Surgical Intervention in Spinal Cord Injury SCI

1. Surgical Intervention in Spinal Cord Injury (SCI) 4B2 Ri ???

2. References Surgical controversies in the management of spinal cord injury --J Am coll Surg, Vol.188, No.5, May 1999 Early versus late surgical decompression in the setting of cervical spinal cord injury --Journal of controversial medical claims, Vol.8, No.4, Nov 2001

3. SCI Prevalence: 500~900 per million population Male : female= 3~4 : 1 Median age: 25 y/o Cause: vehicle accidents(45%), falls(22%), sports(14%), violence(14%)

4. The goal of treating SCI Maximize neurologic recovery Restore normal alignment and correct deformity Promote spinal stability, fusion, or both Minimize pain Facilitate early mobilization and rehabilitation Minimize hospitalization and cost Prevent secondary complications

5. Burden of care Cervical SCI with quadriplegia: $100,000-- initial hospitalization $50,000~$75,000-- rehabilitation Mean duration of survival: >30 years Average lifetime medical cost: $1 million! Indirect cost: lost productivity to the society

6. Medical therapy (NASCIS?) Methylprednisolone iv bolus(30mg/kg), then 5.4mg/kg/hr infusion* 23hrs More effective if started within 3 hrs after injury >24hr therapy: associated with more severe pneumonia BP elevation and volume expansion: enhancing spinal cord blood flow Mechanisms of action -- Anti-inflammatory (glucocorticoid receptor mediated mechanisms) -- Immunosuppression (suppresses cytokine & antibody production) -- Anti-oxidant & lipid peroxidation inhibitor (high dose only) -- Critical time period: 3~5d?maximum cord edema & congestionMechanisms of action -- Anti-inflammatory (glucocorticoid receptor mediated mechanisms) -- Immunosuppression (suppresses cytokine & antibody production) -- Anti-oxidant & lipid peroxidation inhibitor (high dose only) -- Critical time period: 3~5d?maximum cord edema & congestion

7. Surgical therapies (NASCIS?) Stabilization & Decompression --Stabilization Anterior and posterior plates Titanium cage & other vertebral fusion methods --Delayed decompression restore function (Bohlman) --Untethering spinal cord improves function --Adcon gel and other methods to prevent epidural scarring

8. Surgical management Lacking of incontrovertible guidelines to define the role of surgery Retrospective analyses of unrandomized case series Surgical controversies: the role of decompression and stabilization

9. Timing of surgical decompression Animal models Tarlov: using balloons causing compression of L-spine <1min?full recovery <5min?partial recovery >5min?no recovery

10. Surgical decompression NASCIS? trial(487 patients) No statistically significant improvement in the neurological recovery, regardless of the nature or timing of surgical intervention

11. Other clinical studies Vaccaro et al: A prospective randomized study of 62 patients Gr.1(34): surgery within 72 hrs Gr.2(28): 5 days after injury Results: no significant differences in ICU stay, duration of rehabilitation, or neurological recovery May due to an inappropriate definition of �early decompression� Surgery ?? stabilization alone or stabilization with decompressionSurgery ?? stabilization alone or stabilization with decompression

12. Clinical studies Mirza et al: 30 acute C-spine injury at 2 different medical centers 15 p�t?close reduction & surgery within 72 hrs 15 p�t?close reduction & observed*10~14d before surgery Result: Increased length of acute care hospitalization in the delay surgery group Significant improvement between pre-op and post-op neurological function No difference in total No. of complications, length of ICU stay, length of mechanical ventilationNo difference in total No. of complications, length of ICU stay, length of mechanical ventilation

13. Surgical decompression Heiden: early operative intervention was associated with significantly greater pulmonary morbidity(46%) than later surgery(27%) Other studies: delay spinal surgery for 48~72 hrs may decrease intra-op blood loss by two-thirds.

14. Complication rate Schlegel et al: Surgery after 72hrs post-injury and within 48hrs The 72hrs group has higher rates of--- Pulmonary complications(12.2�) Pressure sores(4.8�) UTI(3.2�)

15. Medical cost Schlegel et al: Surgery within 24 hrs of injury Lowest average medical cost Due to decreased ventilator needs and shorter ICU and overall hospital stay

16. Surgical stabilization Decrease hospitalization time Decrease complications Earlier mobilization Overall decreased costs

17. Surgical stabilization Wilberger: early vs late stabilization Post-op neuro. Deterioration-- 0% vs 2.5% Incidence of complications was reduced by over 50%-- pneumonia, thrombophlebitis, pulmonary embolism, etc. Murphy: early surgical stabilization Hospitalized 21 fewer days than treated with external cervical orthoses

18. Conclusions Lack of well-designed prospective studies Overly broad definition of �early surgery�

19. Thanks for your attention!!!