Skip to main content

Advertisement

SpringerLink
Log in

Timing of Surgery in the Setting of Acute Spinal Cord Injury

  • Traumatic Brain Injury Surgery (S. Timmons, Section Editor)
  • Published:
Current Surgery Reports Aims and scope Submit manuscript

Abstract

The efficacy of early surgical decompression in the setting of acute spinal cord injury (SCI) has been actively discussed for decades. Primary spinal cord damage due to spinal cord contusion or compression leads to neurological tissue destruction potentiated by a post-lesion signaling cascade of downstream events, known as the secondary injury. Although there are still few therapeutic options leading to neurological recovery, preclinical animal studies have suggested that persistent spinal cord compression exacerbates secondary injury following SCI and that early surgical decompression of the spinal cord mitigates spinal cord damage, leading to improved functional outcomes. Although the heterogeneity of injuries, surgical procedures, and the definition of early decompression make it difficult to draw a definitive conclusion, clinical studies to date have provided supportive evidence for this preclinical result. Several clinical trials, including a number of prospective studies such as the STASCIS trial, showed benefits of early decompression in terms of neurological improvement, shorter hospital stay, and decreased complications, while other studies have argued that early intervention does not offer an advantage. Systematic reviews have also indicated that early decompression after SCI results in improved clinical outcomes compared to both delayed decompression and conservative treatment. In addition, from an efficacy standpoint, the 24-h cutoff for early decompression has been shown to represent the most effective time window during which surgical decompression had the potential to confer a neuroprotective effect.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine. 2001;26(24S):S2–12.

    Article  CAS  PubMed  Google Scholar 

  2. Pickett GE, Campos-Benitez M, Keller JL, Duggal N. Epidemiology of traumatic spinal cord injury in Canada. Spine. 2006;31(7):799–805.

    Article  PubMed  Google Scholar 

  3. Wyndaele M, Wyndaele J-J. Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? Spinal cord. 2006;44(9):523–9.

    Article  CAS  PubMed  Google Scholar 

  4. Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg. 1991;75(1):15–26.

    Article  CAS  PubMed  Google Scholar 

  5. Dumont RJ, Okonkwo DO, Verma S, Hurlbert RJ, Boulos PT, Ellegala DB, et al. Acute spinal cord injury, part I: pathophysiologic mechanisms. Clin Neuropharmacol. 2001;24(5):254–64.

    Article  CAS  PubMed  Google Scholar 

  6. Bracken MB. Steroids for acute spinal cord injury. Cochrane Database Syst Rev. 2012;1:Cd001046.

    PubMed  Google Scholar 

  7. Bracken MB, Holford TR. Effects of timing of methylprednisolone or naloxone administration on recovery of segmental and long-tract neurological function in NASCIS 2. J Neurosurg. 1993;79(4):500–7.

    Article  CAS  PubMed  Google Scholar 

  8. Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials. J Trauma Acute Care Surg. 1998;45(6):1088–93.

    Article  CAS  Google Scholar 

  9. Jazayeri SB, Firouzi M, Abdollah Zadegan S, Saeedi N, Pirouz E, Nategh M, et al. The effect of timing of decompression on neurologic recovery and histopathologic findings after spinal cord compression in a rat model. Acta Med Iran. 2013;51(7):431–7.

    PubMed  Google Scholar 

  10. Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC. Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology. J Bone Joint Surg Am. 2003;85-A(1):86–94.

    PubMed  Google Scholar 

  11. Dimar JR, Glassman SD, Raque GH, Zhang YP, Shields CB. The influence of spinal canal narrowing and timing of decompression on neurologic recovery after spinal cord contusion in a rat model. Spine. 1999;24(16):1623.

    Article  PubMed  Google Scholar 

  12. Carlson GD, Warden KE, Barbeau JM, Bahniuk E, Kutina-Nelson KL, Biro CL, et al. Viscoelastic relaxation and regional blood flow response to spinal cord compression and decompression. Spine (Phila Pa 1976). 1997;22(12):1285–91.

    Article  CAS  Google Scholar 

  13. Carlson GD, Minato Y, Okada A, Gorden CD, Warden KE, Barbeau JM, et al. Early time-dependent decompression for spinal cord injury: vascular mechanisms of recovery. J Neurotrauma. 1997;14(12):951–62.

    Article  CAS  PubMed  Google Scholar 

  14. Delamarter RB, Sherman J, Carr JB. Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression. J Bone Joint Surg. 1995;77(7):1042–9.

    CAS  PubMed  Google Scholar 

  15. Delamarter RB, Sherman JE, Carr JB. 1991 Volvo Award in experimental studies. Cauda equina syndrome: neurologic recovery following immediate, early, or late decompression. Spine (Phila Pa 1976). 1991;16(9):1022–9.

    Article  CAS  Google Scholar 

  16. Nystrom B, Berglund JE. Spinal cord restitution following compression injuries in rats. Acta Neurol Scand. 1988;78(6):467–72.

    Article  CAS  PubMed  Google Scholar 

  17. Guha A, Tator CH, Endrenyi L, Piper I. Decompression of the spinal cord improves recovery after acute experimental spinal cord compression injury. Paraplegia. 1987;25(4):324–39.

    Article  CAS  PubMed  Google Scholar 

  18. Aki T, Toya S. Experimental study on changes of the spinal-evoked potential and circulatory dynamics following spinal cord compression and decompression. Spine (Phila Pa 1976). 1984;9(8):800–9.

    Article  CAS  Google Scholar 

  19. Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental spinal cord compression injury. J Neurosurg. 1980;53(6):749–55.

    Article  CAS  PubMed  Google Scholar 

  20. Kobrine AI, Evans DE, Rizzoli HV. Experimental acute balloon compression of the spinal cord. Factors affecting disappearance and return of the spinal evoked response. J Neurosurg. 1979;51(6):841–5.

    Article  CAS  PubMed  Google Scholar 

  21. Rabinowitz RS, Eck JC, Harper CM Jr, Larson DR, Jimenez MA, Parisi JE, et al. Urgent surgical decompression compared to methylprednisolone for the treatment of acute spinal cord injury: a randomized prospective study in beagle dogs. Spine. 2008;33(21):2260–8.

    Article  PubMed  Google Scholar 

  22. • Furlan JC, Noonan V, Cadotte DW, Fehlings MG. Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma 2011; 28(8): 1371–1399. This review provided preclinical and clinical evidence indicating the efficacy of early decompression after spinal cord injury.

  23. • Batchelor PE, Wills TE, Skeers P, Battistuzzo CR, Macleod MR, Howells DW et al. Meta-analysis of pre-clinical studies of early decompression in acute spinal cord injury: a battle of time and pressure. PloS One 2013; 8(8): e72659. Well designed meta-analysis of preclinical studies. This study provided the pre-clinical evidence that early decompression improves neurobehavioural deficits in animal models of SCI.

  24. Liu Y, Shi CG, Wang XW, Chen HJ, Wang C, Cao P et al. Timing of surgical decompression for traumatic cervical spinal cord injury. Int Orthop 2015. doi:10.1007/s00264-014-2652-z.

    Google Scholar 

  25. Rahimi-Movaghar V, Niakan A, Haghnegahdar A, Shahlaee A, Saadat S, Barzideh E. Early versus late surgical decompression for traumatic thoracic/thoracolumbar (T1-L1) spinal cord injured patients. Primary results of a randomized controlled trial at one year follow-up. Neurosciences (Riyadh). 2014;19(3):183–91.

    Google Scholar 

  26. •• Fehlings MG, Vaccaro A, Wilson JR, Singh A, Cadotte DW, Harrop JS et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PloS One 2012; 7(2): e32037. Largest prospective international study comparing the efficacy of early and delayed decompression after cervical spinal cord injury.

  27. •• Wilson J, Singh A, Craven C, Verrier M, Drew B, Ahn H et al. Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study. Spinal cord 2012; 50(11): 840–843. Prospective large-scale Canadian cohort study comparing the neurological outcome between early and delayed decompression after spinal cord injury (from cervical to lumbar).

  28. Anderson DG, Sayadipour A, Limthongkul W, Martin ND, Vaccaro A, Harrop JS. Traumatic central cord syndrome: neurologic recovery after surgical management. Am J Orthop (Belle Mead NJ). 2012;41(8):E104–8.

    Google Scholar 

  29. Newton D, England M, Doll H, Gardner B. The case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby. J Bone Joint Surg, Br. 2011;93(12):1646–52.

    Article  CAS  Google Scholar 

  30. Stevens EA, Marsh R, Wilson JA, Sweasey TA, Branch CL, Powers AK. A review of surgical intervention in the setting of traumatic central cord syndrome. Spine J. 2010;10(10):874–80.

    Article  PubMed  Google Scholar 

  31. Chen L, Yang H, Yang T, Xu Y, Bao Z, Tang T. Effectiveness of surgical treatment for traumatic central cord syndrome: clinical article. J Neurosurg. 2009;10(1):3–8.

    Google Scholar 

  32. Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg. 2008;128(9):959–66.

    Article  PubMed  Google Scholar 

  33. Sapkas G, Papadakis S. Neurological outcome following early versus delayed lower cervical spine surgery. J Orthop Surg. 2007;15(2):183–6.

    CAS  Google Scholar 

  34. McKinley W, Meade MA, Kirshblum S, Barnard B. Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury. Arch Phys Med Rehabil. 2004;85(11):1818–25.

    Article  PubMed  Google Scholar 

  35. Pollard ME, Apple DF. Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia. Spine. 2003;28(1):33–8.

    Article  PubMed  Google Scholar 

  36. Guest J, Eleraky MA, Apostolides PJ, Dickman CA, Sonntag VK. Traumatic central cord syndrome: results of surgical management. J Neurosurg. 2002;97(1):25–32.

    PubMed  Google Scholar 

  37. Tator CH, Fehlings M, Thorpe K, Taylor W. Current use and timing of spinal surgery for management of acute spinal cord injury in North America: results of a retrospective multicenter study. J Neurosurg. 1999;91(1):12–8.

    CAS  PubMed  Google Scholar 

  38. Mirza SK, Krengel WF III, Chapman JR, Anderson PA, Bailey JC, Grady MS, et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res. 1999;359:104–14.

    Article  PubMed  Google Scholar 

  39. Vaccaro AR, Daugherty RJ, Sheehan TP, Dante SJ, Cotler JM, Balderston RA, et al. Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine (Phila Pa 1976). 1997;22(22):2609–13.

    Article  CAS  Google Scholar 

  40. La Rosa G, Conti A, Cardali S, Cacciola F, Tomasello F. Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach. Spinal cord. 2004;42(9):503–12.

    Article  PubMed  Google Scholar 

  41. Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006;31(11 Suppl):S28–35 discussion S36.

    Article  Google Scholar 

  42. •• van Middendorp JJ, Hosman AJ, Doi SA. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013; 30(21): 1781–1794. The most well-designed systematic review and meta-analysis regarding neurological outcomes, length of hospital stay and complications after early decompression for traumatic spinal cord injury. .

  43. Bedbrook G, Sakae T. A review of cervical spine injuries with neurological dysfunction. Spinal Cord. 1982;20(6):321–33.

    Article  CAS  Google Scholar 

  44. Marshall LF, Knowlton S, Garfin SR, Klauber MR, Eisenberg HM, Kopaniky D, et al. Deterioration following spinal cord injury: a multicenter study. J Neurosurg. 1987;66(3):400–4.

    Article  CAS  PubMed  Google Scholar 

  45. Wilmot CB, Hall KM. Evaluation of the acute management of tetraplegia: conservative versus surgical treatment. Spinal Cord. 1986;24(3):148–53.

    Article  CAS  Google Scholar 

  46. Bourassa-Moreau E, Mac-Thiong J-M, Feldman DE, Thompson C, Parent S. Non-neurological outcomes after complete traumatic spinal cord injury: the impact of surgical timing. J Neurotrauma. 2013;30(18):1596–601.

    Article  PubMed  Google Scholar 

  47. Bourassa-Moreau E, Mac-Thiong JM, Ehrmann Feldman D, Thompson C, Parent S. Complications in acute phase hospitalization of traumatic spinal cord injury: does surgical timing matter? J Trauma Acute Care Surg. 2013;74(3):849–54.

    Article  PubMed  Google Scholar 

  48. Waters RL, Meyer PR, Adkins RH, Felton D. Emergency, acute, and surgical management of spine trauma. Arch Phys Med Rehabil. 1999;80(11):1383–90.

    Article  CAS  PubMed  Google Scholar 

  49. Kerwin AJ, Frykberg ER, Schinco MA, Griffen MM, Murphy T, Tepas JJ. The effect of early spine fixation on non-neurologic outcome. J Trauma Acute Care Surg. 2005;58(1):15–21.

    Article  Google Scholar 

  50. Duh M-S, Shepard MJ, Wilberger JE, Bracken MB. The effectiveness of surgery on the treatment of acute spinal cord injury and its relation to pharmacological treatment. Neurosurgery. 1994;35(2):240–9.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

Michael Fehlings is supported by the Halbert Chair in Neural Repair and Regeneration and the Dezwirek Family Foundation.

Author information

Authors and Affiliations

  1. Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto Western Hospital, 399 Bathurst St, Toronto, ON, Canada

    Hiroaki Nakashima, Narihito Nagoshi & Michael G. Fehlings

  2. Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan

    Hiroaki Nakashima

  3. Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan

    Narihito Nagoshi

Authors
  1. Hiroaki Nakashima
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Narihito Nagoshi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael G. Fehlings
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael G. Fehlings.

Additional information

This article is part of the Topical Collection on Traumatic Brain Injury Surgery.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nakashima, H., Nagoshi, N. & Fehlings, M.G. Timing of Surgery in the Setting of Acute Spinal Cord Injury. Curr Surg Rep 3, 32 (2015). https://doi.org/10.1007/s40137-015-0115-0

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s40137-015-0115-0

Keywords

Search

Navigation