Original Article
Results of Early and Late Surgical Decompression and Stabilization for Acute
Traumatic Cervical Spinal Cord Injury in Patients with Concomitant Chest Injuries
Mathew David Sewell, Kathak Vachhani, Asif Alrawi, Richard Williams
- BACKGROUND: The benefits of early surgical decom-
pression and stabilisation (within 24 hours of injury) for
patients with acute traumatic spinal cord injury (SCI) is
unclear. The study objective was to investigate the effects
of early (<24 hours of injury) versus late (>24 hours of
injury) decompressive and stabilisation surgery for trau-
matic cervical SCI in patients with concomitant chest
injuries.
- METHODS: This was a retrospective study including
adults aged 16 years or over with traumatic cervical SCI,
Glasgow Coma Scale score >13, and concomitant chest
injuries (e.g. hemopneumothoraces, flail chest and pulmo-
nary contusions) necessitating intensive care unit (ICU)
admission. Forty patients who met the inclusion criteria
and underwent decompressive surgery within 24 hours
were compared with 55 patients who underwent decom-
pressive surgery after 24 hours. Primary outcomes were
ordinal change in the ASIA Impairment Scale (AIS) at 6
months and duration of ICU stay. Secondary outcomes
included complications occurring within 30 days.
- RESULTS: In the early surgery group, 21 patients (52.5%)
showed no improvement in ASIA grade, 13 (32.5%) had a
1-grade improvement, and 6 (15%) had a 2-grade improve-
ment. The median length of ICU stay was 14 days (range,
2e68). 42.5% of patients developed a complication and 45%
required a tracheostomy. In the late surgery group, AIS
grade improvement was as follows: 32 (58%) no improve-
ment, 19 (34.5%) had a 1 grade improvement, 3 (5.5%) had a
2 grade improvement and 1 (2%) had a 3 grade
Key words
- Cervical
- Chest
- Rehabilitation
- Spinal cord injury
- Surgery
- Trauma
Abbreviations and Acronyms
AIS: American Spinal Injury Association Impairment Scale
ASA: American Society of Anesthesiologists
ASIA: American Spinal Injury Association
CI: Confidence interval
ICU: Intensive care unit
WORLD NEUROSURGERY -: e1-e5, - 2018
improvement. Mean ICU stay was 23 days (4e68). 53% of
patients developed a complication and 55% required a
tracheostomy. There was one mortality in the late surgery
group.
- CONCLUSIONS: For patients with acute traumatic cer-
vical SCI and concomitant chest trauma, early surgical
decompression and stabilisation was associated with
reduced ICU stay and a lower complication rate. Neuro-
logical recovery was more likely in younger patients and
those with an incomplete SCI.
INTRODUCTION
T he prevalence of traumatic spinal cord injury (SCI) is esti-
mated as 750 per million population.1 Acute trauma to the
spinal cord results in irreversible primary neurologic
injury, after which a series of complex pathophysiological
processes (inflammation, ischemia, and excitotoxicity) contribute
to preventable secondary damage.2 Neuroprotective strategies are
targeted at minimizing secondary injury in the surrounding
penumbra.
There is universal agreement that prevention of hypoxia and
hypotension in the ischemic penumbra is important.3-6 The
American Association of Neurological Surgeons has published a
level III recommendation suggesting that target mean arterial
blood pressures be maintained between 85 and 90 mmHg for the
first 7 days in patients with acute SCI.7 Historically, steroids have
been used as secondary prevention, but they have fallen out of
favor owing to inconsistent evidence of benefit and potential for
OR: Odds ratio
SCI: Spinal cord injury
Spinal Unit, James Cook University Hospital, Middlesbrough TS43BW, United Kingdom
To whom correspondence should be addressed: Mathew David Sewell, M.D.(Res).
[E-mail: matbuzz1@hotmail.com]
Citation: World Neurosurg. (2018).
https://doi.org/10.1016/j.wneu.2018.06.146
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org e1
 ORIGINAL ARTICLE
MATHEW DAVID SEWELL ET AL. SURGICAL DECOMPRESSION AND STABILIZATION FOR ACUTE TRAUMATIC CERVICAL SCI WITH CONCOMITANT CHEST INJURY

harm.8 The role and timing of decompressive surgery are

controversial. Table 1. Patient Demographic and Injury Characteristics
In animal models of SCI, surgical decompression has been Early Surgery Late Surgery
shown to lessen the severity of neurologic injury.9-12 However, Characteristic Group (n [ 40) Group (n [ 55)
these findings have not been consistently reproduced in human
studies, and the role and timing of decompressive surgery remain Number of patients 40 55
topics of debate. With early surgery defined as within 72 hours, 1 Males:females, number 27:13 36:19
randomized trial and several prospective studies have shown no
Age (years), median (range) 42 (16e78) 46 (18e83)
clear benefit for early decompression.13-15 However, the Spine
Trauma Study Group now defines early surgery as within 24 hours Time from injury to surgery 18 (8e24) 73 (25e504)
of injury.16 With this new definition, 1 multicenter prospective (hours), median (range)
observational study showed a trend toward improved neurologic Mechanism of injury, number (%)
outcomes in patients with traumatic cervical SCI who underwent Road traffic accident 24 (60) 31 (56)
early decompressive surgery (within 24 hours).17
When cervical SCI is combined with chest injuries, the impaired Fall 14 (35) 22 (40)
oxygenation and/or ventilation may worsen secondary injury to the Assault 2 (5) 2 (4)
spinal cord, reducing the likelihood of neurologic recovery; how- Cervical cord injury, number (%)
ever, early surgery still may confer a clinical benefit by facilitating
C1eC3 3 (7.5) 8 (14.5)
intensive care unit (ICU) management. The objective of this study
was to investigate the effects of early (<24 hours of injury) versus C3eC6 28 (70) 34 (62)
late (>24 hours of injury) decompressive and stabilization surgery C6eT1 9 (22.5) 13 (23.5)
for traumatic cervical SCI in patients with concomitant chest
Chest injury, number (%)
injuries. The primary outcomes were ordinal change in American
Spinal Injury Association (ASIA) Impairment Scale (AIS) at Pulmonary contusions 30 (75) 35 (64)
6 months and ICU stay. Secondary outcomes included complica- Hemopneumothorax 8 (20) 17 (31)
tions within 30 days.
Pneumothorax 2 (5) 3 (5)
Baseline AIS grade, number (%)
METHODS
A 11 (27.5) 17 (31)
This was a retrospective observational review of 95 patients with
B 17 (42.5) 19 (35)
acute, traumatic cervical SCI and associated chest injuries treated
at 3 SCI trauma centers between 2010 and 2017. We included C 7 (17.5) 10 (18)
adults age
16 years with traumatic cervical SCI, Glasgow Coma D 5 (12.5) 9 (16)
Scale score >13, and concomitant chest injury necessitating ICU
E 0 (0) 0 (0)
admission. We defined chest injuries as injuries sustained during
the trauma that affected lung ventilation and/or oxygenation AIS grade at 6 months, number
capacity. These included hemothorax, pneumothorax, and/or (%)
pulmonary contusions with or without flail chest. Rib fractures A 9 (22.5) 11 (20)
without underlying pulmonary contusion were not considered a B 6 (15) 14 (26)
chest injury. There were 63 males and 32 females, with a median
C 11 (27.5) 11 (20)
age of 45 years (range, 16e83 years). Forty patients who underwent
decompression and stabilization within 24 hours of injury were D 13 (32.5) 15 (28)
compared with 55 patients who underwent surgery after 24 hours. E 1 (2.5) 3 (6) (1 deceased)
Demographic data for the patients in the 2 groups are presented in
ASA grade, number (%)
Table 1.
The decision to perform surgery and type of surgery performed 1 29 (72.5) 36 (65.5)
(anterior vs. posterior decompression/number of levels stabilized) 2 9 (22.5) 16 (29)
was based on the judgment of the treating spinal surgeon. The
3 2 (5) 3 (5.5)
timing of surgery was also dependent on the surgeon’s judgment
and reflected transfer time to the hospital, experience, need for ASI, American Spinal Injury Association Impairment Scale; ASA, American Society of
further investigations, need to treat associated injuries, and Anesthesiologists.
theatre availability.
Preoperatively, all patients underwent a neurologic examination
in accordance with ASIA standards to determine a neurologic level For each patient, we collected data on age, sex, level of cervical
of injury and overall AIS grade. A second ASIA assessment was injury, American Society of Anesthesiologists (ASA) grade, time
performed at 6 months. All patients underwent radiography and/ from injury to surgery, mechanism of injury, and type of chest
or computed tomography of the cervical spine and magnetic injury. The primary outcomes were an ordinal change in AIS grade
resonance imaging to confirm the presence of SCI. at 6 months and duration of ICU stay. Secondary outcomes

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MATHEW DAVID SEWELL ET AL. SURGICAL DECOMPRESSION AND STABILIZATION FOR ACUTE TRAUMATIC CERVICAL SCI WITH CONCOMITANT CHEST INJURY
Figure 1. Baseline American Spinal Injury Association Impairment Scale grades for patients in the 2 study groups.
included complications within 30 days and requirement for tra-
cheostomy. An Ethics Board review classified this study as a ser-
vice evaluation because it involved an observational retrospective
review of routinely collected data with no experimental group.
Statistical Analysis
Baseline differences in demographics and injury characteristics
between groups were compared using the t test for continuous
data and the Fisher exact test, c2 test, or ManneWhitney U test for
categorical and ordinal data. A P value <0.05 was considered
significant. Multinomial logistic regression was performed to
evaluate the relation between neurologic change and the time of
surgery. The dependent variable was AIS improvement from time
of injury to 6 months, and the independent variable was the group
(early vs. late surgery). Predictor variables included age, sex,
presence of complications, tracheostomy, cervical injury level, type
of chest injury, complete (AIS grade A) or incomplete (AIS grade
BeD) SCI at the time of injury and baseline AIS grade. A backward
stepwise elimination was performed to exclude variables with
P > 0.05.
RESULTS
Baseline Differences Between Groups
At the start of the study, there was no statistical difference be-
tween the 2 groups with respect to age (P ¼ 0.5), sex (P ¼ 0.6),
level of cervical injury (C1eC3, C3eC6, C6eT1) (P ¼ 0.7), AIS
grade at presentation (P ¼ 0.9), etiology of spinal cord injury
(P ¼ 0.9), ASA grade (P ¼ 0.7), and type of chest trauma (P ¼0.3).
The mean time to surgery was 18 hours (range, 8e24 hours) in
the early surgery group and 73 hours (range, 25e504 hours) in the
late surgery group. There was 1 death within 30 days in the late
surgery group.
WORLD NEUROSURGERY -: e1-e5, - 2018
ORIGINAL ARTICLE
Neurologic Changes at 6 Months
Table 1 presents baseline and 6-month AIS grades for patients in
the 2 groups. Figure 1 shows baseline AIS grades, and Figure 2
shows the AIS grade changes at 6 months in the 2 groups.
In the early surgery group, 19 patients demonstrated neurologic
improvement (47.5%), including 13 with a 1-grade improvement
(32.5%) and 6 with a 2-grade improvement (15%). In the late
surgery group, 23 patients had neurologic improvement (42%),
including 19 with a 1-grade improvement (34.5%), 3 with a 2-grade
improvement (5.5%), and 1 (2%) with a 3-grade improvement.
There was no significant difference in the proportion of patients
experiencing neurologic improvement between the early and late
surgery groups overall (P ¼ 0.3), by 1 grade (P ¼ 0.78), or by at
least 2 grades (P ¼ 0.24) independently. Multinomial logistic
regression for early versus late surgery showed that younger age
(odds ratio [OR], 0.952; 95% confidence interval [CI], 0.92e0.99;
P < 0.01) and incomplete SCI (grade ASIA A vs. grade BeD; OR,
14.9, 95% CI, 3.1e72.4; P < 0.01) were significantly associated
with neurologic improvement by 1 grade at 6 months. Perfor-
mance of tracheostomy demonstrated a strong correlational trend
with 1 grade improvement (OR, 3.3; 95% CI, 0.93e11.4; P ¼ 0.07).
Age was the sole significant predictor for achieving at least a
2-grade improvement (OR, 0.92; 95% CI, 0.87e0.99; P ¼ 0.02).
Length of ICU Stay
In the early surgery group, the mean length of ICU stay was
14 days (range, 2e68 days). In the late surgery group, the mean
length of ICU stay was significantly greater at 23 days (range, 4e68
days) (P ¼ 0.013).
Complications and Tracheostomy
Complications developed in 17 patients (42.5%) in the early sur-
gery group and 29 patients (53%) in the late surgery group
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MATHEW DAVID SEWELL ET AL. SURGICAL DECOMPRESSION AND STABILIZATION FOR ACUTE TRAUMATIC CERVICAL SCI WITH CONCOMITANT CHEST INJURY
Figure 2. American Spinal Injury Association Impairment Scale grade
improvement at 6 months for patients in the 2 study groups.
(Table 2). One death occurred in the late surgery group. Eighteen
patients (45%) required a tracheostomy in the early surgery group,
compared with 30 patients (55%) in the late surgery group
(P ¼ 0.32).
DISCUSSION
This study demonstrates that for patients with acute traumatic
cervical SCI and concomitant chest trauma, early surgical
decompression and stabilization were associated with reduced
ICU stay and a lower rate of complications. Neurologic recovery
was more likely in younger patients and those with an incomplete
SCI. We found no correlation between early surgery and neuro-
logic improvement.
In a systematic review published in 2017, the authors advised
that “early surgery be offered as an option for adult acute SCI
patients regardless of level,” although they acknowledged that this
recommendation was based on low-quality evidence.18 There
remains significant debate on the benefits of early surgical
decompression for patients with acute traumatic SCI. In the
2012 STASCIS study, the largest prospective multicenter trial
undertaken to date, the authors found a significant increase in
the proportion of patients improving by at least 2 AIS grades in
those undergoing early surgery with no apparent increase in
surgical risk.17 There was no statistical change in those
improving by 1 AIS grade. The study involved patients with SCI
from all causes (chest trauma and no chest trauma).
We chose to examine a subset of SCI patients with concomitant
chest trauma, believing that these patients may benefit clinically
from early surgery. We did not find a statistical benefit favoring
neurologic recovery in those undergoing early surgery, but did
note a trend toward improved recovery with early surgery, partic-
ularly in patients experiencing a
2-grade AIS improvement (15%
for early surgery vs. 7.5% for late surgery). Multinomial logistic
regression identified younger age (P < 0.01) and incomplete SCI
(P < 0.01) as more important factors favoring neurologic
improvement at 6 months. The lack of statistical significance may
reflect type II error owing to the small sample of a specialized
group of patients with SCI and concomitant chest injury. However,
it also might reflect the fact that these patients would be at greater
e4 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2018.06.146
ORIGINAL ARTICLE
Table 2. Complications Within the First 30 Days
Early Surgery Late Surgery Group
Group (n [ 40), (n [ 55), Number
Complication Number (%) (%)
Patients with complications 17 (42.5) 29 (53)
Cardiorespiratory complications 17 (42.5) 25 (45)
(e.g., ventilator-associated
pneumonia)
Pressure sores 4 (10) 7 (13)
Pulmonary embolus 1 (2.5) 2 (4)
Fixation failure 1 (2.5) 1 (2)
Wound infection 2 (5) 3 (5)
Mortality 0 (0) 1 (2)
risk of compromised ventilation and/or oxygenation to major or-
gans and the spinal cord, which could predispose them to sec-
ondary SCI and limit their potential for neurologic recovery.
We found a reduced length of ICU stay, a lower rate of tra-
cheostomy, and a lower rate of complications in the early surgery
group. Lubelski et al.19 reported similar findings of reduced total
ICU days and fewer complications in polytrauma patients with
cervical and thoracic injuries treated with early spinal
stabilization within 36 hours. In our study, ventilator-associated
pneumonia was a significant problem in both groups, and a
high rate of cardiorespiratory complications should be expected
when patients present with SCI and chest trauma. Early surgery to
create a stable neck enables medical staff to more confidently care
for patients in positions favorable for chest management.
This study has several limitations of note. As a retrospective
observational study tracking 2 groups of patients, one group un-
dergoing early surgery (<24 hours) and the other group under-
going delayed surgery (>24 hours), it was subject to confounding
and bias. We did not perform a power analysis because this is a
rare group of patients, and we wished to assess all patients willing
to be included in the study within the time frame. Type 2 error
may explain the lack of statistical difference for those patients
experiencing a
2-grade AIS improvement. Our analysis did not
show any significant differences in baseline characteristics be-
tween the 2 groups; however, compared with the patients in the
late surgery group, those in the early surgery group tended to be
younger, to have better ASA grades, and to be more likely to have
incomplete injuries. The decision to perform early or late surgery
was at the discretion of the surgeon, based on such factors as
experience, theatre availability, transfer times, need for further
investigation, and need to treat associated injuries. This intro-
duced selection bias. We did not analyze the degree of physio-
logical pulmonary derangement from the chest injury, which
would confound ICU stay and potentially bias division of patients
into early and late surgery groups. There was wide variation in the
time to surgery for patients in the delayed surgery group, which
also may have conferred selection bias.
We excluded patients with head injuries (Glasgow Coma Scale
score 13) to improve the accuracy of preoperative ASIA scores.
 ORIGINAL ARTICLE
MATHEW DAVID SEWELL ET AL. SURGICAL DECOMPRESSION AND STABILIZATION FOR ACUTE TRAUMATIC CERVICAL SCI WITH CONCOMITANT CHEST INJURY

However, a proportion of patients would be in spinal shock during
initial assessment, possibly leading to misrepresentation of the
preoperative ASIA score, favoring a worse preoperative deficit.
This may explain why we observed an apparent high rate of
neurologic recovery in patients sustaining these injuries. The
modern definition of spinal shock includes a physiological spec-
trum consisting of 4 stages, commencing after injury and poten-
tially lasting up to 12 months.20 This may confound neurologic
changes observed in patients at 6 months. Randomized trials
are difficult to perform in this setting, because surgeons may
consider it unethical to delay decompressive surgery for patients
with deteriorating neurology, and a large proportion of SCI
patients cannot undergo surgery within 24 hours of injury owing
to transport issues and the need to provide alternative life-saving
treatment.21
CONCLUSIONS
The objective of this study was to investigate the effects of early
(<24 hours of injury) versus late (>24 hours of injury) decom-
pressive and stabilization surgery for traumatic cervical SCI in
patients with concomitant chest injuries. We found that early
surgery was associated with reduced length of ICU stay and a
lower rate of complications, but not with neurologic recovery.
Neurologic recovery was more likely in younger patients and those
with an incomplete SCI.

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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 13 September 2017; accepted 4 June 2018
Citation: World Neurosurg. (2018).
https://doi.org/10.1016/j.wneu.2018.06.146
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2018 Elsevier Inc. All
rights reserved.

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