Download PDF
J Neurol Surg A Cent Eur Neurosurg 2023; 84(06): 570-577
DOI: 10.1055/a-1811-8201
Review Article

A Review of Strategies Associated with Surgical Decompression in Traumatic Spinal Cord Injury

Ying-Kang Zhu
1   Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
,
Fa-Tai Lu
1   Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
,
Guo-Dong Zhang
1   Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
,
Zun-Peng Liu
1   Department of Orthopedics, The Fourth Affiliated Hospital, China Medical University, Shenyang, China
› Author Affiliations Funding This study was supported by the General program of Postdoctoral Science Foundation of China (2019M66166) and Liaoning Provincial Doctoral Start-up Foundation (20180540065) for the writing, polishing, and publication of the manuscript.
› Further Information
   Permissions and Reprints

Abstract

Traumatic spinal cord injury (TSCI) is frequent. Timely diagnosis and treatment have reduced the mortality, but the long-term recovery of neurologic functions remains ominous. After TSCI, tissue bleeding, edema, and adhesions lead to an increase in the intraspinal pressure, further causing the pathophysiologic processes of ischemia and hypoxia and eventually accelerating the cascade of secondary spinal cord injury. Timely surgery with appropriate decompression strategies can reduce that secondary injury. However, disagreement about the safety and effectiveness of decompression surgery and the timing of surgery still exists. The level and severity of spinal cord injury do have an impact on the timing of surgery; therefore, TSCI subpopulations may benefit from early surgery. Early surgery perhaps has little effect on recovery from complete TSCI but might be of benefit in patients with incomplete injury. Early decompression should be considered in patients with incomplete cervical TSCI. Patient age should not be used as an exclusion criterion for early surgery. The best time point for early surgery is although influenced by the shortest duration to thoroughly examine the patient's condition and stabilize the patient's state. After the patient's condition is fully evaluated, we can perform the surgical modality of emergency myelotomy and decompression. Therefore, a number of conditions should be considered, such as standardized decompression methods, indications and operation timing to ensure the effectiveness and safety of early surgical intervention, and promotion of the functional recovery of residual nerve tissue.

Keywords

TSCI - surgical decompression - surgical timing - functional recovery

Author Contributions

Y.Z. and Z.L. contributed to the study design, study performance, and preparation of the manuscript. Z.L. and Y.Z. contributed to literature analysis and interpretation, and preparation and revision of the manuscript. F.L. and G.Z. contributed to the study performance. All the authors read and approved the final manuscript.




Publication History

Received: 29 December 2021

Accepted: 30 March 2022

Accepted Manuscript online:
30 March 2022

Article published online:
26 July 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Kwon BK, Tetzlaff W, Grauer JN, Beiner J, Vaccaro AR. Pathophysiology and pharmacologic treatment of acute spinal cord injury. Spine J 2004; 4 (04) 451-464
    CrossrefPubMedGoogle Scholar
  • 2 Badhiwala JH, Ahuja CS, Fehlings MG. Time is spine: a review of translational advances in spinal cord injury. J Neurosurg Spine 2018; 30 (01) 1-18
    CrossrefPubMedGoogle Scholar
  • 3 Kumar R, Lim J, Mekary RA. et al. Traumatic spinal injury: global epidemiology and worldwide volume. World Neurosurg 2018; 113: e345-e363
    CrossrefPubMedGoogle Scholar
  • 4 Lee BB, Cripps RA, Fitzharris M, Wing PC. The global map for traumatic spinal cord injury epidemiology: update 2011, global incidence rate. Spinal Cord 2014; 52 (02) 110-116
    CrossrefPubMedGoogle Scholar
  • 5 Singh A, Tetreault L, Kalsi-Ryan S, Nouri A, Fehlings MG. Global prevalence and incidence of traumatic spinal cord injury. Clin Epidemiol 2014; 6: 309-331
    PubMedGoogle Scholar
  • 6 Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine 2006;31(11, Suppl):S28–S35, discussion S36
    PubMedGoogle Scholar
  • 7 Oyinbo CA. Secondary injury mechanisms in traumatic spinal cord injury: a nugget of this multiply cascade. Acta Neurobiol Exp (Warsz) 2011; 71 (02) 281-299
    PubMedGoogle Scholar
  • 8 Summers RL, Baker SD, Sterling SA, Porter JM, Jones AE. Characterization of the spectrum of hemodynamic profiles in trauma patients with acute neurogenic shock. J Crit Care 2013; 28 (04) 531.e1-531.e5
    CrossrefPubMedGoogle Scholar
  • 9 Blight AR, Decrescito V. Morphometric analysis of experimental spinal cord injury in the cat: the relation of injury intensity to survival of myelinated axons. Neuroscience 1986; 19 (01) 321-341
    CrossrefPubMedGoogle Scholar
  • 10 Khaing ZZ, Cates LN, Fischedick AE, McClintic AM, Mourad PD, Hofstetter CP. Temporal and spatial evolution of raised intraspinal pressure after traumatic spinal cord injury. J Neurotrauma 2017; 34 (03) 645-651
    CrossrefPubMedGoogle Scholar
  • 11 Repair, protection and regeneration of spinal cord injury. Neural Regen Res 2015; 10 (12) 1953-1975
    CrossrefPubMedGoogle Scholar
  • 12 Fehlings MG. The impact of continued cord compression following traumatic spinal cord injury. J Neurosurg Spine 2009; 11 (05) 568-569 , discussion 569
    CrossrefPubMedGoogle Scholar
  • 13 Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC. Sustained spinal cord compression: part I—time-dependent effect on long-term pathophysiology. J Bone Joint Surg Am 2003; 85 (01) 86-94
    CrossrefPubMedGoogle Scholar
  • 14 Werndle MC, Saadoun S, Phang I. et al. Monitoring of spinal cord perfusion pressure in acute spinal cord injury: initial findings of the injured spinal cord pressure evaluation study*. Crit Care Med 2014; 42 (03) 646-655
    CrossrefPubMedGoogle Scholar
  • 15 Phang I, Zoumprouli A, Saadoun S, Papadopoulos MC. Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: injured spinal cord pressure evaluation study. J Neurosurg Spine 2016; 25 (03) 398-405
    CrossrefPubMedGoogle Scholar
  • 16 Tykocki T, Poniatowski Ł, Czyż M, Koziara M, Wynne-Jones G. Intraspinal pressure monitoring and extensive duroplasty in the acute phase of traumatic spinal cord injury: a systematic review. World Neurosurg 2017; 105: 145-152
    CrossrefPubMedGoogle Scholar
  • 17 Dvorak MF, Noonan VK, Fallah N. et al; RHSCIR Network. The influence of time from injury to surgery on motor recovery and length of hospital stay in acute traumatic spinal cord injury: an observational Canadian cohort study. J Neurotrauma 2015; 32 (09) 645-654
    CrossrefPubMedGoogle Scholar
  • 18 Piazza M, Schuster J. Timing of surgery after spinal cord injury. Neurosurg Clin N Am 2017; 28 (01) 31-39
    CrossrefPubMedGoogle Scholar
  • 19 Ter Wengel PV, Feller RE, Stadhouder A. et al. Timing of surgery in traumatic spinal cord injury: a national, multidisciplinary survey. Eur Spine J 2018; 27 (08) 1831-1838
    CrossrefPubMedGoogle Scholar
  • 20 Furlan JC, Craven BC, Massicotte EM, Fehlings MG. Early versus delayed surgical decompression of spinal cord after traumatic cervical spinal cord injury: a cost-utility analysis. World Neurosurg 2016; 88: 166-174
    CrossrefPubMedGoogle Scholar
  • 21 Liu Y, Shi CG, Wang XW. et al. Timing of surgical decompression for traumatic cervical spinal cord injury. Int Orthop 2015; 39 (12) 2457-2463
    CrossrefPubMedGoogle Scholar
  • 22 Jones CF, Cripton PA, Kwon BK. Gross morphological changes of the spinal cord immediately after surgical decompression in a large animal model of traumatic spinal cord injury. Spine 2012; 37 (15) E890-E899
    CrossrefPubMedGoogle Scholar
  • 23 van Middendorp JJ, Hosman AJ, Doi SA. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013; 30 (21) 1781-1794
    CrossrefPubMedGoogle Scholar
  • 24 Marshall LF, Knowlton S, Garfin SR. et al. Deterioration following spinal cord injury. A multicenter study. J Neurosurg 1987; 66 (03) 400-404
    CrossrefPubMedGoogle Scholar
  • 25 Inoue T, Suzuki S, Endo T, Uenohara H, Tominaga T. Efficacy of early surgery for neurological improvement in spinal cord injury without radiographic evidence of trauma in the elderly. World Neurosurg 2017; 105: 790-795
    CrossrefPubMedGoogle Scholar
  • 26 Ahn H, Bailey CS, Rivers CS. et al; Rick Hansen Spinal Cord Injury Registry Network. Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury. CMAJ 2015; 187 (12) 873-880
    CrossrefPubMedGoogle Scholar
  • 27 McKinley W, Cifu D, Seel R. et al. Age-related outcomes in persons with spinal cord injury: a summary paper. NeuroRehabilitation 2003; 18 (01) 83-90
    CrossrefPubMedGoogle Scholar
  • 28 Wilson JR, Tetreault LA, Kwon BK. et al. Timing of decompression in patients with acute spinal cord injury: a systematic review. Global Spine J 2017; 7 (3, Suppl): 95S-115S
    CrossrefPubMedGoogle Scholar
  • 29 Sewell MD, Vachhani K, Alrawi A, Williams R. Results of early and late surgical decompression and stabilization for acute traumatic cervical spinal cord injury in patients with concomitant chest injuries. World Neurosurg 2018; 118: e161-e165
    CrossrefPubMedGoogle Scholar
  • 30 Rahimi-Movaghar V. Efficacy of surgical decompression in the setting of complete thoracic spinal cord injury. J Spinal Cord Med 2005; 28 (05) 415-420
    CrossrefPubMedGoogle Scholar
  • 31 Bourassa-Moreau É, Mac-Thiong JM, Li A. et al. Do patients with complete spinal cord injury benefit from early surgical decompression? Analysis of neurological improvement in a prospective cohort study. J Neurotrauma 2016; 33 (03) 301-306
    CrossrefPubMedGoogle Scholar
  • 32 Wutte C, Klein B, Becker J. et al. Earlier decompression (< 8 hours) results in better neurological and functional outcome after traumatic thoracolumbar spinal cord injury. J Neurotrauma 2019; 36 (12) 2020-2027
    CrossrefPubMedGoogle Scholar
  • 33 Du JP, Fan Y, Zhang JN, Liu JJ, Meng YB, Hao DJ. Early versus delayed decompression for traumatic cervical spinal cord injury: application of the AOSpine subaxial cervical spinal injury classification system to guide surgical timing. Eur Spine J 2019; 28 (08) 1855-1863
    CrossrefPubMedGoogle Scholar
  • 34 Wilson JR, Witiw CD, Badhiwala J, Kwon BK, Fehlings MG, Harrop JS. Early surgery for traumatic spinal cord injury: where are we now?. Global Spine J 2020; 10 (1, Suppl): 84S-91S
    CrossrefPubMedGoogle Scholar
  • 35 Aarabi B, Akhtar-Danesh N, Chryssikos T. et al. Efficacy of ultra-early (< 12 h), early (12-24 h), and late (>24-138.5 h) surgery with magnetic resonance imaging-confirmed decompression in American Spinal Injury Association Impairment Scale grades A, B, and C cervical spinal cord injury. J Neurotrauma 2020; 37 (03) 448-457
    CrossrefPubMedGoogle Scholar
  • 36 Fehlings MG, Vaccaro A, Wilson JR. et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One 2012; 7 (02) e32037
    CrossrefPubMedGoogle Scholar
  • 37 Umerani MS, Abbas A, Sharif S. Clinical outcome in patients with early versus delayed decompression in cervical spine trauma. Asian Spine J 2014; 8 (04) 427-434
    CrossrefPubMedGoogle Scholar
  • 38 Rahimi-Movaghar V, Niakan A, Haghnegahdar A, Shahlaee A, Saadat S, Barzideh E. Early versus late surgical decompression for traumatic thoracic/thoracolumbar (T1-L1) spinal cord injured patients. Primary results of a randomized controlled trial at one year follow-up. Neurosciences (Riyadh) 2014; 19 (03) 183-191
    PubMedGoogle Scholar
  • 39 Du JP, Fan Y, Liu JJ. et al. Decompression for traumatic thoracic/thoracolumbar incomplete spinal cord injury: application of AO spine injury classification system to identify the timing of operation. World Neurosurg 2018; 116: e867-e873
    CrossrefPubMedGoogle Scholar
  • 40 Wutte C, Becker J, Klein B. et al. Early decompression (<8 hours) improves functional bladder outcome and mobility after traumatic thoracic spinal cord injury. World Neurosurg 2020; 134: e847-e854
    CrossrefPubMedGoogle Scholar
  • 41 Ter Wengel PV, Martin E, De Witt Hamer PC. et al. Impact of early (<24 h) surgical decompression on neurological recovery in thoracic spinal cord injury: a meta-analysis. J Neurotrauma 2019; 36 (18) 2609-2617
    CrossrefPubMedGoogle Scholar
  • 42 Fehlings MG, Rabin D, Sears W, Cadotte DW, Aarabi B. Current practice in the timing of surgical intervention in spinal cord injury. Spine 2010; 35 (21, Suppl): S166-S173
    CrossrefPubMedGoogle Scholar
  • 43 Wilson JR, Singh A, Craven C. et al. Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study. Spinal Cord 2012; 50 (11) 840-843
    CrossrefPubMedGoogle Scholar
  • 44 Kim M, Hong SK, Jeon SR, Roh SW, Lee S. Early (≤48 hours) versus late (>48 hours) surgery in spinal cord injury: treatment outcomes and risk factors for spinal cord injury. World Neurosurg 2018; 118: e513-e525
    CrossrefPubMedGoogle Scholar
  • 45 Grassner L, Wutte C, Klein B. et al. Early decompression (< 8 h) after traumatic cervical spinal cord injury improves functional outcome as assessed by spinal cord independence measure after one year. J Neurotrauma 2016; 33 (18) 1658-1666
    CrossrefPubMedGoogle Scholar
  • 46 Ma Y, Zhu Y, Zhang B, Wu Y, Liu X, Zhu Q. the impact of urgent (<8 hours) decompression on neurologic recovery in traumatic spinal cord injury: a meta-analysis. World Neurosurg 2020; 140: e185-e194
    CrossrefPubMedGoogle Scholar
  • 47 Jug M, Kejžar N, Vesel M. et al. Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience. J Neurotrauma 2015; 32 (18) 1385-1392
    CrossrefPubMedGoogle Scholar
  • 48 Haldrup M, Schwartz OS, Kasch H, Rasmussen MM. Early decompressive surgery in patients with traumatic spinal cord injury improves neurological outcome. Acta Neurochir (Wien) 2019; 161 (10) 2223-2228
    CrossrefPubMedGoogle Scholar
  • 49 Mattiassich G, Gollwitzer M, Gaderer F. et al. Functional outcomes in individuals undergoing very early (< 5 h) and early (5-24 h) surgical decompression in traumatic cervical spinal cord injury: analysis of neurological improvement from the Austrian Spinal Cord Injury Study. J Neurotrauma 2017; 34 (24) 3362-3371
    CrossrefPubMedGoogle Scholar
  • 50 Ghajarzadeh M, Saberi H. Transportation mode and timing of spinal cord decompression and stabilization in patients with traumatic spinal cord injury in Iran. Spinal Cord 2019; 57 (02) 150-155
    CrossrefPubMedGoogle Scholar
  • 51 Gaudin XP, Wochna JC, Wolff TW. et al. Incidence of intraoperative hypotension in acute traumatic spinal cord injury and associated factors. J Neurosurg Spine 2020; 32 (01) 127-132
    CrossrefPubMedGoogle Scholar
  • 52 Yang DG, Li JJ, Gu R. et al. Optimal time window of myelotomy in rats with acute traumatic spinal cord injury: a preliminary study. Spinal Cord 2013; 51 (09) 673-678
    CrossrefPubMedGoogle Scholar
  • 53 Phang I, Werndle MC, Saadoun S. et al. Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study. J Neurotrauma 2015; 32 (12) 865-874
    CrossrefPubMedGoogle Scholar
  • 54 Saadoun S, Werndle MC, Lopez de Heredia L, Papadopoulos MC. The dura causes spinal cord compression after spinal cord injury. Br J Neurosurg 2016; 30 (05) 582-584
    CrossrefPubMedGoogle Scholar
  • 55 Meyer C, Bendella H, Rink S. et al. The effect of myelotomy following low thoracic spinal cord compression injury in rats. Exp Neurol 2018; 306: 10-21
    CrossrefPubMedGoogle Scholar
  • 56 Khaing ZZ, Cates LN, Dewees DM. et al. Effect of durotomy versus myelotomy on tissue sparing and functional outcome after spinal cord injury. J Neurotrauma 2021; 38 (06) 746-755
    CrossrefPubMedGoogle Scholar
  • 57 Hu AM, Li JJ, Sun W. et al. Myelotomy reduces spinal cord edema and inhibits aquaporin-4 and aquaporin-9 expression in rats with spinal cord injury. Spinal Cord 2015; 53 (02) 98-102
    CrossrefPubMedGoogle Scholar
  • 58 Wilson JR, Jaja BNR, Kwon BK. et al. Natural History, Predictors of Outcome, and Effects of Treatment in Thoracic Spinal Cord Injury: A Multi-Center Cohort Study from the North American Clinical Trials Network. J Neurotrauma 2018; 35 (21) 2554-2560
    CrossrefPubMedGoogle Scholar