Early versus Late Surgical Decompression for Acute Traumatic Spinal Cord Injury: A Pooled Analysis of 1,548 Patients
Christopher Witiw, Michael Fehlings, Jefferson Wilson, Jetan Badhiwala
Introduction: The effect of time to decompression on neurological recovery following acute traumatic spinal cord injury (SCI) is unclear.
Objective: We sought to compare sensorimotor recovery with early (<24 hrs) versus late (≥24 hrs) surgical decompression for traumatic SCI.
Methods: Data were derived from four prospective, multi-center SCI datasets. Patients were dichotomized into early (<24 hrs) and late (≥24 hrs) surgery groups. The primary endpoint was change in ASIA motor score (AMS) at 1-year. Secondary outcomes included AIS grade and change in ASIA light-touch and pin-prick scores at 1-year. One-stage meta-analyses were performed by mixed-effects regression using a stratified intercept to account for clustering of patients within studies. Fixed-effects were specified for baseline score, age, injury mechanism, AIS grade, neurological level, and steroids. The treatment (early vs. late surgery) was specified as a random-effect.
Results: In total, 1,548 patients were eligible. The early surgery group experienced greater improvement than the late surgery group at 1-year for AMS (MD 4.0, 95%CI 1.7-6.2, P=0.001), light-touch score (MD 4.7, 95%CI 2.0-7.3, P=0.001), and pin-prick score (MD 4.4, 95%CI 1.7-7.0, P=0.001). On ‘shift analysis’, the early surgery group achieved more favorable AIS grades at 1-year (cOR 1.49, 95%CI 1.16-1.93, P=0.002). The effect of early surgery was strongest for cervical SCI (P=0.003); however, we observed a trend toward improved motor recovery with early surgery for thoracic SCI (MD 5.2, 95%CI -0.8-11.2, P=0.088).
Conclusions: In an individual patient data meta-analysis adjusting for confounders, we found early surgery, within 24 hours, was associated with superior sensorimotor recovery at 1-year following acute SCI.