Surgical Interventions during the Acute Phase of Spinal Cord Injury Michael Craig MD Rachel Adamson BSc MD Brooke Benton BA Amanda McIntyre PhD (student) RN MSc Mostafa Fatehi MD MSc www.scireproject.com Version 7.0 Key Points Cervical decompression may improve neurological functioning post SCI. Thoracolumbar decompression may improve neurological functioning among those with incomplete, but not complete SCI. Anterior and posterior approaches may be equally effective. Endoscopic approaches may be similarly effective to open decompression approaches. Decompression surgery for lumbar burst and conus injuries may improve neurological outcomes and adjacent nerve root. In acute traumatic SCI, surgery within 24 hours is associated with better neurological outcome, lower complications and shorter length of stay but not a reduction in mortality. Generally, surgery within 72 hours is an acceptable standard of care. With respect to traumatic central cord syndrome, there is no clear evidence of a neurologic benefit from decompression or its timing. Available evidence suggests that age and comorbidities may be appropriate justifications to delay surgery with possible survival benefit for doing so. Method of mechanical stabilization can be variable and consist of non-surgical rigid orthosis or open stabilization (e.g., anterior, posterior or circumferential instrumentation and fusion manoeuvres); however, the methods described in the literature are no longer used in clinical practice today. Although neurological recovery is difficult to predict in traumatic SCI, a number of prognostic variables may influence neurological recovery after surgery post SCI. Individuals with incomplete injuries tend to fare better than those with complete injuries. Surgical correction of ongoing spinal cord compression can improve prognosis, especially if performed early. Compared to patients treated without surgery, those receiving surgery post SCI experienced lower mortality but no difference in neurological outcome; however, the techniques are from an early surgical era and should be interpreted with caution. While it appears autologous bone marrow transplant is safe, it is not effective for neurological or functional recovery post SCI. There is no evidence that one approach is superior to another with respect to decompression or stabilization for compression by metastatic lesions; all approaches. Radiotherapy and surgery for the management of symptomatic metastatic spine compression is effective; early surgical intervention to decompress the spine should be performed after considering tumor features and patient status. It is impossible to compare laminectomy and fusion with conservative management in individuals who have ongoing cord compression or column instability. The clinical utility of decompressive laminectomies is obvious; however, in appropriately selected individuals one may elect to perform a percutaneous technique. There are no studies that compare similar subsets of patients undergoing laminoplasty or conservative management. There are no good studies comparing laminectomy to laminoplasty in patients with acute SCI. InThere the surgical are no studies decompression that compare of cervicalsimilar subs spondylosisets of patients myelopathy, undergoing both laminoplasty anterior and or posterior approaches are clinically effective. Anterior decompression may have a higher level of neurological recovery but is also subject to more complications and demonstrates no clear superiority in terms of disability or quality of life when compared to posterior decompression. While it is difficult to predict the effectiveness of surgical decompression in degenerative compressive myelopathy, there is good evidence that some MRI findings, including absence of spinal cord hyperintensity on MRI, can predict surgical outcomes. Radiological signs of cervical spinal cord are quite common, but risk of progression to symptoms is low overall. Patients with co-existing cervical radiculopathy or electrophysiological changes are at higher risk of progression to clinical myelopathy. Post-traumatic tethered cord and syringomyelia has an estimated incidence of 1-4%. Low quality evidence suggests that prophylactic decompression should not be performed, but that patients with progressive motor decline attributable to tethering or syrinx can have an arrest of their decline with surgical management. Table of Contents 1.0 Executive Summary ........................................................................................................... 3 2.0 Methods .............................................................................................................................. 3 3.0 Introduction ........................................................................................................................ 3 4.0 Surgery for Traumatic SCI ................................................................................................. 3 4.1 Decompression Surgery ................................................................................................ 3 4.2 Effect of Timing on Decompression and/or Stabilization Surgery Post SCI .............. 9 American Spinal Injury Association Impairment Scale (AIS) A ; Mean time since injury: 22.6 hr. ......................................................................................................................................10 4.3 Surgery for Traumatic Central Cord Syndrome ...........................................................17 4.4 Surgical Stabilization ....................................................................................................22 4.5 Prognosis Following Surgery for SCI ...........................................................................25 4.6 Surgical Management versus Other Methods .............................................................30 4.7 Bone Marrow Transfer ...................................................................................................31 5.0 Management of Spinal Cord Compression by Metastatic Lesions ................................33 5.1 Decompression or Stabilization ...................................................................................33 5.2 Surgery in Combination with Radiotherapy .................................................................36 6.0 Laminoplasty and Laminectomy ......................................................................................41 6.1 Laminectomy and Fusion ..............................................................................................41 6.2 Laminoplasty .................................................................................................................42 7.0 Surgery for Miscellaneous Myelopathies ........................................................................45 7.1 Cervical Spondylosis ....................................................................................................45 7.2 Degenerative Compressive Myelopathy ......................................................................49 7.3 Spinal Stenosis ..............................................................................................................50 7.4 Syringomyelia and Tethered Spinal Cord ....................................................................52 8.0 Summary ...........................................................................................................................55 9.0 References .........................................................................................................................58 Abbreviations ..........................................................................................................................65 Surgical Interventions during the Acute Phase of Spinal Cord Injury 1.0 Executive Summary Gaps in the Evidence 2.0 Methods 3.0 Introduction Spinal cord injuries (SCI) often causes life-altering sequelae and can lead to significant morbidity. As such, there has been long-standing interest in improving the interventions used in the management of affected individuals. In the acute phase, various medical and surgical approaches have been proposed and studied to reduce the tremendous impact of trauma. In addition to evaluating the efficacy of different surgical strategies, clinicians have evaluated the benefit of early surgical decompression and stabilization. In this chapter, we will describe and evaluate current surgical approaches and summarize the evidence for these interventions. 4.0 Surgery for Traumatic SCI Surgical treatment of traumatic SCI has several proposed benefits. First, after the primary insult has occurred, relief of any ongoing spinal cord compression is theorized to minimize any secondary neurologic injury that might occur via ischemia, inflammation, etc. In a similar manner, surgical decompression is thought to minimize the risk any further cord injury at the injured level. Mechanical stabilization of the injured spinal segment is thought to reduce the risk of future instability and reduce pain at the injured segment. Surgical stabilization often also obviates the need for activity limitations or a cervical collar, thereby facilitating nursing care, and allowing earlier mobilization and ongoing rehabilitation. The purported benefits must be weighed against the risks of surgical treatment. These include the physiological stress of a potentially long, time-intensive, and morbid procedure in a population of individuals who are often critically ill at the time of surgery. Several aspects