Guidelines Suggest Early Decompression for Acute Spinal Cord Injury

Michael G. Fehlings, MD, PhD, FRCSC, FACS, comments on the clinical interpretations of the guildelines.

New guidelines suggest that early surgical decompression (≤24 hours) should be considered for adult patients with traumatic central cord syndrome and acute spinal cord injury (SCI), regardless of injury level. The quality of evidence for these recommendations was considered low using the GRADE methodology, as they are not based on findings from randomized controlled trials. Although these data should be interpreted with caution, the utilization of early surgical decompression does appear to be an important factor in improving functional recovery following SCI.
Multi-colored clock concept art"Time is Spine" in adult patients with traumatic central cord syndrome and acute spinal cord injury.“The clinical interpretation of the guidelines is that, barring unforeseen circumstances (eg, radiologic evidence of mechanical instability) or a patient who is medically unstable, early surgical intervention should be done in any patient with an acute SCI, regardless of level,” explained Michael G. Fehlings, MD, PhD, FRCSC, FACS, who led the multidisciplinary group that developed the guidelines. “This is the first guideline statement that has come out in favor of this approach and, from that perspective, this is a landmark document.”

The guidelines were developed under the guidance of AOSpine North America, AOSpine International, and the American Association and Congress of Neurological Surgeons. The findings were published in a special focus issue of the open-access Global Spine Journal.

“One of the challenges is that there are no randomized controlled trials on early versus late surgical decompression,” said Dr. Fehlings, who is Professor of Neurosurgery and Co-Director of the Spine Program at the University of Toronto in Ontario, and Chair of the AOSpine International Spinal Cord Injury Knowledge Forum.

“The strongest trial was one that I had led known as the STASCIS trial [Surgical Timing in Acute Spinal Cord Injury Study],” which found significantly improved neurologic recovery and no difference in complication rates with early (≤24 hours) versus late (>24 hours) decompression after cervical SCI,” Dr. Fehlings told SpineUniverse.1 “This was a prospective cohort, comparative effectiveness study, but was not randomized.”

“The STASCIS study was validated by several other studies that showed a similar compelling, positive role for early surgical intervention,” Dr. Fehlings said. “Ultimately, because of the important clinical benefits seen with early surgical intervention with SCI patients, a recommendation for early surgical intervention was made,” Dr. Fehlings said.

Key Findings From the Systematic Review
The recommendations were based on the following findings:

  • Isolated studies show statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation2
  • One study showing a marginally significant improvement in total motor score at 6 and 12 months post-injury with early versus late surgery in acute central cord syndrome without instability3
  • No significant differences in length of acute care/rehabilitation stay or in rates of complications with early versus late surgery1,4,5

“These guidelines are meant to guide clinical management. Ultimately, any physician needs to assess what is appropriate for their patient, and then use the guidelines to provide guidance for that management.” Dr. Fehlings said.

Clinical Relevance of the Guidelines
“The guidelines are clinically important given that many surgeons get push back at the hospital level when they try to book a SCI for early surgical intervention,” Dr. Fehlings said. “This guideline provides the evidence to support what surgeons are already in favor of doing.”

“Secondly, from a systems perspective, while SCI is viewed as a very serious event and has tragic circumstances, it is actually not viewed currently by the American College of Surgeons and other organizations as being a time critical event,” Dr. Fehlings explained. “Thus, from a triage perspective, this document provides evidence that patient transfer to a center with a high level of expertise with SCI needs to be expedited,” he said.

“Time is Spine”
Dr. Fehlings said that the next step in guideline development is knowledge translation, with the goal of educating healthcare professionals and the public that SCI injury should be treated quickly and at a center of excellence.

“In many cases, guideline statements don’t actually influence clinical management,” Dr. Fehlings said. “Thus, we now want to engage the community as a whole—surgeons and lay people—to inform them that SCI is a time-critical event, much like a stroke.”

“From a systems perspective, we’ve seen dramatic changes in stroke care. Now strokes are treated in an extremely timely manner, and hospitals are judged by how quickly patients receive CT scans, MRIs, and clot-busting treatment for strokes,” Dr. Fehlings said. “We borrowed from the ‘time is brain’ stroke campaign to come up with the concept that ‘time is spine.’”

“We want to change the systems that occur from a payer perspective and the American College of Surgeons triage systems with the goal of optimizing outcomes of treatment and reducing delays in the transfer of SCI patients to centers of excellence,” Dr. Fehlings concluded.

Disclosure
Dr. Fehlings disclosed no relevant financial relationships.

Updated on: 11/03/17
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