Do I Need to Decompress Patients with Spinal Cord Injury Right Away?

Lali H.S. Sekhon and Michael G. Fehlings

BRIEF ANSWER

Despite strong experimental evidence that early decompression after acute spinal cord injury (SCI) improves outcome in animal models, no class I or class II evidence indicates that decompression, either early or late, improves outcome in patients. However, numerous retrospective studies, anecdotes, and case reports document the benefit of surgery (both acute and even many months after injury) for spinal cord decompression. It is quite possible that the prospective studies that have investigated the timing of decompression did not use a sufficiently short time window; that is, they did not perform “early decompression” soon enough. No level I or level II recommendations regarding this intervention can be made. Early decompression can thus be viewed only as a treatment option. Clinical experience, however, suggests that early intervention should be considered in patients with bilaterally jumped facets and in patients with incomplete SCI who demonstrate neurologic deterioration.

Background

Despite the widespread use of operative intervention in patients with acute SCI in North America, the role of surgery in enhancing neurologic recovery remains controversial because of the lack of well-designed and well-executed randomized controlled trials. Experimental evidence from animal models suggests that early decompression of the spinal cord improves recovery after SCI.¹ However, using these animal models to determine the time window for the effective application of decompression in the clinical setting is difficult. So far, clinical studies that have examined the role of surgical decompression in SCI are limited to class II and class III evidence.

Literature Review

The Role of Conservative Management

Prior to evaluating the role of surgery in the management of SCI, one must, for comparative purposes, examine the results of conservative, nonoperative treatment. The nonoperative approach has been advocated by those who adhere to the tenets of Sir Ludwig Guttmann, founder of the Stoke-Mandeville Hospital in England. Guttmann used postural techniques combined with bed rest to achieve reduction and spontaneous fusion of the spine. Operative approaches were used only rarely because of a higher incidence of neurologic complications and poor recovery with laminectomy (class III data).^2,3

Spontaneous improvement in neurologic status with conservative therapy alone has been demonstrated in several more recent studies (class III data).^4,5 Accordingly, any beneficial results of surgical treatment need to be weighed against any spontaneous recovery that might occur after SCI. Indeed, some authors have reported that neither spinal surgery nor anatomic realignment of the spinal column improves neurologic outcome in patients with acute SCI, with the possible exception of those with bilateral locked facets (class III data).6,7

Pearl

Spontaneous improvement in neurologic status often occurs with conservative therapy alone. This phenomenon makes it important to include a control group in any surgical study.

To date, studies of nonoperative management have been limited to noncontrolled, retrospective analyses of clinical databases and accordingly provide class III evidence. Furthermore, it is now well recognized that laminectomy as the sole surgical technique is contraindicated in most cases of acute SCI because it usually fails to produce adequate decompression of the cord and often causes spinal instability, which in and of itself may lead to neurologic deterioration.

The Role and Timing of Decompressive Surgery

Although meticulous conservative care remains the cornerstone of SCI management, surgical techniques have evolved considerably since the era of Guttmann. Furthermore, use of a policy of exclusively nonoperative treatment of SCI would have major limitations. Up to 10% of patients with incomplete cervical SCI who undergo an exclusively conservative management protocol may neurologically deteriorate (class III data).⁸ For such reasons, the role of prompt surgical management has been revisited. With a few notable exceptions, most studies consist of retrospective case series, sometimes with historical controls (i.e., class III evidence). These studies offer no clear consensus as to the appropriate timing of surgical intervention, and they provide no compelling evidence that decompression influences the neurologic outcome after SCI.^8,9

The benefits of early reduction of dislocations of the spine by either open or closed techniques are difficult to evaluate in the absence of randomization (class III studies).^9,10 Accounts of impressive neurologic recovery in cervical injuries decompressed early by traction must be considered anecdotal (class III data).¹¹ Moreover, some studies have not found any neurologic benefit to reduction (class III data),^6,7 with the possible exception of patients with bilateral facet dislocation (class III data).¹² Aebi et al⁹ retrospectively examined the records of 100 patients with cervical spine injuries and attempted to relate neurologic recovery to the timing of the reduction by closed manual traction or open surgical reduction (class III data). A manual or surgical reduction was performed within the first 6 hours after the accident in only 25% of the cases and within the first 24 hours in 57%. Overall, 31% of the 100 patients demonstrated neurologic improvement, and 75% of the recoveries were in patients reduced manually or surgically within the first 6 hours. Mirza et al¹⁰ retrospectively reviewed 30 patients who sustained cervical spine injuries and underwent surgical decompression and stabilization either within or beyond 72 hours (class III data). They suggested that the group that underwent early surgery exhibited immediate postoperative neurologic improvement without an increased complication rate.