Surgical decompression after spinal cord injury: the earlier, the better!

History and Accomplishments of the North American Clinical Trials Network for Spinal Cord Injury, 2004-2022

This is a historical account of the origin and accomplishments of the North American Clinical Trials Network (NACTN) for traumatic spinal cord injury (SCI), which was established in 2004 by Christopher Reeve and Robert Grossman. Christopher Reeve was an actor who became quadriplegic and started the Christopher & Dana Reeve Foundation (CDRF), and Robert Grossman was a neurosurgeon experienced in neurotrauma and a university professor in Houston. NACTN has member investigators at university and military centers in North America and has contributed greatly to the improvement of care, primarily acute care, of patients sustaining traumatic SCI. Its accomplishments are a clinical registry database of >1000 acute SCI patients documenting the care pathways, including complications. NACTN has assessed the effectiveness of treatment, including pharmacotherapy and the role and timing of surgery, and has also identified barriers to early surgery. The principal focus has been on improving neurological recovery. NACTN has trained many SCI practitioners and has collaborated with other SCI networks and organizations internationally to promote the care of SCI patients.

Surgical outcome and risk factors for cervical spinal cord injury patients in chronic stage: a 2-year follow-up study

PURPOSE

This study aims to assess the nerve function deficient recovery in surgically treated patients with cervical trauma with spinal cord injury (SCI) in chronic stage and figure out prognostic predictors of improvement in impairment and function.

METHODS

We reviewed the clinical and radiological data of 143 cervical SCI patients in chronic stage and divided into non-operative group (n = 61) and operative group (n = 82). The severity of neurological involvement was assessed using the ASIA motor score (AMS) and Functional Independence Measure Motor Score (FIM MS). The health-related quality of life was measured using the SF-36 questionnaire. Correspondence between the clinical and radiological findings and the neurological outcome was investigated.

RESULTS

At 2-year follow-up, surgery resulted in greater improvement in AMS and FIM MS than non-operative group. Regression analysis revealed that lower initial AMS (P = 0.000), longer duration after injury (P = 0.022) and injury above C4 level (P = 0.022) were factors predictive of lower final AMS. Longer duration (P = 0.020) and injury above C4 level (P = 0.010) were associated with a lower FIM MS. SF-36 scores were significantly lower in higher age (P = 0.015), female patients (P = 0.009) and patients with longer duration (P = 0.001).

CONCLUSION

It is reasonable to consider surgical decompression in patients with cervical SCI in chronic stage and persistent spinal cord compression and/or gross cervical instability. Initial AMS, longer duration, injury above C4 level, higher age and female patients are the five major relevant factors of functional recovery.

Analysis of Delays to Surgery for Cervical Spinal Cord Injuries

STUDY DESIGN

A retrospective study of surgically treated patients with cervical spinal cord injury (SCI) from the National Trauma Data Bank Research Data Set.

OBJECTIVE

To determine how time to surgery differs between SCI subtypes, where delays before surgery occur, and what factors are associated with delays.

SUMMARY OF BACKGROUND DATA

Studies have shown that patients with cervical SCI undergoing surgery within 24 hours after injury have superior neurological outcomes to patients undergoing later surgery, with most evidence coming from the incomplete SCI subpopulation.

METHODS

Surgically treated patients with cervical SCI from 2011 and 2012 were identified in National Trauma Data Bank Research Data Set and divided into subpopulations of complete, central, and other incomplete SCIs. Relationships between surgical timing and patient and injury characteristics were analyzed using multivariate regression.

RESULTS

A total of 2636 patients with cervical SCI were identified: 803 with complete SCI, 950 with incomplete SCI, and 883 with central SCI. The average time to surgery was 51.1 hours for patients with complete SCI, 55.3 hours for patients with incomplete SCI, and 83.1 hours for patients with central SCI. Only 44% of patients with SCI underwent surgery within the first 24 hours after injury, including only 49% of patients with incomplete SCI.The vast majority of time between injury and surgery was after admission, rather than in the emergency department or in the field. Upper cervical SCIs and greater Charlson Comorbidity Index were associated with later surgery in all 3 SCI subpopulations.

CONCLUSION

The majority of patients with SCI do not undergo surgery within the first 24 hours after injury, and the majority of delays occur after inpatient admission. Factors associated with these delays highlight areas of focus for expediting care in these patient populations.

LEVEL OF EVIDENCE

4.