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The Urgency of Surgical Decompression in Acute Central Cord Injuries With Spondylosis and Without Instability

Lenehan, Brian MD, MCh, FRCSI*; Fisher, Charles G. MD, MHSc, FRCSC*; Vaccaro, Alex MD, PhD†; Fehlings, Michael MD, PhD‡; Aarabi, Bizhan MD§; Dvorak, Marcel F. MD, FRCSC*

Spine:
doi: 10.1097/BRS.0b013e3181f32a44
Prospective Clinical Study
Abstract

Study Design. Systematic review, ambispective analysis of observational data.

Objective. To make recommendations as to whether or not urgent surgical decompression is ever indicated as the optimal treatment for enhancing neurologic recovery in a patient with acute central cord injury without fracture or instability.

Summary of Background Data. There are currently no standards regarding the role and timing of decompression in acute traumatic central cord syndrome. In the setting of TCCS without spinal column instability, much controversy exists.

Methods. We have performed a thorough literature search based on the following question: “Is there a role for urgent (within 24 hours from injury to surgery) surgical decompression in acute central cord syndrome without fracture or instability specifically to enhance neurologic recovery?”

Data including patient demographics, mechanism of injury, comorbidities, neurologic status, and surgical treatment was analyzed from a multicenter STSG observational database. Outcome measured included ASIA Motor Score, ASIA Grade, Functional Independence Measure (FIM) Score, SF-36, Sphincter Disturbance, and Ambulatory status. Measures were recorded on admission, discharge, 6 months and 1 year.

Results. At 12-month follow-up, early surgery resulted in a 6.31 point greater improvement in total motor score than did the late surgery group, with a P = 0.0358. At 6-month follow-up, early surgery result in higher chance of improvement in ASIA Grade than late surgery, with an odds ratio = 3.39, while at 12-month follow-up early surgery resulted in a higher chance of improvement in ASIA Grade, with an odds ratio of 2.81. Patients who were operated on within 24 hours had 7.79 U more improvement in FIM Total Score than late surgery at 6 month follow-up, with P = 0.0474.

Conclusion. The consensus of experts following review of relevant and examination of observational dataset concluded that it is reasonable and safe to consider early surgical decompression in patients with profound neurologic deficit (ASIA = C) and persistent spinal cord compression due to developmental cervical spinal canal stenosis without fracture or instability. Those with less severe deficit (ASIA = D) can be treated with initial observation with surgery potentially at a later date depending on the extent and temporal profile of the patients neurologic recovery.

In Brief

Controversy exists regarding the timing of surgery in acute TCCS. Following a comprehensive systematic review of the literature and analysis of observational data, treatment recommendations are presented. It is reasonable and safe to consider early surgical decompression in patients with profound neurologic deficit and persistent spinal cord compression due to cervical stenosis without fracture or instability.

Author Information

From the *Division of Spine, Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada; †Department of Orthopaedic Surgery, Thomas Jefferson University, The Rothman Institute at Jefferson, Philadelphia, PA; ‡Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; and §Division of Neurosurgery, University of Maryland, Baltimore, MD.

Acknowledgment date: October 19, 2009. Revision date: June 25, 2010. Acceptance date: July 20, 2010.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Supported by AOSpine North America. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence and reprint request to Marcel F. Dvorak, MD, FRCSC, 6th Floor, Blusson Spinal Cord Centre, 818 West 10th Ave, Vancouver, BC, V5Z 1M9, Canada; E-mail: marcel.dvorak@vch.ca

© 2010 Lippincott Williams & Wilkins, Inc.