‘Time is Spine’: new evidence supports decompression within 24\u2009h for acute spinal cord injury

Abstract

The timing of decompression for acute spinal cord injury (SCI) has been a topic of great debate for many years. Despite the strong biological rationale for early surgical decompression, there has, until very recently, been a paucity of high-quality evidence to support this intervention. As a result, there is substantial variability in surgical practice throughout the world with available guidelines only providing recommendations based on weak clinical evidence [1]. It is well known that acute SCI has tremendous biological, psychosocial and economic impacts on patients, families and society. In spite of advancements in our understanding of the pathophysiology of spinal cord injury and thorough investigative efforts into neuroprotection and regenerative therapies, treatment options have remained limited to targeted blood pressure control, medical therapy, external immobilization and finally, surgical decompression of the spinal cord [2]. The rationale for urgent surgical decompression includes a potential for restoring blood flow and improving perfusion whilst potentially mitigating the course of secondary injury [3]. Although there has been growing recognition that early decompressive surgery is a safe and reasonable treatment option, prior clinical studies have only been suggestive of such due to low quality data arising from small sample sizes, retrospective analyses and inconsistent methods and outcome reporting. Other recent studies have indicated that factors such as intramedullary lesion length may be more important than timing of intervention with regards to clinical outcomes in SCI [4]. To directly address this gap in clinical evidence and potentially inform future clinical practice, our group recently published our findings, which are the largest and highest quality analysis (to our knowledge) pertaining to the influence of timing of decompressive surgery for acute SCI [5]. We aimed to test the efficacy of surgery within 24 h of injury as this cut-off had been studied most frequently [6]. To achieve this goal, a pooled analysis was performed on 1548 individual patients with a SCI from 1991 to 2017. The data were derived from four high quality, prospective, multicenter acute SCI databases. These were specifically chosen as they contained the highest quality granular data, including time elapsed from injury to surgery. Included were the North American Clinical Trials Network (NACTN) SCI Registry [7], the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) [8], the Sygen trial [9] and the National Acute Spinal Cord Injury Study (NASCIS III) [10]. The mean age of the patients was 39.1 years, with 528 patients undergoing early surgical decompression within 24 h and the remaining 1020 patients undergoing later surgery. Four major findings were apparent from this study: