Early versus Delayed Surgical Decompression in Spinal Cord Injury: A Systematic Review and Meta-Analysis

Abstract

Spinal cord injury is a devastating clinical condition that causes secondary damage, which can be prevented with some treatments. Early surgical decompression may have a beneficial effect and lead to a better neurological outcome. This study aims to demonstrate the effectiveness of early compared with delayed surgical decompression to evaluate neurological improvement in patients with traumatic spinal cord injury. A systematic review and meta-analysis were conducted following the PRISMA-2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Until April 2024, PubMed, Scopus, Web of Science, and Embase were searched for randomized controlled clinical trials. The primary outcome is an improvement of one grade or more on the American Spinal Injury Association Impairment Scale at 12 months' follow-up. Secondary outcomes included hospital stay, postoperative complications, and mortality. Of the 4,101 records identified, 4 studies and 430 patients were included. A statistically significant difference was found in favor of the early surgical decompression group regarding neurological improvement (mean difference 0.88, 95% confidence interval [CI] = –0.03 to 1.73, p = 0.04). Also, in patients with complete spinal cord injuries (relative risk [RR] 3.65, 95% CI = 1.10–12.17, p = 0.03) reduction of postoperative complications was observed in the early group (RR 0.42; 95% CI = 0.20–0.88, p = 0.02). Regarding hospital stay, there were no significant differences between the two groups (RR –7.95, 95% CI = –18.53 to 2.63, p = 0.14) and mortality (RR = 1.27, 95% CI = 0.30–5.38, p = 0.75). Our study demonstrates that early surgical decompression within the first 24 hours after spinal cord injury leads to better neurological outcomes with statistical significance. Furthermore, statistically significant results were found in favor of early surgical decompression in patients with complete spinal cord injuries and to statistically reduce the risk of complications in the early group.

 

MissingLinkText

Keywords

meta-analysis - outcome assessment - spinal cord injury - surgical decompression - timing of surgery

Introduction

A spinal cord injury (SCI) represents a distressing clinical situation.[1] [2] [3] The incidence varies from 10.4 to 83 cases per million,[4] [5] and the prevalence is 750 cases per million.[6] The leading causes are car accidents as well as extreme sports, violence, and accidents at work,[3] and occur between 33 and 41 years of age.[7] The cervical spine is most frequently affected,[8] followed by the thoracic spine.[9] [10] [11] Trauma to the cervical and upper thoracic level can cause loss of sympathetic innervation with a predominance of the parasympathetic system.[12]

After a SCI, initial pathological alterations occur due to direct damage to the vertebrae and compression of the spinal cord[13] [14] [15] and subsequently secondary damage that can be preventable with some treatments such as early surgical decompression with or without spinal stabilization, methylprednisolone,[16] and blood pressure control.[3] [6] Of these, surgical decompression and spinal stability are the most used,[15] in addition to improving neurological function in some patients with American Spinal Injury Association (ASIA) grades B to C.[9] Most studies conclude that early surgical decompression has a beneficial effect and better neurological outcome,[7] [17] [18] regardless of the level of injury,[10] in addition to reducing costs and the duration of surgery and hospital stay.[4] There is still controversy about the optimal time for surgical decompression[19] that offers greater benefits on neurological recovery and less risk of complications.[3] [11] [18]

Surgical decompression should be performed within 24 to 36 hours of injury to enhance neurologic recovery.[3] “Early surgical decompression” generally refers to decompression performed within 24 hours of trauma,[6] [11] [19] while “late surgical decompression” refers to decompression performed after 24 hours.[20] Some studies suggest additional benefits if performed within the first 8 hours.[11] However, other studies demonstrate no benefit on functional and neurologic outcomes.[2] In many hospital settings, emergency spine surgery is not always feasible due to multiple factors such as delayed arrival to hospitals, unavailability of an operating room, and lack of on-call anesthesiologists or neurosurgeons,[2] [12] [15] delaying timely treatment and leading to more significant deficits for patients presenting with SCI.

The reason why there is still controversy about whether early surgical decompression would benefit neurological recovery in patients with SCI is that the objective is to demonstrate the effectiveness of early surgical decompression compared with late surgical decompression in improving neurological.

 

MissingLinkText

Materials and Methods

Study Design

We performed a systematic review with a meta-analysis. The PRISMA-2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)[21] recommendations served as parameters of the review process. This study was previously registered in PROSPERO (International Prospective Registry of Systematic Reviews).

 

MissingLinkText

Search Strategy

A search was conducted for all studies found in PubMed, Scopus, Web of Science, and Embase databases. We used Medical Subject Headings phrases on a combination of terms related to “surgical decompression,” “spinal cord injury,” “neurological recovery,” and “randomized controlled trials.” Boolean operators (AND, OR) were employed to merge the search terms ([Table 4]). Language restrictions were not imposed on the results, and the publication date was limited to April 2024. The search strategy underwent peer review by a systematic review methodologies expert using the Peer Review of Electronic Search Strategies guide.[22]

Table 4 Search strategy

Database	Search strategy	Total
PubMed	((“surgical decompression”[All Fields] OR “late surgical”[All Fields] OR “delayed surgical”[All Fields] OR “late surgery”[All Fields]) AND (“spinal cord injured”[All Fields] OR “spinal cord injury”[All Fields] OR “spine stabilization”[All Fields]) AND (“neurologic outcome”[All Fields] OR “neurological outcome”[All Fields] OR “recovery”[All Fields]))	n = 277 RCT: 15
Embase	('surgical decompression'/exp OR 'surgical decompression' OR 'late surgical' OR 'delayed surgical' OR 'late surgery') AND ('spinal cord injured' OR 'spinal cord injury'/exp OR 'spinal cord injury' OR 'spine stabilization'/exp OR 'spine stabilization') AND ('neurologic outcome'/exp OR 'neurologic outcome' OR 'neurological outcome'/exp OR 'neurological outcome' OR 'recovery'/exp OR 'recovery')	n = 1,208 RCT: 27
Web of Science	(“surgical decompression” OR “late surgical” OR “delayed surgical” OR “late surgery”) AND (“spinal cord injured” OR “spinal cord injury” OR “spine stabilization”) AND (“neurologic outcome” OR “neurological outcome” OR “recovery”)	n = 297 RCT: 18
Scopus	ALL((“surgical decompression” OR “late surgical” OR “delayed surgical” OR “late surgery”) AND (“spinal cord injured” OR “spinal cord injury” OR “spine stabilization”) AND (“neurologic outcome” OR “neurological outcome” OR “recovery”))	n = 2,319 RTC: 03

Abbreviation: RCT, Randomized Controlled Trials.

 

MissingLinkText

Eligibility Criteria

We included studies that met the following criteria: randomized controlled trials (RCTs) that compared the clinical outcomes of early versus late surgical decompression surgery in adults diagnosed with SCI. Early surgical decompression was defined as surgery performed within 24 hours of injury, whereas late was defined as surgery performed later than 24 hours after injury. We excluded observational and non-RCT studies, such as cohort studies, case–control studies, cross-sectional studies, descriptive studies, and quasi-randomized trials. Animal studies and nonoriginal research articles, including conference abstracts, reports, case series, systematic reviews, narratives, and editor letters, were excluded.

 

MissingLinkText

 

MissingLinkText

Outcomes

Primary Outcomes

The primary outcome is an improvement of one grade or more on the ASIA Impairment Scale (AIS) at 12 months' follow-up.

 

MissingLinkText

Secondary Outcomes

Secondary outcomes included postoperative complications at 12-month follow-up, such as deep vein thrombosis, wound infection, cerebrospinal fluid fistula, meningitis, and pressure ulcers. All-cause mortality, defined as death from any cause during the study follow-up period, was analyzed.

 

MissingLinkText

Study Selection and Data Collection Process

The search strategy aimed to cover all relevant studies. In addition, the search was expanded by screening the reference lists of included studies and consulting clinical trial registries. Two reviewers independently assessed titles and abstracts for eligibility. The same reviewers obtained the full texts of eligible studies and independently assessed them for inclusion. Any discrepancies were addressed by discussion or consultation with a third reviewer. A data extraction form was used to collect information from included studies and was conducted independently by two reviewers; any disparities were resolved by consensus or involving a third reviewer.

 

MissingLinkText

Risk of Bias Assessment

Two independent reviewers assessed the risk of bias in each of the included studies. The RoB 2.0 (The Cochrane Collaboration's tool for assessing risk of bias in randomized trials)[23] was employed. Any discrepancies in judgment were resolved through consultation with a third author to ensure impartiality and accuracy. The outcomes were categorized as low risk, some concerns, or high risk of bias.

 

MissingLinkText

Data Synthesis

Software and models: Meta-analyses were conducted utilizing the Review Manager Software Version 5.4.1 (The Cochrane Collaboration's). Given the diversity among studies regarding patient characteristics, interventions, and outcomes, a random effects model was employed for all analyses to address heterogeneity between studies.

Outcome measures: The extent of neurological improvement was assessed and compared using the mean and standard deviation (SD) of neurological grade and the mean difference (MD) of neurological improvement between early and late surgical decompression. The relative risk (RR) between groups was computed using the Mantel–Haenszel method and a 95% confidence interval (CI) for dichotomous outcomes.

Management of heterogeneity and variance: To quantify heterogeneity across the included studies, the chi-square (I ²) statistic was employed, where I ² values of 25, 50, and 75% indicate low, moderate, and high heterogeneity, respectively.

Sensitivity analysis and publication bias: Sensitivity analyses were conducted to assess the robustness of the findings by excluding studies with a high risk of bias or employing alternative statistical models, such as fixed-effects models, for comparison. Funnel plots were visually examined to evaluate the potential for publication bias.

 

MissingLinkText

GRADE Assessment

The GRADE system was used to assess the degree of certainty of the evidence and develop recommendations. Furthermore, the GRADEpro Guideline Development Tool with (the Cochrane Collaboration's) created Summary of Findings tables.

 

MissingLinkText

Ethics and Dissemination

Given the nature of this systematic review, ethical approval is unnecessary.

 

MissingLinkText

 

MissingLinkText

Results

Identification of Studies

A total of 4,101 articles were identified, of which 1,578 were duplicates. Of the remaining 2,523 articles, based on their titles and abstracts, the majority was considered irrelevant to the objectives of this study and was excluded. Subsequently, six articles[24] [25] [26] [27] [28] met the eligibility criteria for full-text review. Additional evaluation resulted in the exclusion of one article[24] due to methodological differences. In the end, five articles met the inclusion criteria. However, only four were included in the meta-analysis because one article presented inconsistency in the deficiency of early and late surgical decompression ([Fig. 1]).

Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram for new systematic reviews, which included searches of databases and registers only.

 

MissingLinkText

Characteristics of the Studies Included

All studies were RCTs from three countries and published between 2008 and 2020. A total of 164 patients were assigned to the early surgical decompression group (< 24 hours) and 266 patients to the late group (> 24 hours). The definition of early surgical decompression surgery varied between studies: two studies[27] [28] specified within the first 8 hours, and two studies,[25] [26] indicated less than 24 hours. All studies examined patients with complete and incomplete SCIs and provided demographic details. One study[27] assessed cervical SCIs, while the other three studies[25] [26] [28] assessed thoracic and lumbar SCIs. Postoperative complications were documented in four studies[25] [26] [27] [28] and mortality rates occurred in two studies[25] [26]; in the other two,[27] [28] no mortality occurred. Administration of methylprednisolone before surgery was mentioned in all studies. The mean follow-up period was 12 months in three studies,[25] [26] [27] 14.5 months in one study,[28] and 10 months in one study.[24] Length of hospital stay was reported in two studies,[26] [28] whereas none provided information on the length of intensive care unit (ICU) stay. All included studies were published in English ([Tables 1] and [2]).

Table 1 Main characteristics of the studies analyzed

Author, Year	Journal	Study period	Country (number of patients)	Definitions of time (early/late)	Sample size (early/late)	Average age (y)	Sex (M:W)	Lesion level (early/late)	Scale upon admission (early/late)	Surgical intervention	Scale postoperative (early/late)	Follow-up time (mo)
Haghnegahdar et al, 2020[25]	Neurotrauma, Reports	2010–2018	Iran (73)	Early: < 24 hours	37	29.7 ± 10.3	28:9	T1-T4: 1/4 T5-T8: 5/7 T9-L1: 31/25	AIS: A: 21/20 B: 5/5 C: 4/4 D: 7/7	Posterior fixation of long or short segment with or without instrumentation of the fractured vertebrae, or 360 degree fixation	AIS: A: 16/19 B: 0/0 C: 3/5 D: 12/10 E: 6/2	12
				Late: 24–72 hours	36	34.9 ± 12.0	26:10
Rahimi-Movaghar et al, 2014[26]	Neurosciences	Unmentioned	Iran (35)	Early: < 24 hours	16	31.7 ± 9.1	11:5	Thoracic/Thoracolumbar (T1-L1)	AIS: A:7/9 B: 1/5 C: 4/1 D: 4/4	Posterior fixation of long or short segment with or without instrumentation of the fractured vertebrae, or 360 degree fixation	AIS: A: 5/8 B: 1/1 C: 1/4 D: 3/3 E: 5/2	12
				Late: 24–72 hours	19	37.8 ± 13.7	14:5
Chen et al, 2012[27]	Neurosurg Quarterly	Unmentioned	China (295)	Early: < 8 hours	99	42.38 ± 13.58	1.68:1	Cervical	AIS: A:42/93 B: 10/18 C: 13/23 D: 34/62	Surgical decompression with internal fixation via anterior or posterior. Bone graft, cage or MeSH was placed, if necessary	AIS: 1.15 ± 0.61 / (0.63 ± 0.74)	12
				Late: > 8 hours	196	41.97 ± 13.89	1.62:1
Cengiz et al, 2008[28]	Archives of Orthopaedic and Trauma Surgery	2004–2006	Turkey (27)	Early: < 8 hours	12	39.67 ± 16.08	8:4	T8–L2	AIS: A: 6/7 B: 0/2 C: 6/6 D: 0/0	Surgical decompression, followed by laminectomy and flavectomy, and fusion in complete decompression. All patients underwent posterior stabilization using transpedicular screw-rod systems	AIS: ASIA A-B: 0/1 ASIA A-D: 4/0 ASIA B-C: 0/1 ASIA C-D: 2/2 ASIA C-E: 4/0	14.5 (12–20)
				Late: 3–15 days	15	42.87 ± 13.93	10:5
Vaccaro et al, 1997[24]	SPINE	1992–1995	USA. (62)	Early: < 72 hours	34	39.79 (15–75)	24:10	C3-T1	FRANKEL: A:15/9 B: 4/6 C: 5/7 D: 10/6	Anterior cervical discectomy or corpectomy and fusion, Anterior cervical discectomy or corpectomy and posterior cervical fusion, Posterior cervical decompression, Posterior cervical fusion	FRANKEL: A:11/7 B: 5/5 C: 8/6 D: 10/9	10
				Late: > 5 days	28	39.0 (16–75)	22:6

Abbreviations: AIS, ASIA Impairment Scale; ASIA, American Spinal Trauma Association; M, men; MeSH, Medical Subject Headings; W, women.

Table 2 Summary of treatment modalities and clinical outcomes in analyzed studies

Author, Year	Preoperative neurological deficit	Mean difference in early group motor score	Mean difference in late group motor score	Improvement ≥ 1 grade in complete lesions (early/late)	Improvement ≥ 1 grade in incomplete lesions (early/late)	Neurological Improvement (early/late)	Average hospital stay (days) (early/late)	Hospital stay in ICU (d)	Postoperative complications (early/late)	Mortality (early/late)	Steroids before surgery
Haghnegahdar et al, 2020[25]	Complete: 41 Incomplete: 32	Upon admission (62.3 ± 15.6). At 12 months (12.8. ± 13.2)	Upon admission (58.1 ± 14.1). At 12 months (9.2 ± 19.2)	5 of 21/1 of 20	12 of 16/11 of 16	17/12	Unmentioned	Unmentioned	Deep vein thrombosis: 3/2 Laterally placed screws: 0/2 Bilateral bar fracture: 0/1 Screw loosen: 0/1 Wound infection: 0/2 Cerebrospinal fluid fistula: 0/1 Meningitis: 0/1 Pressure ulcer: 0/1	2/3	100% methylprednisolone
Rahimi-Movaghar et al, 2014[26]	Complete: 16 Incomplete: 19	Upon admission (77 ± 22). At 12 months (92 ± 12)	Upon admission (68 ± 22). At 12 months (82 ± 16)	1 of 7/1 of 9	7 of 9/7 of 10	8/8	(7 ± 7.13)/(9.7 ± 8.28)	Unmentioned	Deep vein thrombosis: 1/1 Wound infection: 0/2 Cerebrospinal fluid fistula: 0/1 Meningitis: 0/1 Pressure ulcer: 0/1 Bilateral bar fracture: 0/1 Screw loosen: 0/1 Screws placed laterally: 1/1	1/1	100% methylprednisolone
Chen et al, 2012[27]	Complete: 135 Incomplete: 160	At admission (43.54 ± 28.09), at 6 months (59.17 ± 34.35), at 12 months (61.06 ± 33.28)	At admission (41.88 ± 26.32), at 6 months (46.94 ± 27.6), at 12 months (51.61 ± 28.90)	Unmentioned	Unmentioned	(1.15 ± 0.61) / (0.63 ± 0.74)	Unmentioned	Unmentioned	15/40	0/0	100% methylprednisolone
Cengiz et al, 2008[28]	Complete: 13 Incomplete: 14	Unmentioned	Unmentioned	4 of 6/1 of 7	6 of 6/3 of 8	10/4 (1.67 ± 1.12) / (0.27 ± 0.836)	(12.5 ± 6.25) / (26.0 ± 10)	0	Lung failure: 0/3 Sepsis: 0/1	0/0	100% methylprednisolone
Vaccaro et al, 1997[24]	Complete: 24 Incomplete: 38	At admission (32.8 ± 30.5), rehabilitation admission (38.6 ± 32.4), rehabilitation discharge (46.2 ± 33.7), most recent follow-up (64.0 ± 35.3)	Admission was 28.4 ± 23.0), rehabilitation admission 38.2 ± 28.4), rehabilitation discharge (50.0 ± 31.3), most recent follow-up (54.2 ± 37.4)	4 of 15/2 of 9	Incomplete data	Incomplete data	(17.7) / (18.5)	Unmentioned	Unmentioned	1/1	100% methylprednisolone

Abbreviation: ICU, intensive care unit.

 

MissingLinkText

Neurological Improvement

Only two studies[27] [28] provided complete data for inclusion in the meta-analysis, comparing the MD of neurological improvement between the early and late surgical decompression groups (0.88, 95% CI: 0.03–1.73, I ² 80%, p < 0.05), the early surgical decompression group demonstrated a more notable neurological improvement in ASIA scores with statistical significance but with high heterogeneity ([Fig. 2]).

Fig. 2 Forest plot of neurological improvement was assessed by the improvement score (WMD) in the early surgical decompression group versus the late surgical decompression group. WMD, weighted mean difference; SD, standard deviation; CI, confidence interval.

Three studies[25] [26] [28] reported neurological improvement in patients with complete SCIs. The fixed effects model was applied due to homogeneity, showing statistically significant differences between the early and late surgery groups (RR 3.65, 95% CI: 1.10–12.17, p < 0.05) ([Fig. 3]).

Fig. 3 Forest plot showing neurological improvement ≥ 1 ASIA grade in complete injuries (ASIA A) in the early versus late surgical decompression group. ASIA, American Spinal Injury Association; CI, confidence interval.

Furthermore, three studies[25] [26] [28] reported neurological improvement in patients with incomplete SCIs. Moderate heterogeneity was observed, although the pooled risk ratio estimates were skewed toward early decompression. No statistical significance was found between the early and late surgery groups (RR 1.27, 95% CI: 0.85–1.88; p > 0.05) ([Fig. 4]).

Fig. 4 Forest plot showing neurological improvement ≥ 1 ASIA grade in incomplete injuries (ASIA BCD) in the early surgical decompression group versus the late surgical decompression group. ASIA, American Spinal Injury Association; CI, confidence interval.

 

MissingLinkText

Improvement of ASIA Motor Score

Improvement in ASIA Motor Score (AMS) at the 12-month follow-up was documented in three studies,[25] [26] [27] covering 403 patients (152 in the early surgical decompression group and 251 in the late group). These studies proved homogeneous (chi-square = 0.55; I ² = 0%), which led to adopting a fixed effects model. Although improvement was observed in the early surgical decompression group, no statistically significant differences were detected (RR = 5.15, 95% CI: –1.83 to 12.13, p > 0.05) ([Fig. 5]).

Fig. 5 Forest plot showing the mean difference in ASIA Motor Score at 1-year follow-up in the early surgical decompression group versus the late surgical decompression group. ASIA, American Spinal Injury Association; SD, standard deviation; CI, confidence interval.

 

MissingLinkText

Length of Hospital Stay

Length of hospitalization was compared and analyzed by mean and SD in two studies,[26] [28] yielding an MD of –7.95 (95% CI: –18.53 to 2.63, I ² 86%, p > 0.05). Patients undergoing early decompression surgery had a shorter hospital stay of 5.95 days than those undergoing late decompression surgery; however, this difference did not reach statistical significance. Additionally, none of the studies reported length of ICU stay ([Fig. 6]).

Fig. 6 Forest plot of length of hospital stay (WMD, in days) in the early surgical decompression group versus the late surgical decompression group. WMD, weighted mean difference; SD, standard deviation; CI, confidence interval.

 

MissingLinkText

Postoperative Complications and Mortality

All studies provided data on postoperative complications in both groups, covering 430 patients (164 in the early group and 266 in the late group). These studies showed moderate heterogeneity (chi-square = 4.71; I ² = 36%). Among the 164 patients in the early group, there were 40 cases of postoperative complications, compared with 64 cases among the 266 patients in the late group. Statistical significance was observed in postoperative complications between the two groups (RR = 0.42, 95% CI: 0.20–0.88, p < 0.05). Patients undergoing early decompression surgery had a 0.42-fold lower risk of complications than those undergoing late decompression surgery ([Fig. 7]).

Fig. 7 Forest plot of postoperative complications (RRs) in the early versus late surgical decompression groups. RRs, relative risk; CI, confidence interval.

All studies addressed postoperative mortality. Two studies[27] [28] did not indicate postsurgical deaths in any of the groups. The analysis included 108 patients (53 in the early group and 55 in the late group), showing homogeneity between the studies (chi-square = 0.12; I ² = 0%). There were three mortality cases in the early group and four in the late group. However, there were no significant differences (RR = 1.27, 95% CI: 0.30–5.38, p > 0.05) ([Fig. 8]).

Fig. 8 Forest plot of the pooled mortality estimate in the early surgical decompression group versus the late surgical decompression group. CI, confidence interval.

 

MissingLinkText

The Quality of the Studies Included

All four studies received a rating of “some concerns.” The quality of the evidence showed some concerns regarding bias, mainly attributable to study limitations and imprecision ([Fig. 9A, B]).

Fig. 9 Risk of bias assessment with Rob2 tool. (A) Risk of bias domains. (B) Overall risk of bias.

 

MissingLinkText

GRADE Analysis

The GRADE assessment of the certainty of the evidence in the four clinical trials highlights a moderate certainty regarding the improvement of ≥ 1 ASIA grade in complete SCIs with statistical significance and the difference in the AMS at 1-year follow-up, which was not statistically significant, early surgical decompression probably increases neurological improvement by ≥ 1 ASIA grade and AMS in patients with SCI. Furthermore, low certainty of evidence is observed regarding neurological improvement, ≥ 1 ASIA grade in incomplete SCIs, postoperative complications, and mortality. Therefore, early surgical decompression may increase neurological improvement and ≥ 1-grade improvement in incomplete SCIs. In addition to reducing postoperative complications in the early surgical decompression group, early surgical decompression may slightly reduce mortality ([Table 3]).

Table 3 Certainty of GRADE evidence

Certainty assessment							No. of patients		Effect		Certainty
No. of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	Early Surgery	Delayed Surgery	Relative(95% CI)	Absolute (95% CI)
Neurological improvement weighted mean differences (assessed with: MD)
2	Randomized trials	Not serious	Very serious	Not serious	Serious	None	111	211	−	MD 0.88 higher neurological improvement (0.03 higher to 1.73 higher)	⨁◯◯◯ Very low
Neurological improvement ≥ 1 ASIA grade in complete injuries (ASIA A) (assessed with: RR)
3	Randomized trials	Not serious	Not serious	Not serious	Serious	None	10/34 (29.4%)	3/36 (8.3%)	RR 3.65(1.10 to 12.17)	221 more per 1,000(from 8 more to 931 more)	⨁⨁⨁◯ Moderate
Neurological improvement ≥ 1 ASIA grade in incomplete injuries (ASIA BCD) (assessed with: RR)
3	Randomized trials	Not serious	Serious	Not serious	Serious	None	25/31 (80.6%)	21/34 (61.8%)	RR 1.27(0.85 to 1.88)	167 more per 1,000(from 93 fewer to 544 more)	⨁⨁◯◯ Low
Mean difference in ASIA motor score at 1-year follow-up (assessed with: MD)
3	Randomized trials	Not serious	Not serious	Not serious	Serious	None	152	251	−	MD 5.15 force higher(1.83 lower to 12.13 higher)	⨁⨁⨁◯ Moderate
Hospital stay (assessed with: MD)
2	Randomized trials	Not serious	Very serious	Not serious	Serious	None	28	34	−	MD 7.95 days lower(18.53 lower to 2.63 higher)	⨁◯◯◯Very low
Postoperative complications (assessed with: RR)
4	Randomized trials	Not serious	Serious	Not serious	Serious	None	20/164 (12.2%)	64/266 (24.1%)	RR 0.42(0.20 to 0.88)	140 fewer per 1,000(from 192 fewer to 29 fewer)	⨁⨁◯◯ Low
Mortality (assessed with: RR)
2	Randomized trials	Not serious	Not serious	Not serious	Very serious	None	4/58 (6.9%)	3/55 (5.5%)	RR 1.27(0.30 to 5.38)	15 more per 1,000(from 38 fewer to 239 more)	⨁⨁◯◯ Low

Abbreviations: ASIA, American Spinal Trauma Association; CI, confidence interval; MD, mean difference; RR, risk ratio.

 

MissingLinkText

 

MissingLinkText

Discussion

Traumatic SCIs present motor and sensory deficits, neurogenic bladder, and intestinal alterations.[1] [2] [29] The theoretical rationale supporting early surgical decompression is based on mitigating secondary damage characterized by an acute hemorrhage, alteration of the spinal blood–brain barrier, infiltration of inflammatory cells and cytokines,[2] [12] [14] and displacement of cerebrospinal fluid through multiple vertebral segments.[30]

Regarding the use of methylprednisolone, a study conducted by Joaquim et al[31] shows that controversies persist about its effectiveness in neurological outcomes, generating concern about adverse effects. Analyzing data from NASCIS II[32] and other studies, Geisler et al[33] concluded that administration of methylprednisolone after SCI did not result in any improvement in neurological recovery.

Our analysis suggested that early surgical decompression (< 24 hours) tended to result in superior neurological recovery, which reached statistical significance compared with late surgical decompression (> 24 hours). These findings are similar to those found in the study by Papadopoulos et al[34] who included 91 patients with traumatic cervical SCIs, 34 of whom underwent surgical decompression, demonstrating that immediate spinal stabilization and decompression significantly improved neurological outcomes.

Postoperative neurological improvement was observed in both groups, with more favorable results in the early surgical decompression group. The complete SCI group achieved statistical significance in favor of early surgical decompression. These findings are similar to those reported by Ma et al[5] in a meta-analysis that included 716 patients, where they obtained a significantly greater neurological recovery in the early surgical decompression group (< 8 hours) compared with the late group (> 8 hours) (RR, 3.96; 95% CI, 2.02–7.76; p < 0.05). In addition, the complete SCI group did achieve statistical significance in favor of late surgical decompression, which did not occur with the incomplete SCI group.

Regarding improvement in AMS, there was a favorable trend toward the early surgical decompression group. These findings are consistent with a meta-analysis conducted by Fehlings et al[35] where they examined 21 studies, of which 16 compared early (< 24 hours) with late (> 24 hours) surgical decompression. At 12-month follow-up, they showed that early surgery was associated with improved AMS in four studies (pooled MD 4.50 points, 95% CI: 1.70–7.29, I2 = 0; p < 0.05).

In the STASCIS study,[36] where early versus late surgical decompression in cervical SCIs was evaluated during 6 months of follow-up, they found an improvement of at least two grades in the AIS (odds ratio [OR] = 2.83, 95% CI: 1.10–7.28; p < 0.05). Patients undergoing early surgery had a statistically significant improvement of 2.8 times compared with the late group. In addition, a one grade improvement in the AIS (OR = 1.37, 95% CI: 0.80–2.57; p > 0.05), patients who underwent early surgical decompression had 1.4 times more improvement than the late group. However, statistical significance was not obtained. These findings justify early surgical decompression in the treatment of cervical SCIs.

No significant differences were found in terms of hospital stay in both groups. Fehlings et al[35] reported that early surgical decompression was associated with a slight reduction in intensive care length of stay in five studies (pooled MD –3.5 days, 95% CI 4.1–3.0 days, I ² = 0%). In a nonrandomized controlled clinical trial conducted by Xue et al,[7] no differences were found in the length of stay in the ICU or the duration of mechanical ventilation.

The incidence of postoperative complications presented statistical significance in favor of the early surgical decompression group, which favors early surgical decompression to reduce the risk of postoperative complications. In the study by Xue et al,[7] the incidence of postoperative complications was 3.6% in the early surgical decompression group and 2.2% in the late surgical decompression group, without statistical significance.

No differences in mortality were observed between both groups. These findings align with Qiu et al[29] who performed a meta-analysis and found no statistically significant differences in mortality between both groups.

The four[25] [26] [27] [28] included studies used anterior, posterior, and combined (anterior and posterior) approaches. One study[28] used decompression and posterior fixation, while the remaining three studies[25] [26] [27] used anterior and/or posterior decompression with fixation. The choice of surgical approach depended on a combination of clinical and radiological factors for each case.[20]

No correlation was observed in the studies regarding the use of methylprednisolone and the resulting neurological improvement it may cause in patients with traumatic SCI. In all the studies analyzed, methylprednisolone was used according to the NASCIS II[32] recommendation. Although this could be a confounding factor, the effects were balanced in both study groups, and the protocol standardization reduces the effect of bias. On the other hand, using methylprednisolone may be a confounding factor in randomized clinical trials but not in a meta-analysis.

There needs to be a consensus on the definition of early versus late surgical decompression, leading to different definitions between studies. Early surgical decompression is usually considered when it is performed within the initial 24 hours posttrauma,[6] [11] [19] while late decompression is after this period.[20] This study follows the PRISMA-2020 guidelines for systematic reviews and meta-analyses. The results have external validity because they follow a systematic search sequence.

 

MissingLinkText

Limitations

Meta-analyses are inherently limited by factors such as heterogeneity and variations in study quality, including publication bias. A significant limitation concerns the need for further consensus regarding classifying early versus late surgical decompression. Furthermore, the relatively small number of studies included in this meta-analysis is a notable limitation despite its randomized clinical trial design, underscoring the need for more comprehensive literature searches in future research.

 

MissingLinkText

Conclusion

Our study suggests that early surgical decompression within the first 24 hours after SCI leads to better neurological outcomes with statistical significance. Furthermore, statistically significant results were found in favor of early surgical decompression in patients with complete SCIs and to statistically reduce the risk of complications in the early group. However, it is essential to note that additional high-quality randomized clinical trials are needed to validate and reinforce our findings.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

None declared.

Note

All authors certify they meet the International Committee of Medical Journal Editors' (ICMJE) current authorship criteria.

Authors' Contributions

G.V.-P. contributed to the conceptualization, data collection, and original draft preparation. C.Z.-C. and J.C.-A. were responsible for methodology, resources, software, validation, and visualization. Additionally, J.C.-A. handled writing, review and editing, and provided approval of the final manuscript.

• References

• 1 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
• 2 Tanaka C, Tagami T, Kaneko J. et al. Early versus late surgery after cervical spinal cord injury: a Japanese nationwide trauma database study. J Orthop Surg Res 2019; 14 (01) 302
• 3 Qiu Y, Chen Y, Xie Y, Xie H, Dong J. Comparative analysis of the efficacy of early and late surgical intervention for acute spinal cord injury: a systematic review and meta-analysis based on 16 studies. Int J Surg 2021; 94: 106098
• 4 Thompson C, Feldman DE, Mac-Thiong JM. Surgical management of patients following traumatic spinal cord injury: Identifying barriers to early surgery in a specialized spinal cord injury center. J Spinal Cord Med 2018; 41 (02) 142-148
• 5 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
• 6 Lee DY, Park YJ, Kim HJ, Ahn HS, Hwang SC, Kim DH. Early surgical decompression within 8 hours for traumatic spinal cord injury: Is it beneficial? A meta-analysis. Acta Orthop Traumatol Turc 2018; 52 (02) 101-108
• 7 Xue F, Zhan SZ, Zhang DY, Jiang BG. Early versus delayed surgery for acute traumatic cervical/thoracic spinal cord injury in Beijing, China: the results of a prospective, multicenter nonrandomized controlled trial. Orthop Surg 2021; 13 (08) 2246-2254
• 8 Ter Wengel PV, De Witt Hamer PC, Pauptit JC, van der Gaag NA, Oner FC, Vandertop WP. Early surgical decompression improves neurological outcome after complete traumatic cervical spinal cord injury: a meta-analysis. J Neurotrauma 2019; 36 (06) 835-844
• 9 Li P, Huang Y, Liang Z. et al. Clinical efficacy and therapeutic value of delayed surgery in patients with symptomatic old thoracolumbar fractures. BMC Surg 2021; 21 (01) 290
• 10 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
• 11 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
• 12 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
• 13 Badhiwala JH, Wilson JR, Witiw CD. et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol 2021; 20 (02) 117-126
• 14 Lee DY, Park YJ, Song SY, Hwang SC, Kim KT, Kim DH. The importance of early surgical decompression for acute traumatic spinal cord injury. Clin Orthop Surg 2018; 10 (04) 448-454
• 15 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
• 16 Bracken MB, Shepard MJ, Holford TR. et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997; 277 (20) 1597-1604
• 17 Burke JF, Yue JK, Ngwenya LB. et al. Ultra-early (<12 hours) surgery correlates with higher rate of American Spinal Injury Association impairment scale conversion after cervical spinal cord injury. Neurosurgery 2019; 85 (02) 199-203
• 18 Yousefifard M, Rahimi-Movaghar V, Baikpour M. et al. Early versus late spinal decompression surgery in treatment of traumatic spinal cord injuries; a systematic review and meta-analysis. Emergency (Tehran) 2017; 5 (01) e37
• 19 Rabinstein AA. Traumatic spinal cord injury. Continuum (Minneap Minn) 2018; 24 (2, Spinal Cord Disorders): 551-566
• 20 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 (03) 95S-115S
• 21 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) n71
• 22 McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS Peer Review of Electronic Search Strategies: 2015 guideline statement. J Clin Epidemiol 2016; 75: 40-46
• 23 Higgins JPT, Altman DG, Gøtzsche PC. et al; Cochrane Bias Methods Group, Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011; 343: d5928
• 24 Vaccaro AR, Daugherty RJ, Sheehan TP. et al. Neurologic outcome of early versus late surgery for cervical spinal cord injury. Spine 1997; 22 (22) 2609-2613
• 25 Haghnegahdar A, Behjat R, Saadat S. et al. A randomized controlled trial of early versus late surgical decompression for thoracic and thoracolumbar spinal cord injury in 73 patients. Neurotrauma Rep 2020; 1 (01) 78-87
• 26 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
• 27 Chen Q, Li F, Fang Z. et al. Timing of surgical decompression for acute traumatic cervical spinal cord injury: a multicenter study. Neurosurg Q 2012; 22 (01) 61
• 28 Cengiz SL, Kalkan E, Bayir A, Ilik K, Basefer A. Timing of thoracolomber spine stabilization in trauma patients; impact on neurological outcome and clinical course. A real prospective (rct) randomized controlled study. Arch Orthop Trauma Surg 2008; 128 (09) 959-966
• 29 Qiu Y, Chen Y, Xie Y, Xie H, Dong J. Comparative analysis of the efficacy of early and late surgical intervention for acute spinal cord injury: a systematic review and meta-analysis based on 16 studies. Int J Surg 2021; 94: 106098
• 30 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
• 31 Joaquim AF, Daniel JW, Schroeder GD, Vaccaro AR. Neuroprotective agents as an adjuvant treatment in patients with acute spinal cord injuries: a qualitative systematic review of randomized trials. Clin Spine Surg 2020; 33 (02) 65-75
• 32 Bracken MB, Shepard MJ, Collins WF. et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 1990; 322 (20) 1405-1411
• 33 Geisler FH, Moghaddamjou A, Wilson JRF, Fehlings MG. Methylprednisolone in acute traumatic spinal cord injury: case-matched outcomes from the NASCIS2 and Sygen historical spinal cord injury studies with contemporary statistical analysis. J Neurosurg Spine 2023; 38 (05) 595-606
• 34 Papadopoulos SM, Selden NR, Quint DJ, Patel N, Gillespie B, Grube S. Immediate spinal cord decompression for cervical spinal cord injury: feasibility and outcome. J Trauma 2002; 52 (02) 323-332
• 35 Fehlings MG, Hachem LD, Tetreault LA. et al. Timing of decompressive surgery in patients with acute spinal cord injury: systematic review update. Global Spine J 2024; 14 (3_suppl, suppl): 38S-57S
• 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

Publikationsverlauf

Artikel online veröffentlicht:
30. Dezember 2024