A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery

doi:10.1177/2192568217706367

. 2017 Sep;7(3 Suppl):195S-202S.

doi: 10.1177/2192568217706367. Epub 2017 Sep 5.

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery

Michael G Fehlings^{1

2}, Lindsay A Tetreault^{1

3}, Jefferson R Wilson^{2

4}, Bizhan Aarabi⁵, Paul Anderson⁶, Paul M Arnold⁷, Darrel S Brodke⁸, Anthony S Burns⁹, Kazuhiro Chiba¹⁰, Joseph R Dettori¹¹, Julio C Furlan², Gregory Hawryluk⁸, Langston T Holly¹², Susan Howley¹³, Tara Jeji¹⁴, Sukhvinder Kalsi-Ryan¹, Mark Kotter¹⁵, Shekar Kurpad¹⁶, Ralph J Marino¹⁷, Allan R Martin¹, Eric Massicotte¹, Geno Merli¹⁷, James W Middleton¹⁸, Hiroaki Nakashima¹⁹, Narihito Nagoshi^{1

20}, Katherine Palmieri²¹, Anoushka Singh¹, Andrea C Skelly¹¹, Eve C Tsai²², Alexander Vaccaro²³, Albert Yee²⁴, James S Harrop²⁵

Affiliations

¹ Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
² University of Toronto, Toronto, Ontario, Canada.
³ University College Cork, Cork, Ireland.
⁴ St. Michael's Hospital, Toronto, Ontario, Canada.
⁵ University of Maryland, Baltimore, MD, USA.
⁶ University of Wisconsin, Madison, WI, USA.
⁷ University of Kansas Medical Center, The University of Kansas, Kansas City, KS, USA.
⁸ University of Utah, Salt Lake City, UT, USA.
⁹ Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.
¹⁰ National Defense Medical College, Saitama, Japan.
¹¹ Spectrum Research, Inc, Tacoma, WA, USA.
¹² University of California at Los Angeles, CA, USA.
¹³ Christopher & Dana Reeve Foundation, Short Hills, NJ, USA.
¹⁴ Ontario Neurotrauma Foundation, Toronto, Ontario, Canada.
¹⁵ University of Cambridge, Cambridge, England.
¹⁶ Medical College of Wisconsin, Milwaukee, WI, USA.
¹⁷ Thomas Jefferson University Hospital, Philadelphia, PA, USA.
¹⁸ University of Sydney, Sydney, New South Wales, Australia.
¹⁹ Nagoya University, Nagoya, Japan.
²⁰ Keio University, Keio, Japan.
²¹ The University of Kansas, Kansas City, KS, USA.
²² University of Ottawa, Ottawa, Ontario, Canada.
²³ Department of Orthopedic Surgery, Jefferson Health, Thomas Jefferson University, Philadelphia, PA, USA.
²⁴ Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
²⁵ Thomas Jefferson University, Philadelphia, PA, USA.

PMID: 29164024
PMCID: PMC5684850
DOI: 10.1177/2192568217706367

A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery

Michael G Fehlings et al. Global Spine J. 2017 Sep.

. 2017 Sep;7(3 Suppl):195S-202S.

doi: 10.1177/2192568217706367. Epub 2017 Sep 5.

Authors

Affiliations

¹ Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.
² University of Toronto, Toronto, Ontario, Canada.
³ University College Cork, Cork, Ireland.
⁴ St. Michael's Hospital, Toronto, Ontario, Canada.
⁵ University of Maryland, Baltimore, MD, USA.
⁶ University of Wisconsin, Madison, WI, USA.
⁷ University of Kansas Medical Center, The University of Kansas, Kansas City, KS, USA.
⁸ University of Utah, Salt Lake City, UT, USA.
⁹ Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.
¹⁰ National Defense Medical College, Saitama, Japan.
¹¹ Spectrum Research, Inc, Tacoma, WA, USA.
¹² University of California at Los Angeles, CA, USA.
¹³ Christopher & Dana Reeve Foundation, Short Hills, NJ, USA.
¹⁴ Ontario Neurotrauma Foundation, Toronto, Ontario, Canada.
¹⁵ University of Cambridge, Cambridge, England.
¹⁶ Medical College of Wisconsin, Milwaukee, WI, USA.
¹⁷ Thomas Jefferson University Hospital, Philadelphia, PA, USA.
¹⁸ University of Sydney, Sydney, New South Wales, Australia.
¹⁹ Nagoya University, Nagoya, Japan.
²⁰ Keio University, Keio, Japan.
²¹ The University of Kansas, Kansas City, KS, USA.
²² University of Ottawa, Ottawa, Ontario, Canada.
²³ Department of Orthopedic Surgery, Jefferson Health, Thomas Jefferson University, Philadelphia, PA, USA.
²⁴ Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
²⁵ Thomas Jefferson University, Philadelphia, PA, USA.

PMID: 29164024
PMCID: PMC5684850
DOI: 10.1177/2192568217706367

Abstract

Objective: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome.

Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as "we recommend," whereas a weak recommendation is presented as "we suggest."

Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at 6 and 12 months in patients managed with early versus late surgery; and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations were: "We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome" and "We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level." Quality of evidence for both recommendations was considered low.

Conclusions: These guidelines should be implemented into clinical practice to improve outcomes in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies, and encouraging clinicians to make evidence-informed decisions.

Keywords: center cord syndrome; guideline; spinal cord injury; surgery; time of surgery.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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[1] Guha A, Tator C, Endrenyi L. Decompression of the spinal cord improves recovery after acute experimental spinal cord compression injury. Paraplegia. 1987;25:324–339. - PubMed

[2] Guha A, Tator C, Endrenyi L. Decompression of the spinal cord improves recovery after acute experimental spinal cord compression injury. Paraplegia. 1987;25:324–339. - PubMed

[3] Dimar J, Glassman S, Raque G, Zhang YP, Shields CB. The influence of spinal canal narrowing and timing of decompression on neurologic recovery after spinal cord contusion in a rat model. Spine (Phila Pa 1976). 1999;24:1623–1633. - PubMed

[4] Dimar J, Glassman S, Raque G, Zhang YP, Shields CB. The influence of spinal canal narrowing and timing of decompression on neurologic recovery after spinal cord contusion in a rat model. Spine (Phila Pa 1976). 1999;24:1623–1633. - PubMed

[5] Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006;31(11 suppl):S28–S35. doi:10.1097/01.brs.0000217973.11402.7f. - PubMed

[6] Fehlings MG, Perrin RG. The timing of surgical intervention in the treatment of spinal cord injury: a systematic review of recent clinical evidence. Spine (Phila Pa 1976). 2006;31(11 suppl):S28–S35. doi:10.1097/01.brs.0000217973.11402.7f. - PubMed

[7] Batchelor PE, Wills TE, Skeers P, et al. Meta-analysis of pre-clinical studies of early decompression in acute spinal cord injury: a battle of time and pressure. PLoS One. 2013;8:e72659 doi:10.1371/journal.pone.0072659. - PMC - PubMed

[8] Batchelor PE, Wills TE, Skeers P, et al. Meta-analysis of pre-clinical studies of early decompression in acute spinal cord injury: a battle of time and pressure. PLoS One. 2013;8:e72659 doi:10.1371/journal.pone.0072659. - PMC - PubMed

[9] Shiffman RN, Michel G. Toward improved guideline quality: using the COGS statement with GEM. Stud Health Technol Inform. 2004;107:159–163. - PubMed

[10] Shiffman RN, Michel G. Toward improved guideline quality: using the COGS statement with GEM. Stud Health Technol Inform. 2004;107:159–163. - PubMed

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery

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