Results of Early and Late Surgical Decompression and Stabilization for Acute Traumatic Cervical Spinal Cord Injury in Patients with Concomitant Chest Injuries

Sewell, Mathew D.; Vachhani, Kathak; Alrawi, Asif; Williams, Richard

doi:10.1016/j.wneu.2018.06.146

Cited by 34 publications

(56 citation statements)

References 16 publications

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“…63,64 The therapeutic effectiveness of timing (early vs. late) of surgical decompression and its relationship with neurological outcome following cervical TSCI is at equipoise ( Table 7). 28,30,59,66,67 Heterogeneity in design, methodology, surgical technique, neurological assessment, timing of decompression, number of patients enrolled, length of follow-up, and outcome assessment tools used makes interpretation of the results difficult and the therapeutic effectiveness of timing of decompression uncertain. Notably, most of the studies published during the past 20 years have confirmed preoperative spinal cord compression by CT or MRI, but seldom has there been a precise, anatomic definition of the term decompression, the purported goal of surgery.…”

Section: Discussionmentioning

confidence: 99%

“…28,30,46,47,68 Almost universally, decompressive surgery was not followed by post-operative MRI to verify complete decompression of a swollen spinal cord. 28,29,47,48,58,59,[66][67][68][69][70][71][72][73] By contrast, Papadopoulos and coworkers, 47 and Sapkas and Papadakis, 67 used MRI following closed traction reduction to assess for any residual compression following anatomical realignment and to decide on the need for further spinal cord decompression. In the multi-center prospective observational study by Fehlings and coworkers, 28 postoperative MRI was performed only in patients who had neuroworsening following surgical decompression.…”

Section: Discussionmentioning

confidence: 99%

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Efficacy of Ultra-Early (< 12 h), Early (12–24 h), and Late (>24–138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Aarabi

Akhtar–Danesh

Chryssikos

et al. 2020

Journal of Neurotrauma

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In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Efficacy of Ultra-Early (< 12 h), Early (12–24 h), and Late (>24–138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Aarabi

Akhtar–Danesh

Chryssikos

et al. 2020

Journal of Neurotrauma

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“…Conventionally, tracheostomies performed in the first week are classified as early, while tracheostomies performed later than 7 days are defined as late [5]. The ideal timing for a tracheostomy is uncertain since the evidence on the advantages of early over late tracheostomy is conflicting, and no real differences in mortality have been identified between early and late tracheostomy so far [6,7].…”

Section: Introductionmentioning

confidence: 99%

Tracheostomy practice and timing in traumatic brain-injured patients: a CENTER-TBI study

et al. 2020

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Indications and optimal timing for tracheostomy in traumatic brain-injured (TBI) patients are uncertain. This study aims to describe the patients' characteristics, timing, and factors related to the decision to perform a tracheostomy and differences in strategies among different countries and assess the effect of the timing of tracheostomy on patients' outcomes. Methods: We selected TBI patients from CENTER-TBI, a prospective observational longitudinal cohort study, with an intensive care unit stay ≥ 72 h. Tracheostomy was defined as early (≤ 7 days from admission) or late (> 7 days). We used a Cox regression model to identify critical factors that affected the timing of tracheostomy. The outcome was assessed at 6 months using the extended Glasgow Outcome Score. Results: Of the 1358 included patients, 433 (31.8%) had a tracheostomy. Age (hazard rate, HR = 1.04, 95% CI = 1.01-1.07, p = 0.003), Glasgow coma scale ≤ 8 (HR = 1.70, 95% CI = 1.22-2.36 at 7; p < 0.001), thoracic trauma (HR = 1.24, 95% CI = 1.01-1.52, p = 0.020), hypoxemia (HR = 1.37, 95% CI = 1.05-1.79, p = 0.048), unreactive pupil (HR = 1.76, 95% CI = 1.27-2.45 at 7; p < 0.001) were predictors for tracheostomy. Considerable heterogeneity among countries was found in tracheostomy frequency (7.9-50.2%) and timing (early 0-17.6%). Patients with a late tracheostomy were more likely to have a worse neurological outcome, i.e., mortality and poor neurological sequels (OR = 1.69, 95% CI = 1.07-2.67, p = 0.018), and longer length of stay (LOS) (38.5 vs. 49.4 days, p = 0.003). Conclusions: Tracheostomy after TBI is routinely performed in severe neurological damaged patients. Early tracheostomy is associated with a better neurological outcome and reduced LOS, but the causality of this relationship remains unproven.

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“…Decompression surgery is one of the treatments used to relieve pressure, reducing hypoxia and ischemia caused by edema and hemorrhage [15,16] . Studies have shown that patients who underwent decompression surgery before 24 h after SCI showed an improvement compared to patients who underwent surgery more than 24 h after SCI [16][17][18] . Fehlings et al [17] showed that more than half of the patients who underwent surgery (before or after 24 h) had at least one grade of improvement on the American Spinal Injury Association Impairment Scale (AIS) without statistical difference between the groups.…”

Section: Treatmentsmentioning

confidence: 99%

“…However, a higher percentage of patients had two or three grade improvement on the AIS scale in the group who underwent surgery before 24 h after 6 months of follow-up. Sewell et al [18] observed that patients with spinal cord injury (cervical level) who underwent surgery before and after 24 h showed no neurological improvement on the AIS scale with significant difference after 6 months of follow-up. However, there is a tendency for improvement in patients with early surgery, particularly in patients experiencing > 2-grade AIS improvement.…”

Section: Treatmentsmentioning

confidence: 99%

Mesenchymal stromal cells as a choice for spinal cord injury treatment

Fracaro¹,

Zoehler²,

Rebelatto³

2020

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Spinal cord injury (SCI) is a serious clinical problem that affects approximately 17,500 new patients per year in the United States. The main causes of SCI are vehicle collisions, falls, violence (mainly gunshot wounds), and sports/recreational activities. The final severity of the damage results from primary and secondary mechanisms that begin at the time of injury and last for months after trauma. To reduce the extent of damage, several treatments have been proposed. This review summarizes results from several studies that have pointed to cell therapy as the main form of neuroregenerative treatment. Mesenchymal stromal cells (MSCs) are important candidates for tissue regeneration due to the release of bioactive factors, as well as antiapoptotic effects, scar inhibitors, and angiogenic effects. Studies have shown that MSCs act in various ways on injured tissue, such as immunomodulation of the inflamed environment, release of bioactive factors, restoration of axon myelin, prevention of neuronal apoptosis, and neuroregeneration. Current research using MSCs aims to prevent secondary injury, promote regeneration, and replace destroyed spinal cord tissue. This review presents information about the damage from primary and secondary events after SCI, treatments usually used, and preclinical and clinical results aiming at the cell therapy using MSCs as a tissue regeneration strategy.

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Results of Early and Late Surgical Decompression and Stabilization for Acute Traumatic Cervical Spinal Cord Injury in Patients with Concomitant Chest Injuries

Cited by 34 publications

References 16 publications

Efficacy of Ultra-Early (< 12 h), Early (12–24 h), and Late (>24–138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Efficacy of Ultra-Early (< 12 h), Early (12–24 h), and Late (>24–138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Tracheostomy practice and timing in traumatic brain-injured patients: a CENTER-TBI study

Mesenchymal stromal cells as a choice for spinal cord injury treatment

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