Traumatic central cord syndrome is the most commonly encountered pattern of incomplete spinal cord injury in the US. However, when considering the acute central injury patient without spinal fracture or instability, the question of timing of surgical decompression remains controversial. Lenehan and colleagues (Spine, October, 2010, Vol 35, No 215) attempt to provide guidance on this issue by conducting a systemic review and analysis of the literature, utilizing prospective observational datasets from the Spine Trauma Study Group to analyze neurological outcome related to timing of surgery in acute central cord injuries without instability, and, finally, to offer summary recommendations informed by expert opinion, risk-benefit analysis, patient preference, and costs.
A thorough literature review was conducted, and relevant study evidence was graded by the authors. Six studies were referenced related to the question of the role for urgent surgical decompression in acute central cord syndrome without fracture or instability. While there does not seem to be conclusive evidence of a significant difference between early and late intervention, there does not seem to be any increased risk associated with early surgery. There is low quality evidence supporting the view that early intervention leads to better long term improvement, but it seems the literature is in agreement that early compression does lead to shorter hospital and ICU lengths of stay, and, for these reasons, might be safer and more cost effective.
The Spine Trauma Study Group's prospective observational datasets were combed for patients with acute central cord syndrome without concurrent instability secondary to fracture or cervical disc herniation, ASIA grade of C or D, sacral sensory sparing, and those with motor scores greater in lower than upper limbs. Basic patient demographic information was obtained, and outcome measures included ASIA Motor Score, ASIA Grade, FIM Score, SF-36, sphincter disturbance, and ambulatory status with follow-up periods on admission, discharge, 6 months, and 1 year time intervals. The sample analyzed was composed of 17 early surgery patients and 56 late surgery patients with mean ages of 55 and 59.1, respectively. Early surgery was defined as within 24 hours.
The study's analysis showed an improvement in ambulatory score at 6 month and 12 month postoperatively in patients with traumatic central cord syndrome and spondylosis who underwent surgical intervention. Furthermore, there was a 7.47 U improvement in the Total Motor Score for patients operated on within 24 hours over those who had late surgery at 6 months follow-up. (P = .0511) At 12 months follow-up, there was still a 6.31 U improvement in Total Motor Score in early vs late surgery patients. (P = .0358) Functionally, early surgery patients registered a 6.9 point and 7.79 point improvement on FIM Motor Subscore and FIM Total Score, respectively, over late surgery. (P = .0537, .047, respectively)
Incorporating past studies, data analysis of the Spine Trauma Study Group data, and expert opinion of the Spine Trauma Study Group, the authors recommend that surgical decompression is a safe and effective intervention at optimizing neurologic recovery in patients with acute traumatic central cord syndrome. Patients with high grade cord compression and significant neurologic deficits should be candidates for early surgery. Since patients are already admitted to hospital, and are commonly prescribed long term intensive rehabilitation, it would be more efficient to perform the procedure during this emergent hospitalization rather than scheduling an elective procedure later on.
There is a paucity of strong evidence in the literature regarding this topic, and this study contains a relatively small cohort with only 17 early intervention patients. Since all studies reported thus far have been observational, there exists the very likely possibility that patients selected for early surgery were chosen based on extraneous clinical factors that were not corrected for imparting a strong selection bias. However, given the lack of data showing any added risk or long term decrease in neurological improvement of patients undergoing early intervention relative to those who delay surgery, and the inherent advantages of operating on patients who are already admitted to hospital, it seems reasonable to consider early surgical decompression in patients with persistent spinal cord compression due to cervical spinal canal stenosis that has lead to significant neurological deficit.
Spinal cord edema in the cervical spine corresponding to an incomplete central cord syndrome.
Spinal cord edema in the cervical spine corresponding to an incomplete central cord syndrome.
Allen Ho
John H. Chi
