A multicenter retrospective study was performed in 36 participating North American centers to examine the use and timing of surgery in the treatment of acute spinal cord injury (SCI). The study was conducted to obtain information required for the planning of a randomized controlled trial of early compared with late decompressive surgery.
The records of all patients aged 16 to 75 years with acute SCI who were admitted to the 36 centers within 24 hours of injury over a 9-month period (August 1994 to April 1995) were examined to obtain data on admission variables, methods of diagnosis, use of traction, and surgical variables including type and timing of surgery.
A total of 585 patients with acute SCI or cauda equina injury were admitted to these centers, although approximately half were ultimately excluded because they did not meet inclusion criteria. Common causes for exclusion were late admission, age, gunshot wound, and an absence of spinal cord compression demonstrated on imaging studies. Thus, only approximately 50% of acute SCI patients would be eligible for inclusion in a study of acute decompressive procedures. Although 100% of patient underwent computerized tomography (CT) scaning, only 54% underwent magnetic resonance imaging, and CT myelography was performed in only 6%. Complete neurological injuries (American Spinal Injury Association Grade A) were present in 57.8%. Traction was applied in only 47% of patients with cervical injuries, of which only 42% demonstrated successful decompression by traction. Neurological deterioration occurred in 8.1% of patients after traction. Surgery was performed in 65.4% of patients. The timing of surgery varied widely: less than 24 hours in 23.5% of patients; 25 to 48 hours in 15.8%; 48 to 96 hours in 19.0%; and 5 days or longer in 41.7% of patients.
These data indicate that whereas surgery is commonly performed in patients with acute SCI, one-third of the cases are managed nonoperatively, and there is very little agreement on the optimum timing of surgical treatment. The results of this study confirm the need for a randomized controlled trial to determine the optimum timing of surgical decompressive procedures in patients with SCI.