Efficacy of Early Surgery for Neurological Improvement in Spinal Cord Injury without Radiographic Evidence of Trauma in the Elderly

doi:10.1016/j.wneu.2017.06.070

World Neurosurgery

Volume 105, September 2017, Pages 790-795

https://doi.org/10.1016/j.wneu.2017.06.070 Get rights and content

Background

The optimal timing for surgery for patients with spinal cord injury without radiographic evidence of trauma (SCIWORET) remains unclear. This is especially true in the elderly, given that most studies are done with younger patients to avoid age-related comorbidities. We aimed to compare the efficacy of early (<24 hours postinjury) and late (>24 hours postinjury) surgery in patients with SCIWORET aged ≥65 years.

Methods

We identified patients aged ≥65 years who underwent surgery for SCIWORET between January 1995 and February 2016. The primary outcome was a change in the Japanese Orthopaedic Association (JOA) score at discharge, with a recovery of >50% defined as a favorable neurologic outcome. Logistic regression analysis was performed, and model fit was assessed using the Hosmer–Lemeshow test.

Results

Eighty patients aged ≥65 years with SCIWORET underwent surgery were enrolled. Favorable neurologic outcomes were seen in 43.3% of those who underwent early surgery, but only in 18.0% of those who underwent late surgery. Logistic regression analysis, adjusted for age, sex, comorbidities (Charlson Comorbidity Index), and JOA score, revealed that early surgery independently predicted favorable outcomes (odds ratio, 4.06; 95% confidence interval, 1.25–13.20), with excellent calibration (Hosmer–Lemeshow, P = 0.857).

Conclusions

The present study indicated that early surgery within 24 hours of injury for elderly patients with SCIWORET could lead to more favorable neurologic improvements. We believe that chronological age alone should not be considered sufficient justification to deny patients early surgical decompression for SCIWORET.

Introduction

The incidence of spinal cord injury (SCI) is increasing among the elderly because this population is growing faster than any other age group.1, 2 Unlike younger patients, the elderly tend to suffer from acute traumatic myelopathy, described as SCI without radiographic evidence of trauma (SCIWORET). This condition is characterized by hyperextension injury at higher cervical levels, coupled with spinal cord compression from a preexisting degenerative disease, such as cervical spondylosis (CS), ossification of posterior longitudinal ligaments, cervical disc herniation, hypertrophy of the ligamentum flavum, and osteophytes.3, 4, 5, 6, 7, 8, 9, 10 Given the lack of either persuasive evidence in favor of surgical or conservative treatment for SCIWORET in the elderly, strategies for managing the condition warrant further investigation.3, 4, 5, 9, 11

In 2012, the Surgical Timing in Acute Spinal Cord Injury Study demonstrated that early surgery (<24 hours after injury) was associated with a higher rate of improvement (of 2 or more grades on the American Spinal Injury Association Impairment Scale) at 6 months compared with late surgery (>24 hours after injury).¹² However, that study did not distinguish among the subtypes of SCI, leaving the optimal treatment of SCIWORET controversial, especially regarding whether early decompression might improve neurologic outcomes in this disorder.8, 9, 13, 14, 15, 16 Furthermore, no evidence-based therapeutic recommendations have been developed for elderly patients with SCIWORET, because discussions about the effectiveness of surgery have focused on patients aged <65 years, who are less likely to have preexisting comorbidities and distorted pathophysiology.4, 8, 17, 18, 19 In our institution, we do not consider patient age an exclusion criterion for early decompression, and frequently perform this surgery irrespective of age.

To our knowledge, no previous studies have focused on the association between surgical decompression and the odds of improving motor function in elderly patients (age ≥65 years) with SCIWORET. In the present study, we aimed to assess the influence of time from injury to surgical decompression in this population. We focused in particular on comparing the effect of early (<24 hours after injury) and delayed (>24 hours after injury) intervention on our primary outcome of neurologic recovery at acute care discharge. This study is presented in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statement,²⁰ which provides guidelines to ensure transparency in issues regarding confounding, bias, and generalizability.

Section snippets

Study Design, Ethical Approval, and Setting

We performed a retrospective cohort study to evaluate the effects of early surgery on elderly patients with SCIWORET admitted to Sendai Medical Center between January 1995 and February 2016. The research procedures were approved by the Institutional Review Board of Sendai Medical Center, which exempted us from the need to obtain the consent of individual participants.

Participants

We retrospectively identified patients with a principal diagnosis of SCIWORET (code 952.0) according to the International

Baseline Patient Characteristics

During the study period, 80 patients (64 men and 16 women) aged 65–89 years (mean age, 72.9 years) diagnosed with SCIWORET underwent surgical decompression. These patients' key demographic, clinical, and outcome parameters are summarized by study group in Table 2. Twenty-two patients (27.5%) underwent surgical decompression <24 hours after the injury (early surgery group; mean time to surgery, 16.4 ± 4.7 hours), and 58 patients (72.5%) underwent decompression >24 hours after the injury (late

Results of the Present Study

Our results demonstrate the short-term effectiveness in improving neurologic outcomes of early surgery for elderly patients (≥65 years) with SCIWORET. Possibly owing to comorbidities and altered pathophysiology associated with aging, most clinical studies in SCIWORET have included patients aged <65 years,³⁰ leading to a paucity of evidence concerning the efficacy of surgical decompression in the elderly. In this study, we used univariate logistic regression analysis to show that age did not

Conclusions

The present study indicates that early surgery within 24 hours of injury in elderly patients with SCIWORET could lead to more favorable neurologic improvements in terms of the JOA recovery rate. Thus, our results underscore the significance of early surgery for elderly patients with SCIWORET. We believe that chronological age alone should not be considered sufficient justification to deny patients early surgical decompression for SCIWORET. Specifically, age >65 years should not automatically

Acknowledgments

We thank Enago for the English language review.

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Cited by (15)

Influence of the timing of surgery for cervical spinal cord injury without bone injury in the elderly: A retrospective multicenter study
2024, Journal of Orthopaedic Science
Although previous studies have demonstrated the advantages of early surgery for traumatic spinal cord injury (SCI), the appropriate surgical timing for cervical SCIs (CSCIs) without bone injury remains controversial. Here, we investigated the influence of relatively early surgery within 48 h of injury on the neurological recovery of elderly patients with CSCI and no bone injury.
In this retrospective multicenter study, we reviewed data from 159 consecutive patients aged ≥65 years with CSCI without bone injury who underwent surgery in participating centers between 2010 and 2020. Patients were followed up for at least 6 months following CSCI. We divided patients into relatively early (≤48 h after CSCI, n = 24) and late surgery (>48 h after CSCI, n = 135) groups, and baseline characteristics and neurological outcomes were compared between them. Multivariate analysis was performed to identify factors associated with neurological recovery.
The relatively early surgery group demonstrated a lower prevalence of cardiac disease, poorer baseline American Spinal Injury Association (ASIA) impairment scale grade, and lower baseline ASIA motor score (AMS) than those of the late surgery group (P < 0.030, P < 0.001, and P < 0.001, respectively). Although the AMS was lower in the relatively early surgery group at 6 months following injury (P = 0.001), greater improvement in this score from baseline to 6-months post injury was observed (P = 0.010). Multiple linear regression analysis revealed that relatively early surgery did not affect postoperative improvement in AMS, rather, lower baseline AMS was associated with better AMS improvement (P < 0.001). Delirium (P = 0.006), pneumonia (P = 0.030), and diabetes mellitus (P = 0.039) negatively influenced postoperative improvement.
Although further validation by future studies is required, relatively early surgery did not show a positive influence on neurological recovery after CSCI without bone injury in the elderly.
Time to Surgery in Spinal Trauma: A Meta-Analysis of the World's Literature Comparing High-Income Countries to Low-Middle Income Countries
2022, World Neurosurgery
Citation Excerpt :
In addition, 23 articles had only time from injury to admission (9 available means ± SD), and 33 articles with only time from admission to OR (4 available means ± SD) and were thus excluded from the analysis (Figure 1). Of 163 studies, 23 articles were eligible for meta-analysis with 16 studies from HICs and 7 from LMICs (Table 1).11,14-16,26-45 A total of 3819 patients with spinal trauma were included.
We conducted a systematic review and meta-analysis to: 1) compare time from traumatic spinal injury (TSI) to operating room (OR) in high-income countries (HICs) versus low-middle-income countries (LMICs), and 2) evaluate hospital length of stay (LOS) in HICs versus LMICs.
A systematic literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines involving articles of all languages. Inclusion criteria: published between 1991 and 2021, spine trauma population, single country/region, and recorded time from injury to OR. The primary outcome was time from injury to OR, and the secondary outcome was LOS. Means and standard deviations were estimated in a random effects model by DerSimonian and Laird methods.
Of 2367 articles, 163 met the inclusion criteria for systematic review. Regarding time from injury to OR, 23 articles were eligible for meta-analysis; 16 studies were conducted in HICs and 7 in LMICs, comprising 3819 patients with TSI. A significantly shorter mean time from injury to OR was found in HICs (1.92 days, 95% confidence interval 1.44–2.41) compared with LMICs (3.27 days, 95% confidence interval 2.27–4.27) (P = 0.020). Regarding length of stay, 14 articles were eligible for meta-analysis, 10 studies were conducted in HICs and 4 in LMICs, comprising 11,003 patients. There was no difference in LOS between HICs and LMICs (25.76 days vs. 20.48 days, P = 0.140).
Patients with traumatic spinal injuries in HICs were more likely to undergo earlier surgery compared to patients in LMICs. No difference was found in total LOS between HICs and LMICs. While multiple factors can influence time to surgery, these findings draw attention to the global disparity in spinal trauma care.
Impact of timing of surgery on traumatic central cord syndrome without fracture or dislocation
2022, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Citation Excerpt :
Numerous clinical trials of traumatic spinal cord injury (SCI) have shown that early surgical decompression and fixation may enhance neurological improvement[17,18]. This rationale is based on 1) complete SCI requires early decompression to salvage existing neural tissue and reduce further damage to the blood and parenchyma of the spinal cord, and 2) fractures or associated instability can cause unpredictable secondary injury to the spinal cord[19]. However, ATCCS is an incomplete SCI with the potential for spontaneous neurological recovery, so it is not known whether its neurological recovery is related to the timing of surgery.
The management of acute traumatic central cord syndrome (ATCCS) remains controversial. The purpose of this study was to evaluate the impact of timing of surgery on patients with ATCCS without fracture or dislocation.
Forty-one patients with ATCCS without fracture or dislocation were identified and divided into three groups described as the conservative treatment group, early surgery group, and delayed surgery group. Clinical outcomes including ASIA Motor Score (AMS), Japanese Orthopaedic Association (JOA) score upon admission and follow-up, change in AMS, and JOA recovery rate were analyzed. Logistic regression analysis was performed to show the correlation between timing of surgery and clinical outcomes.
All patients received a minimum of 1-year follow-up and showed significant neurological recovery at the final follow-up. No statistical differences in final AMS and JOA scores were observed between the three groups. Patients who underwent early surgery achieved a faster motor recovery at the first 6-months postoperatively compared to conservative treatment(p < 0.01). There was a significant negative correlation between the timing of surgery and the change in AMS (r = -0.41, p = 0.02) in the initial 6-months postoperatively and throughout the follow-up period (r = -0.42, p = 0.02).
The present study indicated that both conservative and surgical treatments can lead to good neurological recovery in patients with ATCCS without fracture or dislocation. Early surgery allowed for rapid early motor recovery compared to conservative treatment. The choice of timing of surgery still requires individualized decision-making.
Surgical management of cervical spinal cord injury in extremely elderly patients, aged 80 or older
2021, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
Citation Excerpt :
Accordingly, vertebral fracture was significantly less in Group 2. In previous reports, elderly patients were more likely to sustain cervical spinal injuries without vertebral fracture or dislocation (without radiographic evidence of trauma) [12]. This situation is characterized by hyperextension injury of the degenerative cervical spine with spinal stenosis due to hypertrophy of the ligaments, disc herniation, and osteophytes [12,13].
Spinal cord injury in elderly populations has increased in recent years. This study aimed to investigate the pathology, severity, efficacy of the surgery, and complications of cervical spinal cord injury in extremely elderly patients aged >80 years.
Sixty-three patients who underwent surgical treatment for cervical spinal cord injury were enrolled in this retrospective multicenter study. Forty patients were aged <80 years (Group 1), and 23 patients were aged ≥80 years (Group 2). The etiology of the injury, American Spinal Injury Association impairment scale (AIS) grade, surgical procedure, neurological improvement, and surgical complications were evaluated.
Most causes of injury in extremely elderly patients were of low-energy impact. The prevalence of vertebral fracture/dislocation was low and neurological impairment was milder in these patients, than in younger patients. Although overall neural recovery was similar in both groups, patients with complete motor paralysis did not show any improvement in AIS grade in the older group. The mortality rate was the same between the groups. Complication rates in surgical treatment were similar in both groups, with a high incidence of respiratory disorder (average 19%). Respiratory complications were noted during the perioperative period.
Surgical treatment of cervical spinal cord injury in extremely elderly patients can be performed safely, with a similar neurological recovery and low rate of surgical complications as those in younger patients. Respiratory complications should be attended to in the perioperative period. Early ambulation after admission coupled with strict respiratory management is probably essential to prevent complications and mortality.
Preliminary Findings After Nonoperative Management of Traumatic Cervical Spinal Cord Injury on a Background of Degenerative Disc Disease: Providing Optimum Patient Care and Costs Saving in a Nigerian Setting
2020, World Neurosurgery
Citation Excerpt :
In contrast, others have advocated for surgical decompression and stabilization in patients with TCSI without a destabilizing skeletal injury.15,16 Inoue et al.17 reported that early surgical intervention within 24 hours in elderly patients demonstrated a favorable neurological outcome. Guest et al.18 also compared the benefits of early and late surgical intervention for patients with acute traumatic central cord syndrome (CCS) and found slightly better motor recovery rates for patients who had undergone early surgery (<24 hours) than for those who had undergone late surgery (>24 hours).
We assessed the hypothesis that nonoperative management would be a viable treatment option for patients with underlying degenerative disease who have traumatic cervical spinal cord injury (TCSI) without neurological deterioration and/or spinal instability during hospitalization.
Data were collected prospectively from 2011 to 2016. All the patients had been treated nonoperatively with hard cervical collar immobilization. The clinical parameters assessed included the Frankel grade at presentation and discharge, the occurrence of deep vein thrombosis, urinary tract infection, sphincter dysfunction, and pressure sores. The radiographic data collected included magnetic resonance imaging signal cord changes. P ≤ 0.05 represented a significant association between the Frankel grade at presentation and the outcome parameters.
A total of 28 patients were included in the present study. Of the patients who had presented with Frankel grade B, 85.71% had improved to a higher grade, 90.91% of the patients with Frankel grade C had improved to a higher grade, and 14.29% of the patients with Frankel grade D had improved to Frankel grade E. All the patients had satisfactory spinal stability, as evidenced by dynamic radiographs, after treatment.
The findings from the present study have shown that nonoperative management can result in improved neurological outcomes for patients with underlying degenerative disease who have experienced TCSI without evidence of neurological deterioration and spinal instability. The Frankel grade at presentation was significantly associated with outcome parameters such as the neurological outcome on discharge and the occurrence of urinary tract infection. The results from the present study could be helpful to neurological surgeons in rural and other low-resource settings because the cost savings realized by nonoperative treatment will not sacrifice the provision of adequate care to their patients.
Prognostic factors and optimal management for patients with cervical spinal cord injury without major bone injury
2019, Journal of Orthopaedic Science
Citation Excerpt :
The Surgical Timing in Acute Spinal Cord Injury Study in patients with CSCI (though the subtype of SCI was not specified) demonstrated that early surgery within 24 h of injury was associated with a higher rate of improvement at 6 months compared with late surgery [20]. For patients with CSCI without major bone injury, Inoue et al. concluded that early surgery within 24 h of injury for elderly patients (age ≥65 years) could lead to more favorable neurological improvement [21]. Songs et al. reported that all patients who underwent surgery within 72 h after injury achieved good neurological outcome [22].
Even though the number of patients with cervical spinal cord injury (CSCI) without major bone injury is increased, the treatment with either surgery or conservative measures remains controversial. The aim of this study was to assess its prognostic value in the prediction of useful motor recovery and to clarify whether the patients should be treated surgically are present.
We reviewed 63 patients (conservative, n = 36; surgery, n = 27) with CSCI without major bone injury (Frankel A-C). Neurological examination using modified Frankel grade at admission and 6 months after injury and International Stoke Mandeville Games (ISMG) classification at subacute phase after injury, MRI findings including rate of spinal cord compression, extent of cord damage and type of signal intensity change were assessed.
Thirty-five of 63 patients were improved to walk at 6 months after injury. In multivariate analysis, rate of spinal cord compression, extent of cord damage and improvement of ISMG grade were associated with useful motor recovery. There was no difference in the neurological improvement between conservative and surgical groups. However, patients with spinal cord compression of ≥33.2% showed better motor recovery at 6 months post-injury after surgery than those treated conservatively. There was a positive correlation between the improvement of ISMG grade at subacute phase and Frankel grade at 6 months post-injury. It is difficult to obtain satisfactory surgical outcome for patients with Frankel A or B1 on admission and/or extensive spinal cord damage on T2-weighted image.
Conservative treatment is recommended for patients with CSCI without major bone injury. However, we also recommend surgical treatment to acquire walking ability for patients with spinal cord compression of ≥33.2% and low ISMG grade at subacute phase. Among such patients, careful consideration should be given to patients with Frankel A or B1 and/or extensive spinal cord damage on MRI.

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: Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleEfficacy of Early Surgery for Neurological Improvement in Spinal Cord Injury without Radiographic Evidence of Trauma in the Elderly

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study Design, Ethical Approval, and Setting

Participants

Baseline Patient Characteristics

Results of the Present Study

Conclusions

Acknowledgments

Lancet

Surg Neurol

J Clin Neurosci

Ann Phys Rehabil Med

J Chronic Dis

J Clin Epidemiol

World Neurosurg

Spine J

The epidemiology of traumatic spinal cord injury in British Columbia, Canada

Spine (Phila Pa 1976)

Acute cervical cord injury without fracture or dislocation of the spinal column

J Neurosurg

Prediction of prognosis in patients with cervical spinal cord injury without radiologic evidence of trauma using MRI

Orthopedics

Sequential MRI studies in patients with cervical cord injury but without bony injury

Paraplegia

Clinical relationship between cervical spinal canal stenosis and traumatic cervical spinal cord injury without major fracture or dislocation

Eur Spine J

Clinical and radiological outcomes of spinal cord injury without radiologic evidence of trauma with cervical disc herniation

Arch Orthop Trauma Surg

The potential for functional recovery of upper extremity function following cervical spinal cord injury without major bone injury

Spinal Cord

The syndrome of acute central cervical spinal cord injury

J Neurol Neurosurg Psychiatry

Spinal cord injury without radiologic abnormalities in adults: a systematic review

J Trauma Acute Care Surg

Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS)

PLoS One

Outcome of decompression surgery for cervical spinal cord injury without bone and disc injury in patients with spinal cord compression: a multicenter prospective study

Spinal Cord

Early MRI finding in adult spinal cord injury without radiologic abnormalities does not correlate with the neurological outcome: a retrospective study [letter]

Spinal Cord

Quantitative magnetic resonance imaging analysis correlates with surgical outcome of cervical spinal cord injury without radiologic evidence of trauma

Spinal Cord

Treatment of atypical central cord injury without fracture or dislocation

Orthopedics

Effect of older age on treatment decisions and outcomes among patients with traumatic spinal cord injury

CMAJ

Original Article
Efficacy of Early Surgery for Neurological Improvement in Spinal Cord Injury without Radiographic Evidence of Trauma in the Elderly