"There's a big difference between hard to do and impossible." So said Michael Fehlings, a physician who also does science, and who has done his part to stoke the flames of hope for people with spinal cord injuries.
Fehlings' grandfather steered him toward "an honorable pursuit," one that would "make a difference." He chose medicine. "I knew I wanted to be a surgeon," said Fehlings, "and early on I had an interest in the neurosciences because of the complexity of the brain, so neurosurgery seemed like a good combination."
At the University of Toronto, Fehlings had no idea he would have anything to do with spinal cord injury or spine surgery. A mentorship with Dr. Charles Tator -- a doctor who did research -- exposed him to young people who had spinal trauma. "At first I had little interest in research. But my surgeon-scientist mentor showed me ways to model trauma so one could study it and approach it with an eye toward treatment. To be candid, I felt a sense of frustration that as a physician I couldn't do more to help."
Out of that frustration has come a lifelong commitment to the field of spinal cord injury and paralysis, including key roles within the Reeve Foundation science program. Fehlings' large body of research has been funded in part by the Foundation. Moreover, Fehlings is a member of the Science Advisory Council, is a key advisor to the NeuroRecovery Network and is a principal investigator in the Foundation's North American Clinical Trials Network (NACTN). Dr. Fehlings' research on acute SCI underpins the first NACTN trial, testing the neuroprotective drug riluzole.
"Dr. Fehlings is an absolutely essential part of our science mission," said Susan Howley, Executive VP for Research, "because he has that relatively rare perspective of the M.D., Ph.D. His clinical experiences influence his work at the research bench and it's important that the clinical realities of SCI are married to the basic science. For this reason alone, his contributions to the Foundation and to the field are significant."
(Dr. Tator, too, plays a major role at the Foundation; he sits on the Consortium Advisory Panel, which helps guide the International Research Consortium on Spinal Cord Injury.)
A positive outlook toward SCI
Fehlings has helped reshape the outlook of the neurosurgeon toward spinal cord paralysis. When he came into the profession in the early 1990s he said it was "marked by nihilism. There were people committed to spinal cord injury but the focus was more on do no harm, with a reluctance to operate and an avoidance of intervention. We put people in bed for a long time and the focus was on rehabilitation to adjust to the injury. As doctors we were telling these kids there wasn't a lot to be done."
Surgical techniques came along, however, to change the outlook in emergency management. Fehlings asked the questions, what if the spinal cord could be decompressed early after injury, what if the unstable spine could be reconstructed right away. Would this facilitate better recovery? With Tator, Fehlings began to see in animals that early decompression (surgical removal of spinal bone fragments impinging the cord, done soon after injury) improved recovery. It was a struggle to validate the finding so a clinical trial was initiated; they indeed got data to support a more aggressive approach.
The multi-center Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS) showed that 24 percent of patients who received decompressive surgery within 24 hours of their injury had a significant (2-grade or greater) improvement on the American Spinal Injury Association (ASIA) scale compared with 4 percent of those in the delayed-treatment group. When Fehlings presented that data last year to colleagues at the American Association of Neurological Surgeons, he noted, "It is still not a home run and far from a cure, but what it means is that 1 in 5 individuals is walking away from an injury they wouldn't normally walk away from."
"In a nutshell, we have shown that at least for cervical injuries, early decompression and stabilization are safe and feasible and appear to improve neurological outcome. The validation has been gratifying."
Indeed the shift, said Fehlings, has been dramatic. Fehlings' group recently polled 1000 neurosurgeons and spine surgeons about their attitude toward early decompression. "Overwhelmingly, the attitude now is to decompress and to do it early."
Drug and therapy treatment
Surgical technique is only part of the shift in optimism among neurosurgeons. Drugs and therapies are coming to trial soon. What this means, said Fehlings, is that spinal cord injury may be treatable. "It may never be curable but now we can look at the possibility that effective treatments can limit disability and improve quality of life, as we salvage as good an outcome as we can."
The first treatments will focus on acute SCI, which is understandable, said Fehlings. "Initially, research studies will focus on acute injuries; this is what we can address with what we know. The big challenge is to solve the riddle of chronic paralysis. It's a tough problem." The next few years, however, will witness significant developments. "Chronic spinal cord injury is really the central focus of my lab. I see this as the big question that needs to be solved."
Fehlings believes restoring the circuitry of the damaged spinal cord will require a combination of approaches. "It won't be just drugs or stem cells or some bioengineered solution."
Fehlings lab is addressing the notion that nerve regeneration will require some sort of scaffolding. "One way to make a bridge is to inject nanofibers into the area of disrupted spinal cord. They self-organize to create a latticework. We are also using absorbable materials that encuff the cord and provide a reparative environment.
"We're going to need more than that though: We need a source of cells. One day we may harness the stem cells in the nervous system. These cells exist but are not available in sufficient quantity. We need an exogenous source. One of the areas of biggest promise is induced pluripotent stem cells (iPS). The discovery of these in just the past few years has been one of the big breakthroughs in the field. You have the potential to take one of your own cells, say a skin fibroblast, introduce key molecules called transcription factors and turn the skin cell into an iPS cell, which resembles an embryonic stem cell. You can take that iPS cell and make a nerve cell out of it."
Fehlings noted that numerous labs are working with other cell types, including olfactory ensheathing glia, Schwann cells and adult neural cells. "The cool thing," said Fehlings, "is that these cell types are all about to go to clinical trial or are in late-stage preclinical development. I see great hope for people with chronic spinal cord injury.
"One of the important messages the Reeve Foundation needs to convey is that this research is going to make an impact. Not only for spinal cord injury but for other disorders. We may be able to apply knowledge to traumatic brain injury, stroke, even developmental conditions such as cerebral palsy."
Fehlings and Christopher Reeve met on several occasions. "Reeve was a pretty determined individual. And very inspirational. When he was on the podium, he was just magnetic. Reeve had a huge impact raising awareness of spinal cord injury. He inspired a lot of scientists and clinicians to think about SCI. It was very gratifying to see someone raise awareness and work to increase funding to make it happen. He is very much missed."
Reeve was known to push hard on the research community. "Oh, he had impatience. He wanted things to move forward; he didn't like to hear the word no. He did not like to hear that things could not be done."
Some scientists were put off by Reeve's challenge to move forward with more focus and speed. Not Fehlings. "I was like him in that way: I also don't want to hear that things can't be done. I am a person who likes to try to find the solutions."
The 70-hour Shift: Not Work, Passion
Dr. Fehlings sees patients, teaches students, runs a busy lab and manages numerous professional obligations. He joined the neurosurgical staff at the Toronto Western Hospital in 1992. He is currently Professor in the Department of Surgery, full member of the Institute of Medical Sciences School of Graduate Studies, Director of the Spinal Program at the Toronto Western Hospital, Director of the Neural and Sensory Sciences Program at the University Health Network and Krembil Chair in Neural Repair and Regeneration. His main clinical interests are in spinal neurosurgery, and his research focus is in molecular mechanisms underlying spinal cord injury.
Overcommitted? Fehlings laughs. "It's all a very good fit for me. He says 60 or 70-hour workweeks don't feel like work -- it's my passion.
"I've tried to balance work, life and family by carving out times when I can focus on leisure or family." He has two daughters in college and a son in high school. The family enjoys their cottage in the Lake District north of Toronto, they take an annual ski trip and Fehlings often brings them along on business trips -- they all visited South America last summer as dad lectured to scientists in Buenos Aires.