In a recent YouTube live Q&A session, Verita Neuro’s Medical Directors Dr. Beatriz Perez Hernandez and Dr. Rodrigo Vilches Aranguren answered questions about spinal cord injury treatment programs at Verita Neuro. The discussion mainly revolved around Epidural Stimulation and Stem Cells as treatment options for spinal injuries and other neurological conditions. The doctors also touched upon realistic expectations for recovery, what other conditions can be treated at Verita Neuro, and addressed listeners’ concerns about their unique cases. Finally, they previewed an exciting new addition to Verita Neuro’s treatment programs, which is a ReWalk personal robotic exoskeleton.
Meet the Medical Team
Dr. Beatriz: I’m Dr. Beatriz, I was born and raised in Mexico. I’m a specialist in physical medicine and rehab, and I have a major in neurological conditions. I studied in Mexico and I’m one of the directors here at Verita Neuro Clinic in Mexico.
Dr. Rodrigo: I’m Dr. Rodrigo. I was also born in Mexico. I’m a physical medicine specialist and I have a major in neurological rehabilitation too.
Verita Neuro's Multidisciplinary Approach
How is Verita Neuro different?
Dr. Rodrigo: Verita Neuro has a very different approach to neurological conditions than other clinics in the world. This is because we have a wide, multidisciplinary team dedicated to treating patients. We don’t just provide treatment, we offer programs that include many components and aim to treat the patient as a whole. We address not only neurological, motor and sensory conditions, but also autonomic, bowel and bladder conditions, psychological aspects, and other factors that help patients have the best possible quality of life.
We have some of the best physical therapists, as well as an outstanding medical and surgical team. We are a very united, multidisciplinary team capable of managing a wide range of neurological conditions.
What conditions do you treat?
Dr. Rodrigo: In our programs, we treat not only spinal cord injuries, but also traumatic brain injuries, stroke, cerebral palsy, and autism. We develop a specific program for each patient in collaboration with the medical team.
Dr. Beatriz: In addition, we are willing to see any patients who have difficulties with independence and functional movement, for example, walking, balance, grip, or specific hand tasks, even if they have other conditions. However, we mainly see patients with acquired neurological conditions, not congenital, as these are the cases where we can make the most difference.
Is the clinic specifically for spinal cord injury patients?
Dr. Beatriz: Verita Neuro is not a specific clinic for spinal cord injury patients even though this is the most common type of patients we see.
Treatment Options for Spinal Cord Injury Patients: Epidural Stimulation and LamiSpine
What is Epidural Stimulation?
Dr. Rodrigo: Epidural Stimulation essentially includes placing an electronic device onto the spinal cord. This device can help people regain voluntary movement in the lower or upper limbs.
How does Epidural Stimulation work?
First of all, we place the device, which is a surgical procedure. After the surgery, we start a process called Epidural Stimulator mapping, which is programming the device to each patient. It’s a crucial part since each patient has a very specific, individual neurological condition.
We perform mapping every day to see how the patient responds to this device. On top of that, the patient has daily physical therapy. We also do Stem Cell treatments during this procedure to enhance the outcome of the patients.
It’s a 35-day program, during which the patients stay here in the clinic with us. We have suites where the patients stay and rest in between their physical therapy and programming sessions.
Each patient has their own goals, such as to stand up without assistance. We start the execution of the plan with our surgical team. They perform the surgery, implement the Epidural Stimulation device, then we start the physical therapy and the mapping.
Is Epidural Stimulation a cure?
Dr. Rodrigo: This is not a device that will make people walk again, but most patients are able to take steps with assistance.
After that, the patients have to do a lot of physical therapy at home. We suggest at least 6 months to one year of physical therapy because after a spinal cord injury the muscles are very weak. We have to stimulate them and strengthen them throughout the year to see the best results.
Dr. Beatriz: Indeed, it’s not a magical treatment or cure. I’d like to be very clear about this, because sometimes when patients are accepted for treatment, they ask, “Should I bring my wheelchair?” Yes, you should bring your wheelchair, because you will remain a wheelchair user during the treatment.
We do not know exactly what will happen after the treatment or how far you can progress. We do expect improvements, and we will work to achieve the goals set during the consultation we conduct with the patient via Zoom. However, this is not a complete cure.
What is the role of physical therapy in the outcome of Epidural Stimulation treatment?
Dr. Beatriz: It is also very important to understand that the cornerstone of this treatment is always physical therapy.
The treatment begins with the epidural stimulator, including the surgery and the mapping that Dr. Rodrigo mentioned. However, once you return to your hometown, it is essential to continue with physical therapy. You can take pictures or videos here at our clinic during your entire treatment period so you can do the same exercises at home. You need to continue therapy for at least a year to ensure the improvement and to achieve the goals we outlined.
Did Verita Neuro create the Epidural Stimulation treatment?
Dr. Beatriz: No, Epidural Stimulator was created around 20 years ago and initially used for pain management. It has advanced a lot over the years. Verita Neuro has had the most number of epidural stimulators inserted through surgery, but we do it with voluntary movements and mobility objectives in mind.
Who is eligible for Epidural Stimulation?
Dr. Rodrigo: The Epidural Stimulation treatment is offered to patients that have a spinal cord injury. Usually we treat patients with a neurological injury level between C5 and T11. For injuries higher than C5, the treatment is usually not useful for regaining movement. For injuries lower than T11 or T12 it’s no longer available because we would have nowhere to place the device. We can treat complete or incomplete spinal cord injury patients. Complete spinal cord injury involves a total loss of motor and sensory function below the level of injury, while an incomplete spinal cord injury means that some level of movement or sensation is preserved.
What is LamiSpine?
Dr. Rodrigo: LamiSpine is a method of delivering stem cells directly into the spinal cord. First, we perform a laminectomy, meaning we remove a little bone from the spine and we micro-inject the stem cells directly to the spinal cord. This treatment can be performed for basically any level of injury.
Where do the stem cells come from? Is it from the patient?
Dr. Rodrigo: No, we don’t take the stem cells from the patient, because it would mean undergoing another procedure. We would have to access the bone and take a bone marrow aspirate. After we extract the bone marrow aspirate, we have to send it to the lab to process that sample. Plus, until the process is finished, we don’t even know how many viable stem cells the patient can provide.
We use mesenchymal stem cells instead. We obtain the mesenchymal stem cells from tissue called Wharton’s jelly, which is found in the umbilical cord. We do this because studies have shown that there is no significant difference in outcomes between allogeneic (stem cells from external sources) and autologous (patient’s own stem cells) approaches. It allows us to avoid performing another invasive procedure on the patient and still achieve good outcomes.
How do you cure complete spinal cord injuries? Is it possible?
Dr. Rodrigo: No, at the moment we don’t have a complete cure for spinal cord injury anywhere in the world. We do have spinal cord injury treatments that help patients gain more function below the injury, but there is no complete cure.
Choosing the Right Treatment
How do you decide which treatment is right for which patient and which condition?
Dr. Beatriz: We do a consultation and review the medical history. We require videos, studies, and documents like MRI (Magnetic Resonance Imaging) and DEXA scan (Dual-Energy X-ray Absorptiometry). We also usually ask for a video of the patient in their everyday life as well as in their physical therapy sessions. The goal is to have grounded expectations, not just a wishlist, especially because many patients travel from abroad to get their treatment with us.
Epidural Stimulation vs. Stem Cells: which one to choose?
Dr. Rodrigo: We always pair Epidural Stimulation with stem cells, but not necessarily the other way around, which means you could get standalone Stem Cell treatments.
The decision depends on a lot of factors. First of all, it depends on the timeframe between the injury and the time of the consultation or the treatment. If the injury is acute or subacute, for example it’s been less than a year since the injury, the stem cells can have great outcomes in the patients with functional goals.
The other factor is the level of injury. We already discussed that Epidural Stimulation is possible between C5 and T11. For patients below T11 and above C5, we can do stem cells treatments.
It’s also important to consider whether the patient is complete or incomplete. An incomplete patient that can stand up and take steps would benefit only from Stem Cell treatment because Epidural Stimulation is not useful in their case.
Live Q&A: General Questions
Programming for Precision: Tailoring Stimulation to Patient Needs
Is there a place where we can see experiences from previous patients?
Dr. Rodrigo: Yes. If we determine that you are a candidate for Epidural Stimulation and Stem Cell treatment, we will provide you with the contacts of previous patients who have a similar injury or have received similar treatment programs and consented in sharing their experience.
Can chronic patients be candidates for the Epidural Stimulation treatment?
Dr. Rodrigo: Sure. Epidural Stimulation can be done on patients with chronic injuries, everything depends more on the condition of the patient than the timing of the injury.
If the patient can’t start treatment immediately after their injury, what can they do in the meantime?
Dr. Beatriz: If you do not have the financial resources to come immediately after your injury, it’s very important that you use this time to prepare. While you are working on securing the necessary resources, you should focus on physical therapy, mobility, and preventing complications, such as pressure ulcers, during the acute phase.
You should also work on managing orthostatic hypotension, establish a urinary and bowel program as well as improve trunk control if possible. If you follow this, you will be at a significant advantage when you arrive at our clinic and it will allow us to deliver more effective treatment.
How intensive is the treatment?
Dr. Rodrigo: This is a very intensive treatment. Each program is personalized, but generally the patients have to stay here 35 to 55 days and on top of other procedures, undergo physical therapy for approximately four hours a day. Therefore, if you do physical therapy beforehand, you will be able to take full advantage of such intensive treatment and the overall outcome will be better.
How can the doctors tell if the patient will have a good outcome with Epidural Stimulation?
Dr. Rodrigo: The success of Epidural Stimulation depends on four main factors: the timeframe, level of injury, age, and condition of the patient.
Young patients, meaning up to 50 years old, can train more effectively, so they usually have better outcomes. Patients that have been involved in post-injury physical therapy and were previously physically active have better outcomes too.
It also depends on whether the injury is complete or incomplete. Patients with incomplete injuries tend to have better outcomes with Stem Cell treatment than those with complete injuries, because they have more preserved neurological tissue to work with.
Can a complete injury become incomplete with your treatments?
Dr. Rodrigo: Yes, and actually they have. Timing is everything in this case. The sooner you come and do the Stem Cell treatment, the more likely it is that your injury will become incomplete.
If walking is not a definite end goal, what are other meaningful improvements that people may notice?
Dr. Rodrigo: Walking is usually not the primary outcome, but patients can gain motor function. People may start moving their legs voluntarily after Epidural Stimulation treatment, which is a significant improvement. If you go from not moving your legs to moving them voluntarily, that is a big step.
However, many improvements do not rely on motor function. One of the most important is bowel and bladder control, which can improve with both Epidural Stimulation and Stem Cell treatment. Patients with spinal cord injuries know that bowel and bladder function is a major concern, and improvements here lead to a much better quality of life.
Other benefits include autonomic functions, such as managing orthostatic hypotension. Patients with this condition often see substantial improvement after treatment, and we have observed several successful cases.
Bone density is another area of improvement. People with spinal cord injuries lose bone density because they have less weight-bearing on the lower limbs. With Epidural Stimulation, patients can bear weight on their legs, which can help improve bone density.
There are many outcomes beyond walking that can be achieved with Epidural Stimulation, all of which mean a significantly better quality of life.
How do we decide whether someone should be only in a rehab program, stem cells, or Epidural Stimulation?
Dr. Beatriz: We are a unique clinic that does not offer physical therapy on its own, we only do programs. We offer regenerative medicine, Epidural Stimulation, and other similar treatments and their combinations. If the patient’s injury can be treated with physical therapy alone, we can refer people to one of the great physical therapy clinics we have in Mexico.
If the person can feel internal processes, does that mean their injury is incomplete?
Dr. Rodrigo: Not necessarily. To determine this, we use a clinical scale that’s called ASIA, the American Spinal Injury Association scale. It depends more on the neurological findings than the patient’s perception.
Do you treat other neurological conditions, such as autism, especially in children?
Dr. Rodrigo: We have treatments for autism. Usually we work with children between 3 and 12. If you get in touch with our team, then we will gladly do a consultation, go through the personal medical form, clinical findings and then give you a program for that.
Can the stimulator be switched on 24 hours per day?
Dr. Rodrigo: The stimulator can and should be switched on and off depending on your activity. If you want to take steps, bear weight, stand up, do some exercise, then you turn it on. Unless you have a specific program, at night turn it off.
What level of long-term hand control recovery can stroke survivors expect?
Dr. Rodrigo: If this is an acute or sub-acute case of stroke, most probably you will regain partial function in your limbs. If a patient is chronic, for example the stroke occurred a decade ago, the possibilities are more limited.
Live Q&A: Case Analysis
Is a patient who injured T7 and does physical therapy daily a good candidate for Epidural Stimulation and stem cells?
Dr. Beatriz: T7 is a very promising level and since a significant amount of time has passed since your injury, you are certainly a candidate for Epidural Stimulation. But until we have a consultation, we cannot determine realistic expectations.
A patient is less than a year post-injury at T6 and has recently been diagnosed on MRI with a 5 mm syrinx extending from T3 to T12. What is the recommended course of action, and can this patient participate in the treatment program?
Dr. Rodrigo: There are two issues to consider. The first is the syrinx. After a consultation, we can determine whether it needs to be drained. If drainage is necessary, it must be performed before beginning treatment. If not, the patient can proceed directly to the program once we have reviewed their medical records, assessed eligibility, and selected the appropriate treatment plan.
Can a C5 patient who previously went through Epidural Stimulation treatment be a candidate for stem cells? The goal is to regain full function of the hands
Dr. Beatriz: We have a protocol that’s called electrostimulation. It’s very similar to the ONWARD device. We follow this protocol with cervical patients and we help them with their grip.
It’s very important to note that we do have patients who are able to use a fork and knife, apply makeup, drive a car, style their hair, and manage their bowel program independently, even those with cervical injuries. These improvements have been primarily achieved through Stem Cell treatment.
I’ve been paralyzed for 4 years, I have a complete T6 spinal cord injury. What progress will I see if I can feel internal processes?
It depends on what treatment you’re aiming for. If it’s Epidural Stimulation, you can potentially start moving your lower limbs voluntarily, bear weight, and stand up with minimal help, potentially even do stepping. There is also potential for measurable improvements with bowel and bladder control. We could tell you more specific goals only after the consultation.
Is it possible for a patient with C5 complete Spinal cord injury to regain individual finger movement following cervical epidural stimulation?
Dr. Beatriz: Epidural Stimulation works with big muscle groups, not intrinsic hand movement. We achieve that with Stem cells and a specific electrostimulation program similar to the ONWARD protocol.
Dr. Rodrigo: In terms of outcomes, you will likely get hand grip, flexion of the arm, extension, but restoring individual finger movement isn’t likely.
Is a person with a T6-T7 dislocation fracture eligible for stem cell injection treatment?
Dr. Rodrigo: It depends. We’re talking about two things here: the dislocation, which is an orthopedic issue, and the neurological stem cells, which is a neurological issue. We don’t treat the dislocation with stem cells, it has to be resolved by an orthopedic procedure. If the dislocation created a neurological injury, then we can treat it with stem cells.
Do the treatments work on an L1 level patient?
Dr. Rodrigo: If we’re talking about Epidural Stimulation, then no, it does not work on L1 patients. Stem Cells can work on an L1 patient, depending on the timeframe and conditions of the patient.
Introducing the ReWalk Exoskeleton
Dr. Beatriz: We’d like to share with you that we’ll soon be adding an exoskeleton.
What is an exoskeleton?
Dr. Beatriz: An exoskeleton is a robotic device which enables the patient to take steps. There are a wide variety worldwide of exoskeletons.
Why did we want to add an exoskeleton here to the clinic?
Dr. Beatriz: First of all, we’ve mentioned that Epidural Stimulation has a lot of advantages both in the autonomic and the mobility area of a spinal cord injured patient, but it is not the only solution for walking or stepping. We were very excited to go and look for new options of treatment. ReWalk exoskeleton is a great solution to regain movement without surgery.
What makes ReWalk different?
Dr. Rodrigo: The exoskeleton that we’ll have is called ReWalk. ReWalk is the only exoskeleton used not just for walking but also to climb stairs. It’s a very functional exoskeleton.
Dr. Beatriz: That’s what makes it unique in comparison to EksoGT, HAL, or Cyberdyne.
We’re not saying they’re not good, we’re simply highlighting why we chose to introduce ReWalk to our clinics. It’s because it really makes a change in the person’s life. ReWalk enables a patient to take steps, turn, walk up the stairs, and generally be very independent.
Dr. Rodrigo: The ReWalk works with a cane and with a watch, where you control the exoskeleton. Very important. It’s FDA approved for walking and climbing stairs, so in the United States this exoskeleton is covered by insurance.
We use the exoskeleton here as part of a comprehensive rehabilitation program. It allows us to achieve many outcomes, but it is integrated with our other treatment programs. So, it’s not just the exoskeleton alone, you participate in the full program, with the exoskeleton included as one component.
Dr. Beatriz: We’ll be bringing the exoskeleton in late April and we’ll be training our team members from all over the world. You’ll be able to see the preview in videos or ads and you’ll realize that it’s a life changing device.
The above is not a verbatim transcript of the live interview. Some comments have been altered or rearranged to improve the reading flow. You can watch the full live on our YouTube channel.
