To the Editor: In their letter,1 the authors first cite the significant association between ultra-early surgery and improved neurological outcomes. They then list a series of limitations of the paper, and finally advocate for future, larger, prospective studies with long-term follow up. We first would like to thank the authors for their interest in our paper2: those who have cared for patients with spinal cord injury (SCI) understand the challenges facing this population. The more we constructively communicate and share treatment strategies, the more quickly we will converge on solutions. Furthermore, we agree that more prospective data are needed and state in the paper that our “results suggest a need for validation in a prospective observational study or in a randomized trial”.2 Ultimately, we hope this paper encourages others to engage in SCI research, hopefully increasing the number and quality of prospective studies. Regarding the authors' specific comments, we offer the following response. First, the author's conclusion that our data is heterogeneous with regard to surgical approach restates what was already presented in the paper. As we discuss, “a major limitation [in our results] is the lack of homogeneity and small sample size in our dataset: surgical decision-making and operative approach was up to the surgeon at the time of injury, and was not standardized across patients”.2 Second, the authors also suggest that injury severity may be a source of bias. We disagree. We measured injury severity and showed that it did not differ in the ultra-early, early, and late groups; it is therefore unlikely that the severity of injury played a major role in the observed improvement in neurological function. Third, the authors also mention a number of limitations that appear unrelated to the central issue of our paper—specifically, surgical timing after SCI. For example, the authors state that “late surgery (>12 h)… is still worthwhile under certain conditions”. This is of course true, but whether late surgery is beneficial or not is irrelevant to our central hypothesis: that surgery performed very early after SCI increases the probability of neurological recovery. Likewise, the authors emphasize that neuroimaging studies, neurophysiological parameters, cerebrospinal fluid biomarkers, and postoperative physical therapy are related to outcome after SCI. Again, although it may be interesting to show that these results somehow interact with early vs late surgery, it is not related to the scope of the paper. The neurosurgeon is often faced with 2 options regarding surgical timing after SCI. One option is to take the patient to the operating room as soon as possible after injury (ultra-early group), the other option is to wait and see how the patient does over 12 to 72 h before operating (early-late group). All other factors being equal, there is growing evidence that the former option (ultra-early) is the correct choice. Our data is another piece of evidence in favor of the ultra-early approach. We understand that a strategy of ultra-early surgery can be difficult to implement. We also understand the skepticism in adopting this approach and agree that future prospective data are needed to justify the costs associated with this strategy. However, the ultimate test is simple: if one of our family members had an SCI, we would choose the ultra-early surgery approach. Therefore, at our institution, we choose to adopt ultra-early surgery until proven otherwise. Disclosures This study was supported by DoD CDMRP Grant SC120259, and the CH Neilsen Foundation. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
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