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EXPLAINER: A neurosurgeon on spinal injuries and David Diamante’s road to recovery

What does the future look like for David Diamante after surgery for three spinal fractures suffered in a motorcycle crash?

David Diamante introduces Demetrius Andrade v Jason Quigley
David Diamante introduces Demetrius Andrade vs Jason Quigley
Photo by Billie Weiss/Getty Images

The surest path to contempt from boxing fans is a job connected to the sport that involves speaking into a microphone. If you’re a boxing broadcaster or a podcaster, you’d better have thick skin. And you’d better not need praise or anything more than grudging acceptance from your audience to sustain your self esteem.

The biggest and best-known ring announcers may be the only exception. Major voices like Michael Buffer and Jimmy Lennon Jr enjoy popular acclaim that a wretched commentator could never hope to receive. And when the modern broadcast era of boxing began, David Diamante joined that tiny club as the man in the middle of the ring for DAZN.

When the news broke during the week of Christmas that a motorcycle accident left Diamante with three spinal fractures, many boxing fans reacted as though a friend, not just a familiar voice, had been hurt. Diamante has since given a few encouraging updates on his injuries and condition, most thoroughly in an excellent December 27th interview with Chris Mannix. The many severe injuries he suffered and his intense, ongoing physical pain sound terrible. But, the story is ultimately very encouraging, given Diamante’s optimistic view on recovering and getting back to work.

But, what comes next in his treatment and recovery? What might the future hold, and how soon might the man affectionately known around here as boxing’s “Diamond Dave” be physically able to introduce another big fight?

For answers to those questions and more, Bad Left Hook spoke with Dr. John Ratliff, a surgeon and professor at Stanford University, where he serves as the Vice Chair of Neurosurgery and Co-Director of the Spine and Peripheral Nerve Surgery Division.

Dr. Ratliff has no involvement with David Diamante’s medical care, and has no first-hand knowledge of his injuries or treatment. But, he was kind enough to provide some general observations based on what Mr. Diamante has shared publicly.

Among the key takeaways? Spinal injury treatment has “improved substantially” over the course of Dr. Ratliff’s career for patients with injuries similar to what we know about David Diamante. Dr. Ratliff also took at least some of the horror out of the phrase “cadaver parts” as it relates to Diamante’s treatment. And, while there are many reasons for optimism in this case, some patients need years before a full picture emerges of their best-case scenario for recovery.

A transcript of our conversation, lightly edited for length and clarity, follows.

Anthony Joshua vs. Andy Ruiz Jr. - Weigh Ins
David Diamante in 2019 before weigh-ins for Anthony Joshua vs. Andy Ruiz Jr.
Photo By Stephen McCarthy/Sportsfile via Getty Images

BAD LEFT HOOK: Spine injuries have terrified me ever since I was a kid. Some people grow up getting warned to “be careful, or you’ll put an eye out” or “don’t do that, people die that way.” When I was a kid, the worst-case scenario was “stop that, or you’ll break your neck.” What is it that makes spinal injuries such a scary proposition?

DR. JOHN RATLIFF, MD, FACS: The thing that’s most terrifying, for me at least, about why spinal injuries are so severe and debilitating is the very fragile nature of the spinal cord. The spinal cord just does not respond well to injury at all. Bones can knit back together and heal. You can develop scar tissue and manifest healing from most other injuries. But the spinal cord is just too fragile. It simply can’t recover when it’s suffered a significant injury or suffered significant trauma. So when you have a spinal injury, many times your opportunity to recover or to regain lost function may be limited.

You’ve been a neurosurgeon and a researcher for a long time. You’ve done presentations on allografts, a subject we’ll talk about later on, at least as far back as 2005. How would you say that treatment and recovery have improved over the course of your professional life? Is Mr. Diamante significantly more likely to see a positive recovery outcome now compared to if he’d had a similar accident 10 or 20 years ago?

We’ve learned a lot about the pathophysiology of spinal cord injury, and why the spinal cord behaves how it does after injury. What has been challenging is developing tools and developing interventions to reverse injury. That’s where we still face challenges today. For many patients where that sort of injury has occurred, it’s difficult to restore function.

Now, I don’t know any details about this individual’s case or care. I’ve never taken care of him. But, it sounds like he had an incomplete injury. Meaning, he was not completely paralyzed by the accident. For patients with an incomplete injury, we have improved substantially in our operative techniques and in our ways to stabilize the spine. And, in preventing further injury and providing the spinal cord maximal opportunity to recover.

In the boxing world, we’ve seen a variety of recovery outcomes from neck and spine injuries. Vinny Paz famously broke two vertebrae in his neck in a car accident, but was back in the ring 13 months later for the first of two dozen more pro fights. Another boxer named Paul Williams had a motorcycle accident in 2012 and has been partially paralyzed ever since. Outcomes obviously vary a great deal from one injury to another… How long does it usually take to get a clear picture of someone’s best-case scenario for recovery?

Oh, that’s a fantastic question. Those anecdotes show the complexity of spinal cord injury, and that there is a wide variety of severity in spinal cord injuries. Some patients have relatively minor spinal cord injuries and are able to achieve complete recovery and return to their previous level of function. Other patients suffer a much more severe loss of function, and sometimes that loss of function is permanent.

It’s a fantastic question to be able to definitively know how much recovery someone is going to enjoy after an injury. And similar to how the injuries can vary in presentation and vary in severity, recovery also has a lot of variation. What I generally tell patients that I’m treating is that we won’t really know, won’t really have a thorough idea of their capacity for recovery until we allow them adequate time to recover from the injury. And that generally means 12-18 months out from the injury.

That being said, I’ve had patients manifest very substantial early recovery, sometimes within the first few weeks. I’ve also had patients where it has taken three or four years after a spinal cord injury before they start seeing recovery. The same way there are different presentations of a spinal cord injury, there are variations in how quickly patients are able to recover.

On that topic, Mr. Diamante has made a few public comments about his accident and surgery. He’s spoken a lot about intense physical pain, but says his doctors tell him it’s a positive sign for long-term recovery of movement. Does his current pain tell us anything about the likelihood he’ll walk again?

It’s hard to correlate that with functional recovery. It is hard to correlate pain with recovery of ambulation or recovery of significant strength in the arms and legs. He is exactly right, though, that having that pain is a good sign.

If you think about hitting your funny bone when you bump your elbow and get a shooting pain down your arm, perhaps the simplest thing everyone can relate to, that’s when you’re impacting and stunning one of the nerves in your arm. When that nerve is stunned, it responds by sending out pain sensations. That’s why you get burning, painful sensations down your arm.

The picture is not as simple, but still similar with spinal cord injuries. That feeling of pain means that there probably is conduction across those nerves and through that part of the spinal cord. It is still working. It may not be working normally, but there are still impulses getting through and some level of function within that portion of the spinal cord. And when we have any level of function, we have cause for hope that rehab, time, and therapy will see further restoration and recovery of function in the future.

It is a hopeful finding that he’s having that pain. It’s very unpleasant, and patients can be miserable from the nerve pain associated with a spinal cord injury. It’s terrible. But it is a good sign in terms of the capacity to recover function.

Mr. Diamante’s post-accident treatment was handled at NYU Langone Health. Do you have any particular insights on the surgical team there, or the facilities and resources at NYU Langone, that might give us reason for optimism?

It’s a phenomenal hospital. A phenomenal spine team. He could not be in better hands. NYU is a national leader in spine care. He’s at a fantastic facility.

Full disclosure, I did my spine fellowship there twenty years ago. But, they are still a phenomenal team and a phenomenal facility.

The recent interview Mr. Diamante did with Chris Mannix for Sports Illustrated mentioned a few specific injury and treatment details: Three spinal fractures, five hours of surgery, nine pins, multiple rods, and the statement that “the bone penetrating his spine was less than two millimeters away from leaving him paralyzed.” What can we interpret from those bits and pieces of information?

It certainly had to be a severe accident to merit this kind of surgery. Acute surgery, meaning surgery done soon after an accident, is often performed when the spine is unstable. Meaning that the structural elements of the spine, the part that holds your head up, keeps your torso stable, stabilizes your mid-thoracic region… The structural elements of the spine are compromised to the point where you are worried about further injury. You’re worried that instability in the spine and the ability of the spine to move in an abnormal fashion could cause even more damage to the spinal cord.

You stabilize the spine to prevent that. To keep the spine in an alignment where the pressure or compression of the spinal cord is removed. And you don’t allow for any abnormal motion or increase in pressure on the spinal cord. The idea being, when you have a spinal cord damaged in the acute accident, if the vertebral column, meaning the bones in the spine, are structurally incompetent and can’t do their job of protecting the spinal cord? Then you’re very worried that the spinal cord could be damaged further by that structural compromise of the bones in the spine. So the surgery is restoring that structural integrity and protecting the spinal cord to prevent any further injury.

One particularly terrifying phrase, at least to a layman, that we’ve seen in multiple stories is that cadaver parts were placed in his spine. What exactly does that mean, and how does it work?

When you’re restoring the structural integrity of the spine, or treating a spine that’s been damaged to the point where the bones of the spine can’t protect the spinal cord anymore, you use little screws and rods to immediately stabilize the damaged vertebral bodies.

But, those screws and rods will break. The things we put in will almost invariably fail over time unless the bone of the spine heals. So you protect the spinal cord acutely and stabilize it with the screws, rods, and pins. But then your body has to heal. You have to form bone and heal across the damaged area.

One of the ways we’re able to encourage that healing and improve the rate of that healing is by using what’s called allograft, meaning bone from a cadaver that allows the body to achieve bony healing and heal across the spot where an accident caused structural compromise.

When someone gets a heart transplant, we don’t hear it described as “cadaver parts placed in their chest.” Why do we hear this Frankenstein-style phrase instead of something similar to “organ transplant” to define an allograft procedure?

That’s a good question. A heart actually has to work. It has to function where it’s transplanted. Same for a kidney or other organ transplants.

With the bone we use, an allograft bone, or cadaver bone, really just acts as a scaffold. It provides a substrate that the patient’s body will heal into. You will actually convert that scaffold into your own bone as you heal. And with many years of research, it’s still one of the most effective things we have to provide bone with a substrate or foundation to grow more bone. It’s most effective to use cadaver bone for this purpose.

It’s almost like a lattice on the side of a house for a vine to grow up and across. If the vine grows well, eventually you just see the vine. You don’t even see the lattice under it. Here, what happens is that the lattice itself is converted into the patient’s bone. If you reoperate on it or look at it during a future surgery after healing has taken place, you wouldn’t be able to tell that a cadaver bone had ever been there. You would just see bone. The patient would have grown more bone across the area.

David Diamante in 2016 with Leo Santa Cruz
David Diamante in 2016 with Leo Santa Cruz
Photo by Edward Diller/Getty Images

This is a seemingly frivolous digression, but Diamante is well known for his signature long dreadlocks. Even casual boxing observers who might not know his name would recognize who we meant if we called him The Guy With The Dreadlocks.

First concern is obviously his physical health and recovery. But, out of curiosity, would emergency needs of either surgery or post-surgery stabilization require cutting away some or all of Mr. Diamante’s famous hairstyle?

I obviously don’t know for sure, but possibly not. You could probably work around his hair and sweep it out of the way to do the surgery. So, I would assume there was the potential to accommodate his hairstyle and still complete the surgery.

I know it might sound trivial, but the thought I had after first hoping the accident wasn’t life-threatening, and then hoping that he would heal and recover enough to work and resume his old lifestyle, was the potential that treating him would mean cutting his hair for the first time in 34 years.

With the Vinny Paz example from earlier, he had a Halo device as part of his stabilization and recovery. And I just assumed that if Diamante needed a similar stabilization option, that might mean losing portions of his hair to accommodate it.

Yes, one of the routine, but I wouldn’t call it common, procedures we use in stabilizing the spine is called a Halo. It is a pretty miserable device to use, but it is very effective for stabilizing some cervical, or neck, spine injuries.

It sounds like in Mr. Diamante’s case, though, they decided on using an open approach to the fracture. Meaning, doing a surgery to stabilize the fractures. That could mean that Mr. Diamante’s fractures and bony injuries were so severe they had to do that surgery. Again, I don’t know his case directly. But the fact that he required an open fixation for his fractures likely indicates they were quite severe.

What is the rehabilitation process and timeline like for someone with this type of injury? Given what we know, if all goes well, how soon might Diamante be able to resume working as an in-ring announcer?

That is unfortunately a question that I just can’t answer. I have no idea. I haven’t treated him, I don’t know the details of his injuries, and I just have no concept beyond guessing.

It’s a good question and a valid question. But even the surgeons taking care of him may not know the answer to that question. They may not be able to reliably predict it at this point. I’m sure he wants to know, too. But the doctors involved likely can’t give him a definitive timeline to when he might return to work.

Any closing thoughts or final words you’d like to share with our readers?

I wish him the best. This is a terrible injury, but I think it’s very encouraging to hear the recovery he’s had to date. I’m hopeful we’ll see further recovery in the future.

Spinal cord injury research is one of the most vital things we have in neuroscience research. Continuing to support funding to help us develop the tools that will help patients like Mr. Diamante in the future is essential for us advancing the field and improving the care for patients with spinal cord injuries.

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