Surgical Considerations to Improve Recovery in Acute Spinal Cord Injury

Neurospine, 2022 · DOI: https://doi.org/10.14245/ns.2244616.308 · Published: September 7, 2022

Simple Explanation

Acute traumatic spinal cord injury (SCI) can be a devastating and costly event for individuals, their families, and the health system as a whole. Prognosis is heavily dependent on the physical extent of the injury and the severity of neurological dysfunction. Initial recognition and rapid treatment of acute SCI are vital to limiting secondary injury, reducing morbidity, and providing the best chance of functional recovery. This article aims to review the pathophysiology of SCI and the most up-to-date management of the acute traumatic SCI Optimal timing, approaches, and parameters for acute surgical and medical interventions are understudied. Moreover, there are distinct ethical considerations for performing clinical trials in this population and setting.

Study Duration

Not specified

Participants

Not specified

Evidence Level

Review Article

Key Findings

1
Patients admitted directly to level I trauma centers had significantly higher odds of receiving a decompressive surgery compared to those who were either transferred to a level I center or went directly to a level II/III/IV center.
2
Patients in the early surgery group were almost 3 times more likely to have a 2 grade AIS improvement at the 6-month postoperative follow-up mark.
3
Preoperative intramedullary lesion length, not the timing of surgery, was the only significant determinant for long-term neurological outcome.

Research Summary

Acute traumatic SCI can leave a lasting impact on the overall well-being of an individual. For urgent cases associated with severe neurological dysfunction, it is crucial to provide emergency, rapid, and specialized therapies to minimize secondary injuries. After initial evaluation, surgical candidates should undergo timely decompression, ideally within 24 hours of injury. For both surgical and nonsurgical candidates, medical management with an emphasis on hemodynamic stability and optimizing cord perfusion should be started regardless of surgical status to maximize chances of recovery. management strategies are constantly evolving, with promising interventions just on the horizon. As described in this review, there are still numerous unanswered questions, new drugs funneling through clinical trials, and fluid protocols hinging on the results of breakthrough studies.

Practical Implications

Surgical Timing

Early surgical decompression (within 24 hours) is generally associated with better neurological outcomes.

Hemodynamic Management

Maintaining hemodynamic stability, particularly mean arterial pressure (MAP) and spinal cord perfusion pressure (SCPP), is crucial for maximizing recovery.

Ethical Trial Design

Clinical trials should be designed with careful consideration of equipoise, patient autonomy, and informed consent, especially in emergency settings.

Study Limitations

1
Optimal timing of surgical intervention remains poorly defined.
2
The superiority of anterior versus posterior surgical approaches depends on the specific injury and patient factors.
3
Further research is needed to determine the best combination of surgical and medical management strategies.

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