'A remarkable era': Groundbreaking innovations in treating spinal cord injury offer new hope for patients
Cutting-edge treatments are poised to take big steps in their journey from experimental to mainstream
Gert-Jan Oskam could no longer walk after a cycling accident 12 years ago in China.
He suffered an incomplete spinal cord injury, so while he had some sensation in his lower body, he used a wheelchair after he returned home to the Netherlands.
But he wanted to be able to stand.
That's why Oskam, 40, agreed to be one of three participants in a Swiss pilot study of an experimental brain implant in 2017.
The implant would allow him not just to stand, but to walk. When he pressed a button, a processor worn in a backpack would analyze his brain signals to try to activate his leg muscles for walking.
It worked, but not completely — his gait was stiff and robotic, and his steps were delayed because they were automated.
Then a few years later, the researchers recruited Oskam to "test pilot" an upgraded implant system that would translate his thoughts into motion. When he thought about walking, electronic implants on his skull would pick up his brain signals, register them as instructions to move his legs, and send them to the corresponding muscles through another implant on his spine.
"You're creating a sort of digital bridge" between the brain and spinal cord, said Canadian neurosurgeon Jordan Squair. Squair treats spinal cord injuries at the Swiss Federal Institute of Technology in Lausanne, Switzerland, where work on Oskam's implant is based.
In May, the researchers reported on Oskam's progress more than a year into the study. His walking is now fluid. He can climb stairs and handle rough terrain; he can walk faster and farther; and he's able to use the technology outside the lab at his home.
"The stimulation before was controlling me, and now I'm controlling the stimulation," Oskam said in a media briefing.
In 2024, medical researchers plan a pivotal clinical trial to test the safety of the implant in more subjects. Their goal is to miniaturize the system and make the technology available worldwide.
Implants have multiple benefits
Oskam's progress and other advances in treatment of spinal cord injury — including a pioneering type of microsurgery that's now being performed in Toronto — signal a promising turning point for the field.
In Canada, more than 86,000 people live with spinal cord injury, according to Praxis Spinal Cord Institute (formerly the Rick Hansen Institute). Doctors say about half to two-thirds of those are incomplete injuries like Oskam's.
Squair said linking spinal cord stimulation to help people walk better by decoding their thoughts, as Oskam's implant does, is a true technological step forward.
Not only does the approach help people with spinal cord injuries regain mobility — which they often rank as their top priority, say Squair and Praxis — but it can help people whose injuries are in the neck to control dangerous spikes in blood pressure.
"People are experiencing a lot less episodes of what we call autonomic dysreflexia — these hypertensive episodes when blood pressure goes up really high," he said.
"We found that over time, as people use the stimulation, that is starting to go away, which is really exciting because those episodes can be life-threatening."
Until now, few existing treatments have worked long-term, he said.
'You will feel this deadness'
John Ruffolo of Toronto takes a keen interest in how the field of spinal cord treatment is progressing as part of his own recovery from severe injuries.
When Ruffolo watches videos of Oskam walk, his reaction is: "I'll be there soon."
He hasn't received an implant, though he says he would get one if he had the opportunity.
An avid cyclist, Ruffolo, 57, was riding his bike on a sunny day in September 2020. He was heading down a rural road about 50 km north of the city when he heard the screeching air brakes of a tractor-trailer coming up on his rear wheel.
He doesn't remember the pain of being hit.
After he landed, he tried to move his legs as his upper body seared with pain.
"You will feel this deadness on your body," he said. "My first reaction was, 'Oh s--t, I'm paralyzed.' I was trying to wiggle my toes, and nothing."
On impact, his pelvis split into six pieces. The force broke every rib in multiple places, collapsing a lung and taking out a kidney. Doctors said he lost 50 per cent of his blood volume.
Witnesses, paramedics and physicians expected he'd suffocate to death because of the broken ribs around his chest, which can hinder breathing.
Paramedics rushed him to Toronto's Sunnybrook Health Sciences Centre, a major trauma hospital.
When he made it 36 hours past the accident, doctors performed multiple surgeries to repair his pelvis and then his back, drilling vertebrae and then delicately placing rods and screws.
Each move had to be carefully planned, like removing a block from a Jenga tower, without causing more damage or even death.
Ruffolo and his wife, Carryn, were told he'd never walk again.
Asked about his reaction, Ruffolo lowers his voice to a whisper, his voice cracking.
"The issue is, never remove someone's hope, right?"
Sunnybrook's surgical team considered Ruffolo to have a complete injury of the spinal cord, which traditionally has a guarded prognosis.
The surgeon had to leave several large bone fragments floating in his spinal fluid because they were located in an area that made them too risky to remove. Ruffolo said his spinal cord felt like it was being squeezed and bruised.
A few weeks later, he met with neurosurgeon Michael Fehlings at the Krembil Brain Institute at Toronto's University Health Network. Fehlings told Ruffolo he could remove the fragments with a type of microsurgery called decompression surgery.
Fehlings told him the surgery could help relieve the squeezing to improve his odds for a significant recovery, but there were risks.
"I looked at him and I said, 'Dude, I'm a VC,'" said Ruffolo — a venture capitalist in the tech industry. "I make investments when there's a one per cent chance. I didn't even flinch, and I said, 'Do it.'"
Ruffolo, founder and managing partner of Maverix Private Equity, now does 18 to 20 hours of intense physiotherapy a week. He can walk with a walker, walking poles or on a treadmill.
"You just gotta keep on going," he said.
"I'm not stopping until I walk independently."
Patient's recovery 'gratifying' for surgeon
Ruffolo is also able to ride again using modified recumbent and upright bikes. When he shares video of his rides with Fehlings today, it inspires the doctor.
"While the injury presented huge challenges to him, where he's at now and where he might have been without the decompressive surgery, I think is quite striking," Fehlings said. "That's very gratifying for me to see."
But Fehlings, who is also a professor at the University of Toronto and a clinician scientist, notes that Oskam's and Ruffolo's injuries should be kept in perspective: not every patient will respond as well to treatments because no two patients are identical in the degree and location of their spinal injury. It also helps that both patients were physically active before and after their accidents.
Not everyone with a spinal cord injury is keen to receive implant technology, either, Fehlings said, although he added it is possible the Swiss implant could help Ruffolo's motor recovery.
"The technology was really quite remarkable," Fehlings said. He isn't involved in the experimental device but sees how it could fit in with efforts in restorative and regenerative medicine.
Another thing giving him optimism is the set of international guidelines on treating spinal cord injury, created with Canadian input, that is set to be published in early 2024. They include evidence on the benefits of early surgical decompression to reduce pain, improve mobility and manage other symptoms like bowel and bladder control.
"We're really on the cusp right now of a remarkable era in regenerative neuroscience," Fehlings said.
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