Sattari Shahab Aldin, Antar Albert, Theodore John N, Hersh Andrew M, Al-Mistarehi Abdel-Hameed, Davidar A Daniel, Weber-Levine Carly, Azad Tej D, Yang Wuyang, Feghali James, Xu Risheng, Manbachi Amir, Lubelski Daniel, Bettegowda Chetan, Chang Louis, Witham Timothy, Belzberg Allan, Theodore Nicholas
Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
Spine J. 2024 Mar;24(3):435-445. doi: 10.1016/j.spinee.2023.10.013. Epub 2023 Oct 27.
The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking.
To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS.
Systematic review and meta-analysis.
Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence.
The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=-0.31 [-3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= -3.30 [-8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=-2.94 days [-3.83, -2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=-0.69 days [-1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups.
The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate.
急性创伤性中央脊髓综合征（ATCCS）患者的最佳减压时间一直存在争议，且缺乏高水平证据。
比较急性创伤性中央脊髓综合征早期（<24小时）与晚期（≥24小时）手术减压的效果。
系统评价和荟萃分析。
检索了从数据库建立至2023年3月15日的Medline、PubMed、Embase和CENTRAL数据库。主要结局指标为美国脊髓损伤协会（ASIA）运动评分。次要结局指标为静脉血栓栓塞（VTE）、总并发症、总体死亡率、住院时间（LOS）和重症监护病房住院时间（ICU LOS）。采用GRADE方法确定证据的确定性。
纳入的9项研究共报道了5619例患者，其中2099例（37.35%）接受了早期减压，3520例（62.65%）接受了晚期减压。早期和晚期减压组的平均年龄（53.3岁对56.2岁，p = 0.505）和入院时ASIA运动评分（平均差[MD]= -0.31[-3.61, 2.98]，p = 0.85）相似。在6个月随访时，两组的ASIA运动评分相似（MD = -3.30[-8.24, 1.65]，p = 0.19）。然而，在1年随访时，早期减压组的ASIA运动评分在总体上高于晚期减压组（MD = 4.89[2.89, 6.88]，p < 0.001，证据质量：中等），上肢（MD = 2.59[0.82, 4.36]，p = 0.004）和下肢（MD = 1.08[0.34, 1.83]，p = 0.004）也是如此。早期减压还与较低的VTE发生率（比值比[OR]= 0.41[0.26, 0.65]，p = 0.001，证据质量：中等）、总并发症发生率（OR = 0.53[0.42, 0.67]，p < 0.001，证据质量：中等）和住院时间（MD = -2.94天[-3.83, -2.04]，p < 0.001，证据质量：中等）相关。最后，两组的ICU住院时间（MD = -0.69天[-1.65, 0.28]，p = 0.16，证据质量：极低）和总体死亡率（OR = 1.35[0.93, 1.94]，p = 0.11，证据质量：中等）相似。
这些研究的荟萃分析表明，早期减压在ASIA运动评分、VTE、并发症和住院时间方面是有益的。此外，早期减压并未增加死亡几率。尽管治疗决策已个体化，但对于急性创伤性中央脊髓综合征患者，在外科医生认为合适的情况下，应考虑早期减压。
