RESEARCH FRONT: Cooling Therapy and a Buffalo Bill

By Tom Scott

Cooling Therapy and a Buffalo Bill

In football, injuries are expected and Kevin Everett, 25, has had his share throughout his career. During his stint at the University of Miami, a shoulder injury required surgery and in 2005, a torn knee ligament during the fi rst day of the Buffalo Bills minicamp sidelined him for the season. But the injury he sustained during the 2007 season’s home opener on September 9 against the Denver Broncos at the Bills’ Ralph Wilson stadium was much worse, one that every player in the League fears.

While attempting to tackle Denver’s punt return specialist Domenik Hixon in what appeared to be a routine play during the kickoff of the 3rd quarter, Everett suffered a “catastrophic” spinal cord injury (SCI), fracturing and dislocating his cervical spine at the C-3 and C-4 level. For 15 minutes, he lay motionless, able to move only his eyes as the team’s medical staff prepared to transport him by ambulance to Millard Fillmore Gates Circle Hospital near Delaware Park, Buffalo.

While en route to the hospital, Bills orthopedic surgeon Andrew Cappuccino made a split-second decision to induce moderate hypothermia to lower Everett’s body temperature to 92 degrees in an attempt to prevent swelling and further degeneration of his injured spinal cord and to make it easier to perform surgery. The procedure employs an intravenous injection of the steroid methylprednisolone (similar to cortisone, which is made in the adrenal glands) and ice cold saline. It is an experimental and somewhat controversial treatment method that has yet to be proven effective in clinical trials, but has shown to reduce inflammation, swelling, and cell death.

Upon his arrival at the hospital, Everett’s lowered body temperature was maintained using an intravenous cooling catheter. Six hours after his injury Everett was in emergency surgery as Cappuccino and neurosurgeon Kevin Gibbons repaired his fractured spinal cord by removing the disc between his third and fourth vertebrae in a 4-hour procedure called an anterior cervical discectomy, which also included a bone graft and the insertion of a plate and four screws in his spinal column. The surgery was a success, relieving pressure on Everett’s spinal cord and realigning and stabilizing the damaged areas.

Although Everett did show minor signs of improvement the day after surgery—regaining some voluntary movement and feeling pressure down his feet—his doctors still gave him a 5-10% chance of a full physical recovery. By September 12, however, Everett started beating the odds. He was no longer on a respirator and was able to move his arms and legs slightly and wiggle his toes. In the following days, he regained considerable strength and movement: he could lift his legs and even sit up on his own.

On October 1, accompanied by his mother and girlfriend, Everett, a Texas-native, was transferred by private plane to Houston’s Memorial Hermann-The Institute for Rehabilitation and Research to be closer to his home and family.

Many are now optimistic that Everett will make a full recovery. Dr. Teodoro Castillo, Everett’s attending physician in Houston, told the Associated Press that there are several factors working in his favor: the rapid response after the injury, the medical and surgical care he received in Buffalo, and his age. He also received the best care possible from a talented and experienced medical staff, a luxury not always afforded to individuals who are injured, especially within the first few hours post-injury. Everett’s injury, furthermore, was incomplete, meaning that some messages from his brain could still be transmitted below his injury, enabling some movement and feeling to be preserved.

Some experts believe the biggest factor, however, was the actions of Cappuccino in inducing hypothermia just minutes after his injury. Investigators at The Miami Project to Cure Paralysis in conjunction with the Department of Neurology at the University of Miami Miller School of Medicine/ Jackson Memorial Medical Center have been conducting research for decades to evaluate the use of hypothermia or “cooling therapy” in patients with acute brain or spinal cord injury.

The Project’s Scientific Director, W. Dalton Dietrich, PhD, and his colleagues are credited with a large body of pre-clinical research in the mid-1980s that discovered the advantages of mild to moderate hypothermia.

During an interview with ESPN, Dr. Barth Green, president and cofounder of The Miami Project and chairman of the department of neurological surgery at the University of Miami said the Everett injury was the first time he was aware of that the doctor was with the patient when he was injured and that the hypothermia was started within minutes of the injury. “We know the earlier it’s started, the better,” Green said.

Hypothermia is presently being used to treat patients after cardiac arrest, especially due to ventricular fibrillation (a condition in which there is uncoordinated contraction of the cardiac muscle of the ventricles in the heart) after results of multi-center clinical trials proved numerous benefits to the procedure.

Very few human trials using hypothermia to treat patients with SCI and TBI have been conducted since the procedure was fi rst developed in the 1950s, due to the lack of effective ways to maintain desired body temperature. Now with the availability of cooling catheters and thermal regulation systems that utilize computer technology, such as those used to maintain Everett’s lowered body temperature, research on human patients can be achieved with a great deal more confi dence and precision.

Many questions on the efficacy of mild to moderate hypothermia in treating SCI and TBI remain. For example, it is not yet clear what is the most efficient time frame to administer methylprednisolone and cold saline, which areas to target (the spinal cord or the whole body), and whether there are any long-term effects. Another concern is that improperly cooling the body, specifically below 92 degrees, can cause severe side effects including cardiac arrhythmias, blood clotting disorders, and infection.

Now that the procedure is in the spotlight and is considered by many to have been used successfully to assist in the recovery of an NFL player with SCI, its proponents hope more research and clinical trials will be conducted in the near future to begin to answer some of these questions. For more information on the latest research involving Cooling Therapy please visit the Miami Project’s Web site at www.themiamiproject.org.