Timing of decompressive surgery of spinal cord after traumatic spinal cord injury

JOURNAL OF NEUROTRAUMA 28:1371–1399 (August 2011) ª Mary Ann Liebert, Inc. DOI: 10.1089=neu.2009.1147

Timing of Decompressive Surgery of Spinal Cord after Traumatic Spinal Cord Injury: An Evidence-Based Examination of Pre-Clinical and Clinical Studies
1,2 Julio C. Furlan, Vanessa Noonan,3 4,5 David W. Cadotte, and Michael G. Fehlings1,4,5

Abstract

While the recommendations for spinesurgery in specific cases of acute traumatic spinal cord injury (SCI) are well recognized, there is considerable uncertainty regarding the role of the timing of surgical decompression of the spinal cord in the management of patients with SCI. Given this, we sought to critically review the literature regarding the pre-clinical and clinical evidence on the potential impact of timing of surgicaldecompression of the spinal cord on outcomes after traumatic SCI. The primary literature search was performed using MEDLINE, CINAHL, EMBASE, and Cochrane databases. A secondary search strategy incorporated articles referenced in prior meta-analyses and systematic and nonsystematic review articles. Two reviewers independently assessed every study with regard to eligibility, level of evidence, and studyquality. Of 198 abstracts of pre-clinical studies, 19 experimental studies using animal SCI models fulfilled our inclusion and exclusion criteria. Despite some discrepancies in the results of those pre-clinical studies, there is evidence for a biological rationale to support early decompression of the spinal cord. Of 153 abstracts of clinical studies, 22 fulfilled the inclusion and exclusion criteria.While the vast majority of the clinical studies were level-4 evidence, there were two studies of level-2b evidence. The quality assessment scores varied from 7 to 25 with a mean value of 12.41. While 2 of 22 clinical studies assessed feasibility and safety, 20 clinical studies examined efficacy of early surgical intervention to stabilize and align the spine and to decompress the spinal cord; themost common definitions of early operation used 24 and 72 h after SCI as timelines. A number of studies indicated that patients who undergo early surgical decompression can have similar outcomes to patients who received a delayed decompressive operation. However, there is evidence to suggest that early surgical intervention is safe and feasible and that it can improve clinical and neurologicaloutcomes and reduce health care costs. Based on the current clinical evidence using a Delphi process, an expert panel recommended that early surgical intervention should be considered in all patients from 8 to 24 h following acute traumatic SCI.
Key words: animal studies; clinical research; spinal cord injury; systematic review; timing of surgery

Introduction

T
1 2

raumatic spinal cord injury(SCI) is a potentially catastrophic event for individuals who develop motor, sensory, and autonomic deficits and for society due to the economic burden. Currently, the management of individuals with acute SCI includes pharmacological agents and surgical intervention. The most promising pharmacological therapies

include drugs that, in pre-clinical studies, improved axonal conduction, antagonizedexcitatory amino acid antagonists, blocked potassium and sodium channel, and attenuated extracellular myelin mediator growth inhibitory proteins (Baptiste and Fehlings, 2007). Surgical intervention is indicated for decompression of the spinal cord in addition to realignment and stabilization of the spine. Although the recommendations for spine surgery in

Department of Genetics and Development,Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada. Lyndhurst Centre, Toronto Rehabilitation Institute, University of Toronto, Toronto, Ontario, Canada. 3 University of British Columbia, Vancouver, British Columbia, Canada. 4 Krembil Neuroscience Centre, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Canada. 5 Department of...