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Experimental surgery gives Reeve breath of hope

For nearly eight years, Christopher Reeve's every breath has been forced into his lungs by a ventilator.

He has renewed hope, though, that he might soon breathe without the long plastic tube attached to his throat. Two weeks ago, Reeve became the third person in the country to undergo an experimental surgery to restore his breathing.

Surgeons at University Hospitals of Cleveland implanted four electrodes into Reeve's diaphragm. Twelve times a minute, a battery-powered control box delivers 20 hertz of electricity to each electrode simultaneously.

With each jolt, the diaphragm contracts, sucking air into his lungs, then relaxes, pushing the air back out.

In the days after the surgery, during a rehabilitation session to help him learn how to breathe again, Reeve asked for silence from everyone in the room. His ventilator was turned off. No one talked.

"All you could hear was me breathing through my nose," Reeve, 50, said, while using a ventilator Thursday. "Regular rhythmic breathing from my nose for the first time in nearly eight years. I haven't heard that sound since May of 1995. It meant a tremendous amount."

A horse riding accident in 1995 left Hollywood's Superman paralyzed, a quadriplegic unable to breathe on his own.

With the new device, a diaphragm pacing system, Reeve has been able to be off his ventilator for about 15 minutes at a time, for about one hour each day, he said during a news conference at University Hospitals. Doctors said it could take two to three months for Reeve's diaphragm to get back in shape after years of little use.

However, there's no guarantee.

The first patient to undergo the experimental surgery was 38-year-old Tom Conlan of Valley City, Ohio, in 2001. He didn't respond well initially. But after moving the electrodes during a second surgery, Conlan was off his ventilator within two months. And he hasn't used a ventilator since, said Dr. Anthony DiMarco, even through a bout with pneumonia.

The second implant did not work because the surgeons discovered during the surgery that the patient's phrenic nerve, which controls the diaphragm, was damaged. They revised their procedure to test Reeve's nerve before scheduling the surgery.

"No one knows if this will be successful," Reeve said, "but I'm a pretty determined individual."

Use of the electrodes eventually might strengthen Reeve's diaphragm muscles enough to allow him to do without a respirator, said Dr. John McDonald, director of the spinal cord injury program at Washington University in St. Louis. He has helped design the actor's treatment program.

However, DiMarco said does not expect Reeve to ever be able to breathe without some stimulation because the damage to the actor's spinal cord cut off the brain's commands to the diaphragm.

Each year, about 10,000 Americans suffer spinal cord injuries, with about 1,000 patients requiring ventilators to help them breathe for some period of time. Not all of those patients can be helped by diaphragm pacing, though, DiMarco said. Only 200 to 300 of those patients still have the crucial connection between the spinal cord and the phrenic nerve.

It's for those 200 or 300 people that Reeve holds out hope.

"My recovery doesn't mean anything," he said, "if it doesn't translate into better care for other patients."

For years, doctors have used electrical stimulation to help quadriplegics breathe without ventilators. But the new procedure _ a joint venture between University Hospitals, Case Western Reserve University, MetroHealth Medical Center and the VA Medical Center in Cleveland _ is a departure.

The key to any attempt to help quadriplegics breathe is the phrenic nerve, which carries signals from the brain to the diaphragm. In a quadriplegic, that signal is blocked.

"You need the nerve for the muscle to work," said Dr. Raymond Onders. "If you injure the nerve, the muscle will never work."

The currently accepted approach to diaphragm pacing has two problems, Onders and DiMarco said. First, the patient's chest is opened to get to the phrenic nerve. Secondly, the electrical stimulation is applied directly to the nerve.

That made the operation a risky one, they say. Not only is infection a real concern, but direct stimulation of the phrenic nerve can ruin it.

The accepted approach costs about $100,000, and requires a two- to three-week hospital stay. By comparison, the new University Hospitals procedure can be outpatient surgery at a cost of about $50,000.

Reeve's surgery was performed in a 4{-hour operation on Feb. 28, after which Reeve returned to his home to allow the wounds to heal.

The University Hospitals operation requires three dime-sized incisions. And the electrodes are not placed in contact with the phrenic nerve, but rather at hard-to-find "motor points" near where the nerve meets the muscle.

Software to map out those motor points was created by J. Thomas Mortimer, a professor of biomedical engineering at Case Western Reserve University, and his colleagues. But even with the software, it's not an exact science. Onders and DiMarco, who developed the experimental procedure, tested nearly 100 spots before placing the four electrodes.

The surgery, called diaphragm pacing via laparoscopy, is supported by grants from the U.S. Food and Drug Administration and the U.S. Surgical Corp., a surgical devices manufacturer. The grants offer enough funding to test the device on five patients, but DiMarco said the hospital needs 30 or 35 more patients to complete the study, requiring an additional $2-million to $3-million.

Not only does the surgery help quadriplegics breathe without a ventilator, it also allows them to talk normally.

When Conlan was fitted with the diaphragm pacer in 2001, University Hospitals showed a video of him counting to 20. While on the ventilator, Conlan managed to get to five before his voice trailed off. On the diaphragm pacer, he sped all the way through 20, up to 30, with no pauses.

Reeve looks forward to such advances.

With the ventilator tube in, his sense of smell was gone. With it removed, he could smell again. He decided to put himself to a test, asking people to bring him various items to smell. The first test _ a cup of coffee. Even after eight years without his sense of smell, he recognized it right away.

"So I literally woke up and smelled the coffee."

_ Information from the Los Angeles Times and Associated Press was used in this report.

Stimulating the lungs

Electrodes implanted in areas of Christopher Reeve's diaphragm called motor points provide impulses to stimulate the muscle that used to be provided by the phrenic nerves, which are unable to function since his accident. The impulses provided by a battery-powered pacing device will allow him to breathe without a respirator.

Source: Dr. Raymond R. Onders, University Hospitals of Cleveland

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