The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence

Study Design. Evidence-based literature review. Objective. To provide updated evidence-based recommendations regarding spinal cord decompression in patients with acute spinal cord injury (SCI). Summary of Background Data. It is controversial whether early decompression following SCI conveys a benefit in neurologic outcome. Methods. MEDLINE search of experimental and clinical studies showing the effect of decompression on neurologic outcome following SCI. We focused on articles published within the last 10 years, with a particular emphasis on research conducted within the past 5 years. Results. A total of 66 articles were retrieved. Animal studies consistently show that neurologic recovery is enhanced by early decompression. There was 1 randomized controlled trial that showed no benefit to early (< 72 hours) decompression. Several recent prospective series suggest that early decompression (< 72 hours) can be performed safely and may improve neurologic outcomes. A recent systematic review showed that early decompression (< 24 hours) resulted in statistically better outcomes compared to both delayed decompression and conservative treatment. Conclusions. There are currently no standards regarding the role and timing of decompression in acute SCI. We recommend urgent decompression of bilateral locked facets in a patient with incomplete tetraplegia or in a patient with SCI with neurologic deterioration. Urgent decompression in acute cervical SCI remains a reasonable practice option and can be performed safely. There is emerging evidence that surgery within 24 hours may reduce length of intensive care unit stay and reduce post-injury medical complications.