By Mary Beth Nierengarten

Preliminary evidence suggests that early decompression of the spinal cord within 24 hours of injury is safe and may be associated with improved neurological recovery, report investigators today at the 76th Annual Meeting of the American Association of Neurological Surgeons (AANS).

Although published data show a strong biological rationale for early decompression of spinal cord injuries to attenuate progressive secondary injury, the clinical role and timing of decompression in patients presenting with acute spinal cord injury remain controversial.

To address this issue, Michael G. Fehlings, MD, Research Director, Division of Neurosurgery, University of Toronto, Toronto, Canada, and colleagues are conducting the ongoing multicentre, prospective Surgical Treatment of Acute Spinal Cord Injury Study (STASCIS) study. The study includes patients with subaxial cervical spinal cord injuries (American Spinal Injury Association [ASIA] grades A-D) and computed evidence of canal/cord compression on tomography/magnetic resonance imaging (CT/MRI) enrolled at 10 centres in Canada and the United States.

Patients were enrolled within 24 hours of sustaining their injury and received decompression either by traction and/or surgery within 7 days. The study stratified patients according to time to decompression -- early (<24 hours) or delayed (>24 hours). The adequacy of decompression was confirmed postoperatively by CT/MRI imaging.

The results presented on April 28 included the 170 patients currently in the study. Of these patients, 44% had complete spinal cord injury as defined by American Spinal Injury Association (ASIA) grade A, and the others had decreasing levels of neurological involvement (22% grade B, 16% grade C, and 18% grade D). The majority of injuries were in males (78%), and the mean age was 42 years.

Preliminary results were reported at 6 months following decompression in 108 patients and after 1 year in 64 patients.

At 6 months, significantly more patients who underwent early decompression had an improvement of more than 2 grades in ASIA score compared with those in the delayed group (24% vs 4%; P = .014). After 1 year of follow-up, significantly more patients who underwent early decompression had an improvement of greater than 1 grade in ASIA score compared with the delayed group (P < .05).

Although frequent complications, particularly those involving the cardiopulmonary system and urinary tract, were noted in both groups, patients treated with early decompression tended to have fewer complications than patients treated with delayed decompression (37.1% vs 48.6%; P = .07).

Based on these results, lead author Dr. Fehlings emphasised that timing and expertise have an impact on outcomes after an acute spinal cord injury. "Patients with an acute spinal cord injury should be transferred urgently to a dedicated acute spinal cord injury unit," he said.

"When feasible, in the absence of life-threatening systemic injuries or medical comorbidities, patients with acute cervical spinal cord injury should undergo early decompression of the spinal cord by surgery or traction," he noted.

Dr. Fehlings also emphasised the many hurdles that have to be overcome in achieving early spinal cord decompression. "Currently systems are not in place to consistently ensure that patients with an acute spinal cord injury are brought to dedicated spinal cord injury treatment centres in a timely manner," he said, adding that systems need to be put in place to ensure access to emergent and consistent imaging, such as MRI, as well as to operating rooms and surgical teams.

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