Efficacy of Ultra-Early (< 12 h), Early (12–24 h), and Late (>24–138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury

Abstract

In cervical traumatic spinal cord injury (TSCI), the therapeutic effect of timing of surgery on neurological recovery remains uncertain. Additionally, the relationship between extent of decompression, imaging biomarker evidence of injury severity, and outcome is incompletely understood. We investigated the effect of timing of decompression on long-term neurological outcome in patients with complete spinal cord decompression confirmed on postoperative magnetic resonance imaging (MRI). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade conversion was determined in 72 AIS grades A, B, and C patients 6 months after confirmed decompression. Thirty-two patients underwent decompressive surgery ultra-early (< 12 h), 25 underwent decompressive surgery early (12-24 h), and 15 underwent decompressive surgery late (> 24-138.5 h) after injury. Age, gender, injury mechanism, intramedullary lesion length (IMLL) on MRI, admission ASIA motor score, and surgical technique were not statistically different among groups. Motor complete patients (p = 0.009) and those with fracture dislocations (p = 0.01) tended to be operated on earlier. Improvement of one grade or more was present in 55.6% of AIS grade A, 60.9% of AIS grade B, and 86.4% of AIS grade C patients. Admission AIS motor score (p = 0.0004) and pre-operative IMLL (p = 0.00001) were the strongest predictors of neurological outcome. AIS grade improvement occurred in 65.6%, 60%, and 80% of patients who underwent decompression ultra-early, early, and late, respectively (p = 0.424). Multiple regression analysis revealed that IMLL was the only significant variable predictive of AIS grade conversion to a better grade (odds ratio, 0.908; confidence interval [CI], 0.862-0.957; p < 0.001). We conclude that in patients with post-operative MRI confirmation of complete decompression following cervical TSCI, pre-operative IMLL, not the timing of surgery, determines long-term neurological outcome.

Trends in Rates of ASIA Impairment Scale Conversion in Traumatic Complete Spinal Cord Injury

“…15 Earlier decompression (within 24 h) for traumatic SCI has been associated with improved outcomes in both cervical and thoracolumbar injuries. [16][17][18] Although the results for surgery sooner than 24 h post-injury have been mixed, 19,20 a recent meta-analysis found better outcomes when surgery was performed within 12 h of injury. 16 Persons with cervical injuries converted at a higher rate than those with thoracic-level injuries, which is consistent with current literature.…”

Targeted Perfusion Therapy in Spinal Cord Trauma

“…After TSCI, patients are transferred to neurosurgical or orthopedic units and most undergo spinal surgery to correct deformity and stabilize the fractured spine by placing screws, plates, and rods. Several surgical controversies exist, e.g., anterior versus posterior approach, number of levels to be fixed, timing of surgery, and the role of laminectomy [4][5][6][7][8][9][10]; thus, operative management largely relies on surgeons' preferences rather than robust evidence. Substantial literature has been devoted to the timing and role of surgery; currently, most surgeons opt for early surgery, once the patient is medically stable [8,10].…”

Motor unit number index detects the effectiveness of surgical treatment in improving distal motor neuron loss in patients with incomplete cervical spinal cord injury

“…Thus, a standard protocol and a fixed examiner were used in the current study [8]. Furthermore, another limitation is that the time cutoffs by which to identify early vs. delayed surgical treatment were different in various studies involving SCI (e.g., 24 hours) [20,21]. However, few patients can accept surgical treatment within 24 hours, due to both transportation issues and referral delays.…”