Outcome of Early Surgical Decompression in Traumatic Incomplete Spinal Cord Injury

Objectives: Central cord syndrome has been reported to occur with particu-lar frequency among older persons with cervical spondylosis who sustain hyperextension neck injury. This study aims to determine the efficacy of early surgical decompression (within 24 hours) of traumatic central cord syndrome patients in comparison with conservative management for central cord syndrome to determine a line of management to these cases. Methods: 60 patients suffering from acute traumatic central cord syndrome with various neurological deficits were divided into 2 groups, group A (conservatively managed) and group B (surgically managed). Patients in group B were operated upon within 24 hr. of trauma by posterior decompression. Clinical as-sessment of each patient on admission, discharge and 3 months follow-ups was done using the ASIA Impairment Scale, FIM, Ashworth scale, bladder function, and neuropathic pain symptoms. Results: Data collected from both groups showed, group A (the conservative group) consisted of 22 male (73.3%) and 8 female subjects (26.6%) with a mean age of 57.5 years while in group B (surgical group) the sample consisted of 20 male (66.6%) and 10 female subjects (33.3%) with a mean age of 58.6 years. There was an improvement in our study—according to ASIA and FIM scales—in 8 patients of 30 (26.6%) in the conservative group. In the surgical group, improvement in 16 patients (53.3%). Conclusions: Early surgical decompression with laminectomy and duroplasty can be considered a reliable modality in the management of traumatic CCS and can effectively reduce the secondary injury of the spinal cord and consequent deterioration with less hospital stay.


Introduction
Traumatic central cord syndrome (CCS) is the most common type of acute incomplete cervical spinal cord injury (SCI) which has been described many years ago by Schneider et al. in 1954 [1] [2]. It's often Happens in older people after experiencing a hyperextension injury that leads to a spinal cord contusion or edema [2]. It is characterized by disproportionately motoring deficit more on the arms, especially the hands, than the legs with bladder dysfunction and varying degrees of sensory loss below the lesion [3]. It occurs more frequently in patients with pre-existing anterior cervical spondylotic changes as bone spurs and in patients with thickened posterior ligamentum flavum [4].
In early description of acute traumatic CCS by Schneider in 1954, the management of traumatic CCS has been frequently discussed. In 1954 surgical management was not recommended, because the reasonably good prognosis of these cases and the spontaneous improvement and/or complete recovery may occur spontaneously [5] [6] [7]. More recent studies and expertise in this field, owing to changes in understanding of the pathophysiology indicate that conservative management and surgical decompression in some patients with persistent compression and neurological deficits can be both beneficial to the patients [7] [8] [9].
The idea of surgical decompressive in patients with ATCCS has been frequently discussed in the treatment of acute spinal cord injuries, if it is beneficial to the patients or even if it is safe [10] [11] [12] [13]. Surgical decompression by laminectomy might affect the stability of the spine with a possibility posttraumatic kyphotic deformity [14]. In some recent studies, early surgical decompression in the cases of traumatic SCI might be harmful and has no benefits to some patients and should be avoided [15] [16] [17].
In this study we aim to evaluate the functional outcome of early surgical decompression (within 24 hours) for ATCCS, where recovery of a certain degree of ambulation, activities of daily life, pain improvement and bladder function are evaluated.

Patients and Methods
This study was done prospectively in the Neurosurgery department, Cairo University hospitals, and conducted on 60 patients diagnosed with acute traumatic CCS. Data were collected over 18 months starting from January 2015 till June 2016. Cases had a follow up period of 6 months after discharge from hospital.
All cases were assessed clinically and radiologically by magnetic resonance imaging (MRI) and computed tomography (CT) and clinically on admission to the hospital.
with various degrees of neurological deficits, No history of associated medical disorders.

The Exclusion Criteria
The exclusion criteria were Non-traumatic cases, Hemodynamically unstable patients (spinal shock), Surgically unfit patients, Patients with disturbed conscious level and associated brain injuries.
Patients with cervical disc herniation or cervical fracture, other clinical incomplete spinal cord syndromes (Brown Sequard, anterior cord syndrome, posterior cord syndrome), complete spinal cord injury or presenting after 24 hours of trauma were excluded from this study.
Patients were divided into 2 groups according to their order at presentation, group A (the conservatively managed group was the odd order) and group B (surgically treated patients were the even order) with no bias to either group.
Initial management of all patients presenting with SCI begins in the field, with appropriate triage by emergency responders. Resuscitation according to the acute traumatic life support protocols should be followed by immobilization using backboard, rigid cervical collar or manual immobilization to prevent further cord damage [18].

Clinical Material
The following data were collected for all subjects: gender, age at the time of injury, associated co-morbidities, hospital stay, treatment of the lesion (conservative or surgical), ASIA scale severity score (A, B, C, D, E) and FIM (functional independence measure) on admission (Table 1).

Follow-Up and Outcome
 Group A: All patients were admitted to the neurosurgical ward with close observation of motor power, spasticity and urinary and bowel continence monitoring until discharge. Initial CT scan and MRI were done within the first few hours of injury and then after 1 month and another one after 3 months from discharge. The average stay of the patients at the hospital was 25 days. After discharge each patient scheduled for follow up date each week for the first month and the less frequent for the rest of the follow-up period.  Group B: Table 1. ASIA Impairment Scale (AIS) [19].

Grade Type of injury
Description of injury A Complete No sensory or motor function is preserved in the sacral segments S4 -S5.

B Sensory Incomplete
Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5, AND no motor function is preserved more than three levels below the motor level on either side of the body.

C Motor Incomplete
Motor function is preserved below the neurological level AND more than half of key muscle functions below the neurological level of injury have a muscle grade less than 3 (Grades 0 -2).

D Motor Incomplete
Motor function is preserved below the neurological level AND at least half (half or more) of key muscle functions below NLI have a muscle grade 3 or more.

E Normal
If sensation and motor function as tested with ISNCSCI are graded as normal in all segments AND the patient had prior deficits then the AIS Grade is E.
Someone without a Spinal Cord Injury does not receive an AIS Grade.
All patients were admitted to the neurosurgical ward with close observation of motor power, spasticity and urinary and bowel continence monitoring until discharge with medical care of the surgical wound or any post-surgical complications. Initial CT scan and MRI were done within the first few hours of injury and within the first 24 hr. after surgery. The average stay of the patients at the hospital was 14 days. After discharge each patient scheduled for follow up date each week for the first month and the less frequent for the rest of the follow-up period.
All patients in both groups were clinically assessed on admission, discharge and 3 months follow-up using the American Spinal Injury Association (ASIA) Impairment Scale, FIM (functional independence measure), spasticity (Ashworth) scale, bladder function, and neuropathic pain.

Results
Sixty cases with traumatic CCS were included in this study in the period from January 2015 to June 2016.   In the conservative group, two cases improved on discharge (6.6%) and in-

Discussion
The conservative strategy of Schneider et al. was widely accepted until the early 1970s when Bosch et al. reported that many conservatively treated patients experienced a late onset neurological deterioration, and only 60% of them remained functional despite a period of initial improvement [20]. From a biological standpoint early decompression seemed to be the most effective management modality due to the prevention of secondary damage [21].
The patients' age in our study was ranging from 40 to 73 years in group A with mean age 57.5 years while ranging from 42 to 78 years with mean age 58.9 years in group B. The best outcome relative to FIM, Improvement of pain, spasticity and sphincteric control recorded in patients who were managed surgically with mean age 49.4 years and among patients whom were managed conservatively with mean age 52.5 years, may be related to higher incidence of comorbid- -97% in younger patients compared to 31% -41% in the elderly (over 50 years of age at the time of injury) [25].
In 2009 Chen studied again that condition and he find that; the best outcomes were observed in patients of younger age when his study population mean age at the time of injury was 55.9 years old [26].
In our study we assessed all patients with ASIA and FIM and we compared the outcome in the two groups. In group A; the total improvement in our study was Study Limitations: The lack of intra-operative neurophysiological monitoring and navigation due to high cost and low resources.
The follow up period is short due to shortage of resources and the poor database and archival in the hospital and the failure to contact some patients after discharge. Many patients are lost to follow up, especially those who have to travel to this tertiary care facility. An extended period of follow up more than 48 months to 5 years at least is required for analysis of rehabilitation and return to work to be included in the final judgment during comparison of these surgical techniques.
An accurate hospital stay cost per patient could not be calculated as the Cairo University hospital is a teaching hospital affiliated to Cairo University and operates on governmental funds and provides care free of charge to its patients. Patients are not billed for neither ER nor operative costs.

Conclusions
While early surgical intervention does not significantly surpass conservative management overall, it offers a safe and fast path to neurological improvement in the ASIA grades in patients with ATCCS. Another important aspect is that surgical intervention minimizes hospital stay and thus, offers a financially convenient solution in third world countries for both the patient and the medical facility during the whole period of management of these cases. Surgical Decompression can be considered a reliable modality in the management of traumatic CCS, effectively reducing the secondary injury of the spinal cord and consequent deterioration with less hospital stay in comparison to the conservative management of these cases; putting in consideration the low socioeconomic state of patients treated in our facility and the poor finances of our hospital.
Cervical laminectomy is a safe, low morbidity, decompressive procedure and in this study, we did not face any post-operative increased incidence of neurological deterioration or instability in the short term of the follow-up period.