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Surgery for Spinal Cord Injuries: What's the Best Timing?

Posted on: 11/30/1999
In this supplemental issue of the publication Spine, the editors tackle a big subject: spinal trauma. Three new studies addressing the optimal time for surgery are included. Timing for surgery after spinal trauma is a very important topic as every hour can make a difference in the final outcomes.

Every year, trauma takes the lives of 1000s of North Americans between the ages of five and 44. For those who are not killed but survive, spinal cord injury is a major problem. If the victim is lucky, there will be a trauma center nearby to address any spinal cord trauma and other injuries that occur at the same time. Even better is the presence of a spine trauma unit.

But even at specialized centers like the Neurosurgery and Spine Program at the University of Toronto in Canada where these studies originated, there is much debate about the best treatment strategy for these types of injuries. In fact, as one of the studies in this journal shows, interviews with 77 neurosurgeons showed a wide range of opinions about the optimal early management of spinal cord injuries.

There isn't just one factor to consider when determining whether surgery should be done immediately (within 24 hours) or later after stabilizing the patient. There are safety issues for the patient, staffing issues (is a properly trained neurosurgeon available?), cost analysis, possible complications to consider, and considerations centered on patient quality of life. Children may be handled differently than adults. Older adults may require a different approach than younger individuals. And the level of the injury can make a difference, too.

There is some evidence that the longer the spinal cord is compressed (crushed, pinched, pressed by the damaged vertebrae), the worse the results. It makes sense to get the pressure off the cord as soon as possible.

But there can be other life-threatening issues that must be taken care of first. And there's some question about what to do when surgery could make matters worse or even prevent the patient from recovering naturally. In cases where the cord is severed all the way across, the value of immediate surgery is less well-known.

From studies done so far, the current recommendations are for early surgery for patients with severe neurologic injury. For those who have mild neurologic symptoms, a wait-and-see approach is advised to give patients time to heal and recover on their own.

Early stabilization of the spine and decompression of the spinal cord has been shown to reduce hospital costs by decreasing length of hospital stay and fewer days on mechanical ventilation (machines keeping the patient alive by breathing for them).

The editors of this journal suggest that if ever there was doubt about the best timing for spinal cord surgery following traumatic injury, the evidence is piling up now to show support for early rather than late stabilization and decompression. Some surgeons advocate surgical intervention even earlier -- within 12 hours rather than the 24 hours previously debated.

A special study conducted at multiple spinal cord trauma centers is currently underway. Many specialists are hoping the results of that study called Surgical Treatment of Acute Spinal Cord Injury Study or STASCIS will bring additional information. Results from STASCIS may help shape future recommended guidelines for the optimal timing of surgery in cases of acute spinal trauma.

References:
Michael G. Fehlings, MD, PhD, FRCSC, FACS, and Jefferson R. Wilson, MD. Timing of Surgical Intervention in Spinal Trauma. What Does the Evidence Indicate? In Spine. October 1, 2010. Vol. 35. No. 21S. Pp. S159-S160.

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