Spinal Cord Regeneration Hope
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Watching the Breakfast News on 21 October 2014, I was intrigued to hear about a Polish gentleman who had been the victim of a stabbing attack 2 years ago, severing his spinal cord, who had apparently regained some sensory and motor function below the level of injury, following a transplant of some cells from his olfactory cells, which normally provide a sense of smell.
I was therefore very keen to watch BBC's 'Panorama' later that evening, to learn more about the case and the hope that it might offer to other victims of spinal cord injury.
The programme was extremely informative and focused upon the conjoined efforts of David Nichols, father to Dan, who suffered devastating spinal cord damage following a swimming accident at the age of 18 and set up the Nicholls Spinal Injury Foundation, Professor Geoffrey Raisman, a neuroscientist and renowned expert at the spinal repair unit at the UCLH Institute of neurology, Dr Pawel Tabakow, a Consultant neurosurgeon based at Wroclaw University Hospital, Poland, and Darek Fidyka, a Polish gentleman whose spinal cord was severed in 2010 in a stabbing attack.
Pioneering research by Prof. Raisman led to the realisation that nerves taken from the olfactory bulb of the brain (which generally determines our sense of smell) could potentially lead to spinal cord cell regeneration. This research was closely followed by Dr Tabakow, and when Mr Nicholl's son suffered such a devastating spinal cord injury, breaking his neck on a sandbank whilst swimming in an apparent safe area of beach on holiday abroad, he learnt about the research being undertaken by Prof. Raisman and Dr Tabakow and decided to raise funds to promote the research and a potential cure for his son's paralysis.
According to the Panorama programme, Prof. Raisman's has studied nerve regeneration for several decades. The electron microscope revealed that nerve synapses do not have a fixed set of junctions. Certain nerve synapses can regenerate and restore function within the brain and Prof. Raisman wondered if this was possible within the spinal cord.
Through my own work, I am aware that children who suffer traumatic brain damage to one side of the brain at a young age are sometimes able to develop normally as the brain is able to reprogramme itself. Individuals who have lost all useful sight in one eye sometimes do not notice this until they begin to suffer visual loss in the other eye. Children who suffer loss of vision in one eye at a very early age are able to have near normal vision and perception as the brain cells compensate for the loss.
However, Prof. Raisman's research has focused upon the abilities of the olfactory nerves. The nerves which control our sense of smell are the only part of our nervous system that continually renew. These nerves are focused in the olfactory bulbs, situated within the skull, rather than the nasal bones. They are the only part of our bodies with a neurological circuitry that regenerates throughout our life. The cells there are therefore unique in their ability to stimulate nerve fibres to grow back. Through further research, Prof. Raisman learned that this particular ability is specific to the olfactory ensheathing cells (OECs). He wondered if these cells were transplanted into a damaged spinal cord, whether they would be able to reopen pathways for regeneration of spinal cord function.
In 2010, Prof. Raisman widely published a paper which recorded the positive results of research into this question, in relation to experiments performed on rats, which apparently have a very similar nervous structure to humans of their spinal cord. I do not propose to comment on the ethics of such experiments and Prof. Raisman gives his reasons for the need to conduct these in the programme, but at the end of the day, the results were positive.
Dr Tabakow had followed Prof. Raisman's research with enthusiasm. He managed to obtain ethical approval to inject OECs into the spinal cord of three informed paralysed patients, in minute quantities, to demonstrate that there would be no ill-effects. None suffered any such ill-effects.
Prof. Raisman's research had led him to believe that in order to retrieve the required number of OECs, he needed permission to remove the entirety of one of the two olfactory bulbs, situated higher in the brain.
David Nicholl's became aware of the research, and desperate to do everything he could to help his now paralysed son, Dan, and others that had suffered spinal cord injury, he began to raise funds to support the research. Mr Nicholls was a chef, and a cookbook that he and fellow chefs, including a number of celebrity chefs, produced a cook book which raised about £400,000. To date the Nicholls Spinal Injury Foundation has raised in excess of £2.5 million, and is supported by the Stem Cell Foundation. His money has gone directly to fund the research of Prof. Raisman and Dr Tabakow.
Subsequently Dr Tabakow was able to gain approval to inject a larger quantity of OECs into the spinal cord of a willing patient to see if the treatment had any therapeutic effect. Darek Fidyka was a Polish gentleman who had been stabbed repeatedly by another man when he went to object to his car being vandalised. One of the stab wounds severed his spinal cord. Previously Darek had been a builder, was in the fire service and a keen hunter. He went on to develop a sinus problem which left him requiring sinus surgery, making him a prime candidate for the pioneering surgery. Given the extent of his disabilities and with no real prospect of any substantive recovery, Darek was happy to volunteer.
Crucial to validating any results from the surgery, Darek had to be monitored and videoed to test his truncal strength, muscle mass, sensory and motor function, before undergoing the procedure. The results are shown in the Panorama documentary, but essentially it appears as though below the level of injury, Darek had minimal spinal cord reflexes, which were only able to be stimulated by his physiotherapist. He had no sensation below the level of injury, affecting not only his mobility, but also his bladder, bowel and sexual function.
From my experience of acting for people with spinal cord injuries, these injuries are often those which individuals find the most distressing and those which impact the most heavily upon every aspect of their lives.
Darek underwent surgery over 2 years ago. Dr Tabakow explained that this involved two separate procedures. Firstly surgeons needed to remove one of Darek's olfactory bulbs, and this was then cultured to encourage further cell growth for a period of two weeks. Secondly Darek underwent further surgery whereby surgeons injected the cultured cells directly into the area of his spinal cord injury.
This procedure involved 10 different personnel in theatre and the surgery commenced at 5am. Three Consultant surgeons were present to expose the spinal cord, a process which took around five hours and the extent of spinal cord damage apparently shocked the surgeons involved. There was a gap in the spinal cord of up to half an inch. On the right hand side of the spinal cord, there were some covering cells intact. The Panorama programme described the amount of injection material of OECs available as 'a tiny drop' of around 'half a million cells'. A 'few' OECs were injected into these bridging cells. The sensory and motor parts of spinal cord both needed to be injected, but the majority of the cells were injected above and below the level of severance. A nerve graft was also taken from Darek's ankle, which was again injected with the OECs to encourage growth and Dr Tabakow emphasised the need for bridging material to be present.
Darek and his therapists described the progress that Darek has made in the two+ years since his surgery. To his credit, and those working with him, Darek has committed to around 5 hours of targeted physiotherapy 5 days per week. At 5 weeks post-operatively, an MRI scan showed that the nerve grafts were holding together. Darek advises that around 3 months post surgery he began to experience a pins and needles type sensation in his lower limbs and a reaction to hot and cold. 4 months post surgery he was able to feel some increased voluntary muscle strength during his physiotherapy exercises, albeit that these remained considerably assisted. Importantly, Darek had experienced some return of sensation which has enabled him to maintain a very positive attitude. He was keen to maintain his level of exercise with the aim of further improvement.
At 5 months post surgery it was demonstrated that Darek had continuity of spinal cord nerve activity. The improvement in Darek's function and increased muscle mass was more noticeable initially in his left side. The fact that most of the OECs were injected into the left side of Darek's spinal cord convinced the treating team that the procedure had contributed to his improvement and that nerve pathways were regenerating. The Panorama programme also showed the results of a light touch test. On the left, sensation was much better. There was deep touch sensation on the right, but Darek found it difficult to tell which leg was being touched. It was felt that this was demonstrative of the fact that the nerve pathways were regenerating up the body. Sensation may travel up the right leg but only be detectable in the brain once the nerves have joined across the base of the spine. Encouragingly, at around 20 months post-operatively, Darek's right leg can be seen to having the same type of reaction and muscle improvement as his left over a year earlier.
Now, Darek has reached a point where he can voluntarily move both lower limbs in a cycling movement with some resistance, and is able to walk very short distances with a walking frame and support. Very importantly though, he has now regained some bladder and bowel sensation as well as sexual function, which has a hugely positive impact upon his daily life.
His physiotherapist commented that Darek was the first patient that he had ever treated in whom he had seen such an improvement. Darek himself comments that the biggest change he has noticed is the improvement in sensation and that this gives him hope for the future. He describes previously being unable to feel half of his body and then when the sensation started coming back, feeling as if he has been born again.
Whilst this is all extremely positive and encouraging for Darek in particular, both Prof. Raisman and Dr Tabakow are keen to point out that Darek's outcome does not mean that this can all be attributed to the OEC transplant, and that it is very important for a larger scale and controlled study to be carried out to prove or disprove the efficacy of this treatment. For the moment at least though, Darek's case does offer some hope of regaining some neurological function in the future to those that have been unfortunate enough to suffer from spinal cord injury, including both Dan and David Nicholls.
In the meantime there are a number of extremely dedicated and helpful charities and support groups who are able to assist with adapting to living with a spinal cord injury and accessing available advice and equipment. These include the Spinal Injuries Association and the Southern Spinal Injuries Trust.
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