Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery

Abstract

Early decompression may improve neurological outcome after spinal cord injury (SCI), but is often difficult to achieve because of logistical issues. The aims of this study were to 1) determine the time to decompression in cases of isolated cervical SCI in Australia and New Zealand and 2) determine where substantial delays occur as patients move from the accident scene to surgery. Data were extracted from medical records of patients aged 15-70 years with C3-T1 traumatic SCI between 2010 and 2013. A total of 192 patients were included. The median time from accident scene to decompression was 21 h, with the fastest times associated with closed reduction (6 h). A significant decrease in the time to decompression occurred from 2010 (31 h) to 2013 (19 h, p = 0.008). Patients undergoing direct surgical hospital admission had a significantly lower time to decompression, compared with patients undergoing pre-surgical hospital admission (12 h vs. 26 h, p < 0.0001). Medical stabilization and radiological investigation appeared not to influence the timing of surgery. The time taken to organize the operating theater following surgical hospital admission was a further factor delaying decompression (12.5 h). There was a relationship between the timing of decompression and the proportion of patients demonstrating substantial recovery (2-3 American Spinal Injury Association Impairment Scale grades). In conclusion, the time of cervical spine decompression markedly improved over the study period. Neurological recovery appeared to be promoted by rapid decompression. Direct surgical hospital admission, rapid organization of theater, and where possible, use of closed reduction, are likely to be effective strategies to reduce the time to decompression.

Acute spinal cord injuries before and after the New Zealand Spinal Cord Impairment Action Plan

“…Early Decompression following Cervical Spinal Cord Injury: Examining the Process of Care from Accident Scene to Surgery published by the Journal of Neurotrauma in 2015 collected the data of 192 patients across Australasia between 2010 and 2013. The aims were to determine the time to decompression in cases of isolated cervical spinal injury and areas of delay from accident scene to surgery with 12 patients in the Auckland region . This audit aims to continue a follow up study to re‐examine the post injury process; and forms a comparison between the patients from 2010 to 2013 to the group after the implementation of the New Zealand Spinal Cord Impairment Action Plan.…”

“…Comparisons were made between the groups before and after the New Zealand Spinal Cord Impairment Action Plan. A previous study analysing the New Zealand demographic showed patients who were admitted directly to a specialist tertiary unit had significantly reduced time to decompression than those admitted first to an initial regional hospital . Our results were consistent with this.…”

“…Another aspect to note is that patients who were admitted to an initial regional hospital had higher numbers of closed reduction (3 versus 1). We know from the previous study by Battistuzzo et al . patients undergoing closed reduction had significantly reduced time to decompression.…”

“…Numbers across Australia and New Zealand indicate an average time from injury to decompression of 21 h with a range of 14–29 h between the years of 2010 to 2013 . Fehlings et al .…”

“…This also allows the assessment between patients admitted first to an initial regional hospital to those admitted directly from the accident scene to the specialist tertiary hospital. Results from the ICED study show that patients directly admitted to a specialist tertiary service had a shorter time to decompression . Therefore four groups of patients are produced Group 1: before policy change with admission to initial regional hospital and subsequently transferred to a tertiary hospital – this is used as our baseline group during analysis, Group 2: before policy change with direct admission to a tertiary hospital, Group 3: after policy change with admission to an initial regional hospital and Group 4: after policy change with direct admission to a tertiary hospital.…”