Traumatic spinal cord injury (SCI) affects over 200,000 people in the USA and is a major source of morbidity, mortality, and societal cost. Management of SCI includes several components. Acute management includes medical agents and surgical treatment that usually includes either all or a combination of reduction, decompression, and stabilization. Physical therapy and rehabilitation and late onset SCI problems also play a role. A review of the literature in regard to surgical management of SCI patients in the acute setting was undertaken. The controversy surrounding whether reduction is safe, or not, and whether prereduction magnetic resonance (MR) imaging to rule out traumatic disc herniation is essential is discussed. The controversial role of timing of surgical intervention and the choice of surgical approach in acute, incomplete, and acute traumatic SCI patients are reviewed. Surgical treatment is an essential tool in management of SCI patients and the controversy surrounding the timing of surgery remains unresolved. Presurgical reduction is considered safe and essential in the management of SCI with loss of alignment, at least as an initial step in the overall care of a SCI patient. Future prospective collection of outcome data that would suffice as evidence-based is recommended and necessary. 1. Introduction Traumatic spinal cord injury (SCI) affects over 200,000 people in the USA, with nearly 10,000 new injuries reported annually [1–3]. People affected by SCI are usually young (average age 32 years) and life expectancy is marginally lower when compared with a non-SCI population. Hence, the ramifications of the injury itself as well as the medical decisions made can result in enormous economic burden and social cost [4]. Long-term outcome after SCI comprises a combination of the initial extent of the injury, natural recovery from injury, medical interventions, rehabilitation, and social/community reintegration. Several components play a role in management of SCI. Initially, acute management includes medical agents administered with the goal of reducing secondary injury cascade, and an initial surgical treatment that usually includes either all or a combination of reduction, decompression, and stabilization. Physical therapy and rehabilitation, which can lead to a significant impact on overall recovery is an additional component. Finally, late onset SCI problems, such as bowel and bladder dysfunction, pain, spasticity, and problems with automatic breathing, play a role. This paper focuses on the surgical management of SCI in the acute setting. Later
References
[1]
J. F. Kraus, C. E. Franti, and R. S. Riggins, “Incidence of traumatic spinal cord lesions.,” Journal of Chronic Diseases, vol. 28, no. 9, pp. 471–492, 1975.
[2]
“Spinal cord injury facts and figures at a glance,” Journal of Spinal Cord Medicine, vol. 33, no. 4, pp. 439–440, 2010.
[3]
“Spinal cord injury. Facts and figures at a glance,” Journal of Spinal Cord Medicine, vol. 28, no. 4, pp. 379–380, 2005.
[4]
B. Go, M. DeVivo, and J. Richards, “The epidemiology of spinal cord injury,” in Spinal Cord Injury: Clinical Outcomes From The Model Systems, S. Stover, J. Delisa, and G. Whiteneck, Eds., pp. 21–55, Aspen, Gaithersburg, Md, USA, 1995.
[5]
R. B. Delamarter, J. Sherman, and J. B. Carr, “Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression,” Journal of Bone & Joint Surgery—American Volume, vol. 77, no. 7, pp. 1042–1049, 1995.
[6]
J. R. Dimar II, S. D. Glassman, G. H. Raque, Y. P. Zhang, and C. B. Shields, “The influence of spinal canal narrowing and timing of decompression on neurologic recovery after spinal cord contusion in a rat model,” Spine, vol. 24, no. 16, pp. 1623–1633, 1999.
[7]
J. M. Cotler, Gerald J. Herbison, Joseph F. Nasuti, J. F. Ditunno Jr., H. An, and B. E. Wolff, “Closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds,” Spine, vol. 18, no. 3, pp. 386–390, 1993.
[8]
C. Gaebler, R. Maier, F. Kutscha-Lissberg, L. Mrkonjic, and V. Vècsei, “Results of spinal cord decompression and thoracolumbar pedicle stabilisation in relation to the time of operation,” Spinal Cord, vol. 37, no. 1, pp. 33–39, 1999.
[9]
A. S. Lee, J. C. MacLean, and D. A. Newton, “Rapid traction for reduction of cervical spine dislocations,” Journal of Bone & Joint Surgery—British Volume, vol. 76, no. 3, pp. 352–356, 1994.
[10]
S. J. Rizzolo, M. R. Piazza, J. M. Cotler, R. A. Balderston, D. Schaefer, and A. Flanders, “Intervertebral disc injury complicating cervical spine trauma,” Spine, vol. 16, no. 6, supplement, pp. S187–S189, 1991.
[11]
R. L. Waters, R. H. Adkins, J. S. Yakura, and I. Sie, “Effect of surgery on motor recovery following traumatic spinal cord injury,” Spinal Cord, vol. 34, no. 4, pp. 188–192, 1996.
[12]
W. G. Crutchfield, “Skeletal traction in treatment of injuries to the cervical spine,” Journal of the American Medical Association, vol. 155, no. 1, pp. 29–32, 1954.
[13]
S. E. Doran, S. M. Papadopoulos, T. B. Ducker, and K. O. Lillehei, “Magnetic resonance imaging documentation of coexistent traumatic locked facets of the cervical spine and disc herniation,” Journal of Neurosurgery, vol. 79, no. 3, pp. 341–345, 1993, See comment.
[14]
D. J. Maiman, G. Barolat, and S. J. Larson, “Management of bilateral locked facets of the cervical spine,” Neurosurgery, vol. 18, no. 5, pp. 542–547, 1986.
[15]
D. D. Brunette and G. L. Rockswol, “Neurologic recovery following rapid spinal realignment for complete cervical spinal cord injury,” Journal of Trauma-Injury Infection & Critical Care, vol. 27, no. 4, pp. 445–447, 1987.
[16]
J. F. Harrington, M. J. Likavec, and A. S. Smith, “Disc herniation in cervical fracture subluxation,” Neurosurgery, vol. 29, no. 3, pp. 374–379, 1991.
[17]
C. Olerud and H. Jonsson Jr., “Compression of the cervical spine cord after reduction of fracture dislocations. Report of 2 cases,” Acta Orthopaedica Scandinavica, vol. 62, no. 6, pp. 599–601, 1991.
[18]
D. K. Evans, “Reduction of cervical dislocations,” Journal of Bone & Joint Surgery—British Volume, vol. 43, no. 3, pp. 552–555, 1961.
[19]
M. Hadley and P. Argires, “The acute/emergent management of vertebral column fracture dislocation injuries,” in Neurological Emergencies, AANS, Ed., pp. 249–262, AANS, Park Ridge, Ill, USA, 1994.
[20]
M. Kilburn, D. Smith, and M. Hadley, “The initial evaluation and treatment of the patient with spinal trauma,” in Textbook of Neurological Surgery: Principles and Practice, H. Batjer and C. Loftus, Eds., Lippincott Williams & Wilkins, Philadelphia, Pa, USA, 2003.
[21]
M. N. Hadley, “Initial closed reduction of cervical spine fracture-dislocation injuries,” Neurosurgery, vol. 50, no. 3, supplement, pp. S44–S50, 2002.
[22]
M. G. Fehlings and J. R. Wilson, “Timing of surgical intervention in spinal trauma: what does the evidence indicate?” Spine, vol. 35, no. 21, supplement, pp. S159–S160, 2010.
[23]
M. G. Fehlings and R. G. Perrin, “The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence,” Spine, vol. 31, no. 11, supplement, pp. S28–S35, 2006.
[24]
M. E. Pollard and D. F. Apple, “Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia,” Spine, vol. 28, no. 1, pp. 33–39, 2003.
[25]
A. P. Amar and M. L. Levy, “Pathogenesis and pharmacological strategies for mitigating secondary damage in acute spinal cord injury,” Neurosurgery, vol. 44, no. 5, pp. 1027–1039, 1999.
[26]
C. H. Tator, “Biology of neurological recovery and functional restoration after spinal cord injury,” Neurosurgery, vol. 42, no. 4, pp. 696–707, 1998.
[27]
M. B. Bracken, M. J. Shepard, W. F. Collins et al., “A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the second national acute spinal cord injury study,” New England Journal of Medicine, vol. 322, no. 20, pp. 1405–1411, 1990.
[28]
H. H. Bohlman, E. Bahniuk, G. Raskulinecz, and G. Field, “Mechanical factors affecting recovery from incomplete cervical spinal cord injury: a preliminary report,” Johns Hopkins Medical Journal, vol. 145, no. 3, pp. 115–125, 1979.
[29]
G. D. Carlson, Y. Minato, A. Okada et al., “Early time-dependent decompression for spinal cord injury: vascular mechanisms of recovery,” Journal of Neurotrauma, vol. 14, no. 12, pp. 951–962, 1997.
[30]
T. J. Croft, J. S. Brodkey, and F. E. Nulsen, “Reversible spinal cord trauma: a model for electrical monitoring of spinal cord function,” Journal of Neurosurgery, vol. 36, no. 4, pp. 402–406, 1972.
[31]
E. J. Dolan, C. H. Tator, and L. Endrenyi, “The value of decompression for acute experimental spinal cord compression injury,” Journal of Neurosurgery, vol. 53, no. 6, pp. 749–755, 1980.
[32]
A. Guha, C. H. Tator, L. Endrenyi, and I. Piper, “Decompression of the spinal cord improves recovery after acute experimental spinal cord compression injury,” Paraplegia, vol. 25, no. 4, pp. 324–339, 1987.
[33]
A. I. Kobrine, D. E. Evans, and H. Rizzoli, “Correlation of spinal cord blood flow and function in experimental compression,” Surgical Neurology, vol. 10, no. 1, pp. 54–59, 1978.
[34]
B. Nystrom and J. E. Berglund, “Spinal cord restitution following compression injuries in rats,” Acta Neurologica Scandinavica, vol. 78, no. 6, pp. 467–472, 1988.
[35]
I. M. Tarlov, “Spinal cord compression studies. III. Time limits for recovery after gradual compression in dogs,” AMA Archives of Neurology and Psychiatry, vol. 71, no. 5, pp. 588–597, 1954.
[36]
I. Tarlov, Spinal Cord Compression: Mechanisms of Paralysis and Treatment, vol. 34, Charles Thomas, Springfield, Ill, USA, 1957.
[37]
I. M. Tarlov and H. Klinger, “Spinal cord compression studies. II. Time limits for recovery after acute compression in dogs,” AMA Archives of Neurology and Psychiatry, vol. 71, no. 3, pp. 271–290, 1954.
[38]
A. I. Kobrine, D. E. Evans, and H. V. Rizzoli, “Experimental acute balloon compression of the spinal cord. Factors affecting disappearance and return of the spinal evoked response,” Journal of Neurosurgery, vol. 51, no. 6, pp. 841–845, 1979.
[39]
M. G. Fehlings and C. H. Tator, “An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies,” Journal of Neurosurgery, vol. 91, no. 1, supplement, pp. 1–11, 1999.
[40]
G. la Rosa, A. Conti, S. Cardali, F. Cacciola, and F. Tomasello, “Does early decompression improve neurological outcome of spinal cord injured patients? Appraisal of the literature using a meta-analytical approach,” Spinal Cord, vol. 42, no. 9, pp. 503–512, 2004.
[41]
C. H. Tator, M. G. Fehlings, K. Thorpe, and W. Taylor, “Current use and timing of spinal surgery for management of acute spinal cord injury in North America: results of a retrospective multicenter study,” Journal of Neurosurgery, vol. 91, no. 1, supplement, pp. 12–18, 1999.
[42]
W. McKinley, M. A. Meade, S. Kirshblum, and B. Barnard, “Outcomes of early surgical management versus late or no surgical intervention after acute spinal cord injury,” Archives of Physical Medicine and Rehabilitation, vol. 85, no. 11, pp. 1818–1825, 2004.
[43]
A. R. Vaccaro, R. J. Daugherty, T. P. Sheehan et al., “Neurologic outcome of early versus late surgery for cervical spinal cord injury,” Spine, vol. 22, no. 22, pp. 2609–2613, 1997.
[44]
C. H. Tator, E. G. Duncan, V. E. Edmonds, L. I. Lapczak, and D. F. Andrews, “Comparison of surgical and conservative management in 208 patients with acute spinal cord injury,” Canadian Journal of Neurological Sciences, vol. 14, no. 1, pp. 60–69, 1987.
[45]
W. P. Coleman and F. H. Geisler, “Injury severity as primary predictor of outcome in acute spinal cord injury: retrospective results from a large multicenter clinical trial,” Spine Journal, vol. 4, no. 4, pp. 373–378, 2004.
[46]
V. K. Sonntag and M. N. Hadley, “Nonoperative management of cervical spine injuries,” Clinical Neurosurgery, vol. 34, pp. 630–649, 1988.
[47]
M. Greenberg, Handbook of Neurosurgery, Thieme, New York, NY, USA, 6th edition, 2006.
[48]
B. Bose, J. L. Osterholm, B. E. Northrup, and J. M. Cotler, “Management of lumbar translocation injuries: case reports,” Neurosurgery, vol. 17, no. 6, pp. 958–961, 1985.
[49]
M. G. Fehlings and L. H. Sekhon, “Acute interventions in spinal cord injury: what do we know, what should we do?” Clinical Neurosurgery, vol. 48, pp. 226–242, 2001.
[50]
N. Theodore and V. K. Sonntag, “Decision making in degenerative cervical spine surgery,” Clinical Neurosurgery, vol. 48, pp. 260–276, 2001.
