Well, thank you, Mike. That was way too kind of you. I truly consider one of the biggest honors that I have, that I've ever achieved, is to be able to go to a couple of places and have Mike Steinmetz come with me. And perhaps the biggest honor is for him to replace me as chairman at the Cleveland Clinic. Well, I'm going to tell a story here about spinal cord injury and a 40-year perspective. When I was asked to give the talk, I thought about my disclosures, and I have some, but they're really not relevant here. And the only real significant disclosure I have that does pertain here is that I haven't done trauma in 20 years since I've been at the Cleveland Clinic. And when I was asked to give this talk, I said, what am I supposed to talk about? I can talk about being in the trenches for a long period of time. And the answer was, yes, as long as you intertwine spine trauma with it. So here goes my tale. As Mike pointed out, I started off my career after my fellowship and residency in Shreveport. A little dot in the upper left corner here. Crossroads of freeways, a relatively high per capita burden for trauma. And as Dr. Steinmetz pointed out, I had a huge exposure to trauma during my days there. Then in Albuquerque, we're at the crossroads at the University of New Mexico of two major highways and close to multiple American Indian reservations with also a significantly high trauma density. And so my exposure over the years has been quite significant. I then moved to Cleveland, which is not all that far from where I grew up medically, in Milwaukee. Again, the Cleveland Clinic is not a trauma center, and I do not currently take care of much trauma. I, however, have, like I said, been exposed. And I was exposed to Dr. Tatter early in my career, and I have an immense amount of respect for him. And it's an incredible honor to be able to be a Charles Tatter lecturer. We have collaborated on a number of venues, and perhaps this is one of the most meaningful. In the early years of the American Association of Neurological Surgeons topic series, we were able to edit together a book on spinal cord injury. I learned an immense amount from him. But perhaps the dedication that he wrote, I think, tells a story that I would like to emphasize here today. We dedicate this book to the individuals with spinal cord injury who have taught us so much and from whom we have much to learn. I'd like to talk about where we were, where we came from, where we are, and where we're going. And I'll start off where we were. It all began in the early 1900s with Ellen and others who developed the notion of actually studying spinal cord injury. And the RAP model seemed like a good one, and they developed the weight drop technique. And I and others have tried to come up with a better technique, but fundamentally the technique that was developed over 100 years ago still stands today as a foundation for study. Another person who had a major impact and perhaps the greatest impact on spinal cord injury over the last 100 years or so is that of Sir Ludwig Guttmann. He was probably the best neurosurgeon in Germany in the pre-war years. Being Jewish, he figured it was a pretty good idea to get out, and he went to the U.K. where he, for whatever reason, couldn't practice neurosurgery but was assigned the job because of his interest in spine and spinal cord injury to start the Stokes Mandible Hospital, which we all know is legendary for the management of spinal cord injury. It opened February 1, 1944 in the heat of the war. Guttmann made a bunch of observations, two of which were fundamental. He noticed that the vast majority of patients with spinal cord injuries died, and they died of one of two reasons or both, and that is of neurogenic bladder or urosepsis, et cetera, or decubitus, integument problems. And so he came up with the notion of bladder decompression, and he came up with the notion of turning and eliminating pressure from areas that they observed to be significant and to try to prevent this obviously fatal complication of spinal cord injury. He also was very compassionate. He wanted his patients to do well, to lead a new life with their new body, and he actually started the Stoke Mandible Games for the Disabled in 1948. And in 1952, the Dutch joined, and this became the first international games that is basically the precursor of the Paralympics that we see today. And look at the passion for him. He's working with these young men to try to give them a reason to smile, and they're smiling even after a devastating injury that they have incurred. About 15 years ago, maybe 14 or so, I was in New Delhi, and I visited the Spinal Injury Center of India in New Delhi, and I met this man, and I didn't think too much about it. He's a quadriplegic, and I just knew at the time that he was a pretty important dude. I came back a couple years ago and visited again, and I became a little bit more aware of who he was and what he was all about. After this meeting that we had in Delhi, I took a plane trip to Darjeeling, which many of you know is a tea country in India. And I was told that if you sit on the left side of the plane, 20 minutes before landing, you will have the only glimpse of Mount Everest that you're going to see from India. And I'll be darned, there it is, and I got a couple of really good photographs of Mount Everest. However, it didn't end there. When we were up there in Darjeeling, which is in the foothills of the Himalayas, I noticed that they had a climbing school. And a museum, and it's supposed to be one of the best climbing schools in the world. If you look right here, Norgay Wintenzing is buried in this tomb there. He is the person who, with Sir Edmund Hillary, was the first person to summit Everest. Also in this museum is a picture of this man who led the first all-Indian team in 1965 to summit Everest, and that is Major Alawalia, the person that I'd met 12 years earlier. He is a remarkable person. He was a rock star in India. He had summited Everest. Three months after he did that, he was in a war with Pakistan and was injured with a gunshot wound to the neck and became paralyzed. He used his rock star status to do something that nobody else had done in India, and that is to establish something that would mimic Stokes Mandeville, which is where he was taken, because he was a rock star and survived the injury, obviously, since 1965, and he's done well as a quadriplegic. But his first statement in this little handout that I took a picture of is really telling about that man, Mr. Alawalia. He says, while I stood at the top of Mount Everest on 29th of May 1965, I felt I'd achieved the most difficult feat in my life. A few months later, I was confined to the wheelchair as a result of a war injury. In the months that followed, I realized that the real challenge in my life was not the physical climb of Everest, but that of the scaling the summit of my mind. So, moving on, we've learned a lot over the years. We learned how not to transfer patients, and a lot of these pictures are old, old slides of mine. I mean old, 30 years old, that have been converted electronically, and this is an example of that. This is a slide that I have drawn on how not to bind a head while transporting patients, and how to remove helmets. You can take a cast saw, by the way, and zip around it, but you can't cut through this part right down here, because it's going to have a wire or cable in it, and you need to have a wire cutter. So, with a wire cutter and a cast saw, you can remove most modern-day helmets. We've been over a long road also with traction. Hepburn developed this lower left technique in the 1920s. It is basically an ice tong that he held together by cutting a loop of an entire inner tube and wrapping it around the upper part so that it would apply pressure to the head and allow him to apply traction. This was followed by Crutchfield tongs, and I've seen the Hepburn tongs, and I've actually installed some Crutchfield tongs. It's sort of embarrassing to admit that I'm that old, but their fault was that they were placed too much towards the top of the head, towards the apex of the head, and they would pull out, and thank goodness Gardner and Wells came along with their invention and kind of saved the day so that we could apply traction to effectively reduce fractures, to improve neurologic outcome, and to prepare patients for surgery. We became increasingly aware of the importance of proper imaging, particularly cervical spine x-rays, during the early parts of my career, the importance of swimmer views, noting all the way down to T1 so that we could see pathology that might be hidden had we not otherwise seen it. We learned the importance of spinal shock and how to manage it with fluids and with pressures, and the implications of the loss of muscular function and flaccid paralysis early on. We understood the problems with heat loss. People who are out far away from a medical center, by the time they get to a medical center, and proper management can dissipate a lot of heat due to lack of sympathetic control. And we also began to understand the importance of spinal cord perfusion pressure, just like we understood the importance of cerebral perfusion pressure, and of maintaining systolic and diastolic blood pressure. Schneider and Crosby at Michigan took a different slant on things, and they looked at the somatotopic orientation of the spinal cord, and it was being refined as our knowledge was developing over the prior century, and they saw that they could explain the central cord syndrome by having an injury in the central part of the cervical spinal cord, creating a shawl distribution sensory loss and a greater weakness of the hands because of the hands being located more closely to the center of the spinal cord. They also surmised the mechanism of injury, usually in elderly patients with degenerative disease and stenosis, and often associated with a hyperextension injury. I did a lot of creative things early in my career, mostly because of my chairman, Sanford Larson. We didn't like the notion of lipid-based myelography, and so he and others began using gas myelography, basically injecting air into the thecal sac and then seeing the compression and then decompressing the patient. We did all these ourselves, and you can see how, with our C1-2 injection, how close this came to the spinal cord with the needle. We began learning more and more about the anatomy and biomechanics of the spine and how axial loads can cause Jefferson fractures, as depicted here. Hyperextension loads can cause Hangman's fractures, as depicted here, and how important it is to teach people not to dive into shallow water because the axial load, with usually a flexion component, can cause significant devastation. I remember it somewhat being revelational in what we consider standard treatment strategies for rheumatoid arthritis and C1-2 panus formation and instability, but the treatment strategies for this have evolved over the years, as have they for ankylosing spondylitis. We now have evolved so much that we are minimizing the incidence of ankylosing spondylitis because of appropriate therapies, early identification, and using biologics when appropriate to try to minimize the risk of significant injury from trauma. So where are we today? I think we think a lot more about biomechanics. We understand that upper cervical injuries are related to two things, kinetic energy imparted and the trajectory of the force vector, and we can oftentimes predict the injury type based on those two things. We also understand and appreciate the most common and important equation in mechanics, and that is that of the bending moment equation. Bending moment equals force times distance. A force applied at a distance d from the axis of rotation, as depicted here, can cause a concentration of stresses, which increases the chance of fracture ventrally, which is then propagated dorsally. We can also see compression fractures without the application of a bending moment. It requires a much greater stress or force load. We can also see chance fractures in which the axis of rotation is out in front of the spine. We also appreciate, in correcting cervical deformities and sometimes thoracic and lumbar deformities, the importance of viscoelasticity. I can take the pillow out from beneath this patient's head after I've done some work, and the head will gradually move back over time, so a constant load basically allows a body to change its shape or configuration, and we can use that to an advantage. We know a little bit more about spinal cord instrumentation or spinal column instrumentation, the different ways in which we can cause distraction, three-point bending, compression, and the utilization of cantilever beams, fixed moment arm cantilever beams, screws that toggle, or applying bending moments, such as with a cast bar pin. And we can use all of those things to fix spines. We also know more about why implants fail. And keep in mind, implants don't fail. Surgeons fail. Implants either dislodge or fracture. But why did this implant fracture at its base? Well, implants always fail at the point of maximum stress application, and stress is equivalent to or proportional to the bending moment over the strength or section modulus. We see here with a fixed inter-diameter screw that the stress is going to be maximum here, so the screw's going to fracture here. With a tapered inter-diameter screw, as we move along the screw, we see that the denominator of this equation, with the strength being proportional to the third power of the diameter, the denominator of this equation is going to increase exponentially, while the numerator increases linearly as we move from left to right on this curve. And so we're going to tend to see a fracture someplace in the middle or towards the tip. And screws that toggle, or non-fixed-moment arm cantilever beams, if there is subsidence, there will be three-point bending forces applied. And three-point bending is always greatest. The bending moment is always greatest at the fulcrum, which is the middle arrow here, which is why screws that are placed in this way that actually fracture, fracture because of that application of a bending moment. We'll learn a lot more about respiratory care over time and the importance of volume ventilation and increasing the functional residual capacity to inflate the lungs and minimize complications. We understand that the respiratory muscles are some of the most sensitive muscles to malnutrition or poor nutrition that we see oftentimes in the post-injury state. And so using volume ventilation, chest physiotherapy, and an aggressive management, we start to save even more lives. Nutrition is important. We learned this early. Gutmann understood that. And we refined techniques. We did some studies looking at nitrogen balance. And there's an obligatory nitrogen loss after spinal cord injury for about two months. We must understand that because we can over or underfeed patients. And understanding the importance of nutrition in this very vulnerable population is very good, very important. There's a lot of talk about pharmacology. There has been for years. And there will be for probably years, months, years, and centuries. We had tended to think that the original injury was a primary injury. And that's all that happened. You have an injury to the spine or the spinal cord. But we realized that there's something that goes on afterwards. This is a piece of paper that I took a picture of that is at least 35 years old. I can't reach back in my mind to figure out exactly how old it is. But I drew on this piece of paper in the day what I thought were the important mechanisms for secondary injury following spinal cord injury. I think if we were to try to write this diagram today, we'd fill the wall circumferentially in this room with mechanisms of injury. We understand the importance of calcium and other channels and their disruption with the primary injury that can lead to further injury by an influx of calcium and an outflux of calcium. And we developed pharmacotherapy techniques for this, steroids, naloxone, GM1 ganglioside, magnesium. Nowadays, there are newer ones. But politics kind of got in the way here. What we thought was true maybe wasn't true. Here's some data from the methylproducinone study. And you look over here, naloxone, which never saw the light of day from a true clinical application, came very close to being statistically significant as a treatment strategy for spinal cord injury. And yet it has been dropped. And furthermore, what was known to be the most appropriate dose was not used in this clinical trial. So we learned to not always trust these things. And I'll get to that in a minute. Dr. Larson, again, challenged the notion that we should operate on patients early. I'm not saying he's right or wrong. I am saying he had a point. And we also used gas myelography here. And he says, just look at this. Here we have a gas myelogram with no gas getting through the area of injury. And we got a gas myelogram several weeks later. And we see that the spinal cord has been decompressed. And he would say, aha, aren't we glad we didn't operate on this patient? Frankel grading scale. Frankel came through Stokes-Mandeville as well and was a student of Gutmann. He's an orthopedic surgeon. Developed this early Asia score, if you will, ABCDE scoring system. And we modified that. The grades three and four, or C and D, were expanded to give us a little bit more in-depth division of a patient's pathology. And we used that to study patients. And we would watch patients with spinal cord injury until they plateaued. And almost invariably, if they had an incomplete injury, they would improve. And then if they plateaued short of optimal recovery, we would operate on them. And this is the day's following injury that we actually did the surgery. And we found that in many patients, for example, grade two patients, of the six in this series, two improved one grade, one improved two grades, and one improved three grades. And so we saw a stepwise improvement, even with delayed surgery. We also looked at spinal cord injury and foramenotomies. And patients who had foramenotomies had greater recovery of nerve root function than those who did not. And basically, this is how things look today. Grade two or incomplete motor, but preserved sensory myelopathy, we can expect to see a significant recovery of motor function in a small subset. And as the injury severity decreases, we can see more and more recovery. There have been many surgical advancements over the years, maybe starting in the Paul Harrington era. He developed the Harrington distraction which has a little toggle mechanism here and allows one to distract the spine. And actually Zimmer, who made this in Warsaw, Indiana, had a seven-tongue and an 11-cog Harrington distraction rod. What they found is that surgeons would tend to put the hooks up at the end here and they would see a lot of fractures right here because that's where the stress was the greatest in the implant. Lukey came along from Mexico City and taught us that you can do really good fixation using sublaminar wires around rods. And this patient with a significant subluxation and obviously complete myelopathy, we used Harrington rods in him to distract his spine, then pull it back into position, and then fixed him and brought him into alignment utilizing the Lukey technique. Cottrell and Duboiset invented, if you will, universal spinal fixators where you could use screws or hooks and rods to fixate to the spine and started off with predominantly hooks, but we progressed to screws. Weiss developed the Weiss spring. You say, why in the world would you want a Weiss spring unless you're trying to improve your golf game? And Larson picked up on this. This is one of our trauma patients. This is short segment fixation. You couldn't really do it any other way in the day, but you could do it with a strategy like this with a good inner body strut and something behind that applied a clamp. But Larson's notion was, I'm gonna put a rod in the middle of this to provide, you can see the rod sticking out there, to provide some increased stability. We advanced from non-fixed moment arm or tammer lever beam screws to fixed moment arm screws and then deformity correction. How many of you know what this is? This is the best picture I could find. I had taken this probably 20 or 30 years ago. This is a dentate ligament section. Before we had anterior fixation or even did anterior operations, the only thing we had to offer patients with spondylotic myelopathy, excuse me, was a laminectomy. And we had looked at patients who had had the dentate ligament section to allow the spinal cord to float back away from offending ventral osteophytes and found that in selected patients, it actually worked, but it's a highly morbid operation. So we started with the cervical cases, deformity correction, and then developed the anterior thoracic and lumbar techniques, hook rod systems. Then we became using more and more screws and then screws ended up in the cervical spine and now we can really circumferentially deal with spinal cord problems. But we also understand more about kyphosis and bending moments and balance and the importance of that dating back 20 years. We have spinal pelvic, we began becoming cognizant of spinal pelvic balance parameters and in the last 10 years, we've been applying these same parameters to the cervical spine and understanding the importance of trying to prevent this sagittal vertical malalignment that we often see in patients and didn't appreciate a decade or two ago. A case in point is this patient who had a C7T1 traumatic disc herniation and was treated with this contraption and because the patient had severe neck pain, he unfortunately developed a complete fusion. The surgeon took this device out and gave it to the patient. The patient had enough sense to put this in lower doses, but the surgeon evidently did not. So we saw that this patient had no neurological problems, but he's got backache because he has to lean back to look forward and he's got a lot of neck pain and you can see the problems that he has with the kyphosis trapezius sign in his neck. So we took everything apart and used all the mechanisms that I talked about to put him back together in a lordotic posture and look at his neck now. He's very comfortable compared to before. Very different posture, very different set of circumstances. I would be remiss since I wrote in the day one of the papers with the largest number of gunshot wounds to be remiss to not talk about it. We concluded and a group from Houston about five years later concluded the same thing that the indications for gunshot wound surgery is fairly low, but if there is persistent compression of the spinal canal or instability, there's obviously a clear reason. And sometimes if the fragment seems to be in a vulnerable place like the fecal sac, it's good to probably take it out. We positioned this patient on the operating table and did a laminectomy where that bullet is located and there was no bullet there. So we got an intraoperative x-ray and saw that it rolled down to the bottom of the cervical spine. So what we did was tilted the patient's feet up and just stood there with an instrument and captured the missile as it rolled into our lap during the surgery. Well, where are we going? I think we need to look at these areas, but to be honest with you, and call me a curmudgeon, but I'm not real optimistic here. I think we've looked at so many pharmacological strategies and stem cells, and I personally have two patients that I've cared for that have cancer after stem cell injections. So I'd be very leery of being able to turn these things off and functional electrical stimulation will obligatorily be for the very few because it's going to be very expensive to apply this. In closing, I would like to pay homage again to Dr. Tatter and his wisdom and his thoughtfulness and his great thought put into problems and problem solving. He would say, this is too much. One of my old partners, he's now retired, orthopedic spine surgeon, Gordon Bell, didn't exactly use these words, but he said, you can't unscrew a screw up by screwing it again. And so often we tend to just want to, if the first operation doesn't work, we need to do another operation and another and another, and sometimes that just isn't so. While back, I wrote a chapter with a couple of residents at Kenny Gwadcri and Nina Moore. They interviewed me, and we came up with 15 things that I thought were important from the trenches. And the ones I highlighted in red are relevant to spinal cord injury. The surgeon must not underestimate the importance of a well-informed patient and family. The surgeon must work as a team member and as the leader of the team. It is important to consider both the present and future during the decision-making process. For example, alignment and balance. Complications should be disclosed to the patient and family. After every operation, show gratitude and appreciation to those in the room with whom you work. Patients and family universally look forward to seeing their surgeon. Please act accordingly. Outline the plan before the operation with the patient and family. Maintain meaningful and ongoing dialogue with all patients, particularly those who are not doing well or may have had a complication. And I learned a lot from listening to Rabbi Kushner, who spoke maybe 40 years ago as a Cushing orator at this very meeting, and he wrote the book When Bad Things Happen to Good People, and it was about death and dying. But a couple of the things he said apply to us in caring for spinal cord injury patients. He said that people who are dying and people who feel they have died, part of their bodies died, like a spinal cord injury patient, are afraid of two things, pain and abandonment. And all of those people, both the cancer and the spinal cord injury patients alike, put us on a pedestal, and we cannot abandon them. And so, my last one is, sometimes just sit down and talk to these people. Be leery of research. I show, and be leery of research that sets out to prove something. That's conclusion-based research. You can prove anything you want, and it gets into the literature. But the lower left is a threaded interbody fusion cage. The middle one represents the overuse of opiates, which were, both by many studies, demonstrated efficacy early on. And the last one is the data from the methylprednisolone study. So, what are we seeing here? We're seeing the truth wearing off with time. And there's a body of literature that with people looking at these things and trying to sort out how we can better design study trials, process-based research, not conclusion-based research, trials that are designed to find the truth. This is Scott's parabola. Early on, with any of these technologies, we see the technology presented, it finds enthusiasm. People use it more and more. And then somebody says, wait a second. I did it, I'm looking at this, and I'm having complications. I'm gonna do more studies, and we see this falling off. And then finally, we get out here, and my favorite line, Scott was sort of humorous. He says, this last line says, I'll read it to you. Very old surgeons amaze their juniors with rollicking stories of the old days. And the trouble is, under this curve, there's a lot of people who have been harmed and potentially harmed badly. So, this meeting is about the privilege of service. And I've talked about two characters in the spinal cord injury arena who were privileged to serve and rose up from the ashes, if you will, in times of great need. Guttman and his working with spinal cord injury patients. And I said, I just looked at this picture that I found on the internet, and making these young men smile, I think, is probably one of the biggest rewards he had. And then, Mr. Alawalia, who took it upon himself to say, you know, we need Stokes Mandeville here in India. We need to treat our patients the way they do in UK and the way I was treated, and I'm with my rock star status, and you want to make that happen. For that, I thank you very much. Thank you. Thank you, Dr. Penzl, for this wonderful talk.

spinal cord injury

historical context

neurosurgeon

Cleveland Clinic

early pioneers

advancements in imaging

surgical advancements