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Surgical Interventions during the Acute Phase of Spinal Cord Injury

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Craig M, Adamson R, Benton B, McIntyre A, Fatehi M. (2020). Surgical Interventions during the Acute Phase of Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Research Evidence. Version 7.0: p 1-78.



Key Points

  • Cervical decompression may improve neurological functioning post SCI.

    Thoracolumbar decompression may improve neurological functioning among those with incomplete, but not complete SCI. Anterior and posterior approaches may be equally effective. Endoscopic approaches may be similarly effective to open decompression approaches.

    Decompression surgery for lumbar burst and conus injuries may improve neurological outcomes and adjacent nerve root.

    In acute traumatic SCI, surgery within 24 hours is associated with better neurological outcome, lower complications and shorter length of stay but not a reduction in mortality. Generally, surgery within 72 hours is an acceptable standard of care.

    With respect to traumatic central cord syndrome, there is no clear evidence of a neurologic benefit from decompression or its timing. Available evidence suggests that age and comorbidities may be appropriate justifications to delay surgery with possible survival benefit for doing so.

    Method of mechanical stabilization can be variable and consist of non-surgical rigid orthosis or open stabilization (e.g., anterior, posterior or circumferential instrumentation and fusion manoeuvres); however, the methods described in the literature are no longer used in clinical practice today.

    Although neurological recovery is difficult to predict in traumatic SCI, a number of prognostic variables may influence neurological recovery after surgery post SCI. Individuals with incomplete injuries tend to fare better than those with complete injuries. Surgical correction of ongoing spinal cord compression can improve prognosis, especially if performed early.

    Compared to patients treated without surgery, those receiving surgery post SCI experienced lower mortality but no difference in neurological outcome; however, the techniques are from an early surgical era and should be interpreted with caution.

    While it appears autologous bone marrow transplant is safe, it is not effective for neurological or functional recovery post SCI.

    There is no evidence that one approach is superior to another with respect to decompression or stabilization for compression by metastatic lesions; all approaches.

    Radiotherapy and surgery for the management of symptomatic metastatic spine compression is effective; early surgical intervention to decompress the spine should be performed after considering tumor features and patient status.

    It is impossible to compare laminectomy and fusion with conservative management in individuals who have ongoing cord compression or column instability. The clinical utility of decompressive laminectomies is obvious; however, in appropriately selected individuals one may elect to perform a percutaneous technique.

    There are no studies that compare similar subsets of patients undergoing laminoplasty or conservative management. There are no good studies comparing laminectomy to laminoplasty in patients with acute SCI.

  • In the surgical decompression of cervical spondylosis myelopathy, both anterior and posterior approaches are clinically effective. Anterior decompression may have a higher level of neurological recovery but is also subject to more complications and demonstrates no clear superiority in terms of disability or quality of life when compared to posterior decompression.

    While it is difficult to predict the effectiveness of surgical decompression in degenerative compressive myelopathy, there is good evidence that some MRI findings, including absence of spinal cord hyperintensity on MRI, can predict surgical outcomes.

    Radiological signs of cervical spinal cord are quite common, but risk of progression to symptoms is low overall. Patients with co-existing cervical radiculopathy or electrophysiological changes are at higher risk of progression to clinical myelopathy.

    Post-traumatic tethered cord and syringomyelia has an estimated incidence of 1-4%. Low quality evidence suggests that prophylactic decompression should not be performed, but that patients with progressive motor decline attributable to tethering or syrinx can have an arrest of their decline with surgical management.