Clasificacion Fracturas

Introduction Top
The prevalence of traumatic spinal cord injury (SCI) worldwide is approximately 750 per million with an annual incidence that appears to be rising [1]. Given the impact of SCI on the individual and society, it is clear that effective therapies aimed at reducing the extent of tissue destruction and improving neurologic outcomes after the initial spinal cord trauma are urgentlyneeded. Current concepts of the pathophysiology of acute SCI indicate that there are both primary and secondary mechanisms that lead to neurologic injury [2], . The primary injury, usually caused by rapid spinal cord compression and contusion, initiates a signaling cascade of down-stream events collectively known as secondary injury. Preventing and mitigating these secondary mechanisms is whereopportunity for neuroprotection lies and where most attempts at therapeutic intervention have been staged.
The balance of existing laboratory evidence supports the theory that decompressive surgery of the spinal cord after SCI attenuates secondary injury mechanisms and improves neurological outcomes [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. Furthermore, the strength of thisneuroprotective effect seems to vary inversely with the time elapsed from injury to the decompression [8], [15]. This work has translated into the clinical hypothesis that those who undergo surgery in a timely fashion post injury will experience less neural tissue destruction and improved clinical outcomes as compared to injury matched patients treated conservatively or with surgery in a delayed fashion.However, the clinical evidence compiled to date has failed to provide robust support for this hypothesis. One small randomized controlled trial and several other prospective studies showed no benefit to early decompression, with the caveat that early was defined as within 72 hours from the time of injury and that enrolment was limited to a single centre [16], [17], [18], [19]. In contrast, asystematic review suggested that decompression within 24 hours resulted in improved outcomes compared to both delayed decompression and conservative treatment [20]. Based on the best available evidence, the Spine Trauma Study Group adopted the 24 hour cutoff to define early versus late decompressive surgery after SCI [21].
To date, there have been no published studies that have systematicallyexamined a large cohort of patients who underwent decompression earlier than 24 hours. To address this void, we present the results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS), a multi-center prospective cohort study that was undertaken to compare the relative effectiveness of early (less than 24 hours post injury) versus late (24 hours or greater post injury) surgery with respectto neurological outcome 6 months post cervical SCI. As secondary questions, we assessed the impact of surgical timing on in-hospital postoperative complication rates and mortality.
Methods Top
We have completed a prospective, multicenter, cohort study involving hospitals at 6 institutions throughout North America: 1) University of Toronto, Toronto, Ontario, Canada 2) Thomas JeffersonUniversity, Philadelphia, PN, USA 3) University of Virginia, Charlottesville, VA, USA 4) University of Maryland, Baltimore, MD, USA 5) University of British Columbia, Vancouver, British Columbia, Canada; 6) University of Kansas, Kansas City, KS, USA. Each of the hospitals involved are specialized in the management of spinal trauma and spinal cord injury. Patient enrollment began in August 2002 and ended inSeptember 2009. Research ethics board approval was obtained at each of the 6 centers prior to beginning enrollment. During this period any SCI patient presenting to one of these institutions was assessed for suitability against a predefined set of inclusion and exclusion criteria (Table 1).

Table 1. Inclusion/Exclusion Criteria.
doi:10.1371/journal.pone.0032037.t001

At presentation,...