Yousefifard Mahmoud, Hashemi Behrooz, Forouzanfar Mohammad Mehdi, Khatamian Oskooi Rozita, Madani Neishaboori Arian, Jalili Khoshnoud Reza
Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran.
Research Center for Trauma in Police Operations, Directorate of Health, Rescue and Treatment, Police Force, Tehran, Iran.
Arch Acad Emerg Med. 2022 Jan 31;10(1):e11. doi: 10.22037/aaem.v10i1.1471. eCollection 2022.
Early decompression within the first 24 hours after spinal cord injury (SCI) is proposed in current guidelines. However, the possible benefits of earlier decompression are unclear. Thus, the present meta-analysis aims to investigate the existing evidence regarding the efficacy of ultra-early decompression surgery (within 12 hours after SCI) in improving patients' neurological status.
A search was performed in Medline, Embase, Scopus and Web of Science electronic databases, until the end of August 2021. Cohort studies and clinical trials were included in the present study. Exclusion criteria were absence of an early or late surgery group, failure to report neurological status based on the American spinal injury association impairment scale (AIS) grade, failure to perform the surgery within the first 12 hours after SCI, and duplicate reports and review articles. Two independent reviewers performed data collection, and risk of bias and certainty of evidence assessments. The outcome was reported as odds ratio (OR) and 95% confidence interval (CI).
Data from 16 articles, which studied 868 patients, were included. Compared to early or late decompression surgery, ultra-early decompression surgery significantly improves patients' neurological status (OR = 2.25; 95% CI: 1.41 to 3.58). However, ultra-early surgery in thoracolumbar injuries is not significantly more effective than early to late surgery. Moreover, ultra-early surgery in patients with a baseline AIS A increases the chance of neurologic resolvent up to 3.86 folds (OR=3.86; 95% CI: 1.50 to 9.91). Contrastingly, ultra-early surgery does not result in significant improvement compared to early to late surgery in patients with AIS B (OR = 1.32; 95% CI: 0.51 to 3.45), AIS C (OR = 1.83; 95% CI: 0.72 to 4.64), and AIS D (OR = 0.99; 95% CI: 0.31 to 3.17).
Current guidelines emphasize that spinal decompression should be performed within 24 hours after SCI, regardless of injury severity and location. However, results of the present study demonstrated that certain considerations may be taken into account when performing decompression surgery: 1) in patients with AIS A injury, decompression surgery should be performed as soon as possible, since its efficacy in neurological improvement is 3.86 folds higher in the first 12 hours after injury. 2) ultra-early decompression surgery in patients with cervical injury is more effective than in patients with thoracic or lumbar injuries. 3) postponing decompression surgery to 24 hours in SCI patients with AIS B to D does not significantly affect the neurological outcome.
目前的指南建议在脊髓损伤（SCI）后的24小时内尽早进行减压手术。然而，更早进行减压手术可能带来的益处尚不清楚。因此，本荟萃分析旨在研究关于超早期减压手术（SCI后12小时内）改善患者神经功能状态疗效的现有证据。
检索了Medline、Embase、Scopus和Web of Science电子数据库，检索截至2021年8月底的文献。本研究纳入队列研究和临床试验。排除标准包括：没有早期或晚期手术组、未根据美国脊髓损伤协会损伤分级（AIS）报告神经功能状态、未在SCI后12小时内进行手术、重复报告和综述文章。两名独立 reviewers 进行数据收集以及偏倚风险和证据确定性评估。结果以比值比（OR）和95%置信区间（CI）报告。
纳入了16篇研究868例患者的数据。与早期或晚期减压手术相比，超早期减压手术显著改善患者的神经功能状态（OR = 2.25；95%CI：1.41至3.58）。然而，胸腰段损伤的超早期手术并不比早期至晚期手术更有效。此外，基线AIS为A的患者进行超早期手术使神经功能恢复的几率增加至3.86倍（OR = 3.86；95%CI：1.50至9.91）。相比之下，对于AIS为B（OR = 1.32；95%CI：0.51至3.45）、AIS为C（OR = 1.83；95%CI：0.72至4.64）和AIS为D（OR = 0.99；95%CI：0.31至3.17）的患者，超早期手术与早期至晚期手术相比并没有显著改善。
当前指南强调，无论损伤严重程度和部位如何，脊髓减压应在SCI后24小时内进行。然而，本研究结果表明，在进行减压手术时可能需要考虑某些因素：1）对于AIS为A损伤的患者，应尽早进行减压手术，因为其在损伤后前12小时内改善神经功能的疗效高3.86倍。2）颈椎损伤患者的超早期减压手术比胸段或腰段损伤患者更有效。3）对于AIS为B至D的SCI患者，将减压手术推迟至24小时不会显著影响神经功能结局。
