Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis

Abstract

IMPORTANCEThe optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. OBJECTIVE To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. DESIGN, SETTING, AND PARTICIPANTSThis multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. INTERVENTIONS Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. MAIN OUTCOMES AND MEASURES The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. RESULTS Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment).Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, −4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F 1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients).

A New Scale for Predicting the Risk of In-hospital Mortality in Patients With Traumatic Spinal Cord Injury

“…In this study, a less severe neurological impairment on admission (especially C and D) was associated with a decreased risk of inhospital mortality. Early decompression and short transport time after TSCI were found to be associated with better neurological recovery in previous studies (31,32). The role of surgical decompression after TSCI is to relieve the ongoing mechanical compression of the spinal cord, which can impair blood flow causing ischemia and neural tissue injury (5).…”

Prognostic Factors for Cervical Spinal Cord Injury without Major Bone Injury in Elderly Patients

“…A recent randomized clinical trial on incomplete CSCI with pre-existing cervical stenosis suggested that early surgical treatment (<24 h) showed accelerated recovery within the first six months compared with delayed surgical treatment (>2 weeks). 29 …”

Established and Emerging Therapies in Acute Spinal Cord Injury

“…Another recent multicenter clinical trial compared early and delayed surgical treatment (defined as ≤24 hours after injury and after ≥ 2 weeks of conservative therapy, respectively) and assessed motor recovery using the ASIA motor score, spinal cord independence measure, and independent ambulation capacity for 1 year. The study found that the 2 treatment paradigms were not significantly different; however, motor recovery at 2-week, 3-month, and 6-month follow-ups were improved with early surgical treatment, indicating accelerated recovery [ 18 ]. These results align with several large, well-documented trials and underscore the importance of early decompression to improve potential for motor recovery following SCI [ 19 - 21 ].…”