Article by Sally Wu

Graphic design by Colleen Paris

Our spinal cord plays a vital role in day-to-day functions, serving as a bidirectional communication pathway for the brain and body. It allows us to perform a range of motions, from a simple flick of a finger to complex movements like running. Injuries to the spinal cord can result in a loss of sensation, weakness, incoordination, or even complete loss of muscle function. Most spinal cord injury (SCI) cases are now treated with surgery to restore a patient’s independence, however, there are few effective non-surgical treatment options. Dr. Michael Fehlings and his team at the Krembil Brain Institute are pioneers in the field of neural repair and regeneration. The Fehlings Laboratory is leading both clinical and preclinical studies that hold great promise for patients suffering from this irreversible condition.

As a University of Toronto alumnus, Dr. Fehlings completed his MD in 1983 and later received his PhD in 1989 through the Institute of Medical Science (IMS). Growing up in a German immigrant family with minimal experience with academia and medicine, it was the guidance of notable role models that inspired Dr. Fehlings to become a clinician-scientist. As a medical student, Dr. Fehlings attended two inspirational talks that first exposed him to research. One of them was presented by Dr. Nancy McKee, a remarkable plastic surgeon with a specific research interest in microvascular reconstructive surgery. Dr. Fehlings completed a summer student project in Dr. Mckee’s lab under Dr. Howard Clarke’s supervision, who was a PhD candidate at the time. This was an eye-opening experience because it unveiled the idea that as a clinician, one can also embrace research. At the time, there was little treatment for individuals with SCIs and the impact of these injuries were profound. After a particularly difficult on-call weekend as a junior neurosurgery resident, Dr. Charles Tator invited Dr. Fehlings to visit his lab where he studied acute SCIs from a basic science perspective.

“It was transformative because it made the decision for me to pursue graduate training in science,” Dr. Fehlings explained. As both a neurosurgeon and basic researcher, Dr. Tator played a pivotal role in fostering Dr. Fehlings’ passion for scientific inquiry. After graduating from the Surgeon-Scientist program at the University of Toronto, Dr. Fehlings completed a fellowship at the New York University Medical Centre where he built upon the necessary clinical and research skills that led him to where he is today. Dr. Fehlings also acknowledges the strong support of his family as being critical in his career development.

As a recipient of numerous prestigious national and international awards, the two most momentous awards for Dr. Fehlings were the Olivecrona Award (2009) for his work in traumatic SCIs, and most recently the Ryman Prize (2019) for enhancing the quality of life for the elderly. The earlier discoveries from his graduate work with Dr. Tator has directly impacted clinical practice today. Traditionally, it was not recommended to operate on patients with SCIs until they are stabilized.¹ However, it was the basic science discovery of the vascular hypothesis in secondary injuries in SCIs,² that led to clinical trials for early surgical decompression within 24 hours that significantly improved neurological recovery.³  The translational efforts in this bench-to-bedside approach represent a remarkable progress for such a complex injury, improving the quality of life for patients and serving as a standard clinical guideline worldwide.⁴

Today, Dr. Fehlings combines his active clinical practice in complex spinal surgery with translationally oriented research models that specialize in novel treatments such as regenerative medicine for traumatic and non-traumatic forms of SCIs. The Fehlings Lab has developed a line of novel, genetically engineered stem cells called the Spinal Microenvironment Modifying and Regenerative Therapeutic (SMaRT) cells that have the ability to break down glial scarring, a major barrier to regeneration. Although there are limitations to their use, the proof-of-concept has been established and the SMaRT cells are part of a new era of regenerative medicine that has implications for chronic SCIs.

However, the work at the Fehlings Lab goes beyond just SCIs. In fact, Dr. Fehlings explains that the movement towards regenerative medicine has “potential impact for a range of devastating neurological conditions including stroke, brain trauma, multiple sclerosis, Alzheimer’s disease, and Parkinson’s disease.”  Dr. Fehlings described exciting future work that combines regenerative medicine with rehabilitation processes. With the ability of SMaRT cells serving as the regenerative substrate coupled with activity-based rehabilitation, this multi-disciplinary model combines state-of-the-art strategies from both fields that could optimize clinical outcomes.

Like everyone, Dr. Fehlings and his team had to adapt when Toronto went into lockdown for COVID-19. Although it has been “turbulent”, Dr. Fehlings shared a few projects and positive lessons that he has learned over the last eight months. One of the projects includes providing pre and post-operative neurosurgical care virtually for patients in remote communities. This has reduced waitlists for assessments and greatly enhanced the access to care from specialists. In addition, despite the halt of international travel, the advantage of teleconference technology has been transformative in terms of facilitating international collaborations. Going forward, there are lessons learned that demonstrate what can and cannot be done well virtually. Procedures that can be efficiently performed through a virtual setting can save time and costs and redirect those resources to other needed areas.

As a professor and mentor for students and surgeons across the world, Dr. Fehlings also hasn’t forgotten what it was like to be in their shoes. He stated that his greatest achievements stemmed from his graduate work at IMS and it is important to acknowledge that “some of the most important work that you will do in your life is the work you’re doing right now.” Furthermore, he noted the importance to “try your best to get the very best training you can, because it will open your eyes and provide you with skill sets  not just for your professional life, but to all sorts of other areas that will enrich your life.”

References

1. Donovan WH. Spinal cord injury—past, present, and future. J Spinal Cord Med. 2007; 30(2):85-100.
2. Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg. 1991; 75(1):15-26.
3. Fehlings MG, Vaccaro A, Wilson JR, et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (STASCIS). PloS One. 2012; 7(2):e32037. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0032037
4. Fehlings MG, Tetreault LA, Wilson JR, et al. A clinical practice guideline for the management of patients with acute spinal cord injury and central cord syndrome: recommendations on the timing (≤24 hours versus >24 hours) of decompressive surgery. Global Spine J. 2017;7(3 Suppl):195S-202S.