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      Does surgical treatment within 4 hours after trauma have an influence on neurological remission in patients with acute spinal cord injury?

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          Abstract

          Background

          The proper timing for surgery in patients with acute spinal cord injury is controversial. This study was conducted to detect if there is an advantage in early (within the first 4 hours after trauma) compared to late (between 4 and 24 hours after trauma) surgery on neurological outcome.

          Methods

          In this single institution prospective cohort study, data were analyzed from 51 spinal cord injured patients with an average age of 43.4 (±19.2) years. The influence of early (29 patients within the first 4 hours) as opposed to late (22 patients between 4 and 24 hours) decompression was evaluated by comparing data for neurological outcome. Patients of the study collectively suffered acute spinal fractures from C2 to L3 (cervical 39.2%, thoracic 29.4%, and lumbal 21.6%) or nonosseous lesions (9.8%). American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades were assessed at time of admission and 6 months after trauma or longer depending on the time of release. Surgical treatment included early stabilization and decompression within 24 hours.

          Results

          No significant difference between improved neurological function, measured with the AIS, and an early or late surgery time can be seen ( P=0.402). Furthermore, binary logistic regression shows no significant difference between sex or age, and AIS improvement as possible confounders.

          Conclusion

          In our study, all patients with spinal cord injury were treated with spine stabilization and decompression within the first 24 hours after trauma. Surgical decompression within the first 4 hours after trauma was not associated with improved neurological outcome compared to treatment between 4 and 24 hours. In a clinical context, this indicates that there is a time frame of at least 1 day in which optimal care is possible.

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          Most cited references 21

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          Incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey?

          Literature survey. To provide an overview of the literature data on incidence, prevalence and epidemiology of spinal cord injury (SCI) worldwide and to study their evolution since 1977. University Antwerp. The literature from 1995 onwards was searched on Pubmed. To include evolutionary data, we incorporated the results of three older studies. Two studies gave prevalence of SCI, and 17 incidence of SCI. The published data on prevalence of SCI was insufficient to consider the range of 223-755 per million inhabitants to be representative for a worldwide estimate. Reported incidence of SCI lies between 10.4 and 83 per million inhabitants per year. One-third of patients with SCI are reported to be tetraplegic and 50% of patients with SCI to have a complete lesion. The mean age of patients sustaining their injury at is reported as 33 years old, and the sex distribution (men/women) as 3.8/1. There is a need for improved registration of SCI, and publication of the findings in many parts of the world. This survey pleads for uniformity in methodology. The data show that the reported incidence and prevalence have not changed substantially over the past 30 years. Data from Northern America and Europe show higher figures for incidence, but prevalence figures have remained the same. Epidemiology of SCI seems to have changed during the last decades with a higher percentage of tetraplegia and of complete lesions. If such evolution is present worldwide, how it could eventually be prevented needs to be studied. Not applicable.
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            Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies.

            While the recommendations for spine surgery in specific cases of acute traumatic spinal cord injury (SCI) are well recognized, there is considerable uncertainty regarding the role of the timing of surgical decompression of the spinal cord in the management of patients with SCI. Given this, we sought to critically review the literature regarding the pre-clinical and clinical evidence on the potential impact of timing of surgical decompression of the spinal cord on outcomes after traumatic SCI. The primary literature search was performed using MEDLINE, CINAHL, EMBASE, and Cochrane databases. A secondary search strategy incorporated articles referenced in prior meta-analyses and systematic and nonsystematic review articles. Two reviewers independently assessed every study with regard to eligibility, level of evidence, and study quality. Of 198 abstracts of pre-clinical studies, 19 experimental studies using animal SCI models fulfilled our inclusion and exclusion criteria. Despite some discrepancies in the results of those pre-clinical studies, there is evidence for a biological rationale to support early decompression of the spinal cord. Of 153 abstracts of clinical studies, 22 fulfilled the inclusion and exclusion criteria. While the vast majority of the clinical studies were level-4 evidence, there were two studies of level-2b evidence. The quality assessment scores varied from 7 to 25 with a mean value of 12.41. While 2 of 22 clinical studies assessed feasibility and safety, 20 clinical studies examined efficacy of early surgical intervention to stabilize and align the spine and to decompress the spinal cord; the most common definitions of early operation used 24 and 72 h after SCI as timelines. A number of studies indicated that patients who undergo early surgical decompression can have similar outcomes to patients who received a delayed decompressive operation. However, there is evidence to suggest that early surgical intervention is safe and feasible and that it can improve clinical and neurological outcomes and reduce health care costs. Based on the current clinical evidence using a Delphi process, an expert panel recommended that early surgical intervention should be considered in all patients from 8 to 24 h following acute traumatic SCI.
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              Steroids for acute spinal cord injury.

               Michael B Bracken (corresponding) (2012)
              Acute spinal cord injury is a devastating condition typically affecting young people, mostly males. Steroid treatment in the early hours after the injury is aimed at reducing the extent of permanent paralysis during the rest of the patient's life.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2016
                31 August 2016
                : 12
                : 1339-1346
                Affiliations
                [1 ]Department of Paraplegiology and Technical Orthopedics, BG Trauma Centre, Ludwigshafen, Germany
                [2 ]Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord injury, Heidelberg University Hospital, Heidelberg, Germany
                Author notes
                Correspondence: Arash Moghaddam, Heidelberg Trauma Research Group, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, Heidelberg, Germany, Tel +49 6221 563 5394, Fax +49 6221 562 9213, Email arashmoghaddam@ 123456web.de
                Article
                tcrm-12-1339
                10.2147/TCRM.S108856
                5012849
                © 2016 Biglari et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Categories
                Original Research

                Medicine

                ais, spinal cord injury, neurological outcome, neurological remission, surgery

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