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Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS).

Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, Arnold P, Massicotte EM, Lewis S, Rampersaud R - PLoS ONE (2012)

Bottom Line: The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up.In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28).Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).

View Article: PubMed Central - PubMed

Affiliation: Divisions of Neurosurgery and Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. michael.fehlings@uhn.on.ca

ABSTRACT

Background: There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥ 24 hours after injury) decompressive surgery after traumatic cervical SCI.

Methods: We performed a multicenter, international, prospective cohort study (Surgical Timing In Acute Spinal Cord Injury Study: STASCIS) in adults aged 16-80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality.

Findings: A total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(± 5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(± 29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥ 2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).

Conclusion: Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.

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Related in: MedlinePlus

AIS Grade Improvement at 6 months: Early vs. Late Surgery.
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pone-0032037-g002: AIS Grade Improvement at 6 months: Early vs. Late Surgery.

Mentions: In the entire study group, the degree of neurologic improvement was significant as measured by change in AIS grade from presentation to 6 months follow-up (p = 0.02) (Table 3). In the early surgery group, AIS grade improvement was as follows: 56 (42.7%) had no improvement, 48 (36.6%) had a 1 grade improvement, 22 (16.8%) had a 2 grade improvement, 4 (3.1%) had a 3 grade improvement and 1 (0.8%) had a 1 grade worsening (Table 4). In the late group, AIS grade improvement was as follows: 46 (50.6%) had no improvement, 37 (40.7%) had a 1 grade improvement, 8 (8.8%) had a 2 grade improvement, and no patient worsened (Table 5). Based on this information, 74 patients (56.5%) in the early group and 45 patients (49.5%) in the late group experienced at least a 1 grade improvement (early vs. late surgery: OR = 1.33, 95% CI:0.78,2.27) and 26 patients (19.8%) in the early group and 8 patients (8.8%) in the late group experienced at least a 2 grade improvement (early vs. late surgery: OR = 2.57, 95% CI:1.11,5.97) at 6 months (Figure 2).


Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS).

Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS, Aarabi B, Shaffrey C, Dvorak M, Fisher C, Arnold P, Massicotte EM, Lewis S, Rampersaud R - PLoS ONE (2012)

AIS Grade Improvement at 6 months: Early vs. Late Surgery.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3285644&req=5

pone-0032037-g002: AIS Grade Improvement at 6 months: Early vs. Late Surgery.
Mentions: In the entire study group, the degree of neurologic improvement was significant as measured by change in AIS grade from presentation to 6 months follow-up (p = 0.02) (Table 3). In the early surgery group, AIS grade improvement was as follows: 56 (42.7%) had no improvement, 48 (36.6%) had a 1 grade improvement, 22 (16.8%) had a 2 grade improvement, 4 (3.1%) had a 3 grade improvement and 1 (0.8%) had a 1 grade worsening (Table 4). In the late group, AIS grade improvement was as follows: 46 (50.6%) had no improvement, 37 (40.7%) had a 1 grade improvement, 8 (8.8%) had a 2 grade improvement, and no patient worsened (Table 5). Based on this information, 74 patients (56.5%) in the early group and 45 patients (49.5%) in the late group experienced at least a 1 grade improvement (early vs. late surgery: OR = 1.33, 95% CI:0.78,2.27) and 26 patients (19.8%) in the early group and 8 patients (8.8%) in the late group experienced at least a 2 grade improvement (early vs. late surgery: OR = 2.57, 95% CI:1.11,5.97) at 6 months (Figure 2).

Bottom Line: The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up.In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28).Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).

View Article: PubMed Central - PubMed

Affiliation: Divisions of Neurosurgery and Orthopedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. michael.fehlings@uhn.on.ca

ABSTRACT

Background: There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (<24 hours after injury) versus late (≥ 24 hours after injury) decompressive surgery after traumatic cervical SCI.

Methods: We performed a multicenter, international, prospective cohort study (Surgical Timing In Acute Spinal Cord Injury Study: STASCIS) in adults aged 16-80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change in ASIA Impairment Scale (AIS) grade at 6 months follow-up. Secondary outcomes included assessments of complications rates and mortality.

Findings: A total of 313 patients with acute cervical SCI were enrolled. Of these, 182 underwent early surgery, at a mean of 14.2(± 5.4) hours, with the remaining 131 having late surgery, at a mean of 48.3(± 29.3) hours. Of the 222 patients with follow-up available at 6 months post injury, 19.8% of patients undergoing early surgery showed a ≥ 2 grade improvement in AIS compared to 8.8% in the late decompression group (OR = 2.57, 95% CI:1.11,5.97). In the multivariate analysis, adjusted for preoperative neurological status and steroid administration, the odds of at least a 2 grade AIS improvement were 2.8 times higher amongst those who underwent early surgery as compared to those who underwent late surgery (OR = 2.83, 95% CI:1.10,7.28). During the 30 day post injury period, there was 1 mortality in both of the surgical groups. Complications occurred in 24.2% of early surgery patients and 30.5% of late surgery patients (p = 0.21).

Conclusion: Decompression prior to 24 hours after SCI can be performed safely and is associated with improved neurologic outcome, defined as at least a 2 grade AIS improvement at 6 months follow-up.

Show MeSH
Related in: MedlinePlus