By Michael S. Shear, M.D.
A spinal cord injury in a football game is truly frightening. It certainly was for Buffalo Bills tight end Kevin Everett on Sept. 9. Fortunately, Everett's injury was not as bad as it seemed at first, and he received excellent care, both on the field and in the hospital.
While attempting to make a tackle on a kickoff, Everett suffered a fracture and dislocation of his spine between the third and fourth vertebrae in the neck.
The spinal cord runs through the middle of the vertebrae in the neck and carries messages from the senses to the brain, and from the brain to the muscles and organs.
It also helps the body function through cells in the spinal cord that interact with the information coming in from the senses or down from the brain. The information is carried in the cord by long tracts of nerve fibers consisting of axons, and they extend up and down the length of the cord.
When a fracture/dislocation occurs, the damage to the cord begins immediately when displaced bone fragments, disc material or ligaments bruise or tear into the cord. Tracts may be cut or damaged beyond repair, and the cells within the cord may be damaged as well. Blood vessels may rupture and bleed into the tissue, causing additional damage. Only minutes after the trauma, the spinal cord may swell, cutting off the blood supply and leading to further damage. Blood pressure may drop as the body loses its ability to self-regulate.
The nature and extent of the loss of function suffered depends upon the level in the spine where the trauma occurs, the nature of the trauma, and the care received on the field and in the hospital. A complete tear of the cord between the third and fourth vertebrae would lead to loss of motor function and sensation in the arms and legs. If the damage is less than a complete tear, there may be partial function and sensation in the extremities. The player’s neck must be immobilized on the field and care given to avoid further damage to the cord in the process of moving him.
Another process, spinal shock, occurs in about half of the cases of traumatic cervical spine injury. During spinal shock, even undamaged portions of the spinal cord may temporarily stop working and cease to interact with the brain. For this reason, and because of the effects of associated injuries, an assessment of the extent of neurological damage is usually not made for three to seven days.
In Everett’s case, while on the field, he did not demonstrate any movement except for his eyes. He was taken to Millard Fillmore Gates Hospital in Buffalo, under the care of the Bills’ team medical director, Dr. John Marzo, orthopedic spine surgeon Dr. Andrew Cappuccino, and neurosurgeon Dr. Kevin J. Gibbons. While being transported to the hospital, Everett received intravenous ice cold saline to reduce his body temperature and possibly decrease the amount of swelling in his spinal cord.
He was also started on large doses of intravenous steroids, which may help prevent injury by increasing blood flow to the cord. He underwent emergency surgery the night of the accident to try to relieve the pressure on the cord, and to stabilize his spine.
The disc between C3 and C4 was removed, the vertebrae were realigned and fused by bone placed between the vertebrae and by metal spanning the vertebrae in front and in back. The operation lasted about four hours. An ultrasound of the cord was performed in the operating room after the surgery and showed no significant damage to the cord or its covering. He was transferred to the intensive care unit, at which time he had sensation in all four limbs and was able to move his legs. He was then sedated to allow the surgical site to heal. Two days later, his sedation was gradually withdrawn. An MRI of his spine showed only minimal swelling.
Studies have shown that the best predictor of the degree of muscle function recovery is the initial muscle strength at the time of initial evaluation. The assessment is most accurate at Day 3 or later after the accident. By Sept. 12, Everett was moving his arms and legs, at least to some degree. Studies have shown that even a flicker of movement in a muscle increases the likelihood of at least some functional use in the future. Most of the neurological recovery is expected within the first three months.
After two weeks in the hospital in Buffalo, Everett was transferred to a rehabilitation unit in his hometown of Houston, Texas. As of Oct. 16, he was able to stand with the use of a special walker, and was able to lift his arms to chest height. He can also use his legs to self-propel his wheelchair well.
There have been debates as to which aspects of his treatment provided the most benefit to his recovery. The physicians at the University of Miami claim that the cold saline I.V. had the most to do with his recovery. I’m not sure that is so. It appears Everett was fortunate to suffer only swelling of the cord in his accident. The limited cord damage, along with the excellent care he received from the moment he was hurt, are major factors in his relatively rapid neurological recovery.
It is still unknown whether Everett will be able to walk without a walker, cane or braces, but his prognosis is good. It is doubtful that he will make a complete neurological recovery. Only time will tell. He has come a long way, and his will is strong.
Issue 2.43: October 25, 2007