Comparison of Surgical and Conservative Management in 208 Patients with Acute Spinal Cord Injury

Abstract

ABSTRACT:The role of surgery in the management of acute spinal cord or cauda equina injuries remains controversial. The present study analyzed ten admission features and three outcome variables in 208 patients treated in an Acute Spinal Cord Injury Unit, 116 (56%) of whom underwent at least one spinal operation. The surgical and non-surgical groups showed no significant differences in the following seven clinical features: age, sex, distance travelled to the Unit, time interval between trauma and admission, type of accident, severity of injuries to the spinal cord, and severity of associated injuries. However, the two groups showed significant differences in level and type of vertebral column injury, and in the frequency of pre-existing spinal abnormalities. These differences were due to management policies which selected certain injuries for surgical or non-surgical treatment. One-third of the operative procedures were performed primarily for neural decompression, one-third primarily for reduction of bony structures and one-third for fusion. However, 95% of the operative patients had a fusion at the initial operation. Operative treatment was associated with a lower overall mortality rate (6.1%) than non-operative (15.2%), despite a higher frequency of thrombo-embolic complications in the surgical group. Overall, there was no difference between operated and non-operated patients in length of stay or neurological recovery. Surgical management of patients with acute spinal cord injury appears safe in terms of mortality rate and neurological recovery, but it has not been proven to improve the latter.

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

“…Another interesting finding was that the outcome of overall decompressed patients, combining together data of early and late treatment, namely overlooking the time factor, was similar to that of conservatively managed patients. This agree with the observations of other authors, 32,[50][51][52][53] and suggest that timing may play a role in surgical decompression.…”

“…Lack of identification and inclusion of trials through publication or location bias was assessed by a qualitative analysis of the asymmetry of the plots. 32 A w 2 test for homogeneity across studies was then used to assess quantitatively the homogeneity.…”

“…32,34,[40][41][42][43][44][45] Most studies reported on retrospective case series with historical controls (Class III evidence).…”

“…[11][12][13] The limit of 24 h has been used in this study for two practical reasons: (1) very few reports provide data on an earlier treatment; (2) less than 50% of patients can be currently admitted to spinal cord centres within 24 h. 57,58 Analysis of results and limitations of the study The meta-analytic procedure consisted of extraction, pooling and statistical analysis of data from parent studies. Since only one prospective randomized (Class I evidence) 39 and eight prospective nonrandomized case series (Class II evidence) 32,34,40,[41][42][43][44][45] were found from the literature search, the meta-analysis was based on studies reported on retrospective case series with historical controls (Class III evidence). The outcome of patients undergoing a decompressive procedure within 24 h was then compared with that of patients treated through delayed decompressive procedures and that of nonoperatively managed patients.…”

“…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. 37 Clinically, the neurological examination within 24 h of injury is fraught with difficulty.…”