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Front. Biol.    2014, Vol. 9 Issue (2) : 127-136    https://doi.org/10.1007/s11515-014-1297-z
REVIEW
Surgical decompression in acute spinal cord injury: A review of clinical evidence, animal model studies, and potential future directions of investigation
Yiping LI1,Chandler L. WALKER1,Yi Ping ZHANG2,Christopher B. SHIELDS2,*(),Xiao-Ming XU1,*()
1. Spinal Cord and Brain Injury Research Group, Stark Neurosciences Research Institute, Department of Neurological Surgery and Goodman and Campbell Brain and Spine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
2. Norton Neuroscience Institute, Norton Healthcare, Louisville, KY 40202, USA
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Abstract

The goal for treatment in acute spinal cord injury (SCI) is to reduce the extent of secondary damage and facilitate neurologic regeneration and functional recovery. Although multiple studies have investigated potential new therapies for the treatment of acute SCI, outcomes and management protocols aimed at ameliorating neurologic injury in patients remain ineffective. More recent clinical and basic science research have shown surgical interventions to be a potentially valuable modality for treatment; however, the role and timing of surgical decompression, in addition to the optimal surgical intervention, remain one of the most controversial topics pertaining to surgical treatment of acute SCI. As an increasing number of potential treatment modalities emerge, animal models are pivotal for investigating its clinical application and translation into human trials. This review critically appraises the available literature for both clinical and basic science studies to highlight the extent of investigation that has occurred, specific therapies considered, and potential areas for future research.
Keywords acute spinal cord injury      surgical decompression      durotomy      animal models     
Corresponding Author(s): Christopher B. SHIELDS   
Issue Date: 13 May 2014
 Cite this article:   
Yiping LI,Chandler L. WALKER,Yi Ping ZHANG, et al. Surgical decompression in acute spinal cord injury: A review of clinical evidence, animal model studies, and potential future directions of investigation[J]. Front. Biol., 2014, 9(2): 127-136.
 URL:  
https://academic.hep.com.cn/fib/EN/10.1007/s11515-014-1297-z
https://academic.hep.com.cn/fib/EN/Y2014/V9/I2/127
InvestigatorSample sizeLocationStudy typeTiming of decompressionInterventionResults
Levi et al., (1991)103CervicalRetrospective±24 hoursAnterior decompression and stabilizationEarly decompression resulted in reduced hospitalization stay but no significant difference in functional grade improvement at discharge
Krengel et al., (1993)14ThoracicRetrospective±24 hoursPosterior and/or anterior decompression and fusionEarly surgical reduction, stabilization, and decompression is safe and improves neurologic recovery in comparison to historical controls treated by postural reduction or late surgical intervention
Duh et al., (1994)37UnknownRetrospective±24 hoursAnterior and posterior decompression with body and disk excision, internal fixation, and/or fusionThere is no statistically significant advantage to the timing of surgery. However, in these models, the degree of the initial injury is confirmed as the most powerful predictor of motor recovery.
Botel et al., (1997)178UnknownProspective±24 hoursAnterior and posterior decompression and stabilizationNeurological recovery could only be found in those with incomplete lesions in more than 50%
Campagnolo et al., (1997)64Cervical, thoracic, lumbar, cauda equinaRetrospective±24 hoursSpinal stabilizationSpinal stabilization performed<24 hours after injury is associated with a significantly shorter length of stay in the hospital.
Tator, et al., (1999)88Cervical, thoracic, lumbar, cauda equinaRetrospective±24 hoursDecompression and/or stabilizationThere was a lack of consensus among centers concerning the optimum timing of surgical treatment, and only a minority of patients underwent surgery within 24 hours of trauma. Adequate long term follow-up was not obtained.
Guest et al., (2002)50Traumatic central cordRetrospective±24 hoursAnterior and/or posterior decompression and stabilizationEarly surgery is safe and more cost effective than late surgery for the treatment of traumatic CCS, based on ICU stay and LOS and improved overall motor recovery, in patients whose CCS was related to acute disc herniation or fracture. In the setting of spinal stenosis or spondylosis, early surgery was safe but did not improve motor outcome compared with late surgery.
Pollard et al., (2003)412AllRetrospective±24 hoursAnterior decompressionImproved neurologic outcomes were noted in younger patients and those with either a central cord or Brown-Sequard syndrome.
Ng et al., (1999)26CervicalProspective±8 hoursTotal laminectomy, flavectomy, and stabilizationPatients with surgical decompression within 8 hours showed significantly shorter overall hospital and intensive care unit stay and had lesser systemic complications and also exhibited better neurological improvement
Cengiz et al., (2008)27Thoracic lumbarProspective±8 hoursDecompression and stabilizationPatients with surgical decompression within 8 hours showed significantly shorter overall hospital also exhibited better neurological outcomes
Fehlings et al., (2012)313CervicalProspective±24 hoursDecompression and stabilizationGreater % patients with decompression within 24 hours had≥2 ASIA scores at 6 month follow-up than those receiving delayed surgery (≥24 hours)
Wilson et al. (2012)84Cervical thoracic lumbarProspective±24 hoursDecompression and stabilizationPatients with decompression surgery<24 hours post-injury had greater ASIA motor recovery than those with surgery≥24 hours post-SCI.
Tab.1  Clinical research on timing and type of surgical decompression in post-SCI
InvestigatorSpeciesInjury modelTiming of decompressionInterventionResults
Delamarter et al., (1995)DogsCircumferential cable1 hour-1 weekRemoval of the Pressure cableDecompression is inversely proportional to duration of compression
Carlson et al., (1997)DogsPiston5 min, 1, and 3 hoursRemoval of pressure pistonDecompression at 5 min, 30 min, and 1 hour improves recovery of evoked potentials
Dimar et al., (1999)RatsExtradural impactor0, 2, 6, 24, and 72 hoursRemoval of pressure spacerNeurologic recovery is inversely related to extend and duration of compression
Carlson et al., (2003)DogsPiston30 min and 3 hoursRemoval of pressure pistonRecovery was obtained the 30 minute group but absent in the 3 hour group
Rabinowitz et al., (2008)DogsNylon tie6 hoursSurgery±methylprednisoloneSurgical decompression with or without methylprednisolone, improved recovery
Smith, (2010)RatsInfinite horizon impactor4 hoursDurotomy±dural allograftDurotomy alone showed increased scar and cavity formation while durotomy with dural allograft showed improved recovery compared to sham and durotomy alone
Jones et al., (2012a)PigsWeight-drop impact, 8 hours weight compression8 hrsRemoval of 100g weightDecompression post-moderate SCI initially increased cord expansion that generally stabilized; Severe SCI caused sustained cord swelling and occlusion of subarachnoid space
Jones et al., (2012b)PigsWeight-drop impact, 8 hours weight compression8 hrsRemoval of 100g weightCranial CSFP elevated and caudal CSFP slightly decreased during spinal compression; Responses reversed immediately post-decompression, then resolution of pressure differential
Tab.2  Basic research on decompression post-SCI
Fig.1  Spinal cord swelling following traumatic C5 hemicontusion injury in rats. (A) Photomicrograph depicting hemorrhage and swelling due to trauma on the side ipsilateral to injury (right), and no swelling or morphological change on the contralateral uninjured side (left) of the cord. (B) Camera lucida drawing of the photomicrograph in (A) highlighting the morphological differences between the ipsilateral and contralateral sides of injury in the rat cervical spinal cord. The lesion is indicated by the region colored in light-red.
Fig.2  Illustrations of the normal spine, injured vertebra and spinal cord, and surgical decompression methods to alleviate pressure from cord swelling. (A) Transverse illustration of a normal vertebra, dura mater (dark blue), subarachnoid space containing the cerebrospinal fluid (CSF, light blue), pia mater (green), and the spinal cord. (B) Traumatic spine fracture inflicts compressive spinal cord damage, leading to vascular rupture, hemorrhage and swelling of the cord resulting in the occlusion of the subarachnoid space and blockade of the CSF flow. (C) Durotomy, i.e., longitudinal incision of the dura mater, may release the cord pressure caused by tissue swelling and, therefore, reduce secondary tissue damage. (D) Piotomy, i.e., longitudinal incision of the pia mater, may afford further cord expansion to reduce further tissue damage of the injured spinal cord.
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