Efficacy of Early (≤ 24 Hours), Late (25-72 Hours), and Delayed (>72 Hours) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades C and D Acute Traumatic Central Cord Syndrome Caused by Spinal Stenosis

Abstract

The therapeutic significance of timing of decompression in acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis remains unsettled. We retrospectively examined a homogenous cohort of patients with ATCCS and magnetic resonance imaging (MRI) evidence of post-treatment spinal cord decompression to determine whether timing of decompression played a significant role in American Spinal Injury Association (ASIA) motor score (AMS) 6 months following trauma. We used the t test, analysis of variance, Pearson correlation coefficient, and multiple regression for statistical analysis. During a 19-year period, 101 patients with ATCCS, admission ASIA Impairment Scale (AIS) grades C and D, and an admission AMS of ≤95 were surgically decompressed. Twenty-four of 101 patients had an AIS grade C injury. Eighty-two patients were males, the mean age of patients was 57.9 years, and 69 patients had had a fall. AMS at admission was 68.3 (standard deviation [SD] 23.4); upper extremities (UE) 28.6 (SD 14.7), and lower extremities (LE) 41.0 (SD 12.7). AMS at the latest follow-up was 93.1 (SD 12.8), UE 45.4 (SD 7.6), and LE 47.9 (SD 6.6). Mean number of stenotic segments was 2.8, mean canal compromise was 38.6% (SD 8.7%), and mean intramedullary lesion length (IMLL) was 23 mm (SD 11). Thirty-six of 101 patients had decompression within 24 h, 38 patients had decompression between 25 and 72 h, and 27 patients had decompression >72 h after injury. Demographics, etiology, AMS, AIS grade, morphometry, lesion length, surgical technique, steroid protocol, and follow-up AMS were not statistically different between groups treated at different times. We analyzed the effect size of timing of decompression categorically and in a continuous fashion. There was no significant effect of the timing of decompression on follow-up AMS. Only AMS at admission determined AMS at follow-up (coefficient = 0.31; 95% confidence interval [CI]:0.21; p = 0.001). We conclude that timing of decompression in ATCCS caused by spinal stenosis has little bearing on ultimate AMS at follow-up.

Keywords: decompression; outcome; spinal cord injury; timing; trauma.

FIG. 1.

Bar graph depicting the relationship between admission and follow-up American Spinal Injury Association (ASIA) motor score (AMS) when 101 patients with acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis were fully decompressed within 24, 25–72, and >72 h following trauma.

FIG. 2.

Scatter graph of the final American Spinal Injury Association (ASIA) motor score (AMS) versus time to decompression in 101 patients with acute traumatic central cord syndrome (ATCCS) caused by spinal stenosis.

FIG. 3.

Following a ground-level fall, this 75-year-old woman had an American Spinal Injury Association (ASIA) motor score (AMS) of 52. Computed tomography (CT) scan indicated swan-neck deformity (panel A) with a Cobb angle of -13 degrees. Magnetic resonance imaging (MRI) indicated a four-segment spinal stenosis and evidence of mild extension distraction injury at C4/C5 skeletal segment (arrow) (panel B), maximum canal compromise (MCC) was 42.3% and intramedullary lesion length (IMLL) was 22.1 mm. Sixty-nine hours following her trauma, a laminectomy was performed (panels C,D). Her post-operative Cobb angle was 24 degrees. Twelve months after discharge her AMS was 85.