Current use and timing of spinal surgery for management of acute spinal cord injury in North America: results of a retrospective multicenter study

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> A multicenter retrospective study was performed in 36 North American centers to examine the use and timing of surgery in patients who have sustained acute spinal cord injury (SCI). The study was performed to obtain information required for the planning of a randomized controlled trial in which early and late decompressive surgery are compared.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> The records of all patients aged 16 to 75 years with acute SCI admitted to 36 centers within 24 hours of injury over a 9-month period in 1994 and 1995 were examined to obtain data on admission variables, methods of diagnosis, use of traction, and surgical variables including type and timing of surgery.</jats:p> <jats:p content-type="fine-print">A total of 585 patients with acute SCI or cauda equina injury were admitted to participating centers, although approximately half were ultimately excluded because they did not meet inclusion criteria. Common causes for exclusion were late admission, age, gunshot wound, and absence of signs of compression on imaging studies. Thus, only approximately 50% of patients with acute SCI would be eligible for inclusion in a study of acute decompressive surgery. Although all patients underwent computerized tomography (CT) scanning, only 54% underwent magnetic resonance imaging, and CT myelography was performed in only 6%. Complete neurological injuries (American Spinal Injury Association Grade A) were present in 57.8%. Traction was applied in only 47% of patients who sustained cervical injury, in whom decompressive traction was successful in only 42% of cases. Neurological deterioration occurred in 8.1% of cases after traction. Surgery was performed in 65.4% of patients. The timing of surgery varied widely: less than 24 hours postinjury in 23.5%, between 25 and 48 hours postinjury in 15.8%, between 48 and 96 hours in 19%, and more than 5 days postinjury in 41.7% of patients.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> These data indicate that although surgery is commonly performed in patients with acute SCI, one third of cases are managed nonoperatively, and there is very little agreement on the optimum timing of surgical treatment. The results of this study confirm the need for a randomized controlled trial to assess the optimum timing of decompressive surgery in SCI.</jats:p>

Timing of Decompressive Surgery of Spinal Cord after Traumatic Spinal Cord Injury: An Evidence-Based Examination of Pre-Clinical and Clinical Studies

“…In addition, delayed surgical decompression of spinal cord was more inconsistently defined in the literature with time threshold varying from 8 h to 5 days. While 8 out of 22 clinical studies defined early surgical intervention as spinal cord decompression and stabilization obtained prior to 72 h following traumatic SCI (Chipman et al, 2004;Croce et al, 2001;Kerwin et al, 2005;McKinley et al, 2004;Mirza et al, 1999;Sapkas and Papadakis, 2007;Schinkel et al, 2006;Vaccaro et al, 1997), 9 other clinical investigations employed the 24-h limit to define early decompressive operation (Botel et al, 1997;Campagnolo et al, 1997;Duh et al, 1994;Guest et al, 2002;Krengel et al, 1993;Levi et al, 1991;McLain and Benson, 1999;Pollard and Apple, 2003;Tator et al, 1999). Other thresholds have been utilized in some previous clinical studies that compared delayed surgical intervention with spine operations earlier than 8 h (Cengiz et al, 2008;Ng et al, 1999), 48 h (Clohisy et al, 1992), and 4 days (Chen et al, 2009).…”

“…Extracted data from those clinical studies are summarized in Table 2. Most of the clinical studies compared at least two patient groups who underwent early or later decompressive operation of spinal cord (n ¼ 20); the two studies examined only the feasibility and safety of early surgical decompression of spinal cord without group comparisons (Botel et al, 1997;Tator et al, 1999). While the vast majority of the clinical studies were level-4 evidence, there were two studies of level-2b evidence ( Table 2).…”

“…4 1 0 (Continued) for the secondary search. Of the 38 original articles preselected from both primary and secondary searches, 22 clinical studies fulfilled the inclusion and exclusion criteria (Botel et al, 1997;Campagnolo et al, 1997;Cengiz et al, 2008;Chen et al, 2009;Chipman et al, 2004;Clohisy et al, 1992;Croce et al, 2001;Duh et al, 1994;Guest et al, 2002;Kerwin et al, 2005;Krengel et al, 1993;Levi et al, 1991;McKinley et al, 2004;McLain and Benson, 1999;Mirza et al, 1999;Ng et al, 1999;Papadopoulos et al, 2002;Pollard and Apple, 2003;Sapkas and Papadakis, 2007;Schinkel et al, 2006;Tator et al, 1999;Vaccaro et al, 1997). Extracted data from those clinical studies are summarized in Table 2.…”

Medical and Surgical Management after Spinal Cord Injury: Vasopressor Usage, Early Surgerys, and Complications

“…Age, gender, medical diagnoses prior to injury, SCI etiology, Glasgow Coma Scale, level of SCI, completeness/incompleteness of injury based on the American Spinal Injury Association (ASIA) score, ASIA score throughout admission and at discharge, Injury Severity Score (ISS), vital signs, surgical decompression timing, [14][15][16] vasopressor types, and complications. Complications were defined as follows: tachycardia (heart rate > 130), bradycardia (heart rate < 50), new atrial fibrillation, ventricular tachycardia, elevated troponin, electrocardiogram (EKG) ST changes consistent with ischemia, acidosis (pH < 7.0), atrial flutter, and skin necrosis.…”

“…In our initial cohort, 98 out of 131 patients with SCI underwent surgery, and acute stage surgery ( < 24 h after SCI) was performed in 27.5% (n = 27), which is similar to other studies. 15,16 It has been stated that the 24-h cutoff must be the most feasible time window during which surgical decompression had the promise to obtain a neuroprotective effect. 14 Given our findings, surgical timing should be included in any further prospective trials evaluating vasopressor choices and MAP targets.…”