By Elaine Sanchez Wilson
Jesse Thomas was no stranger to sports injuries. As an aspirational Olympic runner-turned-cyclist, he had endured his fair share of tumbles; he had broken his nose twice, his ankle twice, and his foot three times, not to mention the countless overuse injuries, such as his inflamed Achilles tendons.
However, he would have never expected that a seemingly innocuous fall during a slow, leisurely bike ride would result in his gravest fracture to date. After walking himself into the emergency department, x-rays and subsequent CT and MR imaging showed that he had sustained multiple C1 fractures and a C2 odontoid process fracture, completely exposing his spinal column.
Nearly a decade later, the 33-year-old is back on his bike, and this time he’s bringing back the old running sneakers and new swim goggles en route to his dream destination: the Ironman World Championship. And just as his life has shifted in the years since his accident, so too has emergency department imaging of the neck and spine.
Thomas’ story is one of perseverance, dedication, and sheer will, although the modest Oregon native would not hesitate to point out that luck also was on his side. His story is a testament to how quality imaging can really make a difference in people’s lives.
Early Years
Having grown up in Bend, Ore, Thomas spent his youth navigating the mountains and trails of the outdoorsy community. Not only was he a high school runner, but he also played basketball all 4 years. This added athleticism gave him an edge over his competitors during his track and field career at Stanford, where he had received a scholarship to attend as a distance runner. Thomas enjoyed the majority of his collegiate success in the steeplechase event, for which he was an All-American, Pac-10 champion, and school record holder at the time. By his senior year in 2002, he ranked 12th place in the US championship. “I thought I had 2 years to try to pass eight or nine more guys, and I would be an Olympian,” Thomas recalled. “That was the goal.”
Yet the following year, Thomas broke his foot—a stress fracture from overuse of running—and the multiple-sport athlete took up cycling as a means to stay fit as he rested his foot. “At that point, I thought maybe I should become a professional cyclist; it seemed like I had the potential,” he said. “My athletic aspirations shifted to cycling.”
Six months later, Thomas experienced a crash that would change his life trajectory.
The Crash
“Every cyclist crashes,” Thomas said, matter of factly. In his case, Thomas had already fallen four or five times in tumbles that, compared to the life-changing one, seemed much more serious.
Riding at a slow pace with a pal through a parking lot, he was chatting and didn’t notice a speed bump ahead. It was just enough to bump his hands off the front of the handlebars, propelling Thomas up off the seat and over the front of the bike. He landed headfirst onto his helmet. “The ground grabbed my helmet and pinched my head down, and my chin got buried into my chest,” Thomas said. “I remember the first thing I thought was ‘Oh man, I hope I didn’t break my neck.'”
Still, the crash didn’t seem that bad. According to Thomas, his buddy thought that he had just fallen off his bike, nothing too serious. At first, he figured that he had pulled some muscles on the back of his neck.
“The first thing I did was shake my hands and shake my legs,” he said, chuckling at his naivete. “I thought that because I could move everything, I didn’t break my neck. That was all the information that I needed. I stood up and went through this old school mentality that I would just walk it off.”
Soon, he felt an incredible torque on his neck, an immense pain that Thomas had never felt before. He thought he was going to pass out.
“I don’t think I should continue,” Thomas remembers saying to his buddy. “I think we should go to the doctor.”
For the 10 to 15 minutes that his friend was gone to retrieve his car, Thomas concentrated on staying alert and awake. He commanded himself not to faint because he was worried that he had suffered a concussion. Once his friend arrived, Thomas got himself into the car, and the pair made their way to Stanford Hospital. “I was holding my head up straight with my hands,” he said. “I remember [telling my friend], ‘The corners really hurt, so take it easy.'”
Once at the emergency department, Thomas walked himself to triage, where he informed the staff that he had fallen off his bike and thought he had pulled his neck muscle. After some time, he was told that he would undergo precautionary x-rays. While he waited for the results, Thomas sat on the hospital bed, making some friendly small talk with his buddy and the attending nurse. It was a calm, unassuming environment; in fact, Thomas was already thinking about how long it would take until he was discharged. Out of the corner of his eye, he saw a man running through the hallway, carrying big films in hand and wearing a stern expression. To Thomas’ surprise, the man headed straight for his room.
“This guy needs to be strapped down,” Thomas recalls him saying. “No movement at all—he must be completely immobilized. He’s got multiple C1 fractures and a C2 odontoid fracture. His spinal column is completely exposed.”
“All of a sudden the intensity in the room completely flipped, and things got really serious, really quickly,” Thomas said.
Thomas had suffered two fracture modes: a Jefferson’s fracture, where his first cervical vertebra had broken into four separate pieces, and a hangman’s fracture, resulting from when his chin whipped to his chest.
Road to Recovery
Every neurosurgeon in the area would eventually pay Thomas a visit and offer their evaluation of the situation. Each of them told Thomas that he had never seen anything like this; most patients would have been paralyzed or dead with these injuries, they said. Some stipulated that Thomas’ strong neck muscles, well-developed from 20 to 25 hours a week of cycling (“I spent a lot of time bent over with my neck up to look down the road,” Thomas explained) kept his bones from slipping around. Nevertheless, Thomas recognizes that it was mostly luck. It was also to his good fortune that a premier neurosurgeon—Jongsoo Park, MD—was available to perform his surgery.
Prior to surgery, Thomas received a full CT/MRI work-up. After the procedure, during which doctors inserted a long skinny plate and four screws to connect C1 and C2, Thomas went straight back into the scanner in order to assess how the instrumentation had settled in. After he was discharged, Thomas had two or three follow-up scans, and as he would increase his activity level, every 4 to 6 weeks. During the course of the next several months, Thomas would look at these images, studying them to pass the time. “I’m a problem solver,” said Thomas, who holds master’s degrees in mechanical engineering and business administration. “I just wanted to really understand the anatomy and geometry of everything that happened and what I could do, if anything, to make it better.”
After the first 4- to 6-week period when he rested and recuperated, he eventually bought a recumbent bike, setting up a stationary trainer and riding in front of the TV. After 5 months of wearing a stiff neck collar, Thomas took things slow, making sure that he wasn’t exposed to anything too bumpy. Ultimately, it took about 14 months before Thomas could get back on a real bike.
“One of the hardest parts about this whole situation was that I really didn’t know what to expect and the doctors didn’t either,” Thomas said. “I was lucky that I was in a situation where I actually had full ability to recover, but at the same time, it was hard because the doctors didn’t really know what to tell me in terms of how long it would take and what I would be able to do. I had to make up my own mind about what I wanted to eventually do and how much risk I could actually take. There wasn’t a clear typical prognosis to go off of.”
Spinal Trauma Imaging Today
Nearly a decade later, Thomas is currently training for the half-Ironman World Championship in September in Las Vegas. During the time since his injury, he had dabbled in management and evaluation of start-up companies, gotten married, and gone back to school to attain his MBA. Feeling like the athletic chapter in his life was unfinished, Thomas would eventually go on to begin training for triathlon, in his mind a safer sport as compared to cycling. In May 2010, he entered the Escape from Alcatraz race in San Francisco as an amateur; he ended up finishing seventh among the pro field.
Diagnostic imaging helped put Thomas back on course. But what has changed in emergency department imaging and treatment of spine and neck injuries since the time of Thomas’ accident?
“The real premise behind taking care of patients who have had spinal trauma hasn’t really changed all that much,” according to Joel Meyer, MD, vice chairman of the department of radiology at NorthShore University Health System and clinical professor of radiology at the University of Chicago. Thomas’ story is not about the triumph of modern medical technology, “but rather adhering to tried and true medical principles of managing spinal trauma,” he said.
“The imaging that we have nowadays helps us to not miss unstable injuries,” Meyer said. “You can’t do it with the pictures alone, you have to do it with good doctors and good imaging. It sounds like Jesse had both.”
Nowadays, a patient presenting with Thomas’ symptoms would likely go straight to the CT scanner, which has been proven to be a lot more sensitive to finding spinal injuries compared to x-ray. Meyer—himself a triathlete since the age of 22—explained that MR is more common in patients who have suspected ligament abnormality or neurologic dysfunction that is not accounted for on the basis of the CT scan.
Ryan Stanton, MD, an emergency medicine physician at MESA Medical Group, based in Lexington, Ky, agreed that CT has become much more of the mainstay in the last several years. “Ten years ago, you had CT scanners, but they were slower and there was not as much access to them, especially in rural areas,” he said, adding that a hospital for which he previously worked used to perform five x-rays of the neck to evaluate potential injuries. “Now almost every hospital has a CT scanner, which is very important for picking up bone fractures.” MR also has developed to become more accessible, allowing doctors to see inflammation with comprehensive detail.
“Really what has changed from before to now is one, you have pretty good rules on whether you need to do imaging on someone or not, and two, we have a lot more access to more advanced and more sensitive tools to diagnose people,” Stanton said.
Furthermore, digital imaging has led to new possibilities in remote access and collaboration among physicians. Nighthawk services provide support to hospitals that cannot afford to have radiologists on-site overnight. “ER doctors can read the x-rays, but not as well as the radiologists, so there is a risk in the off-hours,” Stanton pointed out. “Each report would need to be reviewed the next day to ensure its accuracy. A lot of hospitals used to not have any coverage at night. So you would be on your own, even for CT scans, which are quite complex.”
Also, patients are better able to keep track of their history, including all previous scans, even as they visit with different physicians at different institutions. “Now, once you have an injury, especially in smaller hospitals, they can put those images on a disk and send them with the patient,” Stanton said. “We can upload them into our system so we don’t have to repeat the imaging.”
“Any disadvantage of moving to the computer for reading film is outweighed by the easy access, easy transferability, and the fact that we don’t lose any pictures any more,” Meyer said. “Digital imaging has made it so much easier to archive and to have multiple people view the same image at the same time.
“It’s a great story, a great success, and most of all a great testament to if we can catch it, we can stabilize it and prevent you from getting [further] injured,” Meyer said, of Thomas’ experience. “When you really make a difference in a patient’s life and you spare them from a disability, that is the best thing that could ever happen. It’s like Kodak moments with your kids—they don’t happen all the time, but when they do, they are really great.”
Lessons Learned
These days, Thomas is committed to training for triathlon. He admitted that his injury does limit him on the bike, as far as the position he can maintain. Thomas cannot hold himself as low as some of the other riders and lost 20% to 30% of his neck movement. He also sets up his bike to ride higher than his competitors. For swimming, Thomas lost 50% of his neck rotation, forcing him to adjust his breathing technique.
Looking back, Thomas’ decision to dive back into professional athletics was obviously a difficult one, and he thoroughly weighed all the pros and cons. Ultimately, he took the advice of a family friend who was also a neurosurgeon.
“He said, ‘I think you have to realize that you have some limitation, so you can’t be cavalier, but at the same time you don’t want to spend your whole life afraid,'” Thomas recounted. “You have to do what makes you happy in life. I took that to heart. Yes, I can crash, but anyone can crash. This is what I love doing, and I want to just go for it. “
After the half-Ironman World Championship in September, Thomas hopes to compete in the Ironman World Championships in a year or two. He lives with his wife in Oregon, and the couple is expecting their first child in June.
Elaine Sanchez Wilson is a contributing writer for Axis Imaging News.
