Effectiveness of decompression surgery in patients with cervical spinal cord injuries

Every year, nearly 12,000 individuals in the United States and Canada, mostly young adults, sustain a spinal cord injury (SCI). According to the Centers for Diseases Control and Prevention (CDC), SCI costs an estimated $9.7 billion each year in the United States alone.

Although there are some surgical interventions, such as decompression, which neurosurgeons administer to SCI patients after injury, these procedures have not dramatically improved overall recovery and outcome. "This is an area of medicine that has not seen tremendous scientific advances, so there remains an urgent need to improve upon current interventions to help restore neurological function in patients with acute SCI," said Michael Fehlings, MD, PhD, FRCSC, FACS, head of the Krembil Neuroscience Center at the University Health Network in Toronto and professor of Neurosurgery at the University of Toronto.

Surgical decompression of the spinal cord is often done after an injury occurs, although the timing of this intervention varies widely. Surgery involves the removal of various tissue or bone fragments that are compressing and comprising the spinal cord. Depending on the unique circumstances of the injury, decompression is accomplished through a variety of surgical approaches, including, for example, approaching the compressed cord from either the front (anterior) or back (posterior).

The role and timing of decompression in patients with SCI is controversial. Despite a strong biological rationale, the clinical data to support early decompression are unconvincing. Accordingly, researchers conducted a prospective multicenter study to evaluate the role and timing of decompressive surgery in a consecutive series of patients with cervical SCI. The Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS) has enrolled 170 patients to date.

The findings of this study, A Prospective Multicenter Trial to Evaluate the Role and Timing of Decompression in Patients with Cervical Spinal Cord Injury: Initial One-Year Results of the STASCIS Study, will be presented by Dr. Fehlings, 10:25 to 10:39 a.m. on Monday, April 28, 2008, during the 76th Annual Meeting of the American Association of Neurological Surgeons in Chicago. Co-authors are Bizhan Aarabi, MD, Marcel Dvorak, MD, FRCSC, Charles G. Fisher, MD, FRCSC, James Harrop, MD, Stephen Lewis, MD, Eric M. Massicotte, MD, FRCSC, Y. Raja Rampersaud, MD, Christopher Shaffrey, MD, and Alexander Vaccaro, MD; FRCSC.

Patients with cervical SCI (American Spinal Injury Association (ASIA) grades A-D) and evidence on computed tomography (CT)/magnetic resonance imaging (MRI) of canal/cord compression were entered into the prospective multicenter nonrandomized case-control study. ASIA grade 'A' designates complete SCI, and Grades 'B' through 'D' designate decreasing levels of neurological involvement. Decompression was achieved by traction and/or surgery. Additional patient demographics were as follows:

• Males: 78.1 percent, Females: 21.9 percent
• Mean age 42.2 (±17.3)
• SCI severity: ASIA A (43.6 percent), B (22.3 percent), C (16.0 percent), D (18.1 percent)

Patients were stratified into "early" (less than 24 hours) or "delayed" (greater than 24 hours) groups based on time to decompression. There were no significant differences in age, gender, or ASIA level or medical comorbidities between the early and delayed groups Outcomes were assessed using the ASIA system. Traction was used in 28.6 percent of patients in the early group and 21.1 percent of patients in the delayed group. To date, six-month and one-year follow-up has been obtained in 108 and 64 cases, respectively.

At six-month follow-up, 24 percent of the patients in the early decompression group had a two-grade or greater improvement in ASIA score compared to 4 percent in the delayed group (p=0.014). "The initial results from our STASCIS research suggest that decompression within 24 hours of injury may be associated with improved neurological recovery at one-year follow-up. However, further recruitment of patients with long-term follow-up is necessary to validate these promising results," stated Dr. Fehlings.

Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 7,200 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system, including the spinal column, spinal cord, brain and peripheral nerves.