Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management

An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies

OBJECT

The authors conducted an evidence-based review of the literature to evaluate critically the rationale and indications for and the timing of decompressive surgery for the treatment of acute, nonpenetrating spinal cord injury (SCI).

METHODS

The experimental and clinical literature concerning the role of, and the biological rationale for, surgical decompression for acute SCI was reviewed. Clinical studies of nonoperative management of SCI were also examined for comparative purposes. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class II (retrospective studies). Examination of studies in which animal models of SCI were used consistently demonstrated a beneficial effect of early decompressive surgery, although it is difficult to apply these data directly to the clinical setting. The clinical studies provided suggestive (Class III and limited Class II) evidence that decompressive procedures improve neurological recovery after SCI. However, no clear consensus can be inferred from the literature as to the optimum timing for decompressive surgery. Many authors have advocated delayed treatment to avoid medical complications, although good evidence from recent Class II trials indicates that early decompressive surgery can be performed safely without causing added morbidity or mortality.

CONCLUSIONS

There is biological evidence from experimental studies in animals that early decompressive surgery may improve neurological recovery after SCI, although the relevant interventional timing in humans remains unclear. To date, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for SCI can only be considered a practice option. Furthermore, analysis of the literature does not allow definite conclusions to be drawn regarding appropriate timing of intervention. Hence, there is a need to conduct well-designed experimental and clinical studies of the timing and neurological results of decompressive surgery for the treatment of acute SCI.

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

OBJECT

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.

METHODS

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. 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.

CONCLUSIONS

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.

Review of clinical trials of neuroprotection in acute spinal cord injury

In this paper the authors review the clinical trials of neuroprotection that have been performed for the treatment of acute spinal cord injury (SCI). The biological rationale for the selection of each treatment modality is discussed with reference to current knowledge of the principles in the management of acute SCI as well as the primary and secondary injury mechanisms identified by experimental and clinical studies of the pathophysiology of acute SCI. The trials are evaluated with regard to the availability and use of accurate clinical outcome measures, and the methodologies of the trials are critically evaluated with an emphasis on prospective randomized controlled studies. A detailed description and critical analysis are provided of the results of the 10 clinical trials conducted to date in which a randomized prospective controlled design has been used. The issue of the therapeutic time window in acute SCI is discussed. To date, methylprednisolone is the only effective neuroprotective agent that has been established for use in human SCI, and the only therapeutic time window established in human SCI is a maximum trauma-to-treatment time of 8 hours.