Early surgical decompression tied to better outcomes in central cord syndrome; JAMA

Based on the finding, Jetan H. Badhiwala, University of Toronto, Toronto, Ontario, Canada, and colleagues suggest redefining treatment paradigms for CCS to include early surgical decompression as a neuroprotective therapy.

Spinal cord contusion following a fall in a patient with underlying cervical spondylosis is one of the most common forms of spinal cord injury (SCI) in the US. This central cord syndrome has produced a vexing modern problem: the belief that CCS carries a more conducive prognosis leads to a higher likelihood of delaying surgical decompression in clinical practice. There is no clarity in the optimal clinical management of CCS, yet this has become an increasingly relevant public health problem in the aging population.

Against the above background, Dr. Badhiwala and associates aimed to provide a head-to-head comparison of the functional and neurologic outcomes of early (<24 hours) vs. late (≥24 hours) surgical decompression for CCS in a propensity score–matched cohort study.

The study identified patients with CCS from 3 international multicenter studies containing data on surgical decompression timing in spinal cord injury. The study included patients who underwent surgery for CCS (defined as lower extremity motor score - upper extremity motor score ≥ 5). Data collection was done from December 1991 to March 2017, and analysis was performed between March 2020 to January 2021. Participants with documented baseline neurologic examination performed within 14 days of injury were included. Patients who underwent surgical decompression for CCS were deemed eligible.

The final study cohort comprised 186 CCS patients. 93 were in the early-surgery group and 93 in the late-surgery group.

The study led to the following findings:

• Early surgical decompression significantly improved recovery in the upper limb (mean difference [MD], 2.3) but not lower limb (MD, 1.1), motor function.
• In an a priori–planned subgroup analysis, outcomes were similar with early or late decompressive surgery in patients with ASIA Impairment Scale (AIS) grade D injury.
• Early surgery in patients with AIS grade C injury resulted in significantly greater recovery in an overall motor score (MD, 9.5), owing to gains in both upper and lower limb motor function.

"In patients with CCS, early surgical decompression resulted in improved recovery in upper limb motor function at one year," the researchers wrote.

"Treatment paradigms for CCS should be redefined to encompass early surgical decompression as a neuroprotective therapy," they concluded.

Reference:

Badhiwala JH, Wilson JR, Harrop JS, et al. Early vs Late Surgical Decompression for Central Cord Syndrome. JAMA Surg. Published online September 28, 2022. doi:10.1001/jamasurg.2022.4454