Spinal cord infarction: A systematic review and meta-analysis of patient's characteristics, diagnosis accuracy, management, and outcome

Abstract

Background: Acute spinal cord infarction (SCI) is a rare ischemic vascular lesion. It is difficult to diagnose during the acute phase because the clinical features can vary widely, and the diffusion-weighted imaging of spinal cord magnetic resonance imaging (MRI) often fails to detect any obvious abnormality. The first aim of this study was to describe the SCI patients' characteristics, evaluate the accuracy of its diagnosis tools and management, and then find the strength of the effect of spinal surgical decompression on the patient's outcome.

Methods: A PubMed keyword and Boolean search using ("spinal cord infarction" OR "spinal cord ischemia" AND diagnosis OR management OR outcome) returned 221,571 results by applying filters. We added 17,400 results from Google Scholar. Fourteen studies were included in the quantitative meta-analysis of mean differences.

Results: The Time to Nadir was <6 h (56.1%), 6-12 h (30.7%), 12-72 h (5.4%), and more than 72 h (7.8%). The higher proportion of Owl's eye findings in the MRI was reported at the cervical level (39.6%) and thoracic level (22.9%) P = 0.031. The T2DWI has a moderate accuracy (area under the curve = 0.835) in detecting the T2 hypersignal intensity (T2HSI) at the hyperacute time to NADIR (<6 h). The median modified Rankin Scale (mRS) at admission was 3 (2-3), and after a follow-up duration of 12 months (6-15.5), the median mRS was reported to be 1 (1-2). About 68.9% benefited from medical treatment and physiotherapy, whereas spinal surgical decompression was done in 22.8%. Seventy percent of the overall studies favor spinal surgical decompression, with the estimated average standardized mean difference between medical and surgical treatment being = 1.2083 (95% confidence interval: 1.0250-1.3917).

Conclusion: The T2DWI has moderate accuracy in detecting the T2HSI at the hyperacute time (NADIR <6 h). Even though surgical decompression favored good outcomes, medical treatment with physiotherapy was mostly used for the management of SCI.

Keywords: Diagnosis; Management and outcome; Patient characteristics; Spinal cord infarction; Spinal cord ischemia.

Figure 1:

Preferred Reporting Items for Systematic Review and Meta-analyses Flowchart for studies selection.

Figure 2:

Time to NADIR, initial T2DWI, and T2HSI by the level of the lesion. T2HSI: T2 hypersignal intensity, T2DWI:T2 diffusion weighted image.

Figure 3:

The outcome and follow-up duration of the spinal cord infarction. mRS: Modified Rankin scale.

Figure 4:

The binomial logistic regression for the accuracy of the MRI T2DWI for the detection of T2HSI at the hyperacute time to NADIR (<6 h). AUC = 0.835, the T2DWI has a moderate accuracy in detecting the T2HSI at the hyperacute time to NADIR (<6 h). MRI: Magnetic imaging imaging, T2DWI: T2 diffusion weighted image, T2HSI: T2 hypersignal intensity. AUC: Area under the curve

Figure 5:

(a) Forest plot comparing the mean differences of the effect of spinal surgical decompression as a treatment of SCI and the medical treatment. Zero is the line of no effect. The overall pooled effect did not cross the line of no effect, suggesting a statistically significant difference in the outcome between surgical and medical treatment of the SCI. More than 70% of the estimates are positive. Thus, the population of the overall studies favors spinal surgical decompression, with the estimated average standardized mean difference between medical and surgical treatment being = 1.2083 (95% CI: 1.0250–1.3917) with z = 12.9188, P < 0.0001. (b) Assessment of study bias with Funnel plots. There is no funnel plot asymmetry (Begg and Mazumdar Rank Correlation, P = 0.2331 and Egger’s Regression test, P = 0.1396). No study bias was found. SCI: Spinal cord infarction, CI: Confidence interval.