An evidence-based review of decompressive surgery in acute spinal cord injury: rationale, indications, and timing based on experimental and clinical studies.
OBJECTIVE
The authors conducted an evidence-based review of the literature to evaluate critically the rationale and indications for and the timing of decompressive surgery for the treatment of acute, nonpenetrating spinal cord injury (SCI).


METHODS
The experimental and clinical literature concerning the role of, and the biological rationale for, surgical decompression for acute SCI was reviewed. Clinical studies of nonoperative management of SCI were also examined for comparative purposes. Evidence from clinical trials was categorized as Class I (well-conducted randomized prospective trials), Class II (well-designed comparative clinical studies), or Class II (retrospective studies). Examination of studies in which animal models of SCI were used consistently demonstrated a beneficial effect of early decompressive surgery, although it is difficult to apply these data directly to the clinical setting. The clinical studies provided suggestive (Class III and limited Class II) evidence that decompressive procedures improve neurological recovery after SCI. However, no clear consensus can be inferred from the literature as to the optimum timing for decompressive surgery. Many authors have advocated delayed treatment to avoid medical complications, although good evidence from recent Class II trials indicates that early decompressive surgery can be performed safely without causing added morbidity or mortality.


CONCLUSIONS
There is biological evidence from experimental studies in animals that early decompressive surgery may improve neurological recovery after SCI, although the relevant interventional timing in humans remains unclear. To date, the role of surgical decompression in patients with SCI is only supported by Class III and limited Class II evidence. Accordingly, decompressive surgery for SCI can only be considered a practice option. Furthermore, analysis of the literature does not allow definite conclusions to be drawn regarding appropriate timing of intervention. Hence, there is a need to conduct well-designed experimental and clinical studies of the timing and neurological results of decompressive surgery for the treatment of acute SCI.
Fehlings
M G
MG
Division of Neurosurgery and Spinal Program, Toronto Hospital and University of Toronto, Ontario, Canada. mfehlings@torhosp.toronto.on.ca
Tator
C H
CH
D000208:Acute Disease; D000818:Animals; D002986:Clinical Trials as Topic; D019299:Decompression, Surgical / Q000009:adverse effects / Q000145:classification / Q000379:methods; D004195:Disease Models, Animal; D019317:Evidence-Based Medicine; D006801:Humans; D009460:Neurologic Examination; D011183:Postoperative Complications; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D013116:Spinal Cord / Q000503:physiopathology; D013119:Spinal Cord Injuries / Q000601:surgery* / Q000628:therapy; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000601:surgery* / Q000628:therapy