Surgical Intervention in Spinal Cord Injury (SCI)

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Surgical Intervention in Spinal Cord Injury (SCI)

• 4B2 Ri ???

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References

• Surgical controversies in the management of
  spinal cord injury
• --J Am coll Surg, Vol.188, No.5, May 1999
• Early versus late surgical decompression in the
  setting of cervical spinal cord injury
• --Journal of controversial medical claims,
  Vol.8, No.4, Nov 2001

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SCI

• Prevalence 500900 per million population
• Male female 34 1
• Median age 25 y/o
• Cause vehicle accidents(45), falls(22),
  sports(14), violence(14)

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The goal of treating SCI

• Maximize neurologic recovery
• Restore normal alignment and correct deformity
• Promote spinal stability, fusion, or both
• Minimize pain
• Facilitate early mobilization and rehabilitation
• Minimize hospitalization and cost
• Prevent secondary complications

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Burden of care

• Cervical SCI with quadriplegia
• 100,000-- initial hospitalization
• 50,00075,000-- rehabilitation
• Mean duration of survival gt30 years
• Average lifetime medical cost 1 million!
• Indirect cost lost productivity to the society

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Medical therapy (NASCIS?)

• Methylprednisolone iv bolus(30mg/kg), then
  5.4mg/kg/hr infusion 23hrs
• More effective if started within 3 hrs after
  injury
• gt24hr therapy associated with more severe
  pneumonia
• BP elevation and volume expansion enhancing
  spinal cord blood flow

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Surgical therapies (NASCIS?)

• Stabilization Decompression
• --Stabilization
• Anterior and posterior plates
• Titanium cage other vertebral fusion methods
• --Delayed decompression restore function
  (Bohlman)
• --Untethering spinal cord improves function
• --Adcon gel and other methods to prevent
  epidural scarring

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Surgical management

• Lacking of incontrovertible guidelines to define
  the role of surgery
• Retrospective analyses of unrandomized case
  series
• Surgical controversies the role of decompression
  and stabilization

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Timing of surgical decompression

• Animal models
• Tarlov
• using balloons causing compression of L-spine
• lt1min?full recovery
• lt5min?partial recovery
• gt5min?no recovery

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Surgical decompression

• NASCIS? trial(487 patients)
• No statistically significant improvement in the
  neurological recovery, regardless of the nature
  or timing of surgical intervention

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Other clinical studies

• Vaccaro et al
• A prospective randomized study of 62 patients
• Gr.1(34) surgery within 72 hrs
• Gr.2(28) 5 days after injury
• Results no significant differences in ICU stay,
  duration of rehabilitation, or neurological
  recovery
• May due to an inappropriate definition of early
  decompression

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Clinical studies

• Mirza et al
• 30 acute C-spine injury at 2 different medical
  centers
• 15 pt?close reduction surgery within 72 hrs
• 15 pt?close reduction observed1014d before
  surgery
• Result
• Increased length of acute care hospitalization in
  the delay surgery group
• Significant improvement between pre-op and
  post-op neurological function

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Surgical decompression

• Heiden early operative intervention was
  associated with significantly greater pulmonary
  morbidity(46) than later surgery(27)
• Other studies delay spinal surgery for 4872 hrs
  may decrease intra-op blood loss by two-thirds.

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Complication rate

• Schlegel et al
• Surgery after 72hrs post-injury and within 48hrs
• The 72hrs group has higher rates of---
• Pulmonary complications(12.2)
• Pressure sores(4.8)
• UTI(3.2)

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Medical cost

• Schlegel et al
• Surgery within 24 hrs of injury
• Lowest average medical cost
• Due to decreased ventilator needs and shorter
  ICU and overall hospital stay

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Surgical stabilization

• Decrease hospitalization time
• Decrease complications
• Earlier mobilization
• Overall decreased costs

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Surgical stabilization

• Wilberger early vs late stabilization
• Post-op neuro. Deterioration-- 0 vs 2.5
• Incidence of complications was reduced by over
  50-- pneumonia, thrombophlebitis, pulmonary
  embolism, etc.
• Murphy early surgical stabilization
• Hospitalized 21 fewer days than treated with
  external cervical orthoses

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Conclusions

• Lack of well-designed prospective studies
• Overly broad definition of early surgery

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Thanks for your attention!!!
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