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Journal of Neurotrauma
J Neurotrauma. Aug 2011; 28(8): 1371–1399.
PMCID: PMC3143409

Timing of Decompressive Surgery of Spinal Cord after Traumatic Spinal Cord Injury: An Evidence-Based Examination of Pre-Clinical and Clinical Studies

Abstract

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.

Key words: animal studies, clinical research, spinal cord injury, systematic review, timing of surgery

Introduction

Traumatic spinal cord injury (SCI) is a potentially catastrophic event for individuals who develop motor, sensory, and autonomic deficits and for society due to the economic burden. Currently, the management of individuals with acute SCI includes pharmacological agents and surgical intervention. The most promising pharmacological therapies include drugs that, in pre-clinical studies, improved axonal conduction, antagonized excitatory amino acid antagonists, blocked potassium and sodium channel, and attenuated extracellular myelin mediator growth inhibitory proteins (Baptiste and Fehlings, 2007).

Surgical intervention is indicated for decompression of the spinal cord in addition to realignment and stabilization of the spine. Although the recommendations for spine surgery in specific cases of acute traumatic 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 background, we sought to critically review the literature with regard to the pre-clinical and clinical evidence on the potential impact of timing of surgical decompression of the spinal cord on outcomes after traumatic SCI.

Methods

This study comprehensively reviews the pre-clinical and clinical evidence for early surgical decompression of the spinal cord in patients after traumatic SCI. Moreover, this systematic review is focused on the following three key questions:

  • 1. Is there pre-clinical evidence for biological benefits of early surgical decompression in animal SCI models?
  • 2. What is the optimal timing for surgical decompression of the spinal cord based on the current clinical evidence?
  • 3. What are the potential effects of early decompression of the spinal cord on the clinical, neurological, and functional outcomes in the acute care setting?

For this purpose, we selected all original articles that examined the potential effects of duration of compression or timing of surgical decompression of spinal cord on outcomes in the setting of traumatic SCI. Case reports, editorial articles, and meeting abstracts were excluded.

Literature search strategy

The primary literature search was carried out using MEDLINE, CINAHL, EMBASE, and Cochrane databases. A secondary search strategy incorporated articles referenced in meta-analyses and systematic and nonsystematic review articles that the primary search strategy yielded.

The literature searches targeted publications from 1966 to April 2009. The search strategy included the following specific terms: “surgical decompression,” “decompression,” “spinal cord compression,” “time,” and “timing.” Those terms were paired with the following Medical Subject Headings (MeSHs): “spinal cord injury,” “SCI,” “tetraplegia,” “quadriplegia,” and “paraplegia.” The literature search was limited to papers written in English. The search results were divided into pre clinical studies (animal SCI models) and clinical studies.

Data abstraction and synthesis

During the culling process, two reviewers (JCF and VN) independently selected the articles that fulfill the inclusion and exclusion. Disagreements were solved by a debate and consensus between both reviewers.

A research assistant extracted the relevant data from each selected article. Subsequently, both reviewers examined all clinical studies with regard to the extracted data and determined the level of evidence according to Sackett et al. (2000). In addition, both reviewers assessed the methodological quality of each article using the criteria of Downs and Black (1998). Divergences during those steps were solved by consensus between both reviewers. The main results of each article and the reviewers' assessments are summarized in Tables 1 and and22.

Table 1.
Summary of the Characteristics and Results of the Pre-Clinical Studies on Timing of Surgical Decompression after Spinal Cord Injury
Table 2.
Summary of the Clinical Studies on Timing of Surgical Decompression of Spinal Cord for Patients with Traumatic Spinal Cord Injury

Establishment of recommendations

Using the information in the summary tables, the authors answered the previously formulated questions and developed a series of statements. An expert panel was established that consisted of two board-certified neurosurgeon/clinician scientists actively practicing in an academic institution (M.D., Ph.D.), two board-certified neurosurgeons engaged in full clinical practice (M.D.), one neurosurgical resident/clinical research fellow (M.D., Ph.D. candidate), one orthopedic spine surgeon/clinician scientist actively practicing in an academic institution (M.D., Ph.D.), one orthopedic spine surgeon engaged in full clinical practice (M.D.), four spinal cord injury scientists (Ph.D.), one physiotherapist/rehabilitation scientist (Ph.D. candidate), and one clinical epidemiologist (Ph.D.). Each member of the expert panel is a member of one or more professional spine organizations including Spine Trauma Study Group, Acute Practice Network, Spinal Cord Injury Solutions Network, Section of Neurotrauma and Critical Care of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, the North American Spine Society, and AOSpine. The expert panel was provided a copy of this manuscript and sufficient time to review it. The expert panel then convened to discuss the series of statements using a modified Delphi method (Reid, 1993). In essence, this method provided the expert panel with time to discuss the posed series of statements and formulate a recommendation based on the evidence provided in the manuscript. Following discussion, with the authors of this manuscript present to address any questions, the expert panel voted and offered recommendations.

Results

Literature search

Pre-clinical studies

Of 198 abstracts captured in our search, 48 full articles were pre-selected to be reviewed by the two reviewers. Of those 48 articles, 19 experimental studies using different animal SCI models fulfilled the inclusion and exclusion criteria of this systematic review (Aki and Toya, 1984; Bohlman et al., 1979; Brodkey et al., 1972; Carlson et al., 1997a, 1997b, 2003; Croft et al., 1972; Delamarter et al., 1991, 1995; Dimar et al., 1999; Dolan et al., 1980; Guha et al., 1987; Hejcl et al., 2008; Kobrine et al., 1978, 1979; Nystrom and Berglund, 1988; Rabinowitz et al., 2008; Thienprasit et al., 1975; Zhang et al., 1993). Extracted data from those 19 pre-clinical studies are summarized in Table 1. In brief, the pre-clinical studies used a spinal cord compression or contusion model in dogs (n = 8), rats (n = 6), cats (n = 3), or monkeys (n = 2). Outcome measures included electrophysiological testing (n = 12), behavioral tests (n = 11), histopathological examination of spinal cord tissue (n = 7), spinal cord blood flow assessment (n = 4), and spinal cord concentration of energy-related metabolites (n = 1). While the majority of the pre-clinical studies compared different time periods of spinal cord compression or contusion, three animal studies reported outcomes of animal SCI models without group comparisons on the timing of spinal cord compression or decompression (Bohlman et al., 1979; Brodkey et al., 1972; Kobrine et al., 1978).

Clinical studies

The primary search of clinical studies yielded 153 abstracts of which three review papers were used for the secondary search. Of the 38 original articles pre-selected from both primary and secondary searches, 22 clinical studies fulfilled the inclusion and exclusion criteria (Botel et al., 1997; Campagnolo et al., 1997; Cengiz et al., 2008; Chen et al., 2009; Chipman et al., 2004; Clohisy et al., 1992; Croce et al., 2001; Duh et al., 1994; Guest et al., 2002; Kerwin et al., 2005; Krengel et al., 1993; Levi et al., 1991; McKinley et al., 2004; McLain and Benson, 1999; Mirza et al., 1999; Ng et al., 1999; Papadopoulos et al., 2002; Pollard and Apple, 2003; Sapkas and Papadakis, 2007; Schinkel et al., 2006; Tator et al., 1999; Vaccaro et al., 1997). Extracted data from those clinical studies are summarized in Table 2. Most of the clinical studies compared at least two patient groups who underwent early or later decompressive operation of spinal cord (n = 20); the two studies examined only the feasibility and safety of early surgical decompression of spinal cord without group comparisons (Botel et al., 1997; Tator et al., 1999). While the vast majority of the clinical studies were level-4 evidence, there were two studies of level-2b evidence (Table 2). The quality assessment scores varied from 7 to 25 with a mean value of 12.41 and a median value of 11.5.

Focused questions

Pre-clinical studies

Although a number of pre-clinical studies suggest no effects of time of spinal cord compression on outcomes, several other experimental investigations indicate that longer spinal cord compression is associated with detrimental effects in animal SCI models. In addition, the three pre-clinical studies that used a single time period of spinal cord compression also showed the histopathological, electrophysiological, and blood flow effects of mechanical compression of spinal cord tissue (Bohlman et al., 1979; Brodkey et al., 1972; Kobrine et al., 1978).

Negative results were reported in pre-clinical studies that used diverse animal SCI models. Using a weight holding device, Croft et al. (1972) studied 15 cats that underwent spinal cord compression of different weights (18 to 58 g) at different time periods from 5 to 20 min. While greater weights produced more severe locomotor deficits and electrophysiological changes, no substantial effect of time of spinal cord compression was reported, but data were not statistically analyzed (Croft et al., 1972). Thienprasit et al. (1975) used an epidural balloon for rapid spinal cord compression followed by immediate release in cats that were subsequently classified according to eletrophysiological recovery within the first 6 h post-SCI. Among animals that had no cortical evoked potentials after 6 h of SCI, there were no significant differences between the group of animals that underwent spinal cord decompression at 6 h after SCI and the group of untreated animals, but laminectomy at 6 h and subsequent spinal cord cooling resulted in improved behavioral outcome when compared to untreated animals and laminectomy-alone animals (Thienprasit et al., 1975). Among those animals that showed some electrophysiological recovery within the first 6 h post-SCI, there were no significant differences between the group of animals that underwent laminectomy only at 6 h and the group of animals that underwent laminectomy at 6 h with subsequent spinal cord cooling (Thienprasit et al., 1975). Using a spinal cord compression model, Aki and Toya (1984) reported that the weight applied to the spinal cord was significantly associated with electrophysiological changes, histopathological findings, and blood flow disturbances; whereas, there were no significant differences between the group of animals that received 30-min compression and the group of animals that underwent 60-min compression with regard to spinal cord blood flow alterations. Studying the effects of circumferential compression of caudal equina (from 2–3 sec to 1 week) in dogs, Delamarter et al. (1991) documented no significant effects of time of compression on electrophysiological, histopathological, and behavioral results. More recently, Hejcl et al. (2008) reported that delayed implantation (at 1 week after injury) of hydrogel between the stubs of transected spinal cord did not adversely affect histopathological and behavioral outcomes in comparison with implantation of hydrogel immediately after spinal cord transection. Of note, both implantation groups showed significantly reduced lesion volume when compared with control animals (Hejcl et al., 2008).

In contrast, numerous pre-clinical studies using different SCI models reported the benefits of short spinal cord compression or early spinal cord decompression. Using an epidural balloon compression model, Kobrine et al. (1979) found that monkeys with 1-min spinal cord compression showed better electrophysiological recovery and reduced adverse effects on spinal cord blood flow in comparison with animals that underwent spinal cord compression for 3 to 15 min. Studying rats that underwent spinal cord clip compression of 16 to 178 g for 3 to 900 sec, Dolan et al. (1980) documented a significant correlation between behavioral recovery and time of spinal cord compression. Guha et al. (1987) also reported behavioral outcomes in rats that underwent a clip compression of 2.3 or 16.9 g depended upon the time of compression, which varied from 15 to 240 min. Similarly, Nystom and Berglund (1988) documented time-dependent differences in behavioral outcomes in rats using a spinal cord compression model of 20 to 50 g for 1 to 10 min. Zhang et al. (1993) found significant elevation of spinal cord concentrations of energy-related metabolites in rats that underwent spinal cord compression of 9 to 50 g for 5 min in comparison with control animals without SCI. Using a circumferential spinal cord compression model in dogs, Delamarter et al. (1995) reported time-related effects on electrophysiological recovery (worsening from 2–3 sec to 1 h or longer), behavioral recovery and histopathological lesion (worsening with compression of 6 h or longer). Studying the effects of spinal cord compression that reduced approximately 50% of the somatosensory-evoked potentials in dogs, Carlson et al. (1997b) found significant differences between the group of animals that received 5-min compression and the group of animals that underwent 3-h compression regarding electrophysiological recovery and spinal cord blood flow recovery. In another study using a similar animal SCI model as previously described, Carlson et al. (1997a) reported that dogs recovered only some degree of electrophysiological deficit and reperfusion flow when the spinal cord was decompressed at 3 h in comparison with animals that had spinal cord decompression at 30 min or at 1 h. Using a spinal cord compression-contusion model in rats, Dimar et al. (1999) documented time dependence of spinal cord compression with regard to electrophysiological recovery (immediate decompression versus 2-h compression), histopathological findings (2-h vs. 6-h compression), and behavioral recovery at 6 weeks after SCI (Dimar et al., 1999). In dogs that underwent spinal cord compression using a loading device, Carlson et al. (2003) showed that animals with 30-min compression had improved electrophysiological recovery, reduced histopathological lesion, and improved behavioral recovery when compared with animal with 3-h compression. Most recently, Rabinowitz et al. (2008) conducted a randomized prospective study in dogs comparing early surgical decompression (6 h) with or without methylprednisolone compared to methylprednisolone alone. Using a model originally described by Delamarter et al. (1995) a single surgeon carried out a laminectomy at the L 4/5 level (equivalent to the thoracolumbar junction in humans) and circumferentially compressed the dura by 60% with a nylon band. The surgical wound was then closed and the animals lifted from anesthesia (the nylon band was left in situ). The animals were then randomized to one of three groups (methylprednisolone + early decompressive surgery, saline + early decompressive surgery, or methylprednisolone only). Medical therapy with methylprednisolone or saline was initiated 1 h after the lesion-inducing surgery. Decompressive surgery was carried out 6 h following the initial insult by taking the animals back to the operating room and removing the nylon band. The animals randomized to not receive decompressive surgery had the band in place for the duration of the experiment. The animals were followed clinically and electrophysiologically for 2 weeks at which point they were sacrificed and examined histologically. The authors demonstrated that surgical decompression with or without methylprednisolone administration offers greater neurological improvement than the use of methylprednisolone alone. This is an important study that compared two therapies at the forefront of human treatment that had yet to be compared head-to-head. The authors rightfully comment on the value of such a trial.

Clinical studies

The definitions of early surgical intervention in patients with traumatic SCI varied from 8 h to 4 days in clinical studies. In addition, delayed surgical decompression of spinal cord was more inconsistently defined in the literature with time threshold varying from 8 h to 5 days. While 8 out of 22 clinical studies defined early surgical intervention as spinal cord decompression and stabilization obtained prior to 72 h following traumatic SCI (Chipman et al., 2004; Croce et al., 2001; Kerwin et al., 2005; McKinley et al., 2004; Mirza et al., 1999; Sapkas and Papadakis, 2007; Schinkel et al., 2006; Vaccaro et al., 1997), 9 other clinical investigations employed the 24-h limit to define early decompressive operation (Botel et al., 1997; Campagnolo et al., 1997; Duh et al., 1994; Guest et al., 2002; Krengel et al., 1993; Levi et al., 1991; McLain and Benson, 1999; Pollard and Apple, 2003; Tator et al., 1999). Other thresholds have been utilized in some previous clinical studies that compared delayed surgical intervention with spine operations earlier than 8 h (Cengiz et al., 2008; Ng et al., 1999), 48 h (Clohisy et al., 1992), and 4 days (Chen et al., 2009). One study did not specify a time frame but did state emergent decompression (Papadopoulos et al., 2002).

In two previous studies, patients who underwent spinal cord decompression within the first 8 h after traumatic SCI were found to have shorter hospitalization, shorter length of stay in the acute care unit, less frequent secondary complications post-trauma, and better neurological outcomes than patients who were operated later than 8 h post-injury (Table 2). However, one study reported no differences between those patient groups in terms of mortality after SCI (Table 2).

Surgical intervention of spinal cord injury earlier than 24 h was associated with shorter length of hospitalization in three studies, shorter length of stay in the intensive care unit in one study, better neurological recovery in one study, and smaller estimated blood loss for anterior procedures in one study (Table 2). In contrast, no effects of early surgical intervention (≤24 h) were documented in previous studies with regard to the frequency of secondary complications after SCI (two studies), neurological outcomes (four studies), or estimated blood loss for anterior procedures (one study) (Table 2).

In only one prior study, patients who underwent anterior decompression of the spinal cord earlier than 48 h had better neurological recovery in comparison with patients who were surgically treated after 48 h of traumatic SCI (Table 2) (Clohisy et al., 1992).

Early surgical operation, defined by a cutoff of 72 h, was associated with shorter length of hospital stay in six previous studies, shorter length of stay in the intensive care unit in three studies, smaller volume of fresh frozen plasma during operation in one study, lower mortality rate in one study, lower frequency of secondary complications after SCI in six studies, better neurological recovery in one study, and less costly care in two studies when compared with delayed operation (Table 2). However, patients who underwent early surgical decompression and stabilization of the spinal cord (≤72 h) did not differ from patients who were surgically treated after 72 h with regard to length of hospitalization (two studies), length of stay in the acute care unit (three studies), intraoperative volume of crystalloid reposition (one study), frequency of secondary complications after SCI (four studies), mortality (three studies), neurological outcome (three studies), rehospitalization (one study), and disability (three studies) (Table 2).

In one previous study, patients who underwent surgical intervention within the first 4 days after SCI showed similar neurological recovery to patients who were surgically treated earlier than 4 days (Table 2).

Discussion

This systematic review identified 19 pre-clinical studies in which timing of spinal cord compression or decompression was examined using animal SCI models. 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. In addition, our systematic review captured 22 clinical studies that examined either the feasibility and safety or efficacy of early surgical intervention to stabilize and align the spine and decompress the spinal cord. The most common definitions of early surgical intervention included 24 or 72 h after SCI as the cutoff time. A number of studies indicated that patients who undergo early surgical decompression can have similar outcomes to patients who received 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.

Is there pre-clinical evidence for biological benefits of early surgical decompression in animal SCI models?

In our systematic review, 5 of 19 pre-clinical studies suggested that time has little or no effect on outcomes in animal SCI models, whereas 11 other pre-clinical investigations indicated a time-dependent effect of spinal cord compression in the behavioral recovery, spinal cord blood flow disturbances, electrophysiological recovery, and histopathological lesion. All pre-clinical studies captured in our review were in vivo experiments that used different SCI models of spinal cord contusion or compression. In addition to rodents, those prior experimental studies also included cats, dogs, and monkeys. Generally speaking, the benefits of spinal cord decompression in those animal studies appear to be optimized when blood flow and electrophysiological parameters were restored earlier than 6 h; however, this did depend on the model of SCI, animal species or strain, methodological quality, outcome measure, use of anesthesia, and time period of follow-up (Akhtar et al., 2009). The critical analysis of the current pre-clinical evidence strongly indicated that time of spinal cord compression is a key determinant of recovery after SCI and, hence, there is a biological rationale to support early spinal cord compression for improved outcomes.

What is the optimal timing for surgical decompression of spinal cord based on the current clinical evidence?

The safety and feasibility of early spine intervention after SCI were examined in at least two level-4 evidence studies (Botel et al., 1997; Tator et al., 1999). Both clinical studies indicated that between 23.5% and 51.4% of the patients could undergo operation within the first 24 h after acute SCI. One may speculate that modifications of the pre-hospital logistics and acute SCI care could substantially increase the number of patients who would undergo operation earlier than 24 h after acute traumatic SCI.

In the literature, the most commonly used timelines to define “early surgical intervention of spine” were 24 and 72 h in studies of level-4 evidence. The results of those studies were consistent with either no effect of timing of surgical intervention on outcomes after SCI (no harm was reported in the early surgery groups) or improved outcomes when earlier surgical treatment was performed. There was one level-2b evidence study that indicated no benefits regarding clinical and neurological outcomes between the group of patients who underwent surgical decompression of spinal cord within the first 72 h after cervical SCI (n = 34) and the group of patients who were surgically treated later than 72 h post-injury (n = 28) (Vaccaro et al., 1997). The relatively small sample sizes of each study group raise the possibility of an underpowered statistical analysis in that prospective cohort study. In addition, another level-2b evidence study suggested that surgical decompression and stabilization of spinal cord earlier than 8 h would provide better neurological outcome, shorter length of hospitalization, shorter length of stay in the intensive care unit, and lower frequency of secondary complications in comparison with patients who underwent surgical intervention from 72 h to 5 days after thoracolumbar SCI (Cengiz et al., 2008).

Despite the lack of definite substantiation for one particular timeline, the current clinical evidence along with data from pre-clinical studies suggest that outcomes after traumatic SCI would be potentially optimized if surgical decompression and stabilization of spinal cord were carried out between 8 and 24 h.

What are the potential effects of early decompression of spinal cord on the clinical, neurological, and functional outcomes in the acute care setting?

In addition to being safe and feasible in many cases, early surgical decompression (≤24 h) has the potential to reduce surgical blood loss, decrease the volume of fresh frozen plasma required during operation, reduce the length of hospitalization, decrease the length of stay in the intensive care unit, improve neurological outcome, and reduce the number of secondary complications after traumatic SCI. While those results on clinical and neurological outcomes were based on a number of level-4 evidence and one clinical study of level-2b evidence, other prior level-4 evidence studies and another level-2b study have challenged those positive effects with regard to reduced number of secondary complications and improved neurological outcomes after early surgical intervention.

Similarly, several prior level-4 evidence studies indicated that surgical intervention earlier than 72 h could reduce length of hospitalization, decrease length of stay in the intensive care, reduce surgical blood loss, decrease the volume of fresh frozen plasma required during operation, improve neurological outcome, reduce acute care costs, and increase survival after traumatic SCI. However, a number of other level-4 evidence studies indicated no differences between a group of patients who underwent early operation and a group of patients surgically treated later than 72 h with regard to length of hospitalization, length of stay in the intensive care, volume of crystalloids required during operation, number of secondary complications, survival, neurological and functional recovery, and need for re-hospitalization.

Although prior studies failed to consistently support better clinical, neurological, and functional outcomes in the early surgery group, there is strong evidence to support that early surgical decompression of spinal cord does not increase the risk of treatment harm in patients with acute traumatic SCI. Moreover, the potential to improve outcomes in the group of patients who undergo early surgical intervention is congruent with the biological rationale supported by the pre-clinical literature.

Of note, the preliminary results from the Surgical Treatment for Acute Spinal Cord Injury Study (STASCIS) also suggest that decompression of the spinal cord earlier than 24 h from injury is associated with improved neurological recovery in patients with isolated cervical SCI (Fehlings and Arvin, 2009). Definite results of this large multicenter prospective cohort study are anticipated in the coming year after completion of data acquisition from long-term follow-up.

Recommendations

In the modified Delphi process, a panel of 10 experts in the field of SCI endorsed the following recommendations:

  • 1. There is strong pre-clinical evidence for biological benefits of early surgical decompression in animal SCI models.
  • 2. It is recommended that surgical decompression of the injured spinal cord be performed within 24 h when medically feasible. The optimal timing of surgical decompression, or whether surgery is indicated at all, in patients with a central cord injury remains unclear.
  • 3. There are clinical, neurological, and functional benefits of early decompression of the spinal cord.

Author Disclosure Statement

No conflicting financial interests exist.

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