Estonian doctors get a boy with a broken back walking again in four days

3. July 2018

“I couldn’t really breathe,“ says Evo, a 6-year-old boy from Võru, trying to put words to his accident that befell him on 8 June. The six-year-old Võru boy fell off a swing and broke his spinal column. He was saved from paralysis and a wheelchair thanks to the action taken by his family members and doctors, Eesti Ekspress weekly reports.

At around seven on the evening of 8 June, Evo was swinging in the yard of his Võru home. All of a sudden, the log swing broke, Evo was flung to the ground on his belly and the log fell on his back.
Luckily, his elder sister saw her little brother lying on the ground and ran outside. The boy wasn’t crying and in fact couldn’t make a sound, so his parents realized something was seriously wrong. They summoned an ambulance and Evo was taken to Võru hospital and on to Tartu University Hospital.
Evo’s parents, who were in shock upon seeing their motionless son, followed the ambulance in their own car.
 “You just find that power in yourself somewhere,“ Evo's mother recalls.  “Only later it hit me, and I wondered how I was able to do anything at all at that moment.”
In Tartu, Evo’s parents heard doctors tell them that their son’s injuries could leave him paralysed.
The paediatric surgeon on duty examined the CAT scan of the child’s back and decided to consult colleagues from East Tallinn Central Hospital – which is where Estonia’s leading spinal surgeons are based.
That evening there was an orthopaedist on duty, the head of the spinal centre Taavi Toomela, who is considered the most experienced surgeon in the Baltics for treating complicated diseases of the spinal column.
To operate or not – that was the question Toomela immediately logged in to an image database to access the uploaded images of the boy’s spine.
 “I realized it was a very critical situation,“ says Toomela.
His spine was severed and caught between vertebrae. Four left ribs were fractured and there was a lung injury.
In that situation, a person’s fate depends on the extent of the damage to the spine.
 “We can get the column aligned, but we can’t restore the spinal nerve. That’s the most critical point – the patients must be treated right away, the pressure on the spine must be relieved and the spinal column stabilized. If a person is broken in half that way, the injury to the spine only gets worse. And a person can be left permanently paralysed,“ Toomela says.
The CAT scan showed that Evo had the beginnings of paralysis. And in response to the question from the hospital’s on-duty surgeon, Toomela reported:  “There no time to lose! We don’t know how fast the paralysis will progress. The boy has to get here.”
 “It was a relief for us,“ Evo’s mother says.  “When the situation is poor, it is good in any case that something is being done. Since I knew that East Tallinn has the finest spinal column specialists, I also knew he was going to be in the best hands.”
Around two at night, the advanced life support vehicle carrying Evo started making its way to Tallinn.
Toomela kept the lines of communication open with the emergency medicine doctor and also prepared his team. In any case, he sent a message to another spinal surgeon, Rasmus Allikvee, who was on also one of Estonia’s best spinal surgeons and treats both adult and paediatric spinal column disorders. Allikvee said he would be ready to come to the hospital immediately if it was necessary.
An operating room was made ready for the boy’s arrival, and an intensive care doctor and duty neurologist were ready to receive him. And of course, the duty physician, Toomela.
At 4am, Evo arrived at East Tallinn Central. He was conscious, awake.
 “In surprisingly good condition given this injury,“ was Toomela’s assessment. The neurologist examined the child and made sure the paralysis had not worsened. It was decided not to operate on the boy at night.
It’s an oft-discussed subject worldwide – if something happens at night, it’s always better to put off the operation until morning. Going into surgery with a team that is rested and fresh,“ explains Toomela.
Had Evo’s condition worsened, the operation would have had to be started right away.
 “If there’s something like this, I usually can’t sleep, or maybe only a few hours during the night,“ says Toomela.  “Time for saving such patients could run out and you have to make an extremely carefully conceived decision. But the most important thing is to make the decision!“
At that moment, was it also possible that Evo would end up in a wheelchair?
 “Yes, but in the case of injuries like that, it’s important not to be too late and do something wrong ourselves.”
His legs are moving!
During the hour-long operation, the boy’s spine was reassembled with implants (titanium screws and rods that hold the column in place), and the pressure on the spine was relieved.
As to whether the operation was successful, the physician could not say right away.
 “We also perform tests during the operation, but not everything can be evaluated. If it isn’t clear, we don’t even put our instruments away. Unfortunately, we're only human, and sometimes complications occur. We also didn’t know what would become of the lung injury,“ says Toomela.
Evo was brought out of anaesthesia 10–15 minutes after surgery. Only at that point could the most important thing be checked: could he move his legs? Yes, he could.
 “That is the thing we really wanted,“ says Toomela.  “We were lucky. I asked my colleagues whether they had treated patients with injuries like that, but it turned out that only extremely seldom. Only a few each year.”
Toomela left the hospital in the afternoon after going basically 34 hours without sleep. But he continued to communicate with the intensive care doctors.
 “I kept calling them the whole time – I felt I was getting on their nerves,“ laughs Toomela. He adds that he doesn’t remember a time when the whole hospital was so moved by a patient.
 “All doctors rooted for the boy and when I made my rounds in the hospital, and everyone asked how the child was doing. I then said I was waiting for the results from an analysis or other.”
But Evo made a rapid recovery. He took his first steps four days after the operation.
Home soon!
Last Thursday, Ekspress and Toomela visited the family ward where circumstances are forcing Evo to reside currently, along with his parents.
Evo lies on the bed and laughter even rings out on occasion when visitors call. Is he in pain?
The boy shakes his head. No.
His parents have been with him at the hospital all these days, trying to overcome their shock.  “Please praise the doctors in the newspaper on our behalf,“ the mother asks quietly.  “We’re very grateful to them.”
 “Do you feel like standing up for a second?“ asks Toomela and approaches Evo.
Evo feels like it. No one assists him, he sits up without a word. And then rises to his feet. And takes a step! He’s really walking!
His first steps are with a walker. Toomela teaches him how to pull the levers on the frame as if “driving a car“. It makes it easier to keep his balance.
Evo’s mother says they didn’t have big plans for the summer, and in the near future Evo was supposed to go to friends’ birthday parties at indoor play centres, but those would probably have to be skipped now.
 “Why?“ the doctor is surprised.
 “The first of the birthdays is this Saturday,“ says Evo’s mother.
Well, in that case, yes, the doctor agrees. Indeed, they won’t make it to Võru that Saturday.
If the family didn’t live so far away, the boy would already be allowed home for weekends. Toomela says that it’s common with complex spinal cord operations today for children to be on their feet and going home in a few days.
 “He’ll have to take the summer fairly easy – no judo for him,“ explains the doctor later as he leaves the ward.
Is Evo allowed to run?
 “In fact, he has to! When children run, everything is OK. “
But Toomela stresses that the reason all went so well with Evo was because the first responders starting with emergency services were so up to the task. It was important that no mistakes were made right after the accident – no one tried to carry Evo indoors or turn him over on his back.
 “When the spinal column is broken, moving someone the wrong way can be a fateful mistake. Twisting or pulling can result in complete paralysis.”
Does Evo need rehabilitative care?
 “No, everything is in order. The child has to be allowed to just be. They can get by with their things.”
Evo made it back home that Monday and now walks without the aid of a walker.
 “There are no signs that he has had a broken back,“ says Toomela in assessing the boy’s walking gait.
Offer of housing in a dormitory responsible for spinal surgeons coming to Tallinn
Kirsti Vainküla
It all started when spinal column doctor professor Rein Raie came back to Estonia from Russia in 1986. He worked in Leningrad from 1972 to 1986 and was slated to start heading up the orthopaedics centre at Tartu University Hospital.
But as housing, he was offered one room in a dorm in Tartu. This was not suitable for Raie, who had a family to raise, and instead he went to work in Tallinn as head of Seppo Clinic. One of Raie’s most famous students is the spinal surgeon Tiit Härma. Earlier on, Härma operated on children at the Children’s Hospital, but now he, too, works at the East Tallinn Central Hospital’s spinal surgery centre, where both paediatric and adult spinal surgery is now based. Taavi Toomela is in turn Tiit Härma’s student, while Rasmus Allikvee is both the student of Toomela and of Härma. Toomela has implemented several dozen new spinal surgical methods, such as an operation performed using pipes – a minimally invasive method, in 2011. In this case, there is no need to cut open the back. Toomela believes that one day, he can also help people with spinal cords severed – those who have dived into shallow water and been left wheelchair bound due to a severed spine. “Scientists are working feverishly in this area,“ says Toomela.
Article published 20 June 2018 in Eesti Ekspress, by Kirsti Vainküla.