord.

Paul Rand: Yep. Okay.

Mohamad Bydon: And so although we’ve reset the bony anatomy and the connections of occiput to cervical, we haven’t done the spinal cord. We proceeded to reset the spinal cord. And the spinal cord, its lining was ripped and there was spinal fluid everywhere, both in the back of the neck and in the front of the neck. In fact, when we came into the front, the spine was so severed that we could see it. We could see the severing, and we could even see nerves that were going into the front of the neck, which is highly unusual. And so we recreated the lining of the spinal cord, resetting, anatomically, the severed cord back to where it belongs and enabling this area of healing. And I should note to you, and some people warned me, I’m the inaugural Chair of Neurological surgery at the University of Chicago, which has a rich and storied history in my specialty of neurosurgery. People said, “Look, you’re the inaugural chair. You’re a new chair. Why take this on?”

Paul Rand: Right. “You’re sure you want to do it?”

Mohamad Bydon: Right. If he passes away, which is a real possibility, that’s going to be terrible. And we got more and more momentum of saying, “No, no, let’s do this. Let’s try to help him.” And sure enough, after the multi-stages of surgeries, Oliver’s heart stopped and it took CPR to save his life. In that moment, I just thought, all this planning, hours of surgery, two multi-hour surgeries, all this work, I just thought, “This is it.”

But the Pediatric ICU team at Comer Children’s Hospital was extraordinary and saved his life, and his parents right there by his side at all times. And it was really something. Seeing them come together, seeing everybody come together. There were people whose shifts would end, who would say, “I’m going to go say goodbye to Oliver.” There were people leaving the hospital at 3:00 A.M. were saying, “Okay, before I leave, let me go say good night to Oliver.” So everybody started to know, “There’s something unique here, and we could be part of something that really, A, changes the life of an individual and of a family for the better, which is so exciting, and B, advances science and medicine and helps others into the future.”

Paul Rand: And how is he today?

Mohamad Bydon: Well, he’s much better. I actually just connected with him and the family this morning by video, and he’s doing extremely well. But he began to recover about... The first week after surgery was harrowing. And then after that we started to see things that were so strange, his hand moving, his foot, his arm. I mean, it was very, very strange. Initially we thought, “These are reflexes,” but it was to command. You would say, “Oliver, squeeze my hand.” He would squeeze your hand. It was, “How could this be?” he had a completely severed spinal cord for four months. And then, more and more, he began to sense when he needed to urinate, he would tell his mom, “I need to pee.” He has movement in arms and legs.

Paul Rand: Tell me the most common, if there is, causes of spinal cord injuries.

Mohamad Bydon: Car accidents.

Paul Rand: Okay.

Mohamad Bydon: Very high. Falls. Very high. There are very many situations like that that create a major problem for people. A major severing of the spinal cord, a major disruption or injury to the spinal cord. There’s primary injury and secondary injury where the body’s trying to heal it but actually makes it worse. It’s a few cases that actually require surgery.

Now, spinal cord injury is a different category, and that’s something that impacts hundreds of thousands of people in the United States, millions around the world. In fact, the likelihood that one of those areas becomes injured at some point in your life is over 80%. Now, usually it’s a muscle sprain and it’ll get better on its own with time. But occasionally when it’s a more severe injury, a disc herniation pushing on a nerve, a problem of the nerve, arthritis that’s so overgrown and ligaments that are so overgrown that they cause stenosis and compress all the nerves, preventing you, maybe, from walking or preventing you from walking far, you have to stop all the time.

All of those are injuries and conditions that we take seriously and want to treat, starting with problems of instability, problems of neurologic compromise, so problems that cause what we call mechanical pain, meaning pain, when you stand or walk, in addition to problems that cause some sort of neurologic problem, meaning pain that goes all the way down the leg, which we call radiculopathy, claudication, where you have trouble walking, you need to stop and rest or lean forward, sometimes myelopathy where your hands get weak and your feet get weak because it’s a problem in the neck. So all of those run the spectrum of conditions that impact the spot

Paul Rand: If you’re getting a lot out of the important research shared on Big Brains, there’s another University of Chicago podcast network show you should check out. It’s called Entitled, and it’s about human rights co-hosted by lawyers and UChicago Law School professors, Claudia Flores and Tom Ginsburg. Entitled explores the stories around why rights matter and what’s the matter with rights.

Paul Rand: You have talked about spine surgery being less of a technical problem and more of a prediction problem, and I wonder what you mean by that.

Mohamad Bydon: The problems are both.

Paul Rand: Okay.

Mohamad Bydon: There’s a technical issue and there’s a prediction issue, and the technical issue is to deliver the surgery safely, effectively, expeditiously. And that’s not so reproducible all the time because of the number of joints involved. So our colleagues, for example, in joint surgery, in hips and knees, you have one joint involved there. It’s a complex joint, but you have one joint involved there. And so when they show outcomes, they’re able to show from a hip replacement, from a knee replacement outcomes that are 96% effective, 97% effective. They’re talking about, “Why can’t we get to 99%?” And eventually once they get there, they’ll talk about 100%.

We’re not there in spinal surgery as a specialty. And I oversee our data for the United States in our national society and a group called NeuroPoint Alliance. We get data from hundreds of hospitals. And on the whole people do very good surgeries, but the number of patients who say, “Yep, I would do it again,” in the cervical is about 95% from an anterior cervical surgery, and then from a lumbar surgery is about 80-85%. So there’s that 15% that say, “I would do this again.”

Paul Rand: “I wouldn’t do it again.”

Mohamad Bydon: Right. And that gap we have to be able to close. And the reason that it’s harder for us to close it than people treating other parts of the body, is the number of joints involved and the number of parameters involved in our treatment delivery.

Paul Rand: It almost sounds like the hardest part of this is not actually the operations, it’s actually deciding whether to operate at all. Is that a fair assessment and where is it that the most harm in spine care actually occurs? And what are you trying to juggle here as you make a recommendation?

Mohamad Bydon: Well, a spine surgery part of it is do we do the surgery, which, if the pain continues to come back and it keeps being a problem and the symptoms aren’t getting better and it’s having a big impact on your quality of life, then you have to think about surgery.

And then the other aspect of it becomes, when we’re delivering the surgery, “What is the surgery that we deliver?” For example, you could solve the same problem in the neck or in the lumbar spine by going through the front, front of the neck or front of the abdomen, back of the neck, back of the abdomen, side of the abdomen, or a combination thereof. You could go back and front, you could go side and back, you could go front and back. So that creates a lot.

And then when you do go in, let’s say you decide, “I’m just going in the back,” you could decide to do a decompression only, which is what we call a laminectomy, you could do a laminectomy infusion, you could do a laminoplasty. So there’s a lot of optionality and a lot of ways to treat these diseases. And that’s why science is important, that’s why data is important. Our surgeries over time are becoming more effective. I think some of our national organized efforts and our scientific community are very key to that continuation. Areas that they have positive outcomes, they have negative outcomes. Our surgeries over time are getting safer. Our surgeries over time are becoming more effective. I think some of our national organized efforts and our scientific community are very key to that continuation.

Paul Rand: Let’s talk for a little bit about what’s new. When people hear about minimally-invasive surgery, they assume that that means minor. What does that actually mean when it comes up in spine surgery?

Mohamad Bydon: Well, spinal surgery, traditionally, requires very large and maximalist incisions to be able to resolve the problem that you have. Minimally-invasive spine surgery, and a prior chair here also was one of the people who really heralded that area and brought that area into being, minimally-invasive spine surgery is an area of smaller incisions with less blood loss, with different visualization, whether that’s microscopic or endoscopic, in order to deliver a similar solution with a similar outcome, but with a much smaller footprint, so to speak. And it opens up a lot. My area that I’ve spearheaded for many years now is robotic spinal surgery, which also makes surgeries safer and more effective and delivers them in a more reproducible manner.

Paul Rand: And when we think about robotic surgery, what does that literally mean?

Mohamad Bydon: Yeah, so robotic surgery is something that was heralded by what’s known as the da Vinci robot, which you might know, and the da Vinci robot initially was utilized in abdominal surgeries and urologic surgeries like for the prostate. And actually a lot of that work occurred right here and our urologists have one of the most robust robotic programs anywhere. It was thought that robotics could not be implemented in the brain and spine because of how, we use the term eloquent, they are, meaning it’s high-risk real estate. Now, on the counter side of that argument, because it’s high-risk real estate, we should be leveraging robotic solutions where we have full faith and confidence in them and where we have appropriate measures to ensure that those solutions are safe and effective.

And sure enough, that’s been the robotic experience from my standpoint. I’ve been a part of that now for many years. I serve on national boards for it. It’s a really important effort. It’s an effort that’s progressed dramatically, that makes surgery safer. It does have a dramatic learning curve. Your first case versus your 20th case versus your 200th case, those are very, very different comfort levels and experiences. And so that’s also really important. But I think it’s the future and it’s something that I believe will continue to be there, and it’ll be for the betterment of patients because it’ll make surgery safer.

Paul Rand: Okay. It would be impossible to talk about the advances that are coming and not think about where the promise of AI during surgery is not going to impact it in some form or another. What does this actually look like in practice today? Where is AI impacting the robotic work becomes part of this equation?

Mohamad Bydon: My laboratory is called the Neuroinformatics Laboratory, and that’s been the case for many years, preceding now the more recent wave of what’s called artificial intelligence. And AI certainly has the ability to change a lot of our pathways. AI is most useful where there is a rote, repetitive, highly-similar movement or task. Any highly repetitive task, AI could be very successful at.

Surgeries, especially surgeries of the brain and spine, are not always so repetitive like that. And so AI can help around the margins, AI can help in pre-op planning, AI can help in post-op predictability, AI can help maybe even intraoperatively in terms of software guidance or in terms of surgical plan production. But at this point, and for the foreseeable future, there’s going to be a surgeon involved in that pathway.

Lea Ceasrine: Big Brains is a production of the University of Chicago Podcast Network. We’re sponsored by the Graham School. Are you a lifelong learner with an insatiable curiosity? Access more than 50 open-enrollment courses every quarter. Learn more at gram.uchicago.edu/bigbrains. And if you like what you heard in our podcast, please leave us a rating and review. The show is hosted by Paul M. Rand, and produced by me, Lea Ceasrine, with help by Eric Fey. Thanks for listening.