Early vs Late Surgical Decompression for Central Cord Syndrome

Timing of decompression in central cord syndrome: a systematic review and meta-analysis

PURPOSE

This study compared the recovery of motor function and the safety of early and delayed surgical intervention in patients with central cord syndrome (CCS).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were employed to retrieve the targeted studies published from inception to February 19, 2023. Comparative studies of early versus delayed surgical decompression in CCS based on American Spinal Injury Association motor score (AMS) recovery, complication rates, and mortality were selected. The statistical analyses were performed using STATA 16.0 and RevMan 5.4.

RESULTS

Our meta-analysis included 13 studies comprising 8424 patients. Results revealed that early surgery improved AMS scores significantly compared with delayed surgery, with an increase in MDs by 7.22 points (95% CI 1.98-12.45; P = 0.007). Additionally, early surgery reduced the complication rates than delayed surgery (OR 0.53, 95% CI 0.42-0.67, P < 0.00001). However, no significant difference was observed in mortality between the two groups (OR 0.97; 95% CI 0.75-1.26; P = 0.84).

CONCLUSIONS

Early surgical decompression for CCS can improve motor function and reduce the incidence of complications without affecting the mortality rate in patients. Future research should focus on investigating and analyzing the optimal window period for early CCS surgery. Additionally, the timing of surgery should be determined based on the patient's condition and available medical resources.

Spinal cord injury: Current trends in acute management

Introduction

Traumatic spinal cord injury (tSCI) is a profoundly debilitating condition necessitating prompt intervention. However, the optimal acute treatment strategy remains a subject of debate.

Research question

The aim of this overview is to elucidate prevailing trends in the acute tSCI management.

Material and Methods

We provided an overview using peer-reviewed studies.

Results

Early surgical treatment (<24h after trauma) appears beneficial compared to delayed surgery. Nonetheless, there is insufficient evidence supporting a positive influence of ultra-early surgery on neurological outcome in tSCI. Furthermore, the optimal surgical approach to decompress the spinal cord remains unclear. These uncertainties extend to a growing aging population suffering from central cord syndrome (CCS). Additionally, there is a paucity of evidence supporting the beneficial effects of strict hemodynamic management.

Discussion and Conclusion

This overview highlights the current literature on surgical timing, surgical techniques and hemodynamic management during the acute phase of tSCI. It also delves into considerations specific to the elderly population experiencing CCS.

Clinical Subsets of Central Cord Syndrome: Is it a Distinct Entity from Other Forms of Incomplete Tetraplegia for Research?

Central cord syndrome (CCS) is the most prevalent and debated incomplete spinal cord injury (SCI) syndrome, with its hallmark feature being more pronounced weakness of the upper extremities compared to the lower extremities. Varying definitions encapsulate multiple clinical features under the single umbrella term of CCS, complicating evaluation of its frequency, prognosis discussions, and outcomes research. Oftentimes, people with CCS are excluded from research protocols, as it is thought to have a favorable prognosis, but the vague nature of CCS raises doubts about the validity of this practice. The objective of this study was to categorize CCS into specific subsets with clear quantifiable differences, to assess whether this would enhance the ability to determine if individuals with CCS or its subsets exhibit distinct neurological and functional outcomes relative to others with incomplete tetraplegia. This study retrospectively reviewed individuals with new motor incomplete tetraplegia from traumatic SCI who enrolled in the Spinal Cord Injury Model Systems (SCIMS) database from 2010 to 2020. Through an assessment of the prevailing criteria for CCS, coupled with data analysis, we used two key criteria, including the severity of distal upper extremity weakness (i.e., hands and fingers) and extent of symmetry, to delineate three CCS subsets: Full CCS, Unilateral CCS, and Borderline CCS. Of the 1,490 participants in our sample, 17.5% had Full, 25.6% Unilateral, and 9% Borderline CCS, together encompassing more than 50% of motor incomplete tetraplegia cases. Despite the increased sensitivity and specificity of these subsets compared to existing quantifiable criteria, substantial variability in clinical presentation was still observed. Overall, individuals meeting CCS subset criteria showed a higher likelihood of AIS D grade compared to those with motor incomplete tetraplegia without CCS, from admission to the 1-year follow-up. The upper extremity motor score (UEMS) for those with CCS was lower on admission, a difference that diminished by discharge, while their lower extremity motor score (LEMS) consistently remained higher compared to those without CCS. However, these neurological distinctions did not result in significant functional differences, as lower and upper extremity functional outcomes at discharge were mostly similar to those with motor incomplete tetraplegia, with some significant differences observed within those with AIS D grade. The AIS grade seems to remain the foremost determinant influencing neurological and functional outcomes, rather than the diagnosis of CCS. We recommend that future studies consider incorporating motor incomplete tetraplegia into their inclusion/exclusion criteria, instead of relying on criteria specific to CCS. While there remains clinical value in characterizing an injury pattern as CCS and perhaps using the different subsets to better characterize the impairments, it does not appear to be a useful research criterion.

Surgical Outcomes in Octogenarians with Central Cord Syndrome: A Propensity-Score Matched Analysis

OBJECTIVE

Central cord syndrome (CCS) is a traumatic cervical spine injury that is treated with surgical decompression. In octogenarians (80-89), surgeons often opt for conservative management instead due to fears of postoperative complications and prolonged recovery times. This study aims to assess the in-hospital complications and outcomes in octogenarians undergoing surgery compared to those undergoing nonsurgical management for CCS.

METHODS

The National Trauma Data Bank was queried from 2017 to 2019 for octogenarians with CCS. Patients who received surgical fusion or decompression were divided into the surgery group and the remaining into the nonsurgical group. The surgery group was sampled and propensity score matched with the non-surgery group. Student t tests and Pearson χ2 tests were used to test for group differences.

RESULTS

A total of 759 octogenarians with CCS were identified. Following sampling and propensity score matching, 225 patients were identified in each group. The surgery group experienced longer intensive care unit (6.8 days vs. 3.21 days, P < 0.001) and hospital (13.79 days vs. 7.8 days, P < 0.001) lengths of stay and higher rates of deep vein thrombosis (4.89% vs. 0.44%, P = 0.02) and ventilator-associated pneumonia (4% vs. 0%, P = 0.02). Patients did not otherwise differ in mortality rate, other hospital complications, and discharge disposition.

CONCLUSIONS

Octogenarians undergoing surgery for CCS experience longer length of stay and complications consistent with prolonged hospitalization but otherwise have similar mortality, hospital complications, and discharge disposition compared to non-surgical treatment. Given the relative lack of short-term drawbacks, surgery should be considered first-line management when the long-term benefits are substantive.

An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery

STUDY DESIGN

Clinical practice guideline development.

OBJECTIVES

Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that "early" surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI).

METHODS

A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the "evidence-to-recommendation" framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence.

CONCLUSIONS

It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

The 2023 AO Spine-Praxis Guidelines in Acute Spinal Cord Injury: What Have We Learned? What Are the Critical Knowledge Gaps and Barriers to Implementation?

STUDY DESIGN

Narrative summary of the 2023 AO Spine-Praxis clinical practice guidelines for management in acute spinal cord injury (SCI).

OBJECTIVES

The objective of this article is to summarize the key findings of the clinical practice guidelines for the optimal management of traumatic and intraoperative SCI (ISCI). This article will also highlight potential knowledge translation opportunities for each recommendation and discuss important knowledge gaps and areas of future research.

METHODS

Systematic reviews were conducted according to accepted methodological standards to evaluate the current body of evidence and inform the guideline development process. The summarized evidence was reviewed by a multidisciplinary guidelines development group that consisted of international multidisciplinary stakeholders. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the certainty of the evidence for each critical outcome and the "evidence to recommendation" framework was used to formulate the final recommendations.

RESULTS

The key recommendations regarding the timing of surgical decompression, hemodynamic management, and the prevention, diagnosis, and management of ISCI are summarized. While a strong recommendation was made for early surgery, further prospective research is required to define what constitutes sufficient surgical decompression, examine the role of ultra-early surgery, and assess the impact of early surgery in different SCI phenotypes, including central cord syndrome. Furthermore, additional investigation is required to evaluate the impact of mean arterial blood pressure targets on neurological recovery and to determine the utility of spinal cord perfusion pressure measurements. Finally, there is a need to examine the role of neuroprotective agents for the treatment of ISCI and to prospectively validate the new AO Spine-Praxis care pathway for the prevention, diagnosis, and management of ISCI. To optimize the translation of these guidelines into practice, important barriers to their implementation, particularly in underserved areas, need to be explored. Ultimately, these recommendations will help to establish more personalized approaches to care for SCI patients.

CONCLUSIONS

The recommendations from the 2023 AO Spine-Praxis guidelines not only highlight the current best practice in the management of SCI, but reveal critical knowledge gaps and barriers to implementation that will help to guide further research efforts in SCI.

Timing of Decompressive Surgery in Patients With Acute Spinal Cord Injury: Systematic Review Update

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

Surgical decompression is a cornerstone in the management of patients with traumatic spinal cord injury (SCI); however, the influence of the timing of surgery on neurological recovery after acute SCI remains controversial. This systematic review aims to summarize current evidence on the effectiveness, safety, and cost-effectiveness of early (≤24 hours) or late (>24 hours) surgery in patients with acute traumatic SCI for all levels of the spine. Furthermore, this systematic review aims to evaluate the evidence with respect to the impact of ultra-early surgery (earlier than 24 hours from injury) on these outcomes.

METHODS

A systematic search of the literature was performed using the MEDLINE database (PubMed), Cochrane database, and EMBASE. Two reviewers independently screened the citations from the search to determine whether an article satisfied predefined inclusion and exclusion criteria. For all key questions, we focused on primary studies with the least potential for bias and those that controlled for baseline neurological status and specified time from injury to surgery. Risk of bias of each article was assessed using standardized tools based on study design. Finally, the overall strength of evidence for the primary outcomes was assessed using the GRADE approach. Data were synthesized both qualitatively and quantitively using meta-analyses.

RESULTS

Twenty-one studies met inclusion and exclusion criteria and formed the evidence base for this review update. Seventeen studies compared outcomes between patients treated with early (≤24 hours from injury) compared to late (>24 hours) surgical decompression. An additional 4 studies evaluated even earlier time frames: <4, <5, <8 or <12 hours. Based on moderate evidence, patients were 2 times more likely to recover by ≥ 2 grades on the ASIA Impairment Score (AIS) at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, moderate evidence suggested that patients receiving early decompression had an additional 4.50 (95% CI 1.70 to 7.29) point improvement on the ASIA motor score. With respect to administrative outcomes, there was low evidence that early decompression may decrease acute hospital length of stay. In terms of safety, there was moderate evidence that suggested the rate of major complications does not differ between patients undergoing early compared to late surgery. Furthermore, there was no difference in rates of mortality, surgical device-related complications, sepsis/systemic infection or neurological deterioration based on timing of surgery. Firm conclusions were not possible with respect to the impact of ultra-early surgery on neurological, functional or safety outcomes given the poor-quality studies, imprecision and the overlap in the time frames examined.

CONCLUSIONS

This review provides an evidence base to support the update on clinical practice guidelines related to the timing of surgical decompression in acute SCI. Overall, the strength of evidence was moderate that early surgery (≤24 hours from injury) compared to late (>24 hours) results in clinically meaningful improvements in neurological recovery. Further studies are required to delineate the role of ultra-early surgery in patients with acute SCI.

Early versus late surgical decompression for patients with acute traumatic central cord syndrome: a systematic review and meta-analysis

BACKGROUND CONTEXT

The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking.

PURPOSE

To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence.

RESULTS

The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=-0.31 [-3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= -3.30 [-8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=-2.94 days [-3.83, -2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=-0.69 days [-1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups.

CONCLUSIONS

The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate.

Concomitant Traumatic Brain Injury Delays Surgery in Patients With Traumatic Spinal Cord Injury

BACKGROUND AND OBJECTIVES

Growing evidence supports prompt surgical decompression for patients with traumatic spinal cord injury (tSCI). Rates of concomitant tSCI and traumatic brain injury (TBI) range from 10% to 30%. Concomitant TBI may delay tSCI diagnosis and surgical intervention. Little is known about real-world management of this common injury constellation that carries significant clinical consequences. This study aimed to quantify the impact of concomitant TBI on surgical timing in a national cohort of patients with tSCI.

METHODS

Patient data were obtained from the National Trauma Data Bank (2007-2016). Patients admitted for tSCI and who received surgical intervention were included. Delayed surgical intervention was defined as surgery after 24 hours of admission. Multivariable hierarchical regression models were constructed to measure the risk-adjusted association between concomitant TBI and delayed surgical intervention. Secondary outcome included favorable discharge status.

RESULTS

We identified 14 964 patients with surgically managed tSCI across 377 North American trauma centers, of whom 2444 (16.3%) had concomitant TBI and 4610 (30.8%) had central cord syndrome (CCS). The median time to surgery was 20.0 hours for patients without concomitant TBI and 24.8 hours for patients with concomitant TBI. Hierarchical regression modeling revealed that concomitant TBI was independently associated with delayed surgery in patients with tSCI (odds ratio [OR], 1.3; 95% CI, 1.1-1.6). Although CCS was associated with delayed surgery (OR, 1.5; 95% CI, 1.4-1.7), we did not observe a significant interaction between concomitant TBI and CCS. In the subset of patients with concomitant tSCI and TBI, patients with severe TBI were significantly more likely to experience a surgical delay than patients with mild TBI (OR, 1.4; 95% CI, 1.0-1.9).

CONCLUSION

Concomitant TBI delays surgical management for patients with tSCI. This effect is largest for patients with tSCI with severe TBI. These findings should serve to increase awareness of concomitant TBI and tSCI and the likelihood that this may delay time-sensitive surgery.

Traumatic spinal cord injury: acute phase treatment in critical care

PURPOSE OF REVIEW

Surgical timing in traumatic spinal cord injury (t-SCI) remains a point of debate. Current guidelines recommend surgery within 24 h after trauma; however, earlier timeframes are currently intensively being investigated. The aim of this review is to provide an insight on the acute care of patients with t-SCI.

RECENT FINDINGS

Multiple studies show that there appears to be a beneficial effect on neurological recovery of early surgical decompression within 24 h after trauma. Currently, the impact of ultra-early surgery is less clear as well as lacking evidence for the most optimal surgical technique. Nevertheless, early surgery to decompress the spinal cord by whatever method can impact the occurrence for perioperative complications and potentially expedite rehabilitation. There are clinical and socioeconomic barriers in achieving timely and adequate surgical interventions for t-SCI.

SUMMARY

In this review, we provide an overview of the recent insights of surgical timing in t-SCI and the current barriers in acute t-SCI treatment.

Benefits of Early Surgical Treatment for Patients with Multilevel Cervical Canal Stenosis of Acute Traumatic Central Cord Syndrome

INTRODUCTION

Currently, there exists considerable debate surrounding the optimal treatment approaches for different subtypes of patients with spinal cord injury (SCI). The purpose of this study was to conduct a comparative analysis of the benefits associated with conservative treatment and treatments with different surgical periods for patients diagnosed with acute traumatic central cord syndrome (ATCCS) and multilevel cervical canal stenosis (CCS).

METHODS

A retrospective cohort study was conducted, and 93 patients who met inclusion and exclusion criteria in our hospital between 2015 and 2020 were followed for a minimum duration of 2 years. Among them, 30 patients (Group A) received conservative treatment, 18 patients (Group B) received early surgery (≤7 days), and 45 patients (Group C) received late surgery (>7 days). The American Spinal Injury Association (ASIA) grade, Japanese Orthopedic Association (JOA) score, and recovery rate (RR) were evaluated. Multivariate linear regression was used to analyze prognostic determinants. Cost-utility analysis was performed based on the EQ-5D scale.

RESULTS

The ASIA grade, JOA score, and RR of all three groups improved compared with the previous evaluation (P < 0.05). During follow-up, the ASIA grade, JOA score, and RR of Group B were all better than for Group A and Group C (P < 0.05), while there was no significant difference between Group A and C (P > 0.05). The EQ-5D scale in Group B was optimal at the last follow-up. The incremental cost-utility ratio (ICUR) of Group A was the lowest, while that of Group B compared to Group A was less than the threshold of patients' willingness to pay. Age, initial ASIA grade, and treatment types significantly affected the outcomes.

CONCLUSIONS

Both conservative and surgical treatments yield good results. Compared with patients who received conservative treatment and late surgery, patients who received early surgery had better clinical function and living quality. Despite the higher cost, early surgery is cost-effective when compared to conservative treatment. Younger age, initial better ASIA grade, and earlier surgery were associated with better prognosis.

Pathophysiology and surgical decision-making in central cord syndrome and degenerative cervical myelopathy: correcting the somatotopic fallacy

Our understanding of Central Cord Syndrome (CCS), a form of incomplete spinal cord injury characterized by disproportionate upper extremity weakness, is evolving. Recent advances challenge the traditional somatotopic model of corticospinal tract organization within the spinal cord, suggesting that CCS is likely a diffuse injury rather than focal lesion. Diagnostic criteria for CCS lack consensus, and varied definitions impact patient identification and treatment. Evidence has mounted for early surgery for CCS, although significant variability persists in surgical timing preferences among practitioners. A demographic shift toward an aging population has increased the overlap between CCS and Degenerative Cervical Myelopathy (DCM). Understanding this intersection is crucial for comprehensive patient care. Assessment tools, including quantitative measures and objective evaluations, aid in distinguishing CCS from DCM. The treatment landscape for CCS in the context of pre-existing DCM is complex, requiring careful consideration of pre-existing neurologic injury, patient factors, and injury factors. This review synthesizes emerging evidence, outlines current guidelines in diagnosis and management, and emphasizes the need for ongoing research to refine our understanding and treatment strategies for this evolving patient population.

Central cord syndrome definitions, variations and limitations

Central cord syndrome (CCS) is the most common, yet most controversial, among the different spinal cord injury (SCI) incomplete syndromes. Since its original description in 1954, many variations have been described while maintaining the core characteristic of disproportionate weakness in the upper extremities compared to the lower extremities. Several definitions have been proposed in an attempt to quantify this difference, including a widely accepted criterion of ≥10 motor points in favor of the lower extremities. Nevertheless, recent reports have recommended revisiting the terminology and criteria of CCS as existing definitions do not capture the entire essence of the syndrome. Due to methodological differences, the full extent of CCS is not known, and a large variation in prevalence has been described. This review classifies the different definitions of CCS and describes some inherent limitations, highlighting the need for universal quantifiable criteria.

Updates in the Early Management of Acute Spinal Cord Injury

Spinal cord injury (SCI) is a leading cause of disability worldwide, and effective management is necessary to improve clinical outcomes. Many long-standing therapies including early reduction and spinal cord decompression, methylprednisolone administration, and optimization of spinal cord perfusion have been around for decades; however, their efficacy has remained controversial because of limited high-quality data. This review article highlights studies surrounding the role of early surgical decompression and its role in relieving mechanical pressure on the microvascular circulation thereby reducing intraspinal pressure. Furthermore, the article touches on the current role of methylprednisolone and identifies promising studies evaluating neuroprotective and neuroregenerative agents. Finally, this article outlines the expanding body of literature evaluating mean arterial pressure goals, cerebrospinal fluid drainage, and expansive duroplasty to further optimize vascularization to the spinal cord. Overall, this review aims to highlight evidence for SCI treatments and ongoing trials that may markedly affect SCI care in the near future.

Early surgical intervention for acute spinal cord injury: time is spine

Acute traumatic spinal cord injury (tSCI) is a devastating occurrence that significantly contributes to global morbidity and mortality. Surgical decompression with stabilization is the most effective way to minimize the damaging sequelae that follow acute tSCI. In recent years, strong evidence has emerged that supports the rationale that early surgical intervention, within 24 h following the initial injury, is associated with a better prognosis and functional outcomes. In this review, we have summarized the evidence and elaborated on the nuances of this concept. Additionally, we have reviewed further concepts that stem from "time is spine," including earlier cutoffs less than 24 h and the challenging entity of central cord syndrome, as well as the emerging concept of adequate surgical decompression. Lastly, we identify barriers to early surgical care for acute tSCI, a key aspect of spine care that needs to be globally addressed via research and policy on an urgent basis.

Current insights into the management of spinal cord injury

Background

Traumatic spinal cord injury (SCI) is a serious disorder that results in severe impairment of neurological function as well as disability, ultimately reducing a patient's quality of life. The pathophysiology of SCI involves a primary and secondary phase, which causes neurological injury.

Methods

Narrative review on current clinical management of spinal cord injury and emerging therapies.

Results

This review explores the management of SCI through early decompressive surgery, optimizing mean arterial pressure, steroid therapy and focused rehabilitation. These management strategies reduce secondary injury mechanisms to prevent the propagation of further neurological damage. The literature regarding emerging research is also explored in cell-based, gene, pharmacological and neuromodulation therapies, which aim to repair the spinal cord following the primary injury mechanism.

Conclusions

Outcomes for patients with SCI can be enhanced and improved if primary and secondary phases of SCI can be addressed.

Alpinetin inhibits neuroinflammation and neuronal apoptosis via targeting the JAK2/STAT3 signaling pathway in spinal cord injury

BACKGROUND

A growing body of research shows that drug monomers from traditional Chinese herbal medicines have antineuroinflammatory and neuroprotective effects that can significantly improve the recovery of motor function after spinal cord injury (SCI). Here, we explore the role and molecular mechanisms of Alpinetin on activating microglia-mediated neuroinflammation and neuronal apoptosis after SCI.

METHODS

Stimulation of microglia with lipopolysaccharide (LPS) to simulate neuroinflammation models in vitro, the effect of Alpinetin on the release of pro-inflammatory mediators in LPS-induced microglia and its mechanism were detected. In addition, a co-culture system of microglia and neuronal cells was constructed to assess the effect of Alpinetin on activating microglia-mediated neuronal apoptosis. Finally, rat spinal cord injury models were used to study the effects on inflammation, neuronal apoptosis, axonal regeneration, and motor function recovery in Alpinetin.

RESULTS

Alpinetin inhibits microglia-mediated neuroinflammation and activity of the JAK2/STAT3 pathway. Alpinetin can also reverse activated microglia-mediated reactive oxygen species (ROS) production and decrease of mitochondrial membrane potential (MMP) in PC12 neuronal cells. In addition, in vivo Alpinetin significantly inhibits the inflammatory response and neuronal apoptosis, improves axonal regeneration, and recovery of motor function.

CONCLUSION

Alpinetin can be used to treat neurodegenerative diseases and is a novel drug candidate for the treatment of microglia-mediated neuroinflammation.

Which treatment provides the best neurological outcomes in acute spinal cord injury?

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.