The timing of surgery in patients with central spinal cord injury

Abstract

To The eDiToR: Spinal cord injury has a profound impact on individuals, their families, and society, with the costs in North America estimated to be in the billions of dollars for direct and indirect costs. There are multimodality approaches to treatment—primarily prevention and secondarily pharmacological agents and surgical intervention. These are likely to bear fruit in the form of reduction in neurological disability and mortality rates in the coming years. In the pharmacological corner, avenues to improve axonal conduction, excitatory amino acid antagonists, potassium and sodium channel blockers, and attenuation of extracellular myelin mediator growth inhibitory proteins are the current front-runners.1 Surgery has 2 principal goals: decompression and stabilization. The timing of surgical decompression has been under intense scrutiny and remains controversial. It is now accepted that early surgery can be done safely and effectively when hemodynamic parameters are controlled and with expert surgical and anesthetic management.3 While there is a clear biological rationale, based on preclinical studies in animal models, to consider early decompression after spinal cord injury (SCI), the clinical evidence to support this is less compelling. However, emerging evidence from the Surgical Treatment for Acute Spinal Cord Injury Study (STASCIS) supports the belief that decompression of the cord within 24 hours of injury, in patients with isolated cervical SCI, may be associated with improved recovery. The STASCIS is continuing to acquire data from long-term follow-up. The results of this trial are anticipated in the coming year. Traumatic central cord syndrome (TCCS) is “a different beast but of the same species.” It occurs in an older age group, and the timing of surgery is yet more controversial. This is due to the natural history of the condition, which shows considerable spontaneous recovery, albeit with a subsequent plateau in neurological function and with the potential for delayed worsening. The authors of some studies have excluded this condition from their analysis of timing of surgery.6 It is difficult to intellectually separate TCCS from the umbrella of traumatic SCI. After all, the same neurological structures are damaged by the fate of trauma, although in a preexisting narrower environment. Is not the decision to operate on a patient with myelopathy more compelling following traumatic damage to the cord? Chen and colleagues2 have analyzed factors that may influence recovery in a group of 49 patients surgically treated with TCCS. The recovery is assessed conventionally using ASIA motor scores, the 36-Item Short Form Health Survey (SF-36), Walking Index For Spinal Cord Injury (WISCI), and self-reported patient satisfaction (scores 1–5), bladder management scores, presence of spasticity, and neuropathic pain. Their results indicate that timing of surgery (before and after 4 days), surgical approach (anterior vs posterior) and different pathology make no difference in outcome according to the aforementioned indices. Furthermore, they showed that the younger spine had more capacity for recovery based on ASIA motor score improvements and WISCI scores. Overall based on patient satisfaction scores, one-third of the participants expressed dissatisfaction with their final outcome, while there were clear improvements in ASIA motor scores. The results of this study are limited by the design (retrospective) and lack of comparative control group as well as by the arbitrary selection of 4 days to define the “early” treatment group. Based on the biology of SCI, the Spine Trauma Study Group has operationally defined early intervention after SCI as being within 24 hours. Whether central cord syndrome is associated with a different rules related to timing remains unclear. In a retrospective study of 50 patients, however, Guest et al.5 showed that using this definition, early surgery was safe and more cost effective than delayed surgery (performed after 24 hours), and improvements in motor recovery was seen in TCCS related to disc herniation and fractures. The study by Chen and colleagues2 raises an interesting point regarding measurement of outcome in traumatic SCI. Should patient satisfaction scores replace functional outcome measures such as ASIA motor, SF36, and WISCI scores? In a recent study we showed that physiotherapy-led measures, such as hand function index, after cervical decompression in patients with myelopathy was a better indicator of outcome than SF-36 and neck disability index. We agree that a better measure of outcome is needed across board following spinal surgery. It is noteworthy that the patients who have sustained spinal trauma are getting older. Just as socioeconomic factors change and the older individual remains active and J Ne osurg Spine 10:1–2