Summary statement: the role and timing of decompression in acute spinal cord injury: evidence-based guidelines.

Abstract

The timing of surgical decompression after an acute spinal cord injury is one of the most controversial topics pertaining to spinal surgery. Based on a meta-analysis of the literature, Fehlings et al. have shown that numerous, reproducible animal studies have significantly demonstrated the benefit of early decompression after objective compression to the spinal cord. Unfortunately, these data have not been reproduced in human trials. Currently, there has been an enormous amount of research and interest in secondary injury cascade pathways after an acute spinal cord injury. This and the fact that some nonoperative surveillance studies have shown neurologic improvement without decompression/reduction has led some to believe that delayed or no surgery in combination with various pharmacologic interventions may be the direction to follow in the setting of spinal cord injury. What is needed to definitely answer the question regarding the timing of surgery following spinal cord injury is a well-designed, prospective, randomized controlled, multicenter trial producing Class I data. The major dilemma with this proposal is that some physicians may have an ethical problem with not decompressing/reducing obviously compressed neural elements (i.e., dislocated facet joints), especially in the patient with an incomplete spinal cord injury. It has been shown that in experienced hands, early decompression and fusion procedures have produced successful results supported by Class II and III data. Nonetheless, well-designed Class I studies designed with adequate sample sizes will undoubtedly shed light on whether early decompression/reduction and stabilization is beneficial or detrimental in modifying the secondary injury cascade. The final answer may be some combination of early surgery and a pharmacologic cocktail of neuromodulating substances in the setting of optimum cardiopulmonary support.