Early Versus Late Surgical Decompression for Acute Spinal Cord Injury: An Individual Patient Data Meta-Analysis of 1548 Patients

Abstract INTRODUCTION We sought to leverage the statistical power derived from pooling 4 high-quality prospective datasets to compare sensorimotor recovery with early (< 24 hr) vs late (≥ 24 hr) surgical decompression for acute traumatic spinal cord injury (SCI). METHODS Patients with acute SCI who underwent surgical decompression were identified from 4 prospective, multi-center SCI datasets (NACTN, STASCIS, Sygen, and NASCIS III). Patients were dichotomized into early (< 24 hr) and late (≥ 24 hr) surgery groups. The primary end point was change in ASIA motor score (AMS) at 1-yr. Secondary outcomes included AIS grade and change in ASIA light touch and pin prick scores at 1-yr. One-stage meta-analyses for each outcome were performed by hierarchical mixed-effects regression using a stratified intercept to account for clustering of patients within studies. Fixed-effect covariates were specified for baseline score, age, injury mechanism, AIS grade, neurological level, and steroids. The treatment (early vs late surgery) was specified as a random-effect. RESULTS A total of 1548 patients were eligible. The early surgery group experienced greater improvement than the late surgery group at 1-yr for AMS (MD 4.0, 95% CI 1.7-6.2, P = .001), light touch score (MD 4.6, 95% CI 1.9-7.2, P = .001), and pin prick score (MD 4.2, 95% CI 1.5-6.9, P = .003). Further, on ‘shift analysis’, the early surgery group achieved a more favorable distribution of AIS grades at 1-yr compared to the late surgery group (cOR 1.46, 95% CI 1.14-1.87, P = .003). The effect of early surgery was strongest for cervical SCI (P = .003); however, we observed a trend toward improved recovery with early versus late surgery for thoracic SCI as well (MD 5.2, 95% CI -0.8-11.2, P = .088). CONCLUSION In an individual patient data meta-analysis adjusting for potential confounders, we found early surgery, within 24 hr of injury, to be associated with superior sensorimotor recovery at 1-yr following acute SCI, as compared to late surgery.

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Impact of Early (<24 h) Surgical Decompression on Neurological Recovery in Thoracic Spinal Cord Injury: A Meta-Analysis

Journal of Neurotrauma ◽

10.1089/neu.2018.6277 ◽

2019 ◽

Vol 36 (18) ◽

pp. 2609-2617 ◽

Cited By ~ 6

Author(s):

Paula Valerie ter Wengel ◽

Enrico Martin ◽

Philip Charles De Witt Hamer ◽

Ricardo E. Feller ◽

Julie Anne E. van Oortmerssen ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Meta Analysis ◽

Surgical Decompression ◽

Neurological Recovery ◽

Thoracic Spinal Cord ◽

Thoracic Spinal ◽

Cord Injury

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Early versus Late Surgical Decompression for Traumatic Spinal Cord Injury on Neurological Recovery: A Systematic Review and Meta-analysis

Journal of Neurotrauma ◽

10.1089/neu.2021.0102 ◽

2021 ◽

Author(s):

Yu-Lin Hsieh ◽

Joyce Tay ◽

Shu-Hsien Hsu ◽

Wei-Ting Chen ◽

Yao-De Fang ◽

...

Keyword(s):

Systematic Review ◽

Spinal Cord ◽

Spinal Cord Injury ◽

Meta Analysis ◽

Surgical Decompression ◽

Neurological Recovery ◽

Traumatic Spinal Cord Injury ◽

Cord Injury

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Results of Early Versus Delayed Decompression for Traumatic Cervical Spinal Cord Injury: A Single Center Prospective Study

Indian Journal of Neurotrauma ◽

10.1055/s-0038-1670529 ◽

2018 ◽

Vol 15 (01) ◽

pp. 023-028

Author(s):

Biswaranjan Nayak ◽

Krishnamurthy B. H ◽

Arun Kumar ◽

Sushanta Patro ◽

Prafulla Sahoo ◽

...

Keyword(s):

Quality Of Life ◽

Spinal Cord ◽

Spinal Cord Injury ◽

Cervical Spinal Cord ◽

Cervical Spinal Cord Injury ◽

Early Surgery ◽

Decompression Surgery ◽

Surgery Group ◽

Cord Injury

Abstract Objective This study was done with the aim to compare the clinical outcome and patient's quality of life between early (within 24 hours post-injury) versus delayed (after 24 hours to 7 days) surgically treated patients of acute cervical spinal cord injury. The current study was based on the hypothesis that early surgical decompression and fixations in acute cervical spinal cord trauma are safe and are associated with improved outcome as compared with delayed surgical decompression. Methods A total of 54 patients were recruited and divided into early decompression surgery group A (operated within 24 hours of trauma; n = 25) and late/delayed decompression surgery group B (operated between 24 hours and 7 days of trauma; n = 29). The patients in both groups were followed up, and comparative differences noted in the neurological outcome, quality of life, and bony fusion. Results The early surgery group had lesser postoperative complications. In group A, 54.17% patients had 1 American Spinal Injury Association Impairment Scale (AIS) grade improvement, while 29.17% experienced > 2 AIS grade improvement (p = 0.015). In group B, the neurological improvement was 50 and 21.43%, respectively (p = 0.003). There was a significant improvement in the postoperative quality of life scores in early surgery group. Conclusion Early surgery in patients with acute cervical spinal cord injury should be considered strongly in view of the lesser complications, better neurological recovery, and reduced mortality.

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Commentary on “The Influence of Timing of Surgical Decompression for Acute Spinal Cord Injury: A Pooled Analysis of Individual Patient Data”

Neurospine ◽

10.14245/ns.2142234.117 ◽

2021 ◽

Vol 18 (1) ◽

pp. 17-19

Author(s):

James David Guest ◽

Steven Kirshblum

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Individual Patient Data ◽

Pooled Analysis ◽

Patient Data ◽

Surgical Decompression ◽

Acute Spinal Cord Injury ◽

Cord Injury

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery

Global Spine Journal ◽

10.1177/2192568217706367 ◽

2017 ◽

Vol 7 (3_suppl) ◽

pp. 195S-202S ◽

Cited By ~ 51

Author(s):

Michael G. Fehlings ◽

Lindsay A. Tetreault ◽

Jefferson R. Wilson ◽

Bizhan Aarabi ◽

Paul Anderson ◽

...

Keyword(s):

Systematic Review ◽

Spinal Cord ◽

Spinal Cord Injury ◽

Clinical Practice ◽

Guideline Development ◽

Surgical Decompression ◽

Early Surgery ◽

Clinical Expertise ◽

Cord Injury ◽

Central Cord Syndrome

Objective: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is presented as “we suggest.” Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at 6 and 12 months in patients managed with early versus late surgery; and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations were: “We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome” and “We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level.” Quality of evidence for both recommendations was considered low. Conclusions: These guidelines should be implemented into clinical practice to improve outcomes in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies, and encouraging clinicians to make evidence-informed decisions.

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The natural history of complete spinal cord injury: a pooled analysis of 1162 patients and a meta-analysis of modern data

Journal of Neurosurgery Spine ◽

10.3171/2017.7.spine17107 ◽

2018 ◽

Vol 28 (4) ◽

pp. 436-443 ◽

Cited By ~ 15

Author(s):

Najib E. El Tecle ◽

Nader S. Dahdaleh ◽

Mohamad Bydon ◽

Wilson Z. Ray ◽

James C. Torner ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Natural History ◽

Conversion Rate ◽

Observational Studies ◽

Meta Analysis ◽

Early Surgery ◽

Cord Injury ◽

History Of ◽

Complete Spinal Cord Injury

OBJECTIVEThe natural history of complete spinal cord injury (SCI) is poorly studied. The classically quoted rate of improvement or conversion for patients with American Spinal Injury Association (ASIA) grade A (ASIA A) injuries is 15%–20%; however, data supporting this rate are very limited. In this paper, the authors conducted a meta-analysis of modern data reporting on ASIA A patients and evaluated factors affecting the natural history of the disease.METHODSThe authors conducted a systematic literature review of all randomized clinical trials (RCTs) and observational studies of patients with traumatic SCI. The Embase, MEDLINE, PubMed, Scopus, CINAHL, and Cochrane databases were reviewed for all studies reporting on SCI and published after 1992. A meta-analysis was conducted using the DerSimonian and Laird (random-effects) model with a summary odds ratio analysis.RESULTSEleven RCTs and 9 observational studies were included in the final analysis. Overall, the 20 included studies reported on 1162 patients with ASIA A injuries. The overall conversion rate was 28.1%, with 327 of 1162 patients improving to at least ASIA B. The overall rate of conversion noted in cervical spine injuries was 33.3%, whereas that in thoracic injuries was 30.6%. Patients undergoing early surgery had a higher rate of conversion (46.1%) than patients undergoing late surgery (25%) (OR 2.31, 95% CI 1.08–4.96, p = 0.03).CONCLUSIONSThe overall rate of conversion of ASIA A SCIs from pooled data of prospective trials and observational series is 28.1%. This rate of conversion is higher than what is reported in the literature. Early surgery is predictive of a higher conversion rate. However, there are not enough data to provide conclusions pertaining to the efficacy of biological and medical therapies.

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Early Surgical Decompression Improves Neurological Outcome after Complete Traumatic Cervical Spinal Cord Injury: A Meta-Analysis

Journal of Neurotrauma ◽

10.1089/neu.2018.5974 ◽

2019 ◽

Vol 36 (6) ◽

pp. 835-844 ◽

Cited By ~ 17

Author(s):

Paula Valerie ter Wengel ◽

Philip Charles De Witt Hamer ◽

Jonah Charley Pauptit ◽

Niels A. van der Gaag ◽

F. Cumhur Oner ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Neurological Outcome ◽

Cervical Spinal Cord ◽

Meta Analysis ◽

Surgical Decompression ◽

Cervical Spinal Cord Injury ◽

Cord Injury

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P.232 Motor Recovery after Early Surgical Decompression in Cervical ASIA A Spinal Cord Injury Patients

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2021.523 ◽

2021 ◽

Vol 48 (s3) ◽

pp. S87-S87

Author(s):

A Moghaddamjou ◽

JR Wilson ◽

MG Fehlings

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Cervical Spinal Cord ◽

Therapeutic Benefit ◽

Surgical Decompression ◽

Early Surgery ◽

Significant Gain ◽

Cervical Injury ◽

Cord Injury ◽

Muscle Groups

Background: Despite growing evidence for early surgical decompression for traumatic cervical spinal cord injury(tCSCI) patients, controversy surrounds the efficacy of early surgical decompression on patients with a complete (ASIA A) cervical injury. Methods: Patients with ASIA A cervical tCSCI were isolated from 4 prospective, multi-center datasets. Patients who had a Glasgow coma scale of less than 13, were over the age of 70 or under 16 were excluded. Significant gain was defined to include those that recovered more than two muscle groups (greater than 3/5 power) below their level of injury. Analysis of variance (ANOVA) was then done to compare significant gain over the 1 year follow-up period for patients with and without early decompressive surgery (<24hrs). Results: We identified 420 cervical ASIA A tCSCI patients. The mean number of muscle groups gained was 2.69 (SD 2.3.12) for those who had early surgery compared to 2.37 (SD 3.38) for those with late surgery. Of those patients who had early surgery 39.67% had a significant improvement vs. 28.76% of those who did not have early surgery (P = 0.030). Conclusions: For the first time, we have shown a clear therapeutic benefit of early surgical decompression within 24 hrs in ASIA A tCSCI patients.

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