timing for surgery in acute spinal cord injury landmark journal of neurosurgery

1. Timing of Surgery for Acute Spinal
Cord Injury
(Landmark papers in Neurosurgery)
Presenter: Dr.Abhishek Gautam
Moderator : Dr. Praful Maste

2. Main Study:
• Vaccaro AR, Daugherty RJ, Sheehan J, Sheehan TP, Dante SJ, Cotle JM, Balsderston, RA, Herbison GJ, Northup BE.
Neurologic outcome of early versus later surgery for cervical cord injury. Spine 1997; 22: 2609–2613.
Related References:
• Bagnall AM, Jones L, Duffy S, Riemsma RP. Spinal fixation surgery for acute traumatic spinal cord injury.
Cochrane Database Syst Rev 2008; 1: CD004725.
• Fehlings MG, Perrin RG. The role and timing of early decompression for cervical spinal cord injury: update
with a review of recent clinical evidence. Injury 2005; 36: SB13–SB26.
• Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a
systematic review of recent clinical evidence. Spine 2006; 31: 528–535.
• Tator CH, Fehlings MG, 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:
12–18.
Study References

3. Study Design
Class of evidence II
Randomization Early surgery versus late surgery for cervical spinal cord
trauma
Number of patients 64 randomized
Follow-up <1 year
Primary outcomes: Neurological outcome, Functional
outcome
Secondary outcomes: Length of hospital stay
Number of centres 1
Stratification Age and sex

4. Inclusion criteria
• Age 15–75 years
• Neurological impairment A–D on American Spinal Injury Association
(ASIA) scale
• Neurological level C3–T1
• Admission within 48 h of injury
• Radiological evidence of cord compression

5. Exclusion criteria
• Other injuries preventing neurological evaluation or surgery
• Coexisting spinal cord disease
• Worsening neurology due to blood, disc, or bony fragments within
the canal

6. • Early surgery is <72hrs days from injury.
• Late surgery was >5 days from injury.
• Surgery included decompression ± stabilization procedures.
• Neurological outcome was assessed by comparing standard
neurological examination before (on admission) and after surgery
(mean 300 days).

7. Results
• Mean time to surgery was 1.8 days in the early group and 16.8 days
in the late group.
• There were no significant differences in the neurological or functional
outcomes between the two groups, or in the length of hospital stay.

8. Conclusions
• There is no benefit between surgery within 72 h of injury and delayed
surgery in cervical spinal cord injury.

9. Critique
• Includes only cases of cervical cord injury, and the length of time to early surgery (mean 1.8 days) may not be early
enough. It is still possible that there may be a benefit of earlier surgery within 8 or 12 hours of injury.
• Tator et al. reported one of the most extensive case series in the literature looking at the effect of the timing of surgery
on outcomes in ASCI at all spinal levels (Tator et al., 1999). They conducted a retrospective analysis of over 500 cases
of ASCI admitted to 36 centers in North America over 9 months. The results suggested that there is no agreement on the
timing of surgery for ASCI and that further RCTs are needed.
To date, the study by Vaccaro et al. remains the only attempt at a randomized trial.
• Fehlings and Perrin have published several comprehensive literature reviews on the timing of surgery in ASCI (Fehlings
and Perrin, 2005, 2006). Based on the published data, they have made recommendations regarding the timing of surgery
in ASCI. However, they emphasize that with the lack of definitive evidence, urgent decompression remains only a
reasonable practice option that can be carried out safely

10. Other recent studies with
their interpretation.

16. CONCLUSION
Regarding surgical treatment, it is our opinion that it is important to proceed with surgical decompression as soon as
possible. At present, the ideal surgical time is within 8 hours from trauma, while if that is not possible it is
recommended not to exceed 24 hours. Furthermore, it emerged that early surgical decompression is indicated not only
for incomplete but also in the case of complete SCI.

19. Thank You..!!