Under pressure - A historical vignette on surgical timing in traumatic spinal cord injury.

Introduction: It was not even a century ago when a spinal cord injury (SCI) would inevitably result in a fatal outcome, particularly for those with complete SCI. Throughout history, there have been extensive endeavours to change the prospects for SCI patients by performing surgery, even though many believed that there was no way to alter the catastrophic course of SCI. To this day, the debate regarding the efficacy of surgery in improving the neurological outcome for SCI patients persists, along with discussions about the timing of surgical intervention. Research question: How have the historical surgical results shaped our perspective on the surgical treatment of SCI? Material and methods: Narrative literature review. Results: Throughout history there have been multiple surgical attempts to alter the course of SCI, with conflicting results. While studies suggest a potential link between timing of surgery and neurological recovery, the exact impact of immediate surgery on individual cases remains ambiguous. It is becoming more evident that, alongside surgical intervention, factors specific to both the patient and their surgical treatment will significantly influence neurological recovery. Conclusion: Although a growing number of studies indicates a potential correlation of surgical timing and neurological outcome, the precise influence of urgent surgery on an individual basis remains uncertain. It is increasingly apparent that, despite surgery, patient- and treatment-specific factors will also play a role in determining the neurological outcome. Notably, these very factors have influenced the results in previous studies and our views concerning surgical timing.

Impact of Surgical Timing on Motor Level Lowering in Motor Complete Traumatic Spinal Cord Injury Patients.

Patients with complete traumatic spinal cord injury (tSCI) have a low potential to recover ambulation. Motor level recovery, adjacent to the level of injury, could influence functional independency. This study addresses whether surgical timing influences motor level recovery in patients with motor complete (American Spinal Injury Association [ASIA] Impairment Scale A [AIS A]) and motor incomplete (AIS B) tSCI. A retrospective cohort study was performed in the Netherlands in patients with AIS A/B tSCI (C2-L2), who consecutively underwent surgery between January 2010 and April 2020. Neurological examination was performed directly at presentation to the emergency room and at discharge from the rehabilitation facility. Motor level lowering, AIS grade, and upper and lower extremity motor score recovery were calculated for patients who underwent early (< 24 h) and late (24 h+) surgery. A total of 96 patients met the inclusion criteria. In the multi-variate analysis, late surgical decompression (24 h+) was negatively associated with ≥1 motor level lowering and ≥2 AIS grade improvement [odds ratio (OR) 0.11 [95% confidence interval (CI): 0.01, 0.67], p = 0.046, and OR 0.06 [95% CI: 0.00, 047], p = 0.030. respectively). The presence of sacral sparing (AIS B) at initial examination, and cervical level of the tSCI were associated with ≥1 motor level lowering. In addition, AO Spine C-type injuries were negatively associated with any type of neurological recovery, except motor level lowering. Although sensorimotor complete injuries as well as thoracolumbar injuries negatively influence neurological recovery, early surgical decompression (< 24 h) appears independently associated with enhanced neurological recovery in patients with traumatic spinal cord injury despite level and severity of injury.

Complete Traumatic Spinal Cord Injury: Current Insights Regarding Timing of Surgery and Level of Injury.

STUDY DESIGN: A narrative literature review. OBJECTIVES: To review the neurological recovery patterns in traumatic spinal cord injury (tSCI) patients with a complete lack of motor and sensory function below the level of injury (ie, ASIA A [American Spinal Injury Association scale]), as well as the impact of level of injury and timing of surgical intervention. RESULTS: Spontaneous neurological recovery in patients with complete tSCI differs per level of injury: patients with cervical and thoracolumbar tSCI recover ≥1 ASIA grade in 17.3% to 34.0% 1 year after injury, compared with 10.7% to 18.6% in thoracic tSCI. Surgical decompression within 24 hours has a beneficial effect on neurological recovery in patients with complete cervical tSCI, whereas this effect is less clear for thoracic and thoracolumbar tSCI. A 1- or 2-grade improvement in the ASIA scale does not necessarily result in functional recovery. CONCLUSION: In complete tSCI, the level of injury as well as surgical timing affect neurological recovery. There appears to be a beneficial effect of early surgical decompression in patients with complete cervical tSCI, more so than for thoracic and thoracolumbar tSCI. Frequently, the effect of surgical intervention is evaluated by an improvement in ASIA grade, but it is unclear whether this scale is sensitive enough to evaluate meaningful effectiveness of the intervention and desired outcome for patients with tSCI.

Cervical spine pathology and treatment: a global overview.

Cervical spine pathology is becoming increasingly prevalent with an aging world population and is associated with significant morbidity, affecting all areas of the world. This review was undertaken to provide a global perspective on cervical spine pathology, including epidemiology, burden of disease, access to care, and plan of care in both developed and developing low- and middle-income countries (LMICs). We found that epidemiology, access to care, plan of care, and health outcomes were relatively similar between nations with similar economies. However, these aspects change dramatically when comparing developing nations to LMICs, with LMICs displaying substantial barriers to care and subsequently higher rates of morbidity and mortality. There is currently a need for large-scale, global, prospective multicenter studies that analyze not only the epidemiology and treatment of cervical spine pathology, but also consider patient outcomes.

Neurological recovery after traumatic spinal cord injury: what is meaningful? A patients' and physicians' perspective.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: Most studies on neurological recovery after traumatic spinal cord injury (tSCI) assess treatment effects using the American Spinal Injury Association Impairment Scale (AIS grade) or motor points recovery. To what extent neurological recovery is considered clinically meaningful is unknown. This study investigated the perceived clinical benefit of various degrees of neurological recovery one year after C5 AIS-A tSCI. SETTING: The Netherlands. METHODS: By means of a web-based survey SCI patients and physicians evaluated the benefit of various scenarios of neurological recovery on a scale from 0 to 100% (0% no benefit to 100% major benefit). Recovery to AIS-C and D, was split into C/C+ and D/D+, which was defined by the lower and upper limit of recovery for each grade. RESULTS: A total of 79 patients and 77 physicians participated in the survey. Each AIS grade improvement from AIS-A was considered significant benefit (all p < 0.05), ranging from 47.8% (SD 26.1) for AIS-B to 86.8% (SD 24.3) for AIS-D+. Motor level lowering was also considered significant benefit (p < 0.05), ranging from 66.1% (SD 22.3) for C6 to 81.7% (SD 26.0) for C8. CONCLUSIONS: Meaningful recovery can be achieved without improving in AIS grade, since the recovery of functional motor levels appears to be as important as improving in AIS grade by both patients and physicians. Moreover, minor neurological improvements within AIS-C and D are also considered clinically meaningful. Future studies should incorporate more detailed neurological outcomes to prevent potential underestimation of neurological recovery by only using the AIS grade.

Impact of Early (<24 h) Surgical Decompression on Neurological Recovery in Thoracic Spinal Cord Injury: A Meta-Analysis.

The impact of surgical timing in neurological recovery in thoracic and thoracolumbar traumatic spinal cord injury (tSCI) is still a subject of discussion. While in cervical tSCI one may expect a beneficial effect of early intervention within 24 h, especially in complete cases, this has not yet been demonstrated clearly for thoracic tSCI. This study addresses neurological improvement after early and late surgery for thoracic and thoracolumbar tSCI. A systematic search retrieved 14 publications of observational studies reporting outcome measurements after surgery in 1075 patients with thoracic and thoracolumbar tSCI from PubMed and Embase databases. Surgery was considered early within 24 h and late thereafter. An improvement of at least one and two grades on the American Spinal Injury Association Impairment Scale (ASIA) was evaluated. The Meta-Analyses and Systematic Reviews of Observational Studies guidelines were followed. Improvement rates were summarized using individual patient data in a Bayesian random effects model and compared for those with early and late surgery. In the qualitative analysis, six of seven studies, which investigated the effect of surgical timing, observed a significant effect of early surgery on at least one ASIA grade improvement. Quantitative analysis in 948 patients with thoracic and thoracolumbar tSCI data, however, did not reveal a significant increase in odds of ≥1 ASIA grade recovery in early surgery (66.8% [95% confidence interval (CI): 45.0-87.8%] compared with late surgery (48.9% [95% CI: 25.1-70.7%; odds ratio (OR) 2.2 (95% CI: 0.6-14.0]). This study did not observe a significant beneficial effect of surgical decompression within 24 h in patients with thoracic and thoracolumbar tSCI.

Early Surgical Decompression Improves Neurological Outcome after Complete Traumatic Cervical Spinal Cord Injury: A Meta-Analysis.

In patients with traumatic spinal cord injury (tSCI) a distinction in surgical urgency is made on the basis of the severity of the initial neurological injury. The optimal timing of surgical decompression, as well as its impact on neurological recovery, is as of yet undetermined. This study addresses neurological improvement after early and late surgery for complete and incomplete cervical tSCI. A systematic search retrieved 15 publications of observational studies reporting outcome measurements after surgery in 1126 patients with cervical tSCI from PubMed and Embase databases. Surgery was considered early within 24 h, and late thereafter. An improvement of at least two grades on the American Spinal Injury Association (ASIA) scale was considered clinically meaningful. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. Improvement rates were summarized using individual patient data in a Bayesian random effects model and compared for those with complete and incomplete tSCI after early and late surgery. In patients with complete cervical tSCI (n = 422), improvement was more frequent after early surgery than after late surgery (respectively, 22.6%, 95% credibility interval [CI]: 16.6-28.7% and 10.4%, 95% CI: 5.6-15.8%; odds ratio [OR] 2.6 [95% CI: 1.4-5.1]). Whereas in patients with incomplete cervical tSCI (n = 636), improvement was similar between early and late surgery (respectively 30.4%, 95% CI: 19.8-41.6% and 32.5%, 95% CI: 21.4-45.8%; OR 0.9 [95% CI: 0.4-1.9]). These data suggest a paradigm shift in the treatment of patients with complete cervical tSCI, as surgical decompression within 24 h is more frequently associated with clinically meaningful improvement. In incomplete cervical tSCI, neurological outcome is similar between early and late surgery.