Early surgical decompression may improve motor function in central cord syndrome
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Patients with central cord syndrome who underwent early surgical decompression had improved recovery in upper limb motor function at 1 year compared with patients who underwent late surgical decompression, according to published results.
“Our paper provides strong evidence based on a propensity-matched prospective comparative cohort study that early surgical intervention (within 24 hours) of injury improves neurological outcomes for all individuals with central cord injury, with a particularly strong signal seen in patients with an [American Spinal Injury Association impairment scale] AIS C severe central cord injury,” Michael G. Fehlings, MD, PhD, FRCSC, professor of neurosurgery and Campeau-Tator Chair in Brain and Spinal Cord Research at the University of Toronto, told Healio. “The impact of early surgery in patients with less severe (AIS D) central cord injury was less clear, likely due to the relatively insensitivity of the outcome measures used.”
Using three international multicenter studies with data on the timing of surgical decompression in spinal cord injury, Fehlings and colleagues propensity score matched patients with central cord syndrome who underwent early surgical decompression (n=93) to those who underwent late surgical decompression (n=93). Researchers calculated propensity scores as the probability of undergoing early surgery compared with late surgery using the logit method and adjusting for relevant confounders.
Researchers considered motor recovery at 1 year as measured by upper extremity motor score, lower extremity motor score and American Spinal Injury Association (ASIA) motor score as the primary endpoint, while secondary endpoints included functional independence measure motor score and complete independence in each functional independent measure motor domain at 1 year.
Results showed significantly improved recovery in upper limb motor function but not lower limb motor function among patients who underwent early surgical decompression. Although patients with an AIS grade D injury had comparable outcomes with either early or late decompression surgery, researchers found significantly greater recovery in overall motor scores with early surgery among patients with AISA grade C injury.
“For patients with AIS C central cord injury, early surgical intervention within 24 hours is strongly recommended. For AIS D central cord injuries, surgery is recommended, but there is a less compelling rationale for early intervention,” Fehlings said. “Future work is required to determine the optimal approaches for AIS D patients. In addition, it is recognized that a subset of patients with central cord injury are elderly and frail with medical comorbidities. Considerable judgment is required in managing these patients and early surgical intervention may not always be feasible.”
Perspective
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This propensity score-matched cohort study demonstrates significant improvements at 1 year in upper and lower extremity motor strength for the group of patients with central cord syndrome who were decompressed less than 24 hours following injury. The narrowly defined group consisted of ASIA C or D patients with a cervical spine injury in which lower extremity motor score minus upper extremity motor score was 5 or greater.
As pointed out in the study discussion, patient improvement is not binary but more of a continuum. There are many individual patient factors that affect the time from injury to decompression. These factors are variable and specific to each patient and their specific spinal cord injury. These may include the time of diagnosis of central cord syndrome, medical comorbidities and the patient’s medical condition. The average age of each surgical group in this study was young at 48 years old. Steroid use was similar in both surgical groups.
This study defined early as less than 24 hours. The findings in this study are consistent with others, including systematic reviews. Other studies in the literature suggest time to decompression of 24 to 48 hours or more for cord level injuries. While patients with less severe spinal cord injuries (Frankel D or E) may more likely be treated nonsurgically, there may be a beneficial role for early surgical intervention in patients with central cord syndrome who present similar to this cohort of incomplete Frankel C and D injuries.
Reference:
Lenehan B, et al. Spine (Phila Pa 1976). 2010;doi:10.1097/BRS.0b013e3181f32a44.
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