Keywords
decompression, surgical - spinal cord injuries - surveys and questionnaires
Introduction
Acute spinal cord injury (ASCI) is a devastating condition with dramatic consequences for the patient, their family, and society. Despite all efforts, the ideal management of these patients remains unclear. Neurological recovery varies with ASCI severity, with incomplete injuries having better results than complete ones (D > C > B> A; American Spinal Injury Association Impairment Scale [ASIA]).[1]
While it is agreed that patients with acute injuries and instability need urgent surgical decompression, the ideal timing for surgical intervention remains controversial. Accumulated evidence suggests that early decompression is associated with better neurologic recovery.[2]
[3]
[4] A recent paper reported that the first 24 to 36 hours after the injury are crucial to perform decompression and achieve an optimal neurological recovery.[5]
Patients with traumatic spinal cord injury without radiological evidence of instability (often called central cord syndrome) are even more controversial to manage. While some advocate early decompression, others are in favor of surgery after clinical stabilization.[6]
[7]
[8]
[9]
In 2017, Fehlings et al.[10] conducted a systematic review of the literature concerning studies about timing (24 hours versus > 24 hours) for decompressive surgery. This group suggests considering early surgery as an option for patients with ASCI, regardless of its level, and for those with traumatic central cord syndrome, despite the low quality of evidence for both.
Ultra-early decompression, performed within 12 hours, has gained relevance, especially in cervical injuries, with some studies suggesting that this approach may allow for improved neurological outcomes compared with early decompression (between 12 to 24 hours).[11]
[12] However, more studies are needed to support this argument.
The aim of the present study was to evaluate the current practice in terms of timing among spinal surgeons from Iberolatinoamerican countries.
Materials and Methods
A descriptive cross-sectional survey was conducted.
A link to a questionnaire was sent three times by email to members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies, and was active from May 6th to June 30th, 2020. The questionnaire had Portuguese and Spanish versions, most questions had multiple response choices, and all questions were mandatory. The survey included three parts: demographic data, timing for surgery in spinal cord injury, and the use of methylprednisolone (MPSS) in ASCI (whose results are part of a separate study).
IBM SPSS Statistics for Windows (IBM Corp., Armonk. NY, USA) was used for the statistical analysis, with statistical significance set at p < 0.05. The groups were compared using the Fisher test and the Pearson chi-squared test (qualitative variables). If more than one variable reached statistical significance, a logistic regression was performed.
Results
Demographic Data
A total of 162 orthopedic surgeons and neurosurgeons participated in the present study, 62.3% (101) of which were orthopedic surgeons and 37.7% (61) were neurosurgeons. More than 50% of the participants were from Portugal or Brazil; countries with < 30 participations were grouped as Spain + Central and South America; from these, 28 were from Spain (17.3%), 15 from Ecuador (9.3%), 12 from Paraguay (7.4%), 5 from Bolivia (3.1%), 2 from Chile (1.2%), 2 from the Dominican Republic (1.2%), 2 from Argentina (1.2%), 1 from Mexico (0.6), and 1 from Uruguay (0.6%). Most (58.0%) surgeons had = 10 years pratice in spine surgery and 101 (62.3%) worked in a institution with a dedicated spinal unit ([Table 1]).
Table 1
|
Characteristics
|
(n = 162)
|
|
Specialty
Orthopedic
Neurosurgery
|
101 (62.3%)
61 (37.7%)
|
|
Country
Portugal
Brazil
Spain + Central and South America (
n
< 30)
|
48 (29.6%)
46 (28.4%)
68 (42.0%)
|
|
Practice in spine surgery
< 5 years
5–10 years
> 10 years
|
32 (19.8%)
36 (22.2%)
94 (58.0%)
|
|
Spinal unit
Yes
No
|
101(62.3%)
61 (37.7%)
|
|
MRI availability in < 12h
Yes
No
|
128 (79.0%)
34 (21.0%)
|
Questions:
Sixty-eight (42.0%) of the respondents considered that ASCI with complete neurology injury should be treated within 12 hours, 54 (33.3%) agreed with early decompression within 24 hours, and 40 (24.7%) agreed with decompression within 48 hours.
There were no significant differences between surgeon seniority (p = 0.509) or type of institution (with or without a dedicated spinal unit) (p = 0.690) for early decompression – within ≤ 24 hours. There was a significant difference between countries (p = 0.017) and specialty (p = 0.023), with surgeons from Portugal and neurosurgeons advocating for earlier decompression than surgeons from other countries and orthopedic surgeons, respectively. After performing a logistic regression, the association with country and specialty remained statistically significant ([Table 2]).
Table 2
|
< 24 hours
|
> 24 hours
|
Proportion of early decompression (%)
|
p-value
|
|
Country
Portugal
Brazil
Spain + Central and South America (
n
< 30)
|
42
36
44
|
6
10
24
|
87.5
78.2
64.7
|
< 0.01
|
|
Specialty
Orthopedic
Neurosurgery
|
70
52
|
31
9
|
69.3
85.2
|
< 0.01
|
There were no significant differences between surgeon seniority (p = 0.412) or type of institution (with or without a dedicated spinal unit [p = 0.647]) for ultra-early decompression. The significant difference between countries (p < 0.01) and specialties (p < 0.01) was also found for ultra-early decompression ([Table 3]), with surgeons from Portugal or Brazil and neurosurgeons advocating for ultra-early decompression as opposed to surgeons from other countries and orthopedic surgeons, respectively.
Table 3
|
< 12 hours
|
> 12 hours
|
Proportion of ultra- early decompression (%)
|
p-value
|
|
Country
Portugal
Brazil
Spain + Central and South America (
n
< 30)
|
25
27
16
|
23
19
52
|
52.1
58.7
23.5
|
< 0.01
|
|
Specialty
Orthopedic
Neurosurgery
|
33
35
|
68
26
|
32.7
57.4
|
< 0.01
|
One-hundred fifty (71.0%) of the respondents reported that they would operate in < 12 hours, 40 (24.7%) within 24 hours, and 7 (4.3%) within 48 hours. There were no significant differences regarding early and ultra-early decompression between countries (p = 0.712 and p = 0.716), specialty (p = 0.712 and p = 0.803), surgeon seniority (p = 0.961 and p = 0.656) or type of institution (with or without a dedicated spinal unit) (p = 0.712 and p = 0.411).
There was a significant difference in the proportion of surgeons that would operate ASCI within ≤ 24 hours, regarding the type of injury (complete injury:122 versus incomplete injury:155; p<0.01) ([Table 4]).
Table 4
|
< 24 hours
|
> 24 hours
|
Proportion of early decompression (%)
|
p-value
|
|
ASIA
A
B-D
|
122
155
|
40
7
|
74.3
95.7
|
< 0.01
|
In the presence of patients with traumatic spinal cord injury without radiological evidence of instability (central cord syndrome), 152 surgeons (93.8%) would perform surgical decompression: 1 (0.6%) in the first 12 hours, 63 (38.9%) in the first 24 hours, 4 (2.5%) in the first 48 hours, 66 (40.7%) as soon as possible in the initial hospital stay, and 18 (11.1%) after neurologic stabilization (weeks or months after trauma). Ten (6.2%) surgeons would not consider surgical treatment regardless of its timing.
There were no significant differences between countries (p = 0.817), surgeon seniority (p = 0.172) or type of institution (with or without a dedicated spinal unit) (p = 0.051). There was a significant difference between specialties (p < 0.01), with neurosurgeons advocating for earlier decompression than orthopedic surgeons ([Table 5]).
Table 5
|
As soon as possible or less
|
After stabilization or more
|
p-value
|
|
Specialty
Orthopedic
Neurosurgery
|
76
58
|
25
3
|
< 0.01
|
One hundred thirty-one surgeons (80.9%) considered that the time of surgery should not be affected by the region of the injury. Thirty (18.5%) reported operating on cervical injuries earlier, and 1 (0.6%) reported operating earlier in thoracic injuries. There were no significant differences between countries (p = 0.457), specialty (p = 0.587), surgeon seniority (p = 0.104) or type of institution (with or without a dedicated spinal unit) (p = 0.723).
Ninety-three (57.4%) of the surgeons feel that the surgery is performed later than the ideal due to restrictions inherent to their institution (availability of MRI, operating room, etc.), while 69 (42.6%) did not refer any limitation.
Discussion
The findings of the present study show that early decompression is the preferable approach for both complete and incomplete injuries with a significant association with country – Portuguese surgeons revealed a tendency to prefer early decompression; speciality – significantly more neurosurgeons prefer early decompression than orthopedic surgeons; and incomplete neurologic injury gathered significantly more consensus in favor of early decompression.
This agrees with a 2018 Netherlands survey with 55 surgeons that showed preference to perform surgery within 24 hours with distinction in surgical timing made based upon the initial neurological injury (57% – ASIA A; 75% – ASIA B; 78% – ASIA C/D).[13]
As expected, there was less consensus regarding surgical treatment of central cord injury, as has been shown in a 2010 survey of 971 spine surgeons.[14]
More than a half of the participants feel that the surgery is performed later than the ideal due to restrictions inherent to their institution (availability of MRI, operating room, etc.). This is in line with a 2017 Canadian survey that found that although most surgeons believed that early decompression should be performed, this was actually accomplished in less than half of the patients, with operating room access and urgent patient transport identified as the main barriers.[15]
While the survey was sent to all SILACO members, participation was mostly from Portugal and Brazil and some countries were under-represented in the present analysis. Hence, this may not accurately reflect the practice regarding timing for surgery in all Iberolatinoamerican countries but in groups of surgeons from those countries.
Despite the increasing advances in knowledge and the growing consensus regarding the need for early decompression in ASCI, barriers continue to be identified. These barriers are mostly related to MRI and operating room availability. The creation of fast-track protocols for these patients and referral centers equipped to treat them in a timely manner may allow for an improvement in their care. Additionally, ultra-early decompression may have advantages over early depression but only future studies will allow to elucidate this matter.
Conclusion
The present study reports the current surgical management of ASCI in countries from Iberolatinoamerican countries. All surgeons inquired in this survey favor early decompression in patients with ACSI, with the majority performing surgery in the first 24 hours. Decompression is performed earlier in cases of incomplete than in complete injuries. In cases of central cord syndrome without radiological evidence of instability, there is a tendency towards early surgical decompression, but the timing is still extremely variable. Future studies are needed to identify the ideal timing for decompression of this subset of ASCI patients.
