Time is Spine: Critical Updates for the Intensivist

Overview

Journal Curr Opin Crit Care

Specialty Critical Care

Date 2025 Feb 27

PMID 40013488

Authors

Ryan Sandarage

Joseph Y Nashed

Eve C Tsai

Affiliations

Soon will be listed here.

Abstract

Purpose Of Review: The concept of 'time is spine' emphasizes early or ultra-early surgical decompression within 24 or 12 h, respectively, after spinal cord injury (SCI) to maximize recovery. This review updates the latest findings on the timing of surgical decompression and hemodynamic management in acute SCI, focusing on neurological outcomes and complications.

Recent Findings: While early decompression may improve neurological outcomes, factors like injury severity, comorbidities, and system resources affect surgical timing. Recent studies question the benefits of ultra-early decompression, finding no significant improvement at 12 months, suggesting earlier analyses may have overstated its benefits. Current recommendations include tailoring decompression timing to individual cases, considering patient-specific and systemic factors. New techniques like spinal cord pressure monitoring, intraoperative ultrasound, and advanced imaging are advancing targeted intervention and hemodynamic management in SCI.

Summary: The timing of spinal decompression and hemodynamic management may impact neurological function, however, because of the deficiencies of current studies, individualized, patient-tailored decision-making is critical. A multidisciplinary approach that considers injury severity and patient characteristics is essential for optimal management. Further research is required to refine the timing of surgical intervention and explore additional factors influencing recovery.

References

Fehlings M, Vaccaro A, Wilson J, Singh A, Cadotte D, Harrop J . Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One. 2012; 7(2):e32037. PMC: 3285644. DOI: 10.1371/journal.pone.0032037. View

Badhiwala J, Wilson J, Harrop J, Vaccaro A, Aarabi B, Geisler F . Early vs Late Surgical Decompression for Central Cord Syndrome. JAMA Surg. 2022; 157(11):1024-1032. PMC: 9520438. DOI: 10.1001/jamasurg.2022.4454. View

Lo V, Esquenazi Y, Han M, Lee K . Critical care management of patients with acute spinal cord injury. J Neurosurg Sci. 2013; 57(4):281-92. View

Hosman A, Barbagallo G, Popescu E, Van de Meent H, Oner F, De Iure F . Neurological recovery after early versus delayed surgical decompression for acute traumatic spinal cord injury. Bone Joint J. 2023; 105-B(4):400-411. DOI: 10.1302/0301-620X.105B4.BJJ-2022-0947.R2. View

Saadoun S, Grassner L, Belci M, Cook J, Knight R, Davies L . Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial. Trials. 2023; 24(1):497. PMC: 10405486. DOI: 10.1186/s13063-023-07454-2. View

Anjum A, Yazid M, Daud M, Idris J, Ng A, Naicker A . Spinal Cord Injury: Pathophysiology, Multimolecular Interactions, and Underlying Recovery Mechanisms. Int J Mol Sci. 2020; 21(20). PMC: 7589539. DOI: 10.3390/ijms21207533. View

Thomas A, Riviello Jr J, Davila-Williams D, Thomas S, Erklauer J, Bauer D . Pharmacologic and Acute Management of Spinal Cord Injury in Adults and Children. Curr Treat Options Neurol. 2022; 24(7):285-304. PMC: 9184374. DOI: 10.1007/s11940-022-00720-9. View

Yang C, Quan Z, Wang G, He T, Chen Z, Li Q . Elevated intraspinal pressure in traumatic spinal cord injury is a promising therapeutic target. Neural Regen Res. 2022; 17(8):1703-1710. PMC: 8820714. DOI: 10.4103/1673-5374.332203. View

Furlan J, Craven B, Massicotte E, Fehlings M . Early Versus Delayed Surgical Decompression of Spinal Cord after Traumatic Cervical Spinal Cord Injury: A Cost-Utility Analysis. World Neurosurg. 2016; 88:166-174. DOI: 10.1016/j.wneu.2015.12.072. View

10.

Badhiwala J, Ahuja C, Fehlings M . Time is spine: a review of translational advances in spinal cord injury. J Neurosurg Spine. 2019; 30(1):1-18. DOI: 10.3171/2018.9.SPINE18682. View

11.

Wilson J, Cadotte D, Fehlings M . Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review. J Neurosurg Spine. 2012; 17(1 Suppl):11-26. DOI: 10.3171/2012.4.AOSPINE1245. View

12.

Fehlings M, Tetreault L, Wilson J, Aarabi B, Anderson P, Arnold P . A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery. Global Spine J. 2017; 7(3 Suppl):195S-202S. PMC: 5684850. DOI: 10.1177/2192568217706367. View

13.

Rahimi-Movaghar V, Niakan A, Haghnegahdar A, Shahlaee A, Saadat S, Barzideh E . Early versus late surgical decompression for traumatic thoracic/thoracolumbar (T1-L1) spinal cord injured patients. Primary results of a randomized controlled trial at one year follow-up. Neurosciences (Riyadh). 2014; 19(3):183-91. PMC: 4727651. View

14.

Chryssikos T, Stokum J, Ahmed A, Chen C, Wessell A, Cannarsa G . Surgical Decompression of Traumatic Cervical Spinal Cord Injury: A Pilot Study Comparing Real-Time Intraoperative Ultrasound After Laminectomy With Postoperative MRI and CT Myelography. Neurosurgery. 2023; 92(2):353-362. PMC: 9815093. DOI: 10.1227/neu.0000000000002207. View

15.

Slack R, Shucart W . Respiratory dysfunction associated with traumatic injury to the central nervous system. Clin Chest Med. 1994; 15(4):739-49. View

16.

Swain A, Dove J, Baker H . ABC of major trauma. Trauma of the spine and spinal cord--II. BMJ. 1990; 301(6743):110-3. PMC: 1663401. DOI: 10.1136/bmj.301.6743.110. View

17.

Walker J, Detloff M . Plasticity in Cervical Motor Circuits following Spinal Cord Injury and Rehabilitation. Biology (Basel). 2021; 10(10). PMC: 8533179. DOI: 10.3390/biology10100976. View

18.

Swain A, Dove J, Baker H . ABC of major trauma. Trauma of the spine and spinal cord--I. BMJ. 1990; 301(6742):34-8. PMC: 1663353. DOI: 10.1136/bmj.301.6742.34. View

19.

Martin M, Bush L, Inaba K, Byerly S, Schreiber M, Peck K . Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association Multi-Institutional Trial and Survey. J Trauma Acute Care Surg. 2017; 83(6):1032-1040. DOI: 10.1097/TA.0000000000001650. View

20.

Badhiwala J, Wilson J, Witiw C, Harrop J, Vaccaro A, Aarabi B . The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol. 2020; 20(2):117-126. DOI: 10.1016/S1474-4422(20)30406-3. View