Spine surgeon Alex Vaccaro stepped back from the operating table to give himself a moment to think.
In a rare and dangerous operation, Vaccaro and his team at Thomas Jefferson University Hospital had removed three vertebrae - the bones encasing his 17-year-old patient's spinal cord - and the surgeon now needed to insert a titanium "spacer" in place of the bones to reconnect the backbone.
The surgeon had two choices, both risky.
He could cut a nerve to give himself the room to get behind the patient's spinal cord. That would cause permanent damage to one leg.
Or he could manipulate the inch-long spacer between two nerves and the spinal cord. If he jostled the cord too much while squeezing by, Vaccaro could paralyze the teen.
"Motors OK?" Vaccaro asked a technician monitoring the motor and sensory impulses from the patient's legs. The 48-year-old surgeon - charismatic, laser-focused, and effortlessly respectful to everyone around him - was buying time to think.
The tech sent a pulse of electricity to electrodes attached to the patient's legs and abdomen.
"Yeah, stable," he responded. The patient's legs still had motor function.
It was time for Vaccaro to decide.
A tuberculosis infection had festered in Netus Madiode's spine for two years or more, eating away at ligaments and disks between the Haitian's vertebrae.
Slowly, his vertebrae were crushed together under his own weight, causing him to develop a rare deformity: a dorsal-fin-like hump in the middle of his back.
The condition would inevitably lead to paralysis and, ultimately, an early death.
After the devastating earthquake hit Haiti on Jan. 12, 2010, doctors from the Philadelphia area, who were among the relief workers flocking to the impoverished country, found the teenager.
Both of his parents had died in the quake.
Madiode had escaped injury. But without a perilous operation that was unavailable in Haiti, Madiode would also die, the victim of the tuberculosis that had entered through his lungs, made its way into his bloodstream, and ravaged his spine.
He needed reconstructive spine surgery.
Luckily for him, the medical team that found him knew a leading surgeon - Alex Vaccaro, vice chairman of orthopedic surgery at Thomas Jefferson University and president of the American Spinal Injury Association.
They had sent other Haitian earthquake victims to Philadelphia to have surgery at Jefferson. Vaccaro and the hospital had readily agreed to take on the huge challenge of fixing Madiode's back for free. The full cost would have easily exceeded $100,000.
It took months to get the patient out of Haiti. His older brother, Marcel Jean Valceau, 30, would act as his guardian and needed to travel to Philadelphia to give permission for the surgery.
In the seventh-floor operating room at Jefferson, Vaccaro and his team wore specially fitted masks to protect them from TB. His patient lay on his stomach.
Vaccaro started by making a foot-long incision in the center of Madiode's back and cut away the flesh to expose the patient's backbone.
He needed to completely remove three vertebrae - something the experienced surgeon had done only once before in his career - and do so without paralyzing the teenager.
After exposing the patient's spine, Vaccaro and his team inserted five pairs of inch-long screws in the vertebrae - three above and two below the bones that the surgeon would later remove.
It was critical to get those screws in so that he could insert a temporary rod to stabilize the patient's back during the surgery.
Without the rods, Madiode's back would collapse on his spinal cord, paralyzing him instantly.
Once Vaccaro placed a rod on the left side of the patient's spine, he used a tool called a rongeur that looked like a pair of pliers to slowly nibble away at the bone covering of the back of Madiode's backbone - the spinous process and laminae, those bumps you can feel in the middle of your back. He had to remove these - the backs of three vertebrae destroyed by the infection - before he could clear out their inner side.
Once he got everything he could safely reach, Vaccaro put another temporary rod on the right side of the backbone and removed the other temporary rod. He then continued to take out small bone fragments, slowly exposing the back of his patient's spinal cord.
Then using instruments like a hammer and chisel, Vaccaro slowly chipped away at the front of the three vertebrae, being careful not to push too far forward. That would cause a fatal puncture of the aorta - the major abdominal artery that runs directly in front of the spine.
After Vaccaro had removed Madiode's first, second, and third lumbar vertebrae - L1 through L3 - the surgeon needed to reconnect the backbone using an inch-long titanium spacer.
Vaccaro decided the best course was to put the device in without cutting a nerve.
Having made that crucial choice, the surgeon manipulated the spacer between two nerves and the spinal cord. To get the device in, he had to gently squeeze it by the spinal cord. But he couldn't make it fit without nudging the cord.
Once it was in place and secured, Vaccaro ordered the technician to run the electrical check of motor function in Madiode's legs.
Nothing. No response.
Had he just paralyzed the teen?
"OK, we need to wait a minute . . . so the cord calms down," Vaccaro said.
The surgeon stepped back from the operating table. After a tense minute, he asked the tech to restimulate the patient's legs.
The response was weak but perceptible.
"He's not going to be paralyzed," the relieved surgeon sighed.
Working more quickly now, Vaccaro placed permanent titanium rods on either side of Madiode's spine. He then seeded that space with bone fragments harvested from the patient's hip at the start of the procedure to generate new bone growth and further stabilize the rebuilt spine.
After 21/2 hours, the most dangerous part of the surgery was over.
Madiode had lost about three liters of blood - roughly half his body's supply - which had to be replaced. That was a lot for the slightly built teenager, but not so much that he had become unstable during the surgery.
Vaccaro knew he would need to bring the teen back to the operating room in a couple of days to drain two large abscesses caused by the tuberculosis on either side of his abdomen.
The TB infection had nearly destroyed the patient's hip flexors - the group of muscles that enable you to move your thigh bone and lift your knee.
A week after the May 3 operation to reconstruct his spine, a nurse and a physical therapist helped Madiode stand up.
The effort caused him to scream in pain.
At first the teenager, who needed a translator to communicate, took small painful steps that were more a hobble than a stride.
Slowly, gritting his teeth, Madiode made his way through the ward's hallways with the aid of a walker usually reserved for frail, elderly patients.
Watching his patient walk, Vaccaro was pleased that this operation had succeeded.
Five weeks after his surgery, Madiode returned for a checkup with Vaccaro.
He walked in smiling, looking like an ordinary teen, and thanked the surgeon.
Unfortunately, Vaccaro's first patient from Haiti - Wilner Pierre, 29, who had broken his back in the earthquake, wasn't as successful.
While the operation to stabilize Pierre's back in early February went well and the wound had healed, the spinal cord damage had been too extensive.
Pierre would not regain the use of his legs. Vaccaro didn't want to crush the man's hopes, but he knew his patient had to take advantage of the two years that he would be allowed to stay in the United States.
He encouraged Pierre to return to school. He made sure to get him in touch with a Haitian advocate to help him build a support group during his stay here.