Abstract
BackgroundThere is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥24 hours after injury) decompressive surgery after traumatic cervical SCI.MethodsWe performed a multicenter, international, prospective cohort study (Surgical Timing in Acute Spinal Cord Injury Study: STASCIS) in adults aged 16–80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality.FindingsA total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(±5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(±29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).ConclusionDecompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.
Highlights
The prevalence of traumatic spinal cord injury (SCI) worldwide is approximately 750 per million with an annual incidence that appears to be rising [1]
We present the results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS), a multi-center prospective cohort study that was undertaken to compare the relative effectiveness of early versus late (24 hours or greater post injury) surgery with respect to neurological outcome 6 months post cervical SCI
Neurologic examination was performed as per standards established by the American Spinal Injury Association (ASIA) and injury characteristics were classified according to neurologic level of injury (NLI), ASIA motor score (AMS), ASIA sensory score (ASS) and the overall ASIA Impairment Scale (AIS) grade
Summary
The prevalence of traumatic spinal cord injury (SCI) worldwide is approximately 750 per million with an annual incidence that appears to be rising [1]. The primary injury, usually caused by rapid spinal cord compression and contusion, initiates a signaling cascade of down-stream events collectively known as secondary injury. Preventing and mitigating these secondary mechanisms is where opportunity for neuroprotection lies and where most attempts at therapeutic intervention have been staged. The balance of existing laboratory evidence supports the theory that decompressive surgery of the spinal cord after SCI attenuates secondary injury mechanisms and improves neurological outcomes [5,6,7,8,9,10,11,12,13,14,15]. Our objective was to evaluate the relative effectiveness of early (,24 hours after injury) versus late ($24 hours after injury) decompressive surgery after traumatic cervical SCI
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