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Comment
. 2022 Nov 1;157(11):1024-1032.
doi: 10.1001/jamasurg.2022.4454.

Early vs Late Surgical Decompression for Central Cord Syndrome

Jetan H Badhiwala  1 , Jefferson R Wilson  1   2 , James S Harrop  3 , Alexander R Vaccaro  4 , Bizhan Aarabi  5 , Fred H Geisler  6 , Michael G Fehlings  1   7
Affiliations
Comment

Early vs Late Surgical Decompression for Central Cord Syndrome

Jetan H Badhiwala et al. JAMA Surg. .

Abstract

Importance: The optimal clinical management of central cord syndrome (CCS) remains unclear; yet this is becoming an increasingly relevant public health problem in the face of an aging population.

Objective: To provide a head-to-head comparison of the neurologic and functional outcomes of early (<24 hours) vs late (≥24 hours) surgical decompression for CCS.

Design, setting, and participants: Patients who underwent surgery for CCS (lower extremity motor score [LEMS] - upper extremity motor score [UEMS] ≥ 5) were included in this propensity score-matched cohort study. Data were collected from December 1991 to March 2017, and the analysis was performed from March 2020 to January 2021. This study identified patients with CCS from 3 international multicenter studies with data on the timing of surgical decompression in spinal cord injury. Participants were included if they had a documented baseline neurologic examination performed within 14 days of injury. Participants were eligible if they underwent surgical decompression for CCS.

Exposures: Early surgery was compared with late surgery.

Main outcomes and measures: Propensity scores were calculated as the probability of undergoing early compared with late surgery using the logit method and adjusting for relevant confounders. Propensity score matching was performed in a 1:1 ratio by an optimal-matching technique. The primary end point was motor recovery (UEMS, LEMS, American Spinal Injury Association [ASIA] motor score [AMS]) at 1 year. Secondary end points were Functional Independence Measure (FIM) motor score and complete independence in each FIM motor domain at 1 year.

Results: The final study cohort consisted of 186 patients with CCS. The early-surgery group included 93 patients (mean [SD] age, 47.8 [16.8] years; 66 male [71.0%]), and the late-surgery group included 93 patients (mean [SD] age, 48.0 [15.5] years; 75 male [80.6%]). Early surgical decompression resulted in significantly improved recovery in upper limb (mean difference [MD], 2.3; 95% CI, 0-4.5; P = .047), but not lower limb (MD, 1.1; 95% CI, -0.8 to 3.0; P = .30), motor function. In an a priori-planned subgroup analysis, outcomes were comparable with early or late decompressive surgery in patients with ASIA Impairment Scale (AIS) grade D injury. However, in patients with AIS grade C injury, early surgery resulted in significantly greater recovery in overall motor score (MD, 9.5; 95% CI, 0.5-18.4; P = .04), owing to gains in both upper and lower limb motor function.

Conclusions and relevance: This cohort study found early surgical decompression to be associated with improved recovery in upper limb motor function at 1 year in patients with CCS. Treatment paradigms for CCS should be redefined to encompass early surgical decompression as a neuroprotective therapy.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Badhiwala reported receiving a fellowship award from the Canadian Institutes of Health Research during the conduct of the study. Dr Wilson reported receiving personal fees from Stryker Canada outside the submitted work. Dr Vaccaro reported receiving personal fees from Aesculap, Atlas Spine, Globus, Medtronic, SpineWave, and Stryker Spine; being a board member of National Spine Health Foundation and Sentryx; and owning stock options from Advanced Spinal Intellectual Properties, Avaz Surgical, AVKN Patient Driven Care, Bonovo Orthopaedics, Computational Biodynamics, Cytonics, Deep Health, Dimension Orthotics LLC, Electrocore, Flagship Surgical, FlowPharma, Innovative Surgical Design, Jushi, Nuvasive, Orthobullets, Parvizi Surgical Innovation, Progressive Spinal Technologies, Replication Medica, Spine Medica, Spineology, Stout Medical, Surgalign, and ViewFi Health outside the submitted work. Dr Fehlings reported receiving funding support from the Robert Campeau Family Foundation/Dr C.H. Tator Chair in Brain and Spinal Cord Research at University Health Network. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flowchart of Patient Eligibility and Enrollment
CCS indicates central cord syndrome; LEMS, lower extremity motor score; NACTN, North American Clinical Trials Network; NASCIS, National Acute Spinal Cord Injury Study; STASCIS, Surgical Timing in Acute Spinal Cord Injury Study; UEMS, upper extremity motor score.
Figure 2.
Figure 2.. Distribution of Propensity Scores
Distribution of propensity scores among raw-treated (A), match-treated (B), raw-control (C), and match-control (D) study groups with 1:1 optimal matching.
See this image and copyright information in PMC

Comment on

References

    1. Badhiwala JH, Wilson JR, Fehlings MG. Global burden of traumatic brain and spinal cord injury. Lancet Neurol. 2019;18(1):24-25. doi:10.1016/S1474-4422(18)30444-7 - DOI - PubMed
    1. Jain NB, Ayers GD, Peterson EN, et al. . Traumatic spinal cord injury in the US, 1993-2012. JAMA. 2015;313(22):2236-2243. doi:10.1001/jama.2015.6250 - DOI - PMC - PubMed
    1. Thompson C, Mutch J, Parent S, Mac-Thiong JM. The changing demographics of traumatic spinal cord injury: an 11-year study of 831 patients. J Spinal Cord Med. 2015;38(2):214-223. doi:10.1179/2045772314Y.0000000233 - DOI - PMC - PubMed
    1. Fehlings MG, Tetreault L, Nater A, et al. . The aging of the global population: the changing epidemiology of disease and spinal disorders. Neurosurgery. 2015;77(suppl 4):S1-S5. doi:10.1227/NEU.0000000000000953 - DOI - PubMed
    1. Pouw MH, van Middendorp JJ, van Kampen A, et al. ; EM-SCI study group . Diagnostic criteria of traumatic central cord syndrome. part 1: a systematic review of clinical descriptors and scores. Spinal Cord. 2010;48(9):652-656. doi:10.1038/sc.2009.155 - DOI - PubMed

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