Anterior Decompression in Cervical Spine Trauma: Does the Timing of Surgery Affect the Outcome?

Abstract

To clarify the ideal timing of anterior decompression and stabilization for all patients with cervical spine trauma as well as its efficacy for patients with complete deficits, we reviewed the records of 103 consecutive patients with cervical spine trauma (50 incomplete deficits, Group A; 53 complete deficits, Group B) who underwent this procedure during a 5-year period at the Shock Trauma Center. We subdivided each group according to time of surgery: early and delayed (<24 and >24 hours past injury, respectively). In Group A, 10 patients underwent early surgery and 40 patients underwent delayed surgery (range, 2 to 77 days past injury; mean, 13 days). One patient (2.5%) in the delayed group died. The following data refer to the early and delayed subgroups, respectively: average acute hospitalization, 20 and 22 days; patient motor score improvement (at discharge), 37.2 and 45.0%; functional grade improvement (at discharge), 5 (50.0%) and 9 (22.5%) patients. At 1-year follow-up, every patient who had had a deficit had progressed to a higher functional grade. In Group B, 35 patients underwent early surgery and 18 underwent delayed surgery (range, 2 to 45 days past injury; mean, 13 days). One patient (2.9%) in the early group died. The following data refer to the early and delayed subgroups, respectively: average acute hospitalization, 38.7 and 45.2 days (P < 0.05); respiratory care (number of daily suction procedures), 6.0 and 9.86 (P < 0.05); patient motor score improvement (at discharge), 3.9 and 4.5%; functional grade improvement (at discharge), 4 (11.4%) and 1 (5.6%) patients. At 1-year follow-up, 16 (45.7%) and 7 (38.9%) patients, respectively, had progressed to a higher functional grade (mean motor score improvement, 15.0 and 16.7%, respectively). Only 5 patients (14.3%) did not gain the function of at lease one more segment. Although our study demonstrated no statistically significant difference in outcome between early surgery and delayed surgery subgroups, we feel early anterior decompression and stabilization is appropriate for selected patients because this process has a comparable adverse sequelae rate to that of delayed surgery; it provides superior ease of patient care, it facilitates earlier transfer to rehabilitation (an important parameter in decreasing medical expenses), and it may benefit even patients with complete deficits diagnosed on the first day.

Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach

“…In the retrospective studies of Wagner and Chehrazi 33 and Levi et al, 21 comparing early-and late-treated patients, there were no differences in neurologic recovery. Even in more recent studies, based on prospective series, such as that of Duh et al, 41 39 based on a prospective randomized series, stated no difference between early and late surgery.…”

“…In fact, although experimental studies demonstrated that early relief of decompression improves neurological outcome in animal models, as first shown convincingly by Tarlov and Klinger 19,20 in dogs and later by Brodkey et al 46 in cats, the results of several clinical studies failed to show that patients treated early made improved recovery compared with those undergoing late surgery. 21,33,39,51 Figure 3 Analysis of homogeneity of pooled studies. Selected studies had been pooled on the basis of treatment and neurological status at admittance: early-treated patients with complete (a) and incomplete neurological deficit (b); latetreated patients with complete (c) and incomplete neurological deficit (d); conservatively managed patients with complete (e) and incomplete neurological deficit (f).…”

“…In acute systemic trauma, there is a greater probability of failure of alignment and fusion, and surgical treatment may be precluded by the lack of specific equipment and experienced personnel. 21,22 Furthermore, definitive and unequivocal evidence to support the practice of early or late surgery are still lacking in clinical studies. 21,[23][24][25][26][27][28][29][30][31][32][33][34][35][36] Recently, in an evidence-based review of the literature, Fehlings and Tator 10 concluded, on the bases of the current knowledge, that early decompression can be considered a practice option.…”

Neurotrophins: Potential Therapeutic Tools for the Treatment of Spinal Cord Injury

“…Acute spinal surgery, within the first 24 h following SCI, to alleviate mechanical shearing and compression forces is used to restrict primary damage to the cord, as well as secondary damage that can result from extended periods of compression [13]. In addition to spinal cord stabilization, arterial oxygenation and maintenance of mean arterial blood pressure between 85 and 90 mm Hg following acute SCI is vital in reducing secondary damage due to ischemia and hypoxia, and improving functional outcome [11,[14][15][16][17][18]. Hypothermia is also currently in clinical testing as a means of limiting secondary damage immediately following injury [19,20].…”

Emerging Approaches to the Surgical Management of Acute Traumatic Spinal Cord Injury

“…One systematic review, considered class 2 evidence, concluded that early surgery (<24 h) results in better neurological outcome than delayed surgery (>24 h) for patients with incomplete injuries [36]. In studies of lower methodological quality, surgery prior to 24 h has also been shown to improve neurological outcomes and to reduce complications, as well as certain measures of resource use, such as overall length of hospital stay and length of intensive care unit stay [37][38][39]. Conversely, studies of similar low methodological quality, using the same time cutoff, have failed to demonstrate a positive effect with respect to neurologic outcome [40,41].…”