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.
Highlights
The pathophysiology of cervical traumatic spinal cord injury (TSCI) is complex, and there remains no effective treatment for this high-impact disorder.[1,2,3,4,5,6] In cervical TSCI, there is disruption of the anatomic integrity of the vertebral column followed by endothelial, neuronal, and axonal damage within fractions of a second of the injury
Patients with higher ASIA motor score at admission had a better rate of conversion at 6 months ( p < 0.0004), but the rate of conversion was not influenced by admission AIS grade ( p = 0.058)
Contrary to much of the literature, surgical decompression in any of the three time periods had no effect on improvements in AIS grade conversion ( p = 0.424).[28,47,58,59]
Summary
The pathophysiology of cervical traumatic spinal cord injury (TSCI) is complex, and there remains no effective treatment for this high-impact disorder.[1,2,3,4,5,6] In cervical TSCI, there is disruption of the anatomic integrity of the vertebral column followed by endothelial, neuronal, and axonal damage within fractions of a second of the injury. Continued compression of the spinal cord during the ensuing hours culminates in ischemia, swelling, and hemorrhagic progression of a compressive contusion.[7,8,9] In this scenario, a deleterious cycle of events ensues, in which molecular cascades instigate the upregulation of cationic channels that promote secondary injury and edema, which is visible on magnetic resonance imaging (MRI) within 10 min and . Leads to further compression of the injured spinal cord.[10,11] The swollen spinal cord becomes compressed circumferentially and longitudinally against the dura mater and rigid bone at the injury epicenter and beyond, resulting in the displacement of cerebrospinal fluid and the effacement of the subarachnoid space across multiple vertebral segments.[7,11,12,13]
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