Annals of Medicine: One Small Step
A paraplegic undergoes pioneering surgery.
BY D. T. MAX The New Yorker
In 2012, Darek Fidyka underwent surgery in which cells from his olfactory nerve were inserted into his damaged spinal cord.
When a spinal cord is damaged, location is destiny: the higher the injury, the more severe the effects. The spine has thirty-three vertebrae, which are divided into five regions—the coccygeal, the sacral, the lumbar, the thoracic, and the cervical. The nerve-rich cord traverses nearly the entire length of the spine. The nerves at the bottom of the cord are well buried, and sometimes you can walk away from damage to these areas. In between are insults to the long middle region of the spine, which begins at the shoulders and ends at the midriff. These are the thoracic injuries. Although they don’t affect the upper body, they can still take away the ability to walk or feel below the waist, including autonomic function (bowel, bladder, and sexual control). Injuries to the cord in the cervical area—what is called “breaking your neck”—can be lethal or leave you paralyzed and unable to breathe without a ventilator.
Doctors who treat spinal-cord-injury patients use a letter-and-number combination to identify the site of the damage. They talk of C3s (the cord as it passes through the third cervical vertebra) or T8s (the eighth thoracic vertebra). These morbid bingo-like codes help doctors instantly gauge the severity of a patient’s injury.
Darek Fidyka, who is forty-one years old, is a T9. He was born and raised in Pradzew, a small farming town in central Poland, not far from Lodz. At 3 A.M. on July 27, 2010, Fidyka and his girlfriend, Justyna, woke up to the sound of someone smashing Fidyka’s Volkswagen outside their house, a few miles from Pradzew. They got out of bed, rushed out the door, and found her ex-husband, Jaroslaw, battering the car with a cinder block. They were not completely shocked. The three of them had been friends since their teen years—Fidyka had gone to Justyna and Jaroslaw’s wedding—but Jaroslaw eventually became a heavy drinker. He started beating Justyna, and then went to prison for it. Justyna obtained an order of protection, and eventually took up with Darek. He moved into her house. “Our earlier relationships hadn’t worked out, so we decided to give it a try,” Fidyka recalls. But Jaroslaw, paranoid, believed that his two friends had begun a relationship while he and Justyna were still married.
Outside the house, Fidyka and Justyna tried to calm Jaroslaw down. Though Fidyka was tall and athletic—he was a contractor and a volunteer fireman—Jaroslaw pounced on him. “I didn’t expect him to have a knife,” Fidyka says. Jaroslaw stabbed him eighteen times. Several of the wounds punctured his lungs, and one nearly cut his spinal cord in half.
As Fidyka lay on the ground, he felt his body change. “I can remember very vividly losing feeling in my legs, bit by bit,” he says. “It started in the upper part of the spine and was moving down slowly while I lay waiting for the ambulance to arrive.” He adds, “I was aware of everything. I could feel my strength leaking out with every thrust.”
Jaroslaw dropped his weapon and ran away. He hanged himself shortly afterward, in a nearby orchard.
Today, Fidyka lives at Akson, a rehabilitation facility in Wrocław, a city in western Poland. The attack left him paralyzed from the waist down. The Akson facility is affiliated with the city’s university hospital—Wrocław is the former German city of Breslau, long a place of medical excellence—and occupies a two-story building on the town’s outskirts. The long, low structure, a former Hare Krishna center, was built on open land, but it is being walled in as Poland prospers and new buildings are constructed. Fidyka lives in a narrow room on the second floor. He has a laptop and a few books; the only picture on the wall is of Pope John Paul II. Justyna left him six months after the knifing.
On the day I visited, there was a bowl of clementines that his mother, who lives in Pradzew, had brought for him. Many nights, she sleeps there, in a bed on the other side of the room. Her scuffs are lined up next to his sneakers, which are eerily spotless.
Fidyka spends much of his time downstairs in an exercise room, trying to gain back his lost strength. I watched him there one sunlit morning this past spring, as a physical therapist helped him stretch. Cramping and spasms are a problem for the paralyzed, and a large part of what therapists do for them is provide artificial impetus to muscles that are meant to be in motion. Fidyka lay near two female patients: a C6-C8, who had been paralyzed from the waist down after a car crash, and a T5-T8, whose spine had been damaged during an operation for a tumor. Fidyka was lying face down on a gym mat; the therapist was sitting on him, on a cushion, and pulling up on his back. Physical therapy is not meant to be watched. It is intimate and awkward, the gap between the well and the diminished underscored at every moment.
Fidyka looked very tired. A cold had sapped his energy, and it was a Friday. When you do physical therapy eight hours a day, five days a week, it is as hard as athletics. On weekends, when Fidyka and his mother go home to Pradzew, about a hundred miles away, he is depleted.
People with a damaged spinal cord can get better without interventions. In the first few months, it is not unusual for a patient, especially one with partial spinal-cord damage, to regain some strength or sensation in the legs, or some bowel control or sexual function. But after this period the likelihood of improvement drops off radically. Scar tissue covers the wound, and even nerves that were initially unscathed die, leaving the body less able to renew or rewire damaged nerve circuits. According to Steven Kirshblum, a medical director at the Kessler Institute for Rehabilitation, in New Jersey, after a year fewer than two per cent of patients with a complete spinal-cord injury show significant motor recovery. Each year that follows shuts the door a bit more firmly. At the time of my visit to the Wrocław facility, the T5-T8 still had a chance of improving—the botched tumor operation had taken place only nine months earlier—but it had been seven years since the car accident that left the C6-C8 unable to walk. For her, physical therapy was maintenance and precautionary—for flexibility and over-all health, and to avoid bedsores.
At first, Fidyka appeared to be on the same path as the C6-C8. After he was assaulted, an ambulance took him to an emergency room in the county capital of Bełchatów, where he lay in a coma for three days. “My family and friends told me that it was touch and go,” he remembers. When he awoke, his first response was joy at being alive. At the time, his sister, Wioletta, was pregnant, and the stress caused by his injury sent her into labor; while he was unconscious, a niece had been born. Upon waking up, he called Wioletta. “This is the first time for her,” he said, of the baby. “The second for me. I’ve received a second life from God.”
He assumed that he could still walk, and when he found that he couldn’t get out of bed he wasn’t worried: he figured that he’d walk soon. He loved to hunt, and expected to be back in the woods outside Pradzew before long.
After a month of basic physical therapy, in Bełchatów, he was transferred to another facility. Physical therapy can help new spinal-cord-injury patients recover function—the body relearns by doing—but after six months Fidyka had regained no strength or feeling. By that point, his public benefits had run out, but his family had friends in Lodz, and he spent six weeks at the university hospital there. It didn’t help. In March, 2011, Fidyka was discharged—incontinent, impotent, and without sensation or strength in his legs—to go on with his life as best he could. He had been a busy general contractor who dabbled in interior design, and in Pradzew he had been a charismatic and well-liked figure. Now, on returning home, he says, he was too depressed even to watch TV. “I didn’t know what to do with myself,” he remembers. “I was empty inside.”
The man I met at Akson was no longer demoralized. Fidyka shook my hand with exaggerated vigor, like a salesman. He wore a T-shirt and sweatpants, and his blue eyes twinkled. When I asked him why he was always chewing gum, he joked that he’d been told to exercise all his muscles. His custom-built red wheelchair has a seat-back cushion with an image of a stallion rearing from a wheelchair; as he rolled himself up and down the halls of Akson, his jaws working fervently, you felt that the same image was in his head. The other patients in the facility seemed beaten down by the irreversibility of their situation, but Fidyka projected an intense, if trammelled, physicality.
After the back-stretching exercises, the physical therapist began pulling up his lower legs. Fidyka, who is six feet tall and weighed a hundred and seventy-two pounds before his injury, remains muscular above the waist, and his frame is large enough so that even his paralyzed lower parts don’t seem atrophied. He grimaced as the therapist stretched his hamstrings—first the left, then the right. Fidyka closed his eyes; he buried his forehead in his fist. The two women in the room were also being stretched, but their faces showed nothing. Their relationship to their limbs seemed distant and polite, as if they were renting them.
Later, the therapist worked with Fidyka to build his strength. He lay on his back and pushed one leg out against the flat of the therapist’s hand. His quadriceps visibly tensed—making clear that he has regained some control over the muscles below his waist. This development is remarkable and has almost no counterparts in the clinical histories of people with spinal injuries. And it suggests that an operation he received at the Wrocław University Hospital, in 2012, was a success. During the procedure, surgeons removed some of the cells surrounding the nerves that run from Fidyka’s nose into his brain and injected them into the gap that the knife wound had left in his spine. Our nasal passages are exposed to a lot of abuse—from pollution to viruses—and the neurons within them die and are reborn constantly. This regrowth is managed by supporting cells, called olfactory ensheathing cells, which form tunnels that neurons thread their way through. (A 2006 article in the London Sunday Times Magazine compared the nodules to the “tiny porous canals” of a Cadbury Flake bar.) Fidyka’s doctors—guided by an idiosyncratic British researcher named Geoffrey Raisman, the head of neurological repair at the Institute of Neurology at University College London—believed that if ensheathing cells were injected into his spinal cord they would help injured neurons to cross the wound, healing his spine. The surgeons had to open his skull and take out the ensheathing cells, a five-hour-long operation, and then open up his spine and put them back in—another five hours. Before Fidyka, no animal more complex than a rat had been subjected to the procedure, which was risky. Yet the gamble appears to be paying off.
As soon as Fidyka had healed from the operation, he began an intensive course of physical therapy. A few months later, there were small signs of muscle activity in his left leg. Soon, he could feel pinpricks in his right. “Sometimes, when I was shifting into or from the wheelchair and I knocked my legs against something, there was this new sensation,” Fidyka remembers. When his right thigh began to ache, he discovered a bedsore that had been there for months. Electrical-muscular studies and M.R.I. scans suggest that neurons in Fidyka’s spinal cord above and below the wound have sprouted extensions again; some may even have crossed the half-inch wound to reconnect with one another.
Upon detecting such signs of progress, Fidyka’s medical team was not stinting in its self-congratulations. The results of the operation, Raisman said in a 2014 BBC documentary, were “more impressive than a man walking on the moon.” He called olfactory ensheathing cells “a magic carpet.” Raisman can be forgiven his pride. Olfactory ensheathing cells have shown surprising promise in healing spinal-cord injuries in a field dominated by far better-funded efforts, principally stem-cell transplants and experiments to stimulate nerve growth through drugs. So far, these two methods have not worked as well as hoped—stem cells turn out to be difficult to manipulate, and the microenvironment of spinal-cord fluid is extremely complicated. Ensheathing cells have become a surprise contender.
Fidyka is now ambulatory, with the help of high leg braces and a walking frame, and he can ride a stationary bike if he is hoisted onto it. His recovery is significant without being miraculous. “He can walk, but he’s not dancing” is how Raisman described Fidyka’s condition to me. In this world, there are no Lazarus stories. But this is a field where even small gains have eluded surgeons for decades. A 2003 book by John Russell Silver, “History of the Treatment of Spinal Injuries,” flatly declares that “the spinal cord cannot be repaired.” So if Fidyka continues to inch along the path to recovery—and if the procedure can be replicated in other patients, with comparable results—he will make medical history. He will be the first person confirmed to have had spinal paralysis reversed by an operation.
It’s not easy to hurt the central nervous system. The load of neurons in the brain is encased in bone worthy of a tank manufacturer, and the cord that transmits their commands is brilliantly defended by the vertebrae, which are set in a mesh of leathery membrane. There is little in nature that can invade this flexible redoubt. Of course, our lives are not subjected to only natural forces anymore. In the United States, roughly forty per cent of spinal-cord injuries are caused by automobile crashes, with gunshots accounting for thirteen per cent. Then there are sports accidents: flips on the trampoline, dives in the wrong end of the pool. Young people are at greatest risk—according to the Mayo Clinic, the most perilous years are between sixteen and thirty—and men are four times as likely to hurt their spines as women. The Christopher & Dana Reeve Foundation reports that more than a million Americans are paralyzed as a result of spinal-cord injuries.
Detailed descriptions of spinal-cord injury date back to the first known medical document, an Egyptian papyrus from 1600 B.C., but it was not until the First World War that interest in treating it began in earnest; before then, it was as infrequent as it was devastating. Of the tens of thousands of spinal-cord-injury patients on both sides of the Great War, eighty per cent died in short order from sepsis initiated by bedsores or kidney infections, and many of the survivors died soon after. Amid so much carnage, it came as a revelation that simple protocols—always using a catheter to remove urine, turning a patient in bed every few hours—increased life expectancy dramatically.
But to what end? Those who survived were eventually sent home from the hospital with no hope of improvement. People with spinal-cord injuries have become far better integrated into society—these days, no one expects a paraplegic to just disappear, and motorized wheelchairs can now be directed by breathing into a tube or by eye movement. For many paralyzed people, disability is a challenge but not a sentence. Yet the condition remains overwhelming for others, as much for its psychological impact as for its physical restrictions. The suicide rate of Americans with spinal-cord injuries is three times higher than the average.
When we hurt, we expect to get better. If you cut your finger, the tissue grows back, and beneath the skin the nerves reknit their severed connections. Soon the finger can move and feel things again. Of all the neurons in the body, only those in the central nervous system—the ones situated in the brain and the spinal cord—seem incapable of this trick. Broken backs do not heal, and, with few exceptions, brain cells do not regenerate. Perhaps it is an artifact of biology: central-nervous-system injuries were so rare in our prehistory that there was no reason for evolution to expend energy devising strategies to fix them.
The belief that there was nothing you could do to repair a spinal injury prevailed for centuries. But in the nineteen-sixties a generation of researchers began to question this assumption, among them Geoffrey Raisman. The grandson of Lithuanian Jews who immigrated to England, he got both his undergraduate and medical degrees from Oxford University. (His father, a tailor, made the suit that he wore at his medical-school graduation, in 1965.) Raisman had planned to become a physician but found himself drawn to basic research, particularly to anatomy.
Raisman, who is seventy-six, is querulous by nature, a determined outsider. When I visited him in London, at the Institute of Neurology, in Queen Square, I found that he worked at a makeshift desk in a corridor, as if he were a graduate student. “I have no office,” he boasted. He called to a colleague, “Do you want a journalist to pester you? I have one!” He has curly brown hair that has receded to the top of his head; his voice often rises to reflect the indignities he has suffered—and the counterblows he has landed. He is a proud polymath: he told me that he has given lectures in Mandarin, and he is fond of quoting Tennyson. Raisman used to run a large lab at the National Institute for Medical Research, in London, but he found managing it a bother, and he now works with only two associates, who have been with him for decades. “Research progresses faster than when I had thirty,” he claims. He gets no government research money, and raises most of his funds from small private charities. Yet, for all his cantankerousness, he is part of the British medical-research establishment. Everyone knows Raisman, and his science—anatomy in an era of molecular biology—is grudgingly admired by many. Susan Barnett, a researcher in spinal-cord injuries at the University of Glasgow, says that Raisman’s “quirky, eccentric” manner stands out in the conservative medical world: “Geoff has this personality that he just wants to do it, and will do it regardless.”
Shortly after graduating from medical school, Raisman took his first look at a spinal cord through an electron microscope—then a novel tool in research. Viewed through a conventional microscope, he remembers, the injured parts looked still and dead—“like a forest of trees, silent in a windless sky,” as he told the Sunday Times Magazine. But with an electron microscope’s higher magnification he was surprised to see surviving neurons spilling into the area of the damage, replacing lost connections. “I suddenly could hear the leaves rustling,” he remembers. To Raisman, the images shattered the dogma that the nerves in the human body declined after infancy. The tissue was clearly attempting to recover lost function. Raisman’s work in the mid-sixties helped establish the doctrine of plasticity—he even takes credit for inventing the term. The central nervous system is not at all static; it is constantly remaking itself in response to both opportunity and insult.
Armed with this idea, Raisman began transplanting nerve cells into the damaged brains and spinal cords of rats. He had theorized that new axons—spidery extensions that carry the neuron’s impulses—would sprout enthusiastically, and this proved correct. The problem was that the axons did not find receptor cells for the electrical impulses that they were trying to relay. He came to think that researchers had misunderstood what went wrong after a spinal-cord injury: that the problem lay not with the neurons but with the pathways they had once travelled along. As he explained to me in his non-office, “Imagine the nerve fibre is a motorcar. You call it an ‘automobile,’ don’t you? Imagine it’s an automobile. They can travel only where there’s a roadway. They can’t travel across water, they can’t travel across plowed fields, they can’t travel across mountains.”
Raisman understood that he had set himself a difficult problem. The ancient Egyptian papyrus about paralysis had warned that it was “an ailment not to be treated,” and he kept a copy of this document on his office wall. But he threw himself into discovering a solution. During the seventies and eighties, he remained “hunched over a sort of periscope, peering down a little green tube,” as he wrote in an unpublished memoir, trying to answer his own question: How does a neuron’s axon find its way to its appropriate target? Neurons are only a portion of what is cumulatively called a “nerve bundle”; they carry the electric impulses that govern muscle contraction or register sensation. But neurons are surrounded by various kinds of ancillary cell, grouped under the name of glia (modern Latin for “glue”). Glial cells vastly outnumber nerve cells. When Raisman began investigating paralysis, no one knew what the glial cells did, though there were hints that their role was significant. “Einstein’s brain had an unusually high proportion of glial cells,” he points out. “Could it be a coincidence? We’d have to kill a lot of geniuses to find out.”
At the time, glial cells were considered the brain’s equivalent of junk DNA, and most neuroanatomists were not interested in them. They seemed to hold little promise in spinal-cord repair; in fact, they appeared to play a contrary role. After an injury, a chain of responses takes place in the spine: broken blood vessels swell, killing off neurons that end up squeezed within the cage of the vertebrae. Other neurons, sensing that the central nervous system has been breached, commit suicide; still others sprout new axons that struggle to reëstablish severed connections. Glial cells appear to hinder this regeneration process: they rush to create a physical barrier, sealing the spinal cord with scar tissue that neurons cannot penetrate. According to many researchers, the glial cells that form the scar are toxic to growing nerves.
But Raisman realized that there is one part of the central nervous system where glial cells encourage regeneration: in the nerves that connect the nose to the brain. The nerves of the nasal cavity regrow when they are damaged or cut, and this healing is directed by special glial cells, which usher neurons along the path from the nose membrane to the brain. When nerves in the nose die, after three months or so, new ones spring forth, allowing people to maintain the ability to smell. In the nineteen-nineties, Raisman damaged the spines of rats with a tiny needle heated at the tip, and then inserted the special glial cells—olfactory ensheathing cells—at the site of the wound, to see what would happen.
As I sat in his corridor, he showed me a short movie that he had made some years ago. It features footage of an unnamed white rat crosscut with video of his granddaughter Amy when she was about a year old. (He noted that his daughter, Ruth, wasn’t thrilled about the juxtaposition.) “Off you go, Amy,” Raisman said to the screen, clicking the play button with excitement. In the video, the toddler crawls up the stairs of her house. But it is not Amy whose crawling you are meant to be excited about; it is the rat that is climbing in subsequent images. Raisman had severed the nerve in its spine that controlled its front left paw, then introduced olfactory ensheathing cells to heal the wound. The movie shows the rat before and after the procedure. In the first shot, the rat, favoring its left paw, is unable to grasp the bars of its cage as it tries to climb out. In the second shot, the rat scampers up the side of the cage “with aplomb,” as Raisman put it to me. He then recalled the story of the day he had noticed the animal’s striking recovery. One evening at midnight, he had gone to visit the lab’s rat enclosure—“Rats are more active in the night,” he explained—and held out a bit of crushed Chinese egg noodles. “It put its paw right out and took the food, and realized it could do it, and I realized we had done it,” he says. “To the best of my knowledge, it was the first evidence ever that you could get spinal reconnection.” The pleasure of that moment hadn’t dimmed in almost twenty years. “That rat convinced me,” he says. “That was the eureka moment, I would say, of my existence.”
Raisman was not a practicing doctor. He knew he was not the right person to lead a human trial. “I don’t even know how to read an M.R.I.,” he cheerily concedes. Yet the need for spinal-cord repair in humans was clearly enormous. There is often a particular intensity to the hope of families whose loved ones may spend fifty or sixty years in a wheelchair, and Raisman seems to have a similar focus—he has spent nearly that long trying to help the paralyzed. When I visited him in his hallway, he had a handwritten letter on his counter from a paraplegic who was hoping to be among the next set of patients for the treatment that he had pioneered in Poland. Raisman is eager to help as many people as he can, but he does not try to control or profit from his ideas. “I can’t patent what’s inside your skull!” he says.
That has not stopped others from trying to do so. And, as once advancing areas of spinal research have slowed, many surgeons have tried implanting olfactory ensheathing cells in humans, despite the scarcity of experimental data. (Only a few scientists, in Spain, Canada, and Australia, have published research as rigorous as Raisman’s.) Over the past two decades, thousands of desperate families have paid for these surgeries, which can cost up to fifty thousand dollars and are not covered by insurance. The procedures are performed in countries where ethics oversight is less stringent than in the United States or Britain, and sometimes there are botched results. In 2005, one such surgery was performed, in Lisbon, on a woman in her early twenties; eight years later, she complained of pain, and a biopsy revealed that there was a three-centimetre growth—mostly nasal tissue—on her spinal cord.
The best-known olfactory-ensheathing-cell surgeon is Huang Hongyun, a Chinese doctor who, since 2001, has operated on thousands of patients with spinal damage and other neurological ailments. Huang injected them with olfactory ensheathing cells taken from aborted fetuses, and claimed that some people were walking again within seventy-two hours. In 2005, the BBC asked Raisman and his team to go to Beijing and evaluate Huang’s procedures. In the resulting documentary, “The Doctor Who Makes People Walk Again?,” Raisman is asked in front of a patient what he thinks of the patient’s putative recovery, and he says, distressed, “I can’t assess it.” He and Huang are now friendly—neurorehabilitation is a small community—and he says that he admires him as “a pioneer,” though with caveats. Huang’s work, he told me, choosing his words carefully, “is not done at the thorough level that I would wish it to be done.” (A 2006 investigation of Huang in Neurorehabilitation & Neural Repair, led by James Guest, a Miami neurosurgeon, suggested that Huang had likely both understated medical complications and overstated results. The investigators were not even certain that Huang had been injecting olfactory ensheathing cells. Huang told me that he was an expert in handling such cells, and added that his patients had made “many improvements both in neurological functions and quality of life.”)
After his eureka moment, Raisman began looking for the right doctor to be his partner. He attended conferences and dropped in on small labs that appeared to be doing ambitious work. But he never found the ideal collaborator. Finally, he forged a connection with Pawel Tabakow, a Bulgarian-born neurosurgeon in Wrocław. Raisman recalls, “The others all rushed to say, ‘Ah, yes! Get the cells from anywhere! Stick them in!’ Pawel was careful, logical, and methodical.”
Polish by training and precise by disposition, Tabakow is now forty-six; like Raisman, he rebelled early in his medical studies against the doctrine that the central nervous system could not heal itself. While attending medical school, in the nineties, he read Raisman’s papers on rats and was fascinated. “We did not get any information from our authorities that something like this was possible,” he remembers. Tabakow pursued a Ph.D. in neuroscience, and for his dissertation he extracted ensheathing cells from human cadavers. Raisman learned of this research and made plans to visit Wrocław, where Tabakow had joined the faculty. Raisman came to a realization: “Pawel and I were blood brothers.”
Tabakow became an expert in culturing olfactory ensheathing cells, further impressing his mentor. In 2008, he began operations using the cells on patients with spinal-cord damage. The results of the first two surgeries were mixed: the operations seemed safe, but patients did not improve significantly. In 2010, he invited Raisman to watch a third surgery. “He viewed the entire operation,” Tabakow recounted to a Polish newspaper. “Ten hours standing. He said, ‘What you are doing will make maimed people start walking.’ ” Raisman recalls it differently: “We didn’t need to say it. If we were right, this was a piece of history.”
By the time Darek Fidyka met Pawel Tabakow, a year after his injury, he was desperate. Doctors had told him repeatedly that he would never walk again. Paralysis often leads to other medical problems, and Fidyka had endured lung infections, inflammation in his leg veins, and pressure sores so bad that they had to be treated with a costly special medicine. “My relatives said that the medicine was like liquid gold—it was that expensive,” Fidyka recalls. “I was so weak physically that I could only lie in bed. I couldn’t even go anywhere in my wheelchair.”
A cousin of Fidyka’s who is a doctor read about Tabakow in a newspaper and urged Fidyka to visit Wrocław and ask to become a patient. Fidyka, whose feelings at this point bounced between absolute despair and wild hope, agreed to go, even though he would have no way to pay for the course of treatment. “The price was enough to make angels weep,” he recalls. When Tabakow examined Fidyka, he initially did not like what he saw. Fidyka had a lot of spasticity—uncontrolled muscle contractions suggesting extensive spinal damage—and he seemed very depressed. Then Tabakow looked at Fidyka’s M.R.I. scans. Most spinal-cord injuries are fractures or compressions in which the cord is crushed or twisted, the vertebrae have damaged the nerves, and the resulting wound is a messy mixture of bone, injured neurons, and dead tissue. But Jaroslaw’s knife had slid in between two of Fidyka’s vertebrae, severing his spinal cord almost entirely and leaving a neat half-inch gap. Fewer than five per cent of spinal-cord injuries resemble Fidyka’s. He recalls watching Tabakow examine the scans: “I can see his eyes getting bigger and bigger.”
Tabakow saw the opportunity for an operation that was easier to execute and likely to produce clearer results. He sent Raisman an excited e-mail. For Fidyka, though, a major obstacle remained: the cost. His family organized a town fair to raise money, and by the time he went back to Wrocław for a second appointment he had forty thousand zloty (about ten thousand dollars) in his pocket.
Before finding Fidyka, Tabakow and Raisman were at a crucial point in their project. The ten-hour operation that Raisman had witnessed in 2010 had also not resulted in significant improvement. They had a suspicion about what was going wrong. The olfactory nerve begins in the nasal cavity and ends in the olfactory bulb, in the brain. The olfactory ensheathing cells in the brain, the doctors surmised, were better suited for promoting growth in the spinal cord, since they were accustomed to conditions in the central nervous system. But, because it was unlikely that an ethics board would allow a doctor to operate on the brain of a human for uncertain gain when a simpler and less risky procedure on the sinuses was possible, surgeons in the West had used only ensheathing cells from the nasal cavity.
The doctors felt a strange form of luck, then, when they discovered that Fidyka had sinusitis so severe that he had undergone an operation to remove part of his sinuses. Ever since, his sense of smell had been diminished. Tabakow and Raisman concluded that there would be few usable olfactory ensheathing cells left in Fidyka’s nose. This posed an opportunity. “You have such a promising spinal-cord injury that I can help you,” Tabakow told Fidyka. “But I need to open your skull.”
Fidyka did not hesitate: he still dreamed of being able to climb the hunting blinds outside Pradzew. “Do whatever you can to make it better, because it can’t be any worse,” he answered. Wioletta, his sister, recalls, “For him, it was win or lose—I will walk or I will not live.”
Tabakow told his hospital ethics board that it essentially had no choice. Some doctors, he acknowledged, might insist that the experiment be performed first on pigs or monkeys. But Fidyka didn’t have the time to wait. “If we had been forced to test our approach, it would have taken us three or four years more,” Tabakow recalls. “We had a patient, and it was already two years after the injury. Darek’s spinal cord was just degenerating.” Tabakow told his colleagues that they should not miss “a historical moment.” (Tabakow was more casual about the matter with me, over a lunch of pierogi and cucumber soup cooked at Akson by Fidyka’s mother. “Everything is dangerous,” he told me. “Surgery is dangerous. Life is dangerous.”)
The operation was approved only after the team had shown that physical therapy alone could not ameliorate Fidyka’s condition. He had spent eight months undergoing an intense exercise regimen, along with electrical stimulation of his injured spine. Compared with the state-run rehab facilities he had used before, the private facility’s equipment and staff seemed amazing, he says. It was, he jokes, like selling a Fiat to buy a Mercedes. He worked as hard as he could, but to the doctors’ perverse relief he did not improve at all.
Meanwhile, Wrocław University Hospital had approved the brain operation. In April, 2012, Tabakow, with his medical team, opened up Fidyka’s skull and removed part of his olfactory bulb. The human sense of smell is not very acute, so the olfactory bulb is relatively small—about the size of a sunflower seed. (A goat’s is larger.) Tabakow and his associates next sliced the extracted tissue into two-millimetre sections, isolated the olfactory ensheathing cells, and then gave them almost two weeks to subdivide, in order to have enough cells—half a million—for the operation. Then he opened Fidyka’s spine around the T9 vertebra and made almost a hundred microinjections to situate the cells above and below the wound. He placed more of the cells onto a strip of nerve tissue that he’d extracted from Fidyka’s lower leg and inserted in his spine, in order to help span the gap in his cord. Tabakow closed the incision, and within a few weeks his patient was beginning his real rehabilitation.
Advances did not happen at once, to Fidyka’s immense distress. In the initial weeks after the operation, he was despondent, again feeling that he’d endured more suffering for nothing. “I would ask Darek, ‘Is it better?’ ” Wioletta remembers. “He would say, ‘You can see that I’m not walking!’ ” He vented his frustration, in part, by smoking—not a good idea for a paraplegic. But, from a clinical perspective, the doctors were pleased that it took several months for the first signs of progress to emerge. Neurons take time to grow across such a large gap, and if Fidyka had got stronger immediately it would likely have been a placebo effect.
After five months, Fidyka began to contract the muscles in his left leg again, and around the same time he started feeling things in his right one. His left leg grew noticeably larger, gaining twelve centimetres in circumference in the first eighteen months. This pattern of amelioration suggested to the doctors that the left side of Fidyka’s spine—where most of the olfactory ensheathing cells had been implanted—had experienced the most regrowth. “It is very, very unlikely that this combination would occur except by reconstruction of the nerve pathways,” Raisman says. “That was the thing that suggested reconnection.”
That October, 2014, Raisman and Tabakow published a paper on their work in the journal Cell Transplantation. Raisman began an extensive, and immodest, press campaign. He called the operation a “breakthrough,” adding that “the continuation of our work will be of major benefit to mankind.”
Since the operation, Fidyka’s core muscles have become strong enough for him to drive a specially designed Renault Mégane that has a braking device on the steering column. Behind the wheel, he looks almost well. He has become a celebrity in Poland, and when the police stop him for speeding they let him go. (Tabakow, for his part, was invited to meet the President of Poland.)
Fidyka’s sexual function has also improved, and last May he told a Polish television station, “Anyone in a wheelchair will agree with me that this is probably the most important thing in this entire situation.” Fidyka is not lonely; he told me that he has received a surprising number of marriage proposals over the Internet. “Polish women are the best and the most beautiful,” he added, noting that he has a girlfriend.
When Fidyka goes to Pradzew on weekends, he sleeps in his parents’ home, in a ground-floor bedroom. A metal gurney helps him lift himself out of bed. Villages in the Polish countryside are not designed for wheelchairs, but he can now drive to friends’ houses to drink beer and watch soccer. He cannot hunt, but he drives into the woods with his friends and observes from the Renault. “I don’t think shooting from the car is very humanitarian,” he jokes. One clear benefit of the surgery has been psychological: Wioletta says that her brother has become nicer and more open.
His family, like many families of disabled people, is fiercely optimistic. Wioletta has left unfinished a wall that Darek began painting before his accident—one day, she tells him, he will complete the job. Fidyka prides himself on his determination, but also tries to be realistic. “Anyone who thinks that it would be O.K. to be in a wheelchair should sit in one for two weeks—and have an accident in your pants,” he told me.
He cannot work, and his disability pension amounts to the equivalent of two hundred and forty dollars a month. Thanks to Raisman, his rehabilitation is now funded by the Nicholls Spinal Injury Foundation, in London. The foundation has given Raisman nearly a million pounds to finance his research, and this has been matched by the U.K. Stem Cell Foundation. But at times this good fortune adds to Fidyka’s anxiety. He worries what will happen—to him and to the research project—if his progress stops. He therefore makes an extra effort whenever Tabakow comes to Akson to observe him.
While I was visiting, Tabakow showed up in the gym. Fidyka, wearing below-the-knee braces, pedalled a stationary bike in front of him for the first time. The doctor was impressed, and said that he’d send a video to Raisman. Fidyka seemed relieved; he had scored another success.
Toward the end of the session, Stefan Okurowski, Fidyka’s chief therapist, pulled him into an upright position. He slotted his patient’s legs into metal braces with leather straps that laced up to his thighs. Being able to stand with braces had been a milestone for Fidyka. Wioletta remembers receiving a thrilled text from him: “Sister, I’m standing on my feet!” Around the same time, one of her children patted his leg during a family visit, and Fidyka startled. It was then that she realized he could feel again.
Okurowski stood behind Fidyka and frog-walked him past various exercise machines to a pair of bars. The patients from the morning had gone home, and two new ones were in the room: a former policewoman who had been hit on the head by a bale of hay, and a boy, lying immobile, who doesn’t remember how he fell from a balcony. (“Some stupidity of youth,” he said.) All the patients at Akson know about Fidyka—and they are by turns hopeful, jealous, and uncertain about him. For most of them, the prospect of brain surgery is frightening. But when Fidyka does his routine he is like a math prodigy called to the blackboard.
Okurowski, who has a bearlike physique, placed Fidyka so that he could hold on to the parallel bars. The eyes of the other patients followed him. Fidyka steadied himself like a skier at the start of a downhill slalom and then began—painfully, laboriously—to put one foot in front of the other. He likes to joke that the scar left by the operation to remove a part of the olfactory bulb from his forehead makes him look like Frankenstein, and his stiff walk, combined with his shaved head, accentuated the impression. Nevertheless, it was a thrill to sense his brain sending commands to his legs.
After about a dozen steps, he turned around and walked back, looking exhausted. “On a good day, I can walk for an hour and a half,” he said. In recent months, Fidyka’s progress has continued. He can now walk fifteen feet in braces with crutches; he has gone to a park and pedalled a tricycle for several hundred yards. “This was a complex cöordination between trunk and lower-limb muscles,” Tabakow noted.
Some researchers have raised doubts about the procedure that seemingly got Fidyka on his feet. Surgery that is effective for a cut spinal cord, they point out, may well not work for the far more common problem of a compressed or fractured cord. Other doctors have noted that a thin strip of tissue on the right side of Fidyka’s spinal cord survived the attack, and argue that this may have been the real source of his partial recovery. A third contingent theorizes that the bridge of nerve tissue taken from Fidyka’s lower leg—not the olfactory ensheathing cells—deserves the credit. (Raisman points out that other doctors’ attempts to use peripheral nerve tissue to repair spinal-cord damage have not been successful.) James Guest, the Miami neurosurgeon who cast doubt on Huang Hongyun’s claims, took the unusual step of publishing a letter to the editor of the Journal of Neurotrauma, highlighting the many open questions. He also registered his objection to the decision to open Fidyka’s skull, noting that this had courted “serious risks of infection, bleeding, and loss of olfactory function.” Recently, he e-mailed me to say that, though Raisman and Tabakow’s work might well have value, the report “came with a level of attention and statements that exceeded what can be realistically interpreted from a single and rather complex case.”
On this point, even Raisman’s friends agree. Jerry Silver, a neuroscience professor at Case Western Reserve University, in Ohio, who has collaborated with him in the past, said, “I think Geoff’s on the right track. But it’s only an n of 1”—a study of a single patient—“and it’s a very special kind of lesion.”
Raisman and Tabakow acknowledge in their paper that they can’t prove that the olfactory ensheathing cells from Fidyka’s brain alone made the difference. Maybe it was the fact that some immature neurons were injected with the olfactory ensheathing cells; maybe it was the removal of scar tissue during surgery. Maybe it was a combination of various factors. The best science happens when the signal can be isolated from the noise, but there was a lot going on in the operating room in Wrocław. “We were looking for a treatment, not proof of principle,” Raisman says, his voice rising defensively.
Raisman and Tabakow are now searching for new patients. Some will undergo Tabakow’s procedure. Others will be operated on by a neurosurgeon in England. To add further rigor, independent observers will be called on to evaluate the patients’ progress. It will not be easy for the doctors to find candidates like Fidyka—a man with an ideally situated wound, a good work ethic, a bad nose, and a strong support network. But Tabakow believes that, as he gets better at the surgery, subsequent patients will recover even more function than Fidyka has. He estimates that the surgery and rehab have restored fewer than ten per cent of Fidyka’s neurons.
“If Geoff does this, he’d be on track to win the Nobel Prize,” Adrian Pini, a professor of neurodegeneration at King’s College London, says. That is, if a rival therapy doesn’t succeed first. Doctors are experimenting with enzymes that prevent scar tissue from forming on the spine. At the University of Louisville, epidural electrical stimulation of the spinal cord has enabled five young men with complete lower-limb paralysis to move their legs again. Susan Howley, who is the head of research at the Reeve Foundation, says, “I would stress that there isn’t a thing out there that’s perfect. This is an iterative process. We’re still turning over the stones.” She considers olfactory ensheathing cells a potentially valuable stone. But she doesn’t want to lapse into hype: this is a field where caution is a necessary defense mechanism. “Even the strongest studies have proved difficult to replicate,” John Martin, an expert on brain and spinal-cord injury at the CUNY School of Medicine, points out.
In 2014, after the BBC ran its documentary on Fidyka, Raisman received more than two thousand letters asking for help. “I’ve stopped counting,” he told me. It was impossible not to detect the pride that he was trying to suppress, but being the object of desperate yearning does make him uncomfortable. He prefers to see himself as a guru leading a contingent of believers among the unenlightened. He has been ill lately, but this has not curtailed his ambitions—or his commitment to his cause. The field of spinal-cord regeneration is fiercely competitive. The only decoration in Raisman’s corridor at University College is a Chinese translation of a Turkish proverb: “May our enemies not prosper.”
Fidyka, meanwhile, accepts that the hunting blinds may remain out of reach. But, he says, “When I go shopping, I’d like to be able to walk to and from the car with a walker.” He adds, “If not for my strong spirit, I wouldn’t even be here now. Psyche is the most important element.” ♦
