Early Decompressive Surgery Research Articles

Operative Timing in Cervical Spine Trauma.

Narrative review. To review existing literature regarding surgical timing in cervical trauma with a focus on acute traumatic central cord syndrome. Traumatic central cord syndrome is the most common incomplete spinal cord injury. Substantial basic science literature has proposed ischemic and secondary injury-driven mechanisms underpinning the urgency of operative intervention. However, only recently has a relative consensus emerged in the clinical literature regarding the safety, efficacy, and necessity of early operative intervention for acute traumatic central cord syndrome. A literature search was conducted of studies in PubMed Central and Cochrane Database related to timing in cervical spine trauma. Recently, several major systematic reviews and consensus statements have endorsed the importance and safety of early (<24h) operative decompression in the setting of traumatic spinal cord injury. Despite decades of conflicting data, a similar trend appears to be emerging for traumatic central cord syndrome. These clinical developments join a large body of basic science work regarding the importance of early decompressive surgery in relieving acute ischemic insult and minimizing the effects of secondary injury. However, further work is needed to delineate optimal surgical timing, especially regarding "ultra-early" (<8 h) protocols, and to aid in creating accelerated screening pathways.

Effect of Yiqi Huoxue Decoction on Neurological Function for Cervical Spinal Cord Injury

Cervical spinal cord injury (CSCI) can lead to neurological dysfunction, such as limb numbness, muscle stiffness, and motor disorders. Although early decompression surgery has demonstrated efficacy in alleviating symptoms for patients with CSCI, there are still some limitations in the recovery of motor function. It has been reported that traditional Chinese medicine (TCM) has advantages in the treatment of CSCI due to its safety and efficacy and its ability to modulate the immune system and promote neuroregeneration. In this study, we investigate the clinical efficacy of combining Yiqi Huoxue Decoction with acupoint massage therapy in patients with CSCI after decompression and fixation surgery. A total of 140 patients who were first diagnosed with CSCI at our hospital and underwent early decompression and internal fixation surgery from October 2022 to June 2023 were included in this study. They were divided into two groups: Group A (n = 70) received conventional Western medicine treatment, and Group B (n = 70) received Yiqi Huoxue Decoction and acupoint massage therapy. We observed significant improvements in the American Spinal Injury Association scores after the combined treatment. Moreover, the levels of neuron-specific enolase decreased, while the levels of nerve growth factor and insulin-like growth factor-1 increased. Additionally, the levels of CD3+, CD4+, and CD8+ T cells exhibited a notable decrease. Furthermore, acupoint massage was found to stimulate nerve endings, thereby promoting nerve regeneration and repair. In summary, this combined treatment effectively improves the neurological function of patients with CSCI.

Early decompressive surgery improves long-term prognosis in patients with intracerebral hemorrhage.

Multiple studies have shown that early decompressive surgery in patients with intracerebral hemorrhage can effectively limit hematoma expansion, reduce perihematomal edema, and improve prognosis. However, these studies are limited by small sample sizes and short follow-up times. To analyze the effect of early decompressive surgery on the long-term prognosis of patients with cerebral hemorrhage and identify the influencing factors for poor prognosis. A retrospective analysis of 78 patients with cerebral hemorrhage admitted between January 2020 and December 2022 was conducted. Patients were divided into early and delayed surgery groups for comparison of outcomes such as mortality rate, modified Rankin Scale score, and Short Form-36 scores. Additionally, factors influencing long-term prognosis were analyzed through logistic regression based on significant differences observed between groups. The early decompressive surgery group showed superior outcomes with lower mortality rates, modified Rankin Scale (mRS) scores, hematoma expansion rates, and perihematomal edema volumes compared to the delayed surgery group (P< 0.05). Additionally, age, preoperative Glasgow Coma Scale (GCS) score, preoperative hematoma volume, and a history of hypertension or diabetes were identified as independent prognostic factors for patients with cerebral hemorrhage, with odds ratios (ORs) greater than 1. Early decompressive surgery can improve the long-term prognosis and quality of life of patients with cerebral hemorrhage, reduce mortality rates, and decrease hematoma expansion and perihematomal edema. Older patients, those with higher preoperative hematoma volume and GCS score, and those with coexisting hypertension and diabetes should be given special attention to decrease the occurrence of adverse prognosis.

Adherence to international guidelines in neurocritical care of cervical traumatic spinal cord injury-a retrospective study

IntroductionThe American Association of Neurologic Surgeons guidelines on the management of traumatic spinal cord injury (SCI), updated in 2013, focus on spinal cord perfusion, early decompressive surgery, and venous thromboembolism (VTE) prophylaxis to improve neurological outcome. Research questionHow neurocritical care and initial management have changed with the implementation of updated management guidelines, focusing on guidelines adherence and neurological outcome. Material and methodsSystemic physiological variables, time to neurosurgical treatment and VTE prophylaxis, and neurological outcome, were retrospectively collected from adult patients treated for cervical SCI 2001–2021. ResultsFifty-two patients were included. Mean arterial blood pressure (MAP) was significantly higher after 2013 (86±9.9 mmHg) when compared to before 2013 (79±9.9 mmHg), p = 0.041. Median time to surgery was 41 h before, and 20 h after 2013 (p = 0.029). Time to VTE prophylaxis was six days before and four days after 2013. Most neurocritical care complications were less commonly observed after 2013. Despite improved adherence to treatment goals, 44 % of MAP levels were below target, and 33% of patients were operated beyond 24h post-injury. Neurological outcome was not improved after implementation of the revised guidelines. Discussion and conclusionWhile implementation of the revised 2013 guidelines improved most aspects of the acute SCI management, many guideline targets were not met in a large subset of patients. Strict adherence to the acute neurocritical management goals, and early surgical treatment, is likely crucial when aiming to improve SCI outcome.

Early decompressive surgery within 72 hours of admission maintains financial advantages for patients with spinal epidural abscess, as evidenced by a retrospective study involving 130 cases

Abstract Background Several recent studies have highlighted the advantages of early decompressive surgery for patients with spinal epidural abscesses, specifically in terms of neurological function and overall quality of life. However, these studies predominantly advocate for surgery within 24 hours of admission, a time frame that may prove challenging for many hospitals because of limited operating room availability and bed occupancy. Consequently, it is pertinent to investigate whether a more flexible definition of “early surgery” yields observable benefits for patients to address these practical constraints. Materials and Methods In this 10-year retrospective study, we analyzed the electronic medical records of 130 patients who underwent decompressive surgery for epidural abscess. Patients were categorized into three groups based on the time intervals between admission and surgery: ≤24 hours (n = 24), 24 to 72 hours (n = 26), and &gt;72 hours (n = 80). Comparative assessments of demographic data, clinical presentations, and preoperative imaging characteristics revealed no statistically significant differences. We conducted separate analyses at 24 hours (n = 24 vs n = 106) and 72 hours (n = 50 vs n = 80) to explore the effects of different cutoff times. Neurological improvement (American Spinal Injury Association Impairment Scale [AIS] grade), daily living function (modified Prolo scale) changes 6 months postdischarge, and financial burden (hospitalization and postoperative stay duration, total expenditure) were evaluated as outcome measures. In addition, we compared the outcomes of patients within the 24- to 72-hour time range with those in the ≤24- and &gt;72-hour group to determine any differences among the three groups. Results Significant changes in AIS grade (1.17 vs 0.66, P = 0.019) and modified Prolo scale (4.21 vs 2.90, P = 0.011) were observed in the 24-hour group, whereas no such changes were seen in the 72-hour group. However, both groups showed reductions in financial burden, including hospitalization duration (24-hour group: 27.8 vs 46.8 days, P &lt; 0.001; 72-hour group: 31.3 vs 50.7 days, P &lt; 0.001) and total cost (24-hour group: $6551 vs $11,024, P &lt; 0.001; 72-hour group: $6709 vs $12,406, P &lt; 0.001). When analyzing the subgroup of patients with a time interval between 24 and 72 hours, we observed a loss of beneficial effects on AIS grade changes (1.2 vs 0.6, P = 0.045) and modified Prolo scale improvement (4.2 vs 3.1, P = 0.044) compared with the ≤24-hour group. However, this subgroup still exhibited positive effects in terms of reduced financial burden, including hospitalization duration (34.6 vs 50.7 days, P = 0.002) and total cost ($6851 vs $12,406, P &lt; 0.001), when compared with the &gt;72-hour group. Conclusions Our findings indicate that delaying decompressive surgery up to 72 hours after admission negates its benefits in enhancing neurological recovery and restoring daily life capacity. Nonetheless, this surgical approach continues to provide financial advantages by alleviating the financial burden on patients and the health care system. Further research with a larger sample size is recommended to deepen our understanding of these advantages.

How do early perioperative changes in AIS grade correlate with long-term neurological recovery? A retrospective cohort study

Context/Objective: Providing accurate counseling on neurological recovery is crucial after traumatic spinal cord injury (TSCI). The early neurological changes that occur in the subacute phase of the injury (i.e. within 14 days of early decompressive surgery) have never been documented. The objective of this study was to assess peri-operative neurological improvements after acute TSCI and determine their relationship with long-term neurological outcomes, measured 6–12 months following the injury. Methods: A retrospective cohort study of 142 adult TSCI patients was conducted. Early peri-operative improvement was defined as improvement of at least 1 AIS grade between the pre-operative and follow-up (6–12 months post-TSCI) assessment. neurological improvement of at least 1 AIS grade. Results: Out of the 142 patients, 18 achieved a peri-operative improvement of at least 1 AIS grade. Presenting a pre-operative AIS grade B and having shorter surgical delays were the main factors associated with stronger odds of achieving this outcome. Out of the 140 patients who still had potential for improvement at the time of the post-operative assessment, 44 achieved late neurological recovery (improvement of at least 1 AIS grade between the post-operative assessment and follow-up). Patients who presented a perioperative improvement seemed more likely to achieve later neurological improvement as well, although this was not statistically significant. Conclusion: Our results suggest that it is important to assess early perioperative neurological changes within 14 days of surgery because it can provide beneficial insight on long-term neurological outcomes for some patients. In addition, earlier surgery may promote early neurological recovery.

Current insights into the management of spinal cord injury

BackgroundTraumatic spinal cord injury (SCI) is a serious disorder that results in severe impairment of neurological function as well as disability, ultimately reducing a patient's quality of life. The pathophysiology of SCI involves a primary and secondary phase, which causes neurological injury. MethodsNarrative review on current clinical management of spinal cord injury and emerging therapies. ResultsThis review explores the management of SCI through early decompressive surgery, optimizing mean arterial pressure, steroid therapy and focused rehabilitation. These management strategies reduce secondary injury mechanisms to prevent the propagation of further neurological damage. The literature regarding emerging research is also explored in cell-based, gene, pharmacological and neuromodulation therapies, which aim to repair the spinal cord following the primary injury mechanism. ConclusionsOutcomes for patients with SCI can be enhanced and improved if primary and secondary phases of SCI can be addressed.

Immediate Cooling and Early Decompression for the Treatment of Cervical Spinal Cord Injury: A Safety and Feasibility Study.

Cervical spinal cord injury (SCI) usually results in severe, long-term disability. Early therapeutic hypothermia (33-34°C) has been used to improve outcomes in preclinical studies, but previous clinical studies have commenced cooling after arrival at hospital. The objective of the study is to determine the feasibility and safety of early therapeutic hypothermia initiated by paramedics and maintained for up to 24 hours in hospital in patients with SCI. This is a pilot clinical study. The study was undertaken at Ambulance Victoria and The Alfred Hospital, Victoria, Australia. A total of 17 consecutive patients with suspected acute traumatic cervical SCI were enrolled. Patients with suspected cervical SCI were administered a bolus (up to 20 mL/kg) intravenous (IV) cold (4°C) normal saline in the prehospital phase of care. After hospital admission and spinal imaging, further cooling used IV catheter temperature control or surface cooling. Major complications and long-term outcomes were compared with historical controls admitted to the same center before the study. A decrease in core temperature of 1.1°C was achieved during prehospital care and the target temperature was achieved in 6 hours with mechanical temperature management devices in the hospital. There were no major safety concerns. Patients with motor complete SCI who underwent early decompressive surgery had a favorable rate of partial spinal cord recovery compared with historical controls. Therapeutic hypothermia induced using bolus, large-volume, ice-cold saline prehospital and maintained for 24 hours using mechanical devices appears to be feasible and safe in patients with SCI. Larger trials need to be undertaken to determine whether prehospital cooling combined with early decompressive surgery improves outcomes in patients with complete cervical SCI. Australian and New Zealand Clinical Trials Registry (ACTRN12616001086459).

Ultraearly Hematoma Evacuation (

Early decompressive surgery within 24 hours improves the functional outcome of patients with traumatic spinal cord injury; however, little is known about the effect of early surgery for spontaneous spinal epidural hematoma (SSEH). In this study, we aimed to investigate the effectiveness of ultraearly hematoma evacuation (<12 hours) for SSEH. Patients with SSEH treated with surgical hematoma evacuation at our institution between January 2000 and July 2021 were retrospectively analyzed. Neurologic function was evaluated using the American Spinal Injury Association Impairment Scale (AIS). AIS grades A-C were defined as severe, and grades D and E as mild. AIS grades D and E at the final follow-up were considered favorable outcomes. Preoperative status and postoperative treatment results were compared between patients who had hematoma evacuation within 12 hours of onset and those who underwent surgery after 12 hours. Twenty-five consecutive patients were included in the analysis. Preoperatively, 23 patients (92.0%) had severe AIS. Fourteen (56.0%) patients underwent early surgery. At the final follow-up, 21 patients (84.0%) achieved favorable outcomes. Patients treated with ultraearly surgery had significantly better outcomes (100% vs. 63.6%, P= 0.03). Additionally, the time from onset to surgery was significantly shorter in patients with AIS improvement by 2 or more grades than that in patients with AIS improvement of 1 or less (median 8 hours vs. 14 hours, P= 0.0001). Ultraearly surgery within 12 hours for SSEH was associated with better functional outcomes.

Early vs Late Surgical Decompression for Central Cord Syndrome

The optimal clinical management of central cord syndrome (CCS) remains unclear; yet this is becoming an increasingly relevant public health problem in the face of an aging population. To provide a head-to-head comparison of the neurologic and functional outcomes of early (<24 hours) vs late (≥24 hours) surgical decompression for CCS. Patients who underwent surgery for CCS (lower extremity motor score [LEMS] - upper extremity motor score [UEMS] ≥ 5) were included in this propensity score-matched cohort study. Data were collected from December 1991 to March 2017, and the analysis was performed from March 2020 to January 2021. This study identified patients with CCS from 3 international multicenter studies with data on the timing of surgical decompression in spinal cord injury. Participants were included if they had a documented baseline neurologic examination performed within 14 days of injury. Participants were eligible if they underwent surgical decompression for CCS. Early surgery was compared with late surgery. Propensity scores were calculated as the probability of undergoing early compared with late surgery using the logit method and adjusting for relevant confounders. Propensity score matching was performed in a 1:1 ratio by an optimal-matching technique. The primary end point was motor recovery (UEMS, LEMS, American Spinal Injury Association [ASIA] motor score [AMS]) at 1 year. Secondary end points were Functional Independence Measure (FIM) motor score and complete independence in each FIM motor domain at 1 year. The final study cohort consisted of 186 patients with CCS. The early-surgery group included 93 patients (mean [SD] age, 47.8 [16.8] years; 66 male [71.0%]), and the late-surgery group included 93 patients (mean [SD] age, 48.0 [15.5] years; 75 male [80.6%]). Early surgical decompression resulted in significantly improved recovery in upper limb (mean difference [MD], 2.3; 95% CI, 0-4.5; P = .047), but not lower limb (MD, 1.1; 95% CI, -0.8 to 3.0; P = .30), motor function. In an a priori-planned subgroup analysis, outcomes were comparable with early or late decompressive surgery in patients with ASIA Impairment Scale (AIS) grade D injury. However, in patients with AIS grade C injury, early surgery resulted in significantly greater recovery in overall motor score (MD, 9.5; 95% CI, 0.5-18.4; P = .04), owing to gains in both upper and lower limb motor function. This cohort study found early surgical decompression to be associated with improved recovery in upper limb motor function at 1 year in patients with CCS. Treatment paradigms for CCS should be redefined to encompass early surgical decompression as a neuroprotective therapy.

22. Early vs (

<h3>BACKGROUND CONTEXT</h3> The optimal clinical management of central cord syndrome (CCS) remains unclear; yet this is becoming an increasingly relevant public health problem in the face of the global aging population. <h3>PURPOSE</h3> To provide a head-to-head comparison of the neurological and functional outcomes of early (<24 hrs) vs late (24 hrs) surgical decompression for CCS. <h3>STUDY DESIGN/SETTING</h3> Propensity, score-matched analysis cohort study. <h3>PATIENT SAMPLE</h3> Participants were included if they had a documented baseline American Spinal Injury Association (ASIA) / International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) neurological examination performed within 14 days of injury. Participants were eligible if they underwent surgical decompression for CCS, as defined by apoint difference of five or more between baseline ASIA lower extremity motor score (LEMS) and upper extremity motor score (UEMS), in favor of the lower limbs (LEMS - UEMS 5). <h3>OUTCOME MEASURES</h3> The primary endpoint was motor recovery (upper extremity motor score (UEMS); lower extremity motor score (LEMS); AMS) at one year. Secondary endpoints were Functional Independence Measure (FIM) motor score and complete independence in each FIM motor domain at one year. <h3>METHODS</h3> This study identified CCS patients from three international, multicentre studies examining the timing of surgical decompression in spinal cord injury. Patients who underwent surgery for CCS (LEMS-UEMS5) were identified from three spinal cord injury (SCI) datasets (NACTN; STASCIS; NASCIS III). Propensity scores were calculated as the probability of undergoing early (< 24 hrs) compared to late (24 hrs) surgery using the logit method and adjusting for data source, age, injury mechanism, and baseline ASIA motor score (AMS), AIS grade, and neurological level. Propensity score matching was performed in a one-to-one ratio by an "optimal matching" technique. Effect sizes for outcomes were summarized by mean differences (MDs) or odds ratios (ORs) and associated 95% confidence intervals. <h3>RESULTS</h3> The final study cohort consisted of 186 patients with CCS. Baseline characteristics were balanced between matched early (N=93) and late (N=93) surgery groups. Early surgical decompression resulted in significantly improved recovery in upper limb (MD 2.3, P=0.047), but not lower limb (MD 1.1, P=0.256), motor function, as compared with late surgery. More patients in the early surgery group appeared to achieve complete independence in various functional activities, particularly those involving upper limb function; however, these associations did not reach statistical significance, and there was no difference in one-year FIM motor score (MD 4.4, P=0.182). On subgroup analysis, outcomes were comparable with early or late decompressive surgery in AIS grade D patients. However, in patients with AIS grade C injury, early surgery resulted in significantly greater recovery in overall motor score (MD 9.5, P=0.038), owing to gains in both upper and lower limb motor function. <h3>CONCLUSIONS</h3> This study found early (<24 hrs) compared to late (24 hrs) surgical decompression to result in improved recovery in upper limb motor function at one year in patients with central cord syndrome. The benefit of early surgery was especially realized in patients with AIS grade C injury. Treatment paradigms for central cord syndrome should be redefined to encompass early surgical decompression as a neuroprotective therapy. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

28. International perspectives on the current practice of acute spinal cord injury management: results of a global survey

28. International perspectives on the current practice of acute spinal cord injury management: results of a global survey

Predicting the Role of Preoperative Intramedullary Lesion Length and Early Decompressive Surgery in ASIA Impairment Scale Grade Improvement Following Subaxial Traumatic Cervical Spinal Cord Injury.

Traumatic cervical spinal cord injury (TCSCI) is a disabling condition with uncertain neurologic recovery. Clinical and preclinical studies have suggested early surgical decompression and other measures of neuroprotection improve neurologic outcome. We investigated the role of intramedullary lesion length (IMLL) on preoperative magnetic resonance imaging (MRI) and the effect of early cervical decompressive surgery on ASIA impairment scale (AIS) grade improvement following TCSCI. In this retrospective study, we investigated 34 TCSCI patients who were admitted over a 12-year period, from January 1, 2008 to January 31, 2020. We studied the patient demographics, mode of injury, IMLL and timing of surgical decompression. The IMLL is defined as the total length of edema and contusion/hemorrhage within the cord. Short tau inversion recovery (STIR) sequences or T2-weighted MR imaging with fat saturation increases the clarity of edema and depicts abnormalities in the spinal cord. All patients included had confirmed adequate spinal cord decompression with cervical fixation and a follow-up of at least 6 months. Of the 34 patients, 16 patients were operated on within 24 hours (early surgery group) and 18 patients were operated on more than 24 hours after trauma (delayed surgery group). In the early surgery group, 13 (81.3%) patients had improvement of at least one AIS grade, whereas in the delayed surgery group, AIS grade improvement was seen in only in 8 (44.5%) patients (early vs. late surgery; odds ratio [OR] = 1.828; 95% confidence interval [CI]: 1.036-3.225). In multivariate regression analysis coefficients, the timing of surgery and intramedullary edema length on MRI were the most significant factors in improving the AIS grade following cervical SCI. Timing of surgery as a unique variance predicted AIS grade improvement significantly (p < 0.001). The mean IMLL was 41.47 mm (standard deviation [SD]: 18.35; range: 20-87 mm). IMLL was a predictor of AIS grade improvement on long-term outcome in bivariate analysis (p < 0.001). This study suggests that patients who had IMLL of less than 30 mm had a better chance of grade conversion irrespective of the timing of surgery. Patients with an IMLL of 31 to 60 mm had chances of better grade conversion after early surgery. A longer IMLL predicts lack of improvement (p < 0.05). If the IMLL is greater than 61 mm, the probability of nonconversion of AIS grade is higher, even if the patient is operated on within 24 hours of trauma. Surgical decompression within 24 hours of trauma and shorter preoperative IMLL are significantly associated with improved neurologic outcome, reflected by better AIS grade improvement at 6 months' follow-up. The IMLL on preoperative MRI can reliably predict outcome after 6 months. The present study suggests that patients have lesser chances of AIS grade improvement when the IMLL is ≥61 mm.

Common fibular nerve palsy due to fabella compression: An illustrative case report

BackgroundThe fabella is a sesamoid bone situated in the tendon of the lateral head of the gastrocnemius muscle behind the lateral femoral condyle. Common fibular nerve injury may occur anywhere on its course and the most common etiology remains compression at the level of the head of the fibula. Compression by a fabella is a very unusual cause of common fibular nerve palsy and only few case reports are described in the literature. We present here an illustrative case. Case DescriptionA 50-year-old female patient presented with a left drop-foot evolving for two weeks without pain or sensory deficit.Clinical examination revealed a paresis of the left foot dorsiflexors muscles (3/5).A compressive neuropathy of the common fibular nerve at the level of the fibula head was demonstrated by nerve conduction studies. Ultrasound of the left knee revealed nerve compression by a fabella. Early decompressive surgery was performed and the fabella was excised. We noticed an almost complete recovery probably due to early treatment (4+/5 two months after surgery). ConclusionsCommon fibular nerve palsy related to fabella compression is very uncommon. Good clinical outcome has been described at 1–2 years with an early work-up and a prompt surgical decompression.

The Lead of Direct Adjuvant Intraoperative Foraminal Steroids' Infiltration.

Low back pain generally involves lumbosacral radicular syndrome, nerve root pain, and nerve root entrapment/irritation. Management options for patients are variable and diverging. To the highlight the efficacy of combined early decompressive surgery plus intraoperative steroid injections in terms of postoperative back pain in patients managed by our combined team. A prospective study conducted by reviewing all consecutive patients managed, over a 1-year period (2018-2019). This study showed that adjunct use of intraoperative foraminal and epidural steroids injections to treat back pain in patients with degenerative spine disease could significantly improve the pain score which leads to significant decrease in working days off and the need for pain killer medications or even obviating the usage rate.

Ultra-early Spinal Decompression Surgery Can Improve Neurological Outcome of Complete Cervical Spinal Cord Injury; a Systematic Review and Meta-analysis.

Introduction:Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in current guidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysis aims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12 hours after SCI) in improving patients’ neurological status.Methods:A search was performed in Medline, Embase, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinical trials were included in the present study. Exclusion criteria were absence of an early or late surgery group, failure to report neurological status based on the American spinal injury association impairment scale (AIS) grade, failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Two independent reviewers performed data collection, and risk of bias and certainty of evidence assessments. The outcome was reported as odds ratio (OR) and 95% confidence interval (CI).Results:Data from 16 articles, which studied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompression surgery significantly improves patients’ neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However, ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. Moreover, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86 folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improvement compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83; 95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).Conclusion:Current guidelines emphasize that spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and location. However, results of the present study demonstrated that certain considerations may be taken into account when performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should be performed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12 hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than in patients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients with AIS B to D does not significantly affect the neurological outcome.

N-Acetylcysteine alleviates spinal cord injury in rats after early decompression surgery by regulating inflammation and apoptosis

ABSTRACT Objective: Decompression surgery in patients with spinal cord injury (SCI) has a neuroprotective effect by alleviating secondary injury and improving neurological outcomes. N-Acetylcysteine (NAC), a drug approved by the United States Food and Drug Administration, has been shown to play neuroprotective roles via attenuation of apoptosis and inflammation. The purpose of the present study was to investigate the effects of early or late decompression surgery in combination with NAC administration on acute SCI, as well as investigate the underlying mechanisms of its actions. Methods: In this study, an acute SCI model was established in rats. The rats were treated with decompression surgery 24/48 h post-SCI in combination with or without NAC. Results: The results showed that decompression surgery in combination with NAC lead to a better outcome than decompression alone, as demonstrated by the higher Basso, Beattie, and Bresnahan scores. Histopathological examination demonstrated that early decompression surgery in combination with NAC exerted the best therapeutic effect on spinal cord recovery, which was further confirmed by the extent of inflammation and apoptosis. Additionally, we found that NAC might compensate for a lack of late surgery. Conclusions: Collectively, early decompression surgery and NAC could be a promising combination for the treatment of acute SCI, and its therapeutic effects may be associated with the regulation of inflammation and apoptosis.

EFEITO DO TEMPO ATÉ DESCOMPRESSÃO NA RECUPERAÇÃO NEUROLÓGICA APÓS TRAUMATISMO RAQUIMEDULAR

ABSTRACT Spinal cord injuries can have serious consequences for the individual, such as loss of motor function, sensory impairment, and alteration of physiological systems functions. Treatments for spinal cord injuries involve the use of drugs and surgical approaches. In the surgical field, there is a question about the ideal time after the trauma to perform the surgical procedure. The studies divide the time until surgery after the injury into two categories: “early” and “late”. To review the scientific literature on this topic, and to assess the relative effectiveness of early versus late decompressive surgery, we considered early intervention up to 24 hours and late intervention from 24 hours after the injury. For this, we performed a literature review and selected retrospective, prospective observational studies, clinical studies, and reviews with meta-analysis that compared the recovery time of patients with spinal cord injury after surgeries performed within 24 hours (early) and after 24 hours (late). The results showed potential for neurological improvement with early or even ultra-early surgical decompression (up to 12 hours) in patients with traumatic cervical spinal cord injury. On the other hand, reports about the advantage of early decompression when there is a thoracic injury are scarce. In addition to the time to decompression, the concomitant use of some drugs seems to play an important role in patients’ recovery. Level of Evidence II; Literature review.

Early Decompression and Short Transport Time After Traumatic Spinal Cord Injury are Associated with Higher American Spinal Injury Association Impairment Scale Conversion.

Retrospective cohort study. This retrospective cohort study aims to determine the association of early decompressive surgery and the impact of transport time on the neurological outcomes of traumatic spinal cord injury (tSCI) patients. tSCI is a catastrophic event that may result in permanent disability or loss of function. To date, there remains significant controversy over the optimal time for surgical decompression in tSCI patients. The aim of this study is to evaluate the neurological outcomes of tSCI patients undergoing early versus late surgical decompression and the impact of transport time on neurological outcomes. Data from 84 patients with tSCI requiring surgical decompression was collected. Regression analysis was used to establish time to decompression classification cutoffs. Patients were classified into the following subgroups: 0 to 12 or >12 hours as a factor of the total or admitting hospital time to decompression. The change in American Spinal Injury Association Impairment (AIS) Grade from admission to discharge was determined. Additionally, the effect of transport time on conversion of AIS grade was assessed as patients were grouped into transport times of <6 or >6 hours. Among the time to decompression subgroups there were no significant differences (P > 0.05) in confounding factors such as age, injury severity, and AIS grade. Patients who received decompression within 0 to 12 hours were associated with significantly (P < 0.0001) higher average improvements in ASIA grade (0.76). Patient transport times <6 hours were associated with significantly (P = 0.004) higher conversion of AIS grade to less impaired states. The present study suggests an association of decompression within 12 hours and short transport times (<6 hours) with significant improvements in neurological outcomes.Level of Evidence: 4.

P.232 Motor Recovery after Early Surgical Decompression in Cervical ASIA A Spinal Cord Injury Patients

Background: Despite growing evidence for early surgical decompression for traumatic cervical spinal cord injury(tCSCI) patients, controversy surrounds the efficacy of early surgical decompression on patients with a complete (ASIA A) cervical injury. Methods: Patients with ASIA A cervical tCSCI were isolated from 4 prospective, multi-center datasets. Patients who had a Glasgow coma scale of less than 13, were over the age of 70 or under 16 were excluded. Significant gain was defined to include those that recovered more than two muscle groups (greater than 3/5 power) below their level of injury. Analysis of variance (ANOVA) was then done to compare significant gain over the 1 year follow-up period for patients with and without early decompressive surgery (&lt;24hrs). Results: We identified 420 cervical ASIA A tCSCI patients. The mean number of muscle groups gained was 2.69 (SD 2.3.12) for those who had early surgery compared to 2.37 (SD 3.38) for those with late surgery. Of those patients who had early surgery 39.67% had a significant improvement vs. 28.76% of those who did not have early surgery (P = 0.030). Conclusions: For the first time, we have shown a clear therapeutic benefit of early surgical decompression within 24 hrs in ASIA A tCSCI patients.