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Effect of Timing on Decompression and/or Stabilization Surgery Post SCI

Surgical timing has been one of the most eagerly studied clinical questions in acute SCI. Generally, the current treatment paradigm states that acute traumatic SCI can involve the acquisition of secondary injury due to ongoing compression, ischemia, inflammatory cascades, vascular phenomena or immune response. As such, it is thought that early correction of ongoing compression and/or instability would limit these processes and produce a favourable neurological outcome. For these reasons, there has been a presumption that earlier surgery is superior; there has therefore not been appropriate clinical equipoise for randomized studies of surgical timing.

The pertinent details relevant to surgical timing tend to relate to whether the individual has residual neurological function that is salvageable with surgery. Individuals with an incomplete SCI are therefore seen as a more emergent surgical problem, although Bourassa et al. (2013) demonstrate that individuals with motor complete SCI can also benefit from early surgery. In addition, the presence of ongoing mechanical compression of the spinal cord is seen as another inherently emergent problem, and one that is generally not specified in the studies reviewed here.

Most of the notable studies on surgical timing use a dichotomized analysis, for example within 24 hours of injury or after. Some studies use a 72 hours cut-off and this distinction must be kept in mind when comparing different results.

Table 2. Effect of Timing on Decompression and/or Stabilization Surgery Post SCI

Author Year

Country
Research Design
Score
Total Sample Size

MethodsOutcome
Dakson et al. (2017)

Canada

Case Control

N=56

Population: Mean age: 47.6±20.7 yr; Gender: male=74, female=20; Level of injury: cervical=66, thoracolumbar=28; Severity of injury: AISA A=31, B=12, C=16, D=29, unknown=6.

Intervention: No intervention. A retrospective review of individuals with SCI to determine the effect of early (<24 hr, n=23) or late (>24 hr, n=33) surgical decompression and maintenance of Mean Arterial Pressure (MAP) ≥85 mmHg for 5 days on neurological recovery.

Outcome measures: American Spinal Injury Association (ASIA).

Chronicity: The mean time from injury to surgical decompression was 13.4±5 hr and 127.7 hr for the early and late groups.

1.     Individuals with MAP <85 mm Hg for at least two consecutive hr during the five-day period post injury were 11 times less likely to have an improvement in AIS grade when compared to individuals with MAP ≥85 mm Hg (p=0.006). This association was independent of early surgery or the severity of SCI.

2.     At a mean of 252 days post injury, a significant proportion of individuals with SCI treated with early surgical decompression improved neurologically when compared to late decompression (p=0.031).

Bourassa-Moreau et al. (2016)

Canada

Case Control

N=53

Population: Mean age: 42.4 yr; Gender: males=45, females=8; Level of injury: C1-C7=20, T1-L2=33; Level of severity:

American Spinal Injury Association Impairment Scale (AIS) A ; Mean time since injury: 22.6 hr.

Intervention: Individuals who underwent decompression surgery following SCI injury were retrospectively analyzed. Comparisons were made between early (<24 hr) and late (>24 hr) surgery as well as cervical (n=20) and thoracolumbar (n=33) injuries.

Outcome Measures: Demographics, AIS.

1.     Individuals operated <24 hr (n=38) were significantly younger than the 15 individuals operated >24 hr (p=0.049).

2.     Overall, 28% (15/53) had improvement in AIS: 34% (13/38) who were operated <24 hr and 13% (2/15) who were operated >24 hr (p=0.182).

3.     64% (9/14) of cervical complete SCI operated <24 hr had improvement in AIS as opposed to none in the subgroup of six individuals with cervical SCI operated >24 hr (p=0.008).

Furlan et al. (2016)

Canada

Case Control

N=61

Population: Motor Complete Early (COMe, n=12): Mean age: 52.1 yr; Gender: males=11, females=1; Level of injury: C1-C4=4, C5-C8=8; Level of severity: AIS A=9, B=3. Motor Complete Late (COMl, n=14): Mean age: 46.8 yr; Gender: males=12, females=2; Level of injury: C1-C4=10, C5-C8=4; Level of severity: AIS A=9, B=5. Motor Incomplete Early (INe, n=11): Mean age: 52.8 yr; Gender: males=7, females=4; Level of injury: C1-C4=4, C5-C8=7; Level of severity: AIS C=7, D=4. Motor Incomplete Late (INl, n=24): Mean age: 49.3 yr; Gender: males=15, females=9; Level of injury: C1-C4=12, C5-C8=12; Level of severity: AIS A=11, B=13.

Intervention: individuals who underwent decompression surgery following cervical SCI injury were retrospectively analyzed. Comparisons were made between early (<24 hr) and late (≥24 hr) surgery as well as complete and incomplete injuries. Outcomes were assessed at baseline and 6 mo follow-up.

Outcome Measures: Cost Effectiveness.

1.     Overall early spinal decompression is more cost effective than late spinal decompression.

·         For individuals with complete SCI injury, cost-effectiveness ratio analysis revealed a savings of US$ 58,368,024.12 per quality adjusted life years gained.

2.   For individuals with incomplete SCI injury, cost-effectiveness ratio analysis revealed a savings of US$ 536,217.33 per quality adjusted life years gained.

Liu et al. (2015)

China

Case Control

NInitial=595, NFinal=489

Population: Early Decompression (ED, n=212): Mean age: 40.4 yr; Gender: males=166, females=46; Injury etiology: motor vehicle accident=121, fall=52, object hit=21, sports=18; Level of injury: C3=16, C4=53, C5=75, C6=43, C7=25; Level of severity: Frankel A=42, B=65, C=68, D=37; Time since injury range: <24 hr. Late Decompression (LG, n=383): Mean age: 41.9 yr; Gender: males=290, females=93; Injury etiology: motor vehicle accident=234, fall=102, object hit=26, sports=21; Level of injury: C3=26, C4=91, C5=141, C6=78, C7=47; Level of severity: Frankel A=82, B=132, C=123, D=46; Time since injury range: >24 hr.

Intervention: Individuals who underwent surgical decompression after lower cervical (C3-C7) spine trauma were retrospectively reviewed and analyzed by timing of decompression surgery (ED versus LD). Outcomes were assessed at a mean follow-up time of 24.9 mo.

Outcome Measures: Frankel Grade, Hospital Length of Stay (H-LOS), Neurological Deterioration, Mortality, Complications, Intensive Care Unit Length of Stay (ICU LOS), Ventilation (VENT) Days.

1.     Overall, 23 individuals died and 83 failed to receive a follow-up.

2.     106 individuals (61.6%) in the ED group and 204 (64.4%) individuals in the LD groups experienced at least one Frankel grade (all p<0.001); however, there was no significant difference between groups (p=0.825).

3.     ED group individuals had significantly fewer H-LOS (p<0.001), greater post-op neurologic deterioration (p<0.001), and greater mortality (p=0.003).

4.     There was no significant difference between ED and LD groups in other complications (all p≥0.166), ICU LOS (p=0.150), or VENT days (p=0.056).

Grassner et al. 2015

Germany

Case Control

N=70

Population: Early decompression (n=35): Mean age: 51.9±16.4 yr; Gender: male=26, female=9, Level of injury: not reported; Severity of injury: American Spinal Injury Association (ASIA) A=14, B=5, C=3, D=13, E=0.

Late decompression (n=35): Mean age: 50.1±18.2 yr; Gender: male=33, female=2, Level of injury: not reported; Severity of injury: ASIA A=17, B=5, C=2, D=11, E=0.

Intervention: A retrospective study examining functional and neurological outcomes at one yr post-surgical decompression in individuals with SCI who underwent surgery early (first 8 hr after injury) or late (>8 hr after injury).

Outcome measures: American Spinal Injury Association (AISA) score; Spinal cord compromise; Neurological level; Sensory level; Motor level; Total motor score; Upper extremity motor score; Pin prick score; Light touch score; SCIM.

Chronicity: The mean length of hospital stay was 127±58 days. The mean time from injury to surgical intervention was not reported.

1.     Individuals from the early decompression group had significantly increased AIS grades (p<0.006) and increased AIS conversion rate (p<0.029).

2.     No significant difference was observed in spinal cord compromise, sensory level, pin prick or light touch score between groups.

3.     The motor and neurological levels of individuals who were operated on within eight hr were significantly more caudal after one yr (p<0.003 and p<0.014).

4.     A significant increase in total motor performance (p<0.025) and upper extremity motor function (p<0.002) after one yr was observed in the early decompression group.

5.     Individuals who were decompressed earlier had a significantly higher SCIM (45.8 vs 27.1, p<0.005).

6.     A regression analysis showed that timing of decompression, age, basal AISA and SCIM scores were independent predictors of a better functional outcome.

Bourassa-Moreau et al. (2013)a

Canada

Case Control

N=431

Population: Early Surgery (ES, n=90): Mean age: 37.0 yr; Gender: males=74, females=16; Level of injury: C1-L2, paraplegic=61, tetraplegic=29; Level of severity: AIS A=55, B=16, C=8, D=11; Time since injury range: <24 hr. Midrange Surgery (MS, n=231): Mean age: 40.7 yr; Gender: males=181, females=50; Level of injury: C1-L2, paraplegic=130, tetraplegic=51; Level of severity: AIS A=109, B=42, C=38, D=42; Time since injury range: 24-72 hr. Late Surgery (LS, n=110): Mean age: 47.9 yr; Gender: males=80, females=30; Level of injury: C1-L2, paraplegic=36, tetraplegic=74; Level of severity: AIS A=33, B=13, C15, D=49; Time since injury range: >72 hr.

Intervention: Participants who underwent surgery following SCI were retrospectively analyzed by timing of surgery.

Outcome Measures: American Spinal Injury Association (ASIA) Grade, Complications.

1.     Individuals who underwent decompression surgery earlier tended to be paraplegic and had a more severe ASIA grade. There were no differences in the other demographic and clinical variables with respect to surgical timing.

2.     Individuals who had later surgery had significantly increased rates of pneumonia (p=0.025); no other complications were different between groups (p>0.1).

3.     There was no significant difference in mortality rate between groups (p=.393).

4.     ASIA grades A and B were significant predictors of all complications (p≤0.05).

Bourassa-Moreau et al.

(2013)b

Canada

Case Control

N=197

Population: Early Surgery (ES, n=55): Mean age: 36.4 yr; Gender: males=49, females=6; Level of injury: C1-C4=6, C5-T1=10, T2-T10=17, T11-S1=22; Level of severity: AIS A=55; Time since injury range: ≤24 hr. Late Surgery (LS, n=142): Mean age: 40.4 yr; Gender: males=116, females=26; Level of injury: C1-C4=15, C5-T1=36, T2-T10=57, T11-S1=34; Level of severity: AIS A=142; Time since injury range: >24 hr.

Intervention: Participants who underwent surgery following SCI were retrospectively analyzed by timing of surgery.

Outcome Measures: Hospitalization Cost, Mortality, Complications.

1.     The cost of hospitalization was significantly lower for the ES group (p<0.05).

2.     The total complication rate indicates that 57% of individuals had at least one complication. The rate of total complications (p=0.01), pneumonia (p=0.04), and UTI (p=0.03) were significantly lower in individuals operated ≤24 hr after injury; the rate of PU was not statistically different between groups (p=0.255).

3.     There was no significant difference in mortality between groups (p=0.672).

4.     Tetraplegia (p=0.006) and late surgery (p=0.01) were significant predictors of total complications.

Fehlings et al. (2012)

Canada

Case Control

NInitial=313, NFinal=222

Population: Mean age: 47.4 yr; Gender: males=236, females=77; Level of injury: C1-C7; Injury etiology: motor vehicle accident=119, fall=121, assault=13, sports=3, other=3; Level of severity: AIS A=101, B=54, C=66, D=92; Mean time since injury: 14.2 hr (early surgery), 48.3 hr (late surgery).

Intervention: Individuals who underwent decompression surgery following cervical SCI injury were retrospectively analyzed. Comparisons were made between early (<24 hr) and late (≥24 hr) surgery. Outcomes were assessed at baseline and 6 mo follow-up.

Outcome Measures: American Spinal Injury Association Impairment Scale (AIS) Change, Complications.

1.     At 6 mo post injury, 19.8% of individuals undergoing early surgery showed a greater than two grade improvement in AIS compared to 8.8% in the late decompression group (p=0.03).

2.     At 6 mo post injury, there was no significant difference in number of individuals who improved by one AIS grade between early and late surgery groups (p=0.31).

3.     Complications occurred in 24.2% of early surgery individuals and 30.5% of late surgery individuals (p=0.21).

 

Wilson et al. (2012)

Canada

Case Control

N=84

Population: Early Decompression (ED, n=35): Mean age: 41.6 yr; Gender: males=29, females=6; Injury etiology: motor vehicle accident=13, fall=13, assault=1, other=8; Level of injury: C=14, T=12, L=9; Level of severity: AIS A=18, B=6, C=5, D=6; Time since injury range: <24 hr. Late Decompression (LG, n=49): Mean age: 47.9 yr; Gender: male=38, female=11; Injury etiology: motor vehicle accident (n=10), fall (n=29), assault (n=3), other (n=7); Level of injury: C=30, T=9, L=10; Level of severity: AIS A=15, B=3, C=6, D=25; Time since injury range: >24 hr.

Intervention: A group of individuals who underwent surgical decompression after spine trauma were retrospectively reviewed and analyzed by timing of decompression surgery (ED versus LD). Outcomes were assessed at baseline, acute discharge (mean: 24.8 days), and rehabilitation discharge (mean: 89.6 days)

Outcome Measures: American Spinal Injury Association (ASIA) Motor Scale (AMS) Score, ASIA Impairment Scale (AIS).

1.     Baseline assessment until acute hospital discharge:

·         Seven individuals (21.2%) in the ED group and nine individuals (18.4%) in the LD group experienced at least 1-Grade AIS improvement (p=0.47).

·         Three individuals (9.1%) in the ED group and one individual (2.0%) in the LD group experienced at least a 2-Grade AIS improvement (p=0.15).

·         The mean AMS improvement in the ED and LD groups were 6.2 and 9.7 points, respectively (p=0.18).

2.     Baseline assessment until rehabilitation discharge:

·         Nine individuals (40.9%) in the ED group and 10 individuals (30.3%) in the LD group experienced at least 1-Grade AIS improvement (p=0.42).

·         Six individuals (27.2%) in the ED group and one individual (3.0%) in the LD group experienced at least a 2-Grade AIS improvement (p=0.01).

·         The mean AMS improvement in the ED and LD groups were 19.5 and 15.4 points, respectively (p=0.46).

Mac-Thiong et al. (2012)

Canada

Cohort

N=477

Population: Mean age: 41.4 yr; Gender: males=374, females=103; Level of injury: C=228, T/L=249; Level of severity: AIS A=205, B=73, C=68, D=131.

Intervention: Participants who received early surgical stabilization and/or decompression (<24 hr; n=93) were compared to those who received late surgery (>24 hr; n=384).

Outcome Measures: Length of Stay; Hospitalization cost.

1.     Rates of complete injury (58% versus 39%, p=0.001) and thoracic/lumbar injury (66% versus 49%, p=0.004) were significantly higher in the early than late surgery group.

2.     Mean length of stay was significantly shorter with early than late surgery (28.1d versus 36.7d, p<0.001).

3.     Mean hospitalization cost was significantly lower with early than late surgery ($20,525 versus $25,036, p<0.0001).

4.     In a dichotomized model (early versus late), timing of surgery was significantly associated with stay (p=0.04) and cost (p=0.003).

5.     In continuous model (time post injury), timing of surgery was significantly associated with cost (p=0.003) but not stay (p=0.32).

6.     Stay and cost were significantly associated with older age, greater injury severity, and higher injury level.

Rahimi-Movaghar (2005)

Iran

Case Series

N=12

Population: Mean age: 26.0 yr; Gender: males=11, females=1; Injury etiology: motor vehicle accident=9, unknown=3; Level of injury: thoracic; Level of severity: Frankel A=12.

Intervention: Individuals with SCI who underwent surgical decompression were retrospectively analyzed. Mean follow-up time was 43.75 mo.

Outcome Measures: Frankel Grade.

1.     One individual improved from Frankel Grade A to C and one individual improved from Frankel Grade A to B following surgery.

2.     Ten individuals remained at Frankel Grade A following surgery.

Mirza et al. (1999)

USA

Case Control

N=30

Population: Mean age: 32 yr; Gender: males=26, females=4; Level of injury: C2-C7; Level of severity: Frankel I=20, II=1, III=2, IV=7.

Treatment: Participants who received early surgical stabilization and/or decompression (<3 days; n=15) were compared to those who received late surgery (>3 days; n=15) in a retrospective review.

Outcome Measures: American Spinal Injury Association Motor Score (AMS); Frankel Grade; Hospitalization periods; Complications.

1.     Early surgery showed significant improvements from baseline in mean AMS (39.2 to 77.1, p=0.006) and Frankel Grade (1.9 to 3.7, p=0.0026).

2.     Late surgery showed non-significant improvements from baseline in mean AMS (23.5 to 39.1, p=0.14) and Frankel Grade (1.8 to 2.1, p=0.30).

3.     Mean postoperative scores were significantly greater with early surgery than late surgery for AMS (77.1 versus 39.1, p=0.01) and Frankel Grade (3.7 versus 2.1, p=0.01).

4.     There was no significant difference between groups in length of surgery, mechanical ventilation, or time in ICU, but overall acute care stay was significantly greater for late than early surgery (37 versus 22 days, p=0.036).

5.     There was no significant difference between groups in the number of minor (p=0.24), major (p=0.12), or total (p=.05) complications.

Table 3. Systematic Reviews Assessing the Effect of Timing on Decompression and/or Stabilization Surgery Post SCI

Authors Year

Country

Date of Studies Included

AMSTAR Score

Total Sample Size

Method

 

Conclusions
Liu et al. (2016)

China

Meta-Analysis

AMSTAR=9

N=9 studies

Objective: To compare outcomes is individuals with traumatic SCIwho had early surgery (<24 hr) with those who had late surgery (>24 hr).

Methods: Comprehensive literature search of controlled trials reporting on surgery for individuals with traumatic SCI published in English. Data analysis was performed by calculating mean difference (MD) or odds ratio (OR) and 95% confidence intervals (95%CI).

Databases: PubMed, MEDLINE, EMBASE, Cochrane.

Evidence: Studies were assessed for quality using the Newcastle-Ottawa Scale (NOS, 0-10). Statistical significance was defined as p<0.05.

1.   Quality of studies was high: NOS=8 (n=7) and NOS=9 (n=2).

2.   In four studies (n=196), motor improvement was significantly greater in early surgery than late surgery (MD=3.30, 95%CI=0.82-5.79, p=0.009).

3.   In seven studies (n=634), neurological improvement was significantly greater in early surgery than late surgery (OR=1.66, 95%CI=1.19-2.31, p=0.003).

4.   In four studies (n=196), length of stay was significantly shorter in early surgery than late surgery (MD=-4.76, 95%CI=-9.19,-0.32, p=0.04).

5.   In six studies (n=502), complication rate was significantly lower in early surgery than late surgery (OR=0.61, 95%CI=0.40-0.91, p=0.02).

6.   In eight studies (n=650), mortality rate was not significantly different between groups (OR=1.39, 95%CI=0.51-3.75, p=0.52).

Van Middendorp et al. (2013)

UK

Meta-Analysis

AMSTAR=7

N=22 studies

Objective: To compare outcomes is individuals with traumatic SCIwho had early surgery (<24 hr) with those who had late surgery (>24 hr).

Methods: Comprehensive literature search of all English studies reporting on surgery only for individuals with acute traumatic SCI aged >14 yr. Data analysis was performed by calculating weighted mean difference (WMD) or odds ratio (OR) and 95% confidence intervals (95%CI).

Databases: MEDLINE.

Evidence: Studies were assessed for quality using a tailored scoring instrument (0-25) that was normalized into a quality index (0-1).

1.   Total of 22 studies were found in systematic review, but only 18 were included in meta-analysis.

2.   Quality scores were 0.08 (n=2), 0.12 (n=2), 0.16 (n=6), 0.20 (n=2), 0.24 (n=5), 0.28 (n=1), 0.32 (n=1), 0.40 (n=1), 0.52 (n=1), and 0.56 (n=1).

3.   In seven studies (n=815), motor improvement was greater with early surgery than late surgery (WMD=4.73, 95%CI=-0.13-9.59).

4.   In six studies (n=495), neurological improvement was greater with early surgery than late surgery (OR=1.74, 95%CI=1.04-2.91).

5.   In six studies (n=1103), length of stay was shorter with early surgery than late surgery (WMD=-8.51, 95%CI=-12.78 -4.25).

6.   In nine studies (n=1148), mortality was similar with both surgeries (OR=0.97, 95%CI=0.40-2.31).

7.   In twelve studies, adverse events were similar with both surgeries (OR=0.86, 95%CI=0.69-1.07).

La Rosa et al. (2004)

Italy

Meta-Analysis

AMSTAR=6

N=27 studies

Objective: To compare outcomes is individuals with traumatic SCI who had early surgery (<24 hr) with those who had late surgery (>24 hr) or conservative treatment.

Methods: Comprehensive literature search of all English studies reporting on surgery for acute traumatic SCI. Data analysis was performed by calculating improvement rate (>1 on Frankel scale) and 95% confidence intervals (95%CI).

Databases: MEDLINE, Cochrane.

Evidence: Levels of evidence were assigned based on class (I=RCTs, II=prospective, III=retrospective, IV=case reports). Statistical significance was defined as p<0.05.

1.   Evidence was Class I (n=1), Class II (n=8), and Class III (n=18).

2.   For early surgery, 11 studies with 409 individuals were found, with only 226 individuals considered in meta-analysis.

3.   For early surgery, improvement rate was 42% (95%CI=33.1-50.8) for complete deficit and 89.7% (95%CI=83.9-95.5) for incomplete.

4.   For late surgery, 13 studies with 827 individuals were found, with 567 individuals considered in meta-analysis.

5.   For late surgery, improvement rate was 8.3% (95%CI=4.8-11.8) for complete deficit and 58.5% (95%CI=53.1-63.9) for incomplete.

6.   For no surgery, nine studies with 1335 individuals were found, with 890 individuals considered in meta-analysis.

7.   For no surgery, improvement rate was 24.6% (95%CI=21-28.2) for complete deficit and 59.3% (95%CI=54-64.6) for incomplete.

8.   Improvement rate was significantly different among all three groups for complete deficit (χ2=55.4, p<0.001) and incomplete (χ2=37.6, p<0.001).

9.   Improvement rate was significantly greater with early surgery than late surgery in complete deficit (χ2=58.1, p<0.001) and incomplete (χ2=35.1, p<0.001).

10. Improvement rate was significantly greater with early surgery than no surgery in complete deficit (χ2=15, p<0.001) and incomplete (χ2=33.7, p<0.001).

Discussion

An earlier retrospective analysis performed by Mirza et al. (1999) compared neurological and functional outcomes of individuals treated at one hospital versus another, each with a different policy for surgical timing (within 72 hours versus after 72 hours). Of note, all individuals received immediate closed reduction/decompression, with the late surgery group then waiting a period of 10-14 days before surgery. In this group, early surgery was associated with better American Spinal Injury Impairment Scale (AIS) motor score improvement as well as Frankel grade improvement. This study was limited by the fact that the two institutions could have varied in a number of other ways. Furthermore, every individual received immediate closed reduction suggesting that a process in addition to mechanical decompression may be occurring that confers neurological benefit with surgery.

Two Canadian multicentre studies demonstrated an association of early surgery with neurological recovery. Wilson et al. (2012) demonstrated an improvement in AIS Grade conversion and AIS motor score improvement using a 24-hour time cut-off for surgery. Similarly, Fehlings et al. (2012) published the c trial (Surgical Timing in Acute Spinal Cord Injury Study) using the same time cut-off in a prospective population of cervical SCI. They also reported a higher grade of AIS conversion at 6 months, as well as fewer complications, in the early surgery group.

Despite the overwhelming, positive outcomes associated with early surgery, the literature does have some heterogeneity. For example, Liu et al. (2016) reported that in their retrospective review, early surgery individuals (<72 hours) had a higher rate of neurological deterioration and mortality, thus arguing for the relative safety of delayed decompression.

Other than neurological outcomes, early surgery is supported in several other dimensions. According to Furlan et al. (2016), early surgery is more cost effective when considered in terms of complications and length of stay. Mac-Thiong et al. (2012) reported comparable results, with early surgery favouring lower complications, shorter length of stay and less overall cost. Similarly, higher medical and postoperative complication rates were found in the late surgery group identified by Bourassa et al. (2013), even despite higher numbers of motor complete injuries in the early group, whom are prone to such complications.

Because one of the rationales for early surgery involves protecting salvageable neural tissue, the role of surgical timing in motor complete injuries is not entirely clear. In their prospective cohort study, Bourassa (2016) demonstrated a statistical difference in AIS grade improvement in a population of individuals with motor complete SCI when dichotomized into early (34%) versus late surgery (13%). Similarly, the same group showed that the above-mentioned advantage in terms of complications and length of stay may also apply to cohorts of motor complete individuals.

Three systematic reviews have been published on surgical timing in acute SCI. La Rosa et al. (2004) conducted a meta-analysis comparing early surgery (defined within 24 hours) versus late surgery versus no surgery. They concluded that early surgery was superior to both other options, in subsets of both motor complete and incomplete injuries. One challenge is that this meta-analysis uses the loosely defined outcome measure “neurological improvement rate,” which is heterogenous and difficult to interpret across studies. The systematic review of Liu et al. (2016) reached similar conclusions regarding motor outcome and found superiority of early surgery regarding length-of-stay and complication rate, but not reduction in mortality. The systematic review of van Middendorp et al. (2013) reached similar conclusions as the other reviews and relayed the continued methodological limitations of included studies. Interestingly, using a funnel plot analysis, the authors found evidence of publication bias in the surgical timing literature but note that equipoise for prospective randomized studies does not exist.

Conclusion

There is level 3 evidence (based on several case control studies) that surgery within 24 hours of injury leads to improved neurological outcomes, shorter length of stay, and fewer complications, but not a reduction in mortality after acute, traumatic SCI.

  • 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.