Timing of Surgery in the Setting of Acute Spinal Cord Injury

The efficacy of early surgical decompression in the setting of acute spinal cord injury (SCI) has been actively discussed for decades. Primary spinal cord damage due to spinal cord contusion or compression leads to neurological tissue destruction potentiated by a post-lesion signaling cascade of downstream events, known as the secondary injury. Although there are still few therapeutic options leading to neurological recovery, preclinical animal studies have suggested that persistent spinal cord compression exacerbates secondary injury following SCI and that early surgical decompression of the spinal cord mitigates spinal cord damage, leading to improved functional outcomes. Although the heterogeneity of injuries, surgical procedures, and the definition of early decompression make it difficult to draw a definitive conclusion, clinical studies to date have provided supportive evidence for this preclinical result. Several clinical trials, including a number of prospective studies such as the STASCIS trial, showed benefits of early decompression in terms of neurological improvement, shorter hospital stay, and decreased complications, while other studies have argued that early intervention does not offer an advantage. Systematic reviews have also indicated that early decompression after SCI results in improved clinical outcomes compared to both delayed decompression and conservative treatment. In addition, from an efficacy standpoint, the 24-h cutoff for early decompression has been shown to represent the most effective time window during which surgical decompression had the potential to confer a neuroprotective effect.