Extent of Spinal Cord Decompression in Motor Complete (American Spinal Injury Association Impairment Scale Grades A and B) Traumatic Spinal Cord Injury Patients: Post-Operative Magnetic Resonance Imaging Analysis of Standard Operative Approaches

Abstract

Although decompressive surgery following traumatic spinal cord injury (TSCI) is recommended, adequate surgical decompression is rarely verified via imaging. We utilized magnetic resonance imaging (MRI) to analyze the rate of spinal cord decompression after surgery. Pre-operative (within 8 h of injury) and post-operative (within 48 h of injury) MRI images of 184 motor complete patients (American Spinal Injury Association Impairment Scale [AIS] grade A = 119, AIS grade B = 65) were reviewed to verify spinal cord decompression. Decompression was defined as the presence of a patent subarachnoid space around a swollen spinal cord. Of the 184 patients, 100 (54.3%) underwent anterior cervical discectomy and fusion (ACDF), and 53 of them also underwent laminectomy. Of the 184 patients, 55 (29.9%) underwent anterior cervical corpectomy and fusion (ACCF), with (26 patients) or without (29 patients) laminectomy. Twenty-nine patients (16%) underwent stand-alone laminectomy. Decompression was verified in 121 patients (66%). The rates of decompression in patients who underwent ACDF and ACCF without laminectomy were 46.8% and 58.6%, respectively. Among these patients, performing a laminectomy increased the rate of decompression (72% and 73.1% of patients, respectively). Twenty-five of 29 (86.2%) patients who underwent a stand-alone laminectomy were found to be successfully decompressed. The rates of decompression among patients who underwent laminectomy at one, two, three, four, or five levels were 58.3%, 68%, 78%, 80%, and 100%, respectively (p < 0.001). In multi-variate logistic regression analysis, only laminectomy was significantly associated with successful decompression (odds ratio 4.85; 95% confidence interval 2.2-10.6; p < 0.001). In motor complete TSCI patients, performing a laminectomy significantly increased the rate of successful spinal cord decompression, independent of whether anterior surgery was performed.

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

“…From this cohort, we screened and selected 72 patients who were eligible for this investigation. The inclusion criteria were being ‡16 years of age; Glasgow Coma Scale (GCS) score ‡14; no concurrent life-threatening injury or disease; imaging studies compatible with subaxial cervical spine fracture dislocations; available good quality pre-and post-operative computed tomography (CT) and MRI studies indicating complete spinal cord decompression following surgery; 35 and follow-up of at least 6 months after trauma and surgical management. The exclusion criteria were being obtunded, stuporous, and non-testable; having penetrating subaxial TSCI; having upper cervical SCI; a post-operative MRI indicating inadequate spinal cord decompression; non-operative management; having had a cervical CT myelogram and not an MRI as the primary imaging study; dying or being lost to follow-up; or having poorquality imaging studies.…”

“…[25][26][27][28][29][30] Ongoing surgical studies on the relationship among imaging biomarkers, surgical strategy, and long-term clinical outcome are shaping the standard of care for these patients. 18,28,[31][32][33][34][35][36] Over the past 30 years, overarching evidence has supported spinal cord decompression following trauma, but the question of surgical timing has yet to be established within this evolving paradigm. 10,12,32,35,[37][38][39][40][41] In addition, although multiple reports have indicated that early anatomical alignment of the spinal column and decompression of the spinal cord followed by internal fixation is neuroprotective, in these studies, decompression of the spinal cord generally has not been verified by post-operative imaging.…”

“…Recent efforts have begun to establish the significance of the extent of spinal cord decompression in neurological outcome. 16,35,42,43 Data reported by Aarabi and coworkers indicated that standard surgical management of cervical SCI achieves decompression of the entire swollen segment of the spinal cord in only 66% of subjects. 35 Additional studies incorporating post-operative MRI indicate that up to 25% of patients may need expansive duraplasty for adequate spinal cord decompression, along with reduction of intraspinal pressure, in order to improve functional outcome.…”

“…16,35,42,43 Data reported by Aarabi and coworkers indicated that standard surgical management of cervical SCI achieves decompression of the entire swollen segment of the spinal cord in only 66% of subjects. 35 Additional studies incorporating post-operative MRI indicate that up to 25% of patients may need expansive duraplasty for adequate spinal cord decompression, along with reduction of intraspinal pressure, in order to improve functional outcome. 14,15,42,44,45 As a result, studies on the effect of timing of surgical intervention have likely been confounded by incomplete spinal cord decompression, and, therefore, the effect of timing on outcome remains uncertain.…”

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].…”