Internal Decapitation -- In Depth Doctor's Interview
Nicholas Theodore, MD, a neurosurgeon at Barrow Neurological Institute discusses the details involved with reattaching a pediatric patient’s skull to his spinal cord after all of the ligaments connecting the two were severed and destroyed due to trauma.
Does seeing the improvements made by Micah leave you awestruck?
Dr. Nicholas Theodore: It does. Micah has sustained an injury that is usually a fatal one. Because of a series of good events, such as being found and mobilized by the paramedics the way that he should, and having the diagnosis made here, followed by a surgery that went utterly flawless, all of those things in succession are going to lead to what I think is going to be a great outcome for him.
What is even more amazing is that his mother sat in the backseat and held his head after the accident. How many mothers do you know that would just grab their babies and do that?
Dr. Nicholas Theodore: Not many. It is not your first instinct to hold your child’s head still. Interestingly enough, when you are in a car seat and properly fastened, the amount of impact is so tremendous for a young child since they don’t have the kind of support from the neck muscles that we do. When you get into a big accident like that (with a seatbelt fastened correctly) your body might not go anywhere, but the head actually acts as a projectile. So the head moves, and unlike an adult who might experience whiplash after enduring a crash, the child’s head gets thrown forward and all of the ligaments connecting his skull to his spine were torn. That makes a very highly unstable situation because the spinal cord is left unprotected. The bones and the ligaments aren’t holding the things together to protect the spinal cord. What we then are faced with is a situation that with every breath he takes they continue to move and that is unstable.
Was his neck also broken?
Dr. Nicholas Theodore: Children under the age of nine who experience a fracture is rare. There were no fractures per say. These were all injuries to the ligaments and supporting structure. Remember that the bones are hard and protective, but with children the bones are spongy and soft. What we are really dealing with here is the ligaments. All of the rubber bands that connect the bones together, and actually hold and fastened the skull to the spine are all torn.
How many are there?
Dr. Nicholas Theodore: There are many, many, many ligaments that connect the skull to the spine . . . all of which in Micah’s case were torn.
How many were torn?
Dr. Nicholas Theodore: Well, we can sort of go into the anatomic stuff, but between the skull and the upper part of the spine, there were a series of ligaments and all of them were ruptured.
When you saw Micah in the ER what were you thinking?
Dr. Nicholas Theodore: Micah had two problems, the first of which was a traumatic brain injury. He wasn’t waking up as someone would if they didn’t have that injury. The second injury was the spine injury, and with that it starts to become very complicated since you are dealing with two separations. First and foremost, we wanted to treat the brain swelling. We put a tube in his brain in an effort to drain the spinal fluid and make sure that the pressure in his head was controlled. The second thing then is to diagnose and treat the problem of the instability because literally, just lying in bed with any sort of movement could have been fatal for him. We had him immobilized and kept him incredibly still before and during surgery. This type of injury is something commonly referred to as interior decapitation. That is really what it is. The head is on the body, connected by the skin and the spinal cord but all of the real supporting structures and ligaments are torn around it and not doing what they are supposed to do.
How many of these types of cases have you seen?
Dr. Nicholas Theodore: The medical term for this is occipito-atlanto dislocation (internal decapitation). We have the largest series here in the world of survivors of this. We have probably treated more than fifty patients here over the last twenty-five to thirty years. If you look in the literature, most patients with these types of injuries die. They die at the scene of the accident, and we have been very fortunate here in Phoenix to have great emergency medical crews who know how to very safely mobilize the spine. The next issue then is making the diagnosis, because interestingly enough it is a diagnosis that can be missed. If you aren’t diligent when looking at the x-rays, MRI’s and CAT scans you can easily miss the diagnosis because it’s a dynamic problem. After the injury occurs, if everything is in alignment after looking at the MRI you might think that everything looks fine. What comes with the second x-ray is the realization that there are torn ligaments that weren’t apparent before. This makes it a very touchy situation.
What did you have to do when you went in for surgery?
Dr. Nicholas Theodore: What we set out to do was reattach his head to his spine. So quite literally, as we exposed everything, and with each breath I could see the skull and spine moving independently rather than simultaneously. That in my mind shows me that we are doing what we need to be doing in order to put those things back together. We took a titanium rod, bend the rod in a configuration of his skull and upper spine, and then wire that rod to the back of the skull and spine in an effort to attach the head. We also need some bone to grow between those two (that is the fusion aspect of the operation). With a child his age, we make an incision on his back and take a piece of rib. Interestingly enough, the rib is curved and it fits perfectly between the skull and the spine. That will grow together and not only do we have the metal there, but we will have the boney bridge between his skull and his spine. In adults, if we do this operation we will lose about seventy to seventy-five percent of motion in our neck. With children that are Micah’s age, as I have followed them over the years, and we have some patients who had this procedure done ten years ago and still have a lot of mobility in their neck. If an adult has this operation, they may be turning their shoulders like this, but for a child that has had this procedure two or so years ago, there is no way of telling that they ever underwent this surgery. This is really amazing.
When you got him out of surgery, did you know that everything was going to be okay?
Dr. Nicholas Theodore: That is when the recovery aspect of the operation commences. Surgery immediately stabilizes the situation, and following surgery we can sit him up and get him out of bed as well as removing the breathing tube so that he can start working towards recovery. He still has a bit of brain injury that we have to contend with. That is the reason he went to rehab. The thankful thing is that he didn’t have a spinal cord injury because at this level a spinal cord injury would have rendered him a quadriplegic. That possibility was very high given the injuries sustained by Micah. That is now not a possibility because his spine is firmly fixed at the top of his skull. Now we are dealing with recovery of the brain injury, and at his age he has already made a phenomenal recovery and we expect those improvements to continue.
Do you think that he is going to be able to fully recover from both of the injuries sustained?
Dr. Nicholas Theodore: I think he will. I really do. At this point he has made so much progress. The younger you are, the better chances you have of recovering from a brain injury because the brain can in due course reorganize itself. The brain can recover or regenerate at any age, however, it does so far slower as we continue to age. With a child that is Micah’s age, the plasticity or ability of his brain to rewire and reorganize itself is exceptionally great. His potential for recovery is actually very, very good.
He has some limitations, right? His father said that he will be unable to participate in any contact sports.
Dr. Nicholas Theodore: Yes. It’s a small price to pay. Alas, Micah will not be playing for the Cardinals, but we have given him the chance of having a very normal life.
Did you hear that Micah was running for the first time this Saturday?
Dr. Nicholas Theodore: I did. There will be milestones that any child makes, however, it is going to be far more special in Micah’s case because of what he has been through. I think and hope and pray that he will continue on his road of recovery and continue to amaze us. I believe that the future is quite bright for him.
He almost seemed more mobile and articulate than most two year olds I have ever met.
Dr. Nicholas Theodore: I don’t know if you saw some of the video of him earlier, but he had such difficulty walking before and that has improved drastically since. Over time, that will continue to get better and better. I think that in a year from now you wont even be able to recognize this child. He is going to look like every other kid his age.
END OF INTERVIEW
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