"Early decompression (< 8 h) after traumatic cervical spinal cord injury improves functional outcome as assessed by Spinal Cord Independence Measure (SCIM) after 1 year"

Abstract

There is an ongoing controversy about the optimal timing for surgical decompression after acute traumatic cervical spinal cord injury (SCI). For this reason, we performed a retrospective study of patients who were operated on after traumatic cervical SCI at the Trauma Center Murnau, Germany and who met in- as well as exclusion criteria (n = 70 patients). Follow-up data was collected prospectively according to the European Multicenter Study about Spinal Cord Injury (EMSCI) protocol over a period of 1 year. Early decompression was defined as within the first 8 h after the insult (n = 35 patients). Primary outcome was the difference in the SCIM (Spinal Cord Independence Measure) 1 year after the trauma. After the follow-up period, patients who were decompressed earlier had a significantly higher SCIM difference (45.8 versus 27.1, p<0.005). A regression analysis showed that timing of decompression, age as well as basal AIS (American Spinal Injury Association Impairment Scale) and basal SCIM scores were independent predictors for a better functional outcome (SCIM). Furthermore, patients from the early decompression group had better AIS grades (p<0.006) and a higher AIS conversion rate (p<0.029). Additionally, this cohort also had a better total motor performance as well as upper extremity motor function after 1 year (p<0.025 and p<0.002). The motor and neurological levels of patients who were operated on within 8 h were significantly more caudal (p<0.003 and p<0.014) after 1 year. The present study suggests that early decompression after traumatic cervical SCI might have a positive impact on the functional and neurological outcome of affected individuals.

Full text

Early Decompression (<8 h) after Traumatic Cervical
Spinal Cord Injury Improves Functional Outcome
as Assessed by Spinal Cord Independence
Measure after One Year
Lukas Grassner,
1,2,3,6
Christof Wutte,
2
Barbara Klein,
3,6
Orpheus Mach,
1
Silvie Riesner,
1
Stephanie Panzer,
4,5
Matthias Vogel,
1
Volker Bu¨ hren,
1
Martin Strowitzki,
2
Jan Vastmans,
1
and Doris Maier
1
Abstract
There is an ongoing controversy about the optimal timing for surgical decompression after acute traumatic cervical spinal
cord injury (SCI). For this reason, we performed a retrospective study of patients who were operated on after traumatic
cervical SCI at the Trauma Center Murnau, Germany, and who met inclusion as well as exclusion criteria (n=70 patients).
Follow-up data were collected prospectively according to the European Multicenter Study about Spinal Cord Injury
(EMSCI) protocol over a period of 1 year. Early decompression was defined as within the first 8 h after the insult (n=35
patients). Primary outcome was the difference in the SCIM (Spinal Cord Independence Measure) 1 year after the trauma.
After the follow-up period, patients who were decompressed earlier had a significantly higher SCIM difference (45.8 vs.
27.1, p<0.005). A regression analysis showed that timing of decompression, age, as well as basal AIS (American Spinal
Injury Association Impairment Scale) and basal SCIM scores were independent predictors for a better functional outcome
(SCIM). Further, patients from the early decompression group had better AIS grades ( p<0.006) and a higher AIS
conversion rate ( p<0.029). Additionally, this cohort also had a better total motor performance as well as upper extremity
motor function after 1 year ( p<0.025 and p<0.002). The motor and neurological levels of patients who were operated on
within 8 h were significantly more caudal ( p<0.003 and p<0.014) after 1 year. The present study suggests that early
decompression after traumatic cervical SCI might have a positive impact on the functional and neurological outcome of
affected individuals.
Key words: cervical spine; decompression; outcome; spinal cord injury; spine surgery
Introduction
Traumatic insults to the spinal cord—especially within
the cervical spine—lead to devastating consequences for the
affected individual. Conceptually, the pathophysiology of trau-
matic spinal cord injury (SCI) is divided into two phases: (1) the
primary damage directly related to the contusion, dislocation, and
sustained compression of the spinal cord, which is followed by (2)
secondary mechanisms including inflammatory processes, edema
formation, spinal cord ischemia, and related events.
1,2
Approxi-
mately 50% of all spinal fractures are accompanied by a com-
pression of the spinal canal and the neural elements within.
3
There
is some evidence from animal studies that decompression of the
affected area ameliorates primary and secondary damage.
4,5
Also,
studies in human patients support this hypothesis by showing a
significant correlation between the duration of spinal cord nar-
rowing and final outcome.
6,7
For these reasons, an early decompression after traumatic cer-
vical SCI is recommended.
8
Early surgical intervention is espe-
cially needed under conditions in which the compression of the SCI
happens acutely, for example, traumatic disc herniation, burst
fractures, or intraspinal hemorrhages.
9
However, the optimal time
point for surgical decompression has been under debate for de-
cades. Especially in motor complete patients and in the early phase
after injury, the benefit of an early surgical intervention has been
questioned previously.
10,11
Two recent studies, however, showed
the advantageous effect of a surgical decompression within the first
24 h
12
or even earlier.
13
Both studies showed a positive effect of
1
Center for Spinal Cord Injuries,
2
Department of Neurosurgery,
4
Department of Radiology, Trauma Center Murnau, Germany.
3
Institute of Molecular Regenerative Medicine, Paracelsus Medical University, Austria.
5
Institute of Biomechanics, Trauma Center Murnau and Paracelsus Medical University Salzburg, Murnau, Germany.
6
Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University Salzburg, Austria.
JOURNAL OF NEUROTRAUMA 33:1–9 (2016)
ªMary Ann Liebert, Inc.
DOI: 10.1089/neu.2015.4325
1

early surgical decompression using the AIS grade (American
Spinal Injury Association Impairment Scale) as primary outcome
parameter.
12,13
Although the AIS scale is a useful tool for an overall
neurological assessment of different SCI grades, it fails to capture
the full spectrum of deficits within affected individuals.
For this reason, the Spinal Cord Independence Measure (SCIM)
has been established solely for SCI patients, as a global outcome
measurement tool assessing especially activities of daily living
(ADLs) and mobility tasks. The SCIM measures parameters, which
are crucial for the subjective well-being of the patients (e.g., res-
piration, bladder, and bowel management; the ability to take care of
basic needs such as food-intake, personal hygiene, and dressing;
and mobility at home and outdoors).
14
The SCIM score has been
validated for acute and chronic SCI as a reliable tool to measure
functional change in SCI patients over time.
15,16
For the present study, the SCIM was chosen as primary outcome
parameter to evaluate the effect of early surgical decompression—
here defined as within the first 8 h after injury—versus later time
points 1 year after the initial trauma. In addition, as secondary
parameters this study analyzed the effect of early surgical decom-
pression on the AIS grade as well as on the segmental change of the
motor, sensory, and neurological (a combination of both) level after
1 year.
Methods
Setting
We performed this study at the Trauma Center Murnau (Bavaria,
Germany)—a cross-regional level-1 trauma center with a special-
ized SCI department. The vast majority of all patients are admitted
on a non-selective basis.
Patients
This study is a retrospective analysis of data from SCI patients
who were admitted between July 2004 and July 2014 to the Trauma
Center Murnau. The clinical data were collected prospectively
within a fixed time schedule according to established standards at
the Trauma Center Murnau and the EMSCI project (European
Multicenter Study about Spinal Cord Injury). These data were in-
serted into the EMSCI database and are available there. The only
exception is data about perioperative complications and about
standardized intensive care, which were collected retrospectively
(based on hospital records) solely for the purpose of this study.
After analyzing the study protocol, the responsible ethics com-
mittee of the Bavarian Medical Board waived the requirement for
an ethical review (2016-003) for this study.
For a patient to be included into this study, a detailed neuro-
logical examination according to the ISNCSCI protocol (Interna-
tional Standards for Neurological Classification of Spinal Cord
Injury) in the very acute (day 1–15) and chronic phase (day 300–
400) after the trauma was necessary. If such an assessment was not
possible due to the condition of the patient, the examination ac-
cording to the ISCNSCI protocol was postponed until day 15–40
(acute phase I according to the EMSCI protocol). If the initial data
acquisition happened after this time-point, the dataset was excluded
from this study.
Patients were stratified into two groups according to decom-
pression time-points within the first 8 h after the incident ( =early
decompression) and thereafter ( =late decompression). For this
study, decompression time was defined as the time that elapsed
between the accident (according to the paramedic protocol) and the
skin incision (as noted in the surgical report). In this context, it is
important to note that all patients were operated on as soon as
possible. To ensure this, it is hospital policy that at all times at least
one trauma surgeon or neurosurgeon, capable of performing pro-
cedures on the cervical spine, be on duty.
From the EMSCI database, we obtained information about the
affected neurological, sensory, and motor level as well as the total
motor score (TMS) (range: 0–100), upper extremity motor score
(UEMS) (range: 0–50), and pin prick as well as light touch ex-
aminations (range 0–112). For the analysis of alterations in the
neurological level (motoric or sensory), only segments important
for upper extremity function were included in the study. This means
that the main focus was on the region between the second cervical
and the first thoracic level (C2–T1). Any improvement beyond this
region was not included.
Most importantly, the SCIM value (range: 0–100), a disability
measure that was especially developed for the functional assess-
ment of SCI patients,
14
was assessed at similar time-points. Until
December 2007, the SCIM-II
17
version was used, after that SCIM-
III was routinely used.
18
Both have the same total value and are
differing in minor subgroups. The differences between SCIM-II
and SCIM-III are summarized in Supplementary Table 1 (see on-
line supplementary material at http://www.liebertpub.com). Note-
worthy, the SCIM assessment of disability after 1 year is done in a
self-reported form, which has been validated.
18
The initial SCIM
investigation, however, is done by experts in SCI care.
18
To reduce potential confounding factors due to different surgical
treatment and perioperative care, we included only cases in which
surgical decompression and spinal instrumentation as well as the
subsequent acute treatment of the patient was done at our institu-
tion. However, patients who were initially examined at local hos-
pitals and then were transferred to our center for surgery and acute
SCI treatment were included in this study. In fact, this was the case
in the majority of patients in the ‘‘late decompression’’ group. For
detailed inclusion and exclusion criteria, please see Table 1.
For classification of injuries, we identified three main injury
patterns, which were assessed for each patient retrospectively.
These patterns were (1) injuries to the discoligamentous complex,
(2) burst/compression fractures, or (3) dislocations –fracture
(Table 2). Perioperative complications were stratified similarly to
previous suggestions.
13,19
After lifesaving interventions and the surgical procedure, the
patients received acute treatment at the intensive care unit. The
main goal during the acute phase after the injury is to stabilize
cardiopulmonary functions. If mechanical ventilation is needed, the
weaning process begins at the intensive care unit and proceeds
further in a specialized unit within the local center for spinal cord
injuries. During the study period, there was no standardized regi-
men for cardiovascular treatment (including blood pressure aug-
mentation). The establishment of a sufficient control of pulmonary,
Table 1. Eligibility Criteria
Inclusion criteria Exclusion criteria
Newly diagnosed traumatic
cervical spinal cord injury
Non-traumatic spinal cord injuries
Age ‡18 years Traumatic brain injury (GCS ‡13)
Adequate follow-up data
(including 1 year after
the injury) available
Polytrauma (e.g., life-threatening
injuries or extremity fractures
impairing neurological
examinations)
Initial GCS ‡14 Pre-existing major neurological
deficits
Initial neurological level
between C2 and T1
Pregnancy
Initial AIS grade A–D Central cord syndrome
GCS, Glasgow Coma Scale; C, cervical; T, thoracic; AIS, American
Spinal Injury Impairment Scale.
2 GRASSNER ET AL.

bowel, and bladder functions as well as early physiotherapy and
occupational therapy are other crucial elements of the rehabilitation
program, which, according to local hospital policy, should start as
soon as possible after SCI.
Radiological examination
Pre- and postoperative spinal canal compromise was assessed
via computed tomography (CT) or magnetic resonance imaging
(MRI) as previously suggested for acute traumatic SCI.
20
The in-
vestigator had no access to clinical data of the patients and was
blinded throughout the examination.
Statistical analysis
All statistical analyses were performed using SPSS Statistics
19 (IBM, New York) software. For analysis, SCI patients were
divided into two groups (early and late decompression) according
to the time that elapsed between injury and surgical decompres-
sion. Each variable was compared for differences between the two
groups. For continuous variables, either ttests or Mann-Whitney
U tests were used, depending on whether the data were normally
distributed or not (assessed by the Kolmogorov-Smirnov test).
Categorical variables (e.g., sex, AIS grade, administration of
methylprednisolone, or sensory, motoric, and neurological levels)
were compared using the chi-square (v
2
) and Fisher’s exact test.
Univariate correlation analyses were done using Spearman’s
ranked correlation. Variables that showed a significant effect in
univariate or bivariate analyses, as well as potentially confound-
ing patient characteristics, were tested as potential predictors of
differences in SCIM values within the 1-year follow-up period.
For this, we used stepwise multivariable regression for potential
predictor variables (early or late surgical decompression, age, sex,
cortisone treatment, baseline AIS score, and baseline SCIM
score), and eliminated non-significant variables ( p>0.05) in a
backwards fashion from the model. Additionally, we analyzed in a
bivariate logistic regression model if the decompression time
(early or late) was a predictor of whether or not an AIS conversion
was observed (i.e., if the AIS score increased for at least 1 score
point during the 1-year follow-up period; =model 1).
Next, we tested if the patients’ age and those variables that
significantly differed between the two decompression groups at
baseline (sex, sensory level, UEMS, and light touch) also were
predictors of AIS conversion using bivariate logistic regression and
a backward stepwise selection of variables with removal of non-
significant predictors based on the Wald test. The resulting best
model ( =model 2) only includes the decompression group as a
significant predictor and the baseline AIS grade (not significant). In
a third model, we did the same analysis and corrected additionally
for baseline patient characteristics (age and sex), even though these
variables also showed no significant effect on AIS conversion in the
final model 3.
Results
Study population
During the observation period, 70 patients (59 males) fulfilled
inclusion and exclusion criteria (Table 1). Out of this cohort, 35 (26
males) underwent surgical decompression within 8 h after the inci-
dent (mean: 04:22 h, standard deviation [SD]: 01:25 h, range: 02:14–
07:45 h; =‘‘early decompression’’ group). The remaining 35 patients
(33 males) were decompressed at later time-points (mean: 89:27 h,
SD: 106:29 h, r ange: 08:27 h–19 days; =‘‘late decompression’’
group). All patients were operated on as soon as possible. Reasons
for later surgical time-points were initial diagnosis and treatment at a
hospital not capable of performing spinal surgeries or the patient’s
wish to be transferred before surgery (usually if the accident hap-
pened abroad). Both groups received prospective follow-up exami-
nations for1 year according to the EMSCI protocol.
The injury categories for the whole cohort and both subgroups are
shown in Table 2. It is noteworthy that the types of injuries are equally
distributed between the two decompression groups (p<0.508).
The main goal of decompression surgery is the removal of os-
seous fragments, disc material, or hematomas, which compress the
spinal canal, followed by surgical stabilization of the spine. In
general, three potential surgical approaches are considered: (1)
anterior-only, (2) posterior-only, as well as (3) circumferential
approaches (one- or two-staged). In this study, all patients were
operated on via an anterior approach. The decision was based on the
judgment of the responsible surgeon after careful examination of all
options. In both groups, initial decompression was sufficient, as
indicated by postoperative tomographical imaging; therefore, no
patient had to be operated on again. Sixty percent (n=21) of pa-
tients underwent MRI prior to the surgery in the early decom-
pression group versus 65.7% (n=23) in the late decompression
group ( p<0.805). There was no case of fatality during the 1-year
observation period. We observed a total perioperative complication
rate of 11.4% (n=8) with an equal distribution between both groups
(n=4 per group; Table 2).
Regarding baseline and demographic characteristics (Table 3),
there were no significant differences in the mean age, administra-
tion of methylprednisolone, length of stay, baseline AIS grades,
preoperative spinal canal compromise, baseline neurological level,
initial motor level, TMS, pin prick, and baseline SCIM score.
Significant differences in baseline characteristics between both
groups were identified in gender distribution ( p<0.045), baseline
sensory level ( p<0.040), initial UEMS ( p<0.019), and light touch
values ( p<0.036). Patients from the early decompression group
tended to display higher UEMS and light touch scores as well as a
more caudal sensory level (Table 3).
Table 2. Categories of Injuries and Perioperative Complications
Overall
(n =70)
Early decompression
(n =35)
Late decompression
(n =35) Pvalue
Injury categories [n] (%) p <0.508
Injury to the discoligamentous complex 31 (44.3%) 13 (37.1%) 18 (51.4%)
Compression or burst fracture 22 (31.4%) 12 (34.3%) 10 (28.6%)
Dislocation –fracture 17 (24.3%) 10 (28.6%) 7 (20.0%)
Perioperative complications [n] (%) p <1.000
No complications 62 (88.6%) 31 (88.6%) 31 (88.6%)
Surgical site infection, wound dehiscence 3 (4.3%) 2 (5.7%) 1 (2.9%)
Implant failure 3 (4.3%) 1 (2.9%) 2 (5.7%)
Cardiovascular problems 2 (2.9%) 1 (2.9%) 1 (2.9%)
FUNCTIONAL OUTCOME AFTER SURGERY FOR CSCI 3

Neurological recovery and functional outcome
after 1 year
Follow-up examination was scheduled in the chronic phase after
SCI according to the EMSCI protocol (day 300–400 after the initial
trauma). Assessed outcome parameters are shown in Table 4. We
identified a significant difference in the AIS grade 1 year after
injury between both groups ( p<0.006) and significantly higher
AIS conversion rates in patients who were decompressed within the
first 8 h ( p<0.029). Figure 1 shows baseline AIS scores and their
development throughout the observation period for both cohorts
(early and late decompression surgery).
There were no differences between the two groups in the postop-
erative spinal canal compromise or in the change between pre- and
postoperative spinal canal compromise, as assessed by CT or MRI
scan, or in the results of sensory examinations (light touch and pin prick
score as well as sensory level). Significant differences were found
between the neurological ( p<0.014) and motor levels ( p<0.003),
which both were more caudal in the early decompression group after 1
year. However, the mean ordinal difference in the neurological and
motor levels between the first assessment (after the surgery) and 1 year
later were not significantly different between the two groups (Table 4).
Further, we found significant differences in the absolute TMS
(p<0.025) and UEMS score ( p<0.002), which both were higher in
the early decompression group after 1 year (Table 4). The differ-
ences in the TMS ( p<0.007) and UEMS ( p<0.008) between the
first and last examinations were significantly higher in the early
decompression group. We also identified a trend ( p<0.067) toward
higher SCIM scores after 1 year in the early decompression
group. However, the difference of the SCIM score between the first
assessment and the 1-year follow-up period was significantly
higher in the early decompression group ( p<0.005; Table 4).
Regression analysis
Based on the univariate analyses and patient characteristics,
variables (early or late surgical decompression, age, sex, admin-
istration of methylprednisolone, baseline AIS score, and baseline
SCIM score) were tested as potential predictors of change in SCIM
after 1 year. Not significant variables ( p>0.05) were eliminated in
a backwards fashion from the model. The best model for predicting
the difference in SCIM score after 1 year (R
2
: 0.513, F value:
17.115, p<0.001) contains the decompression group, basal AIS,
SCIM scores, and age as independent predictors and shows a sig-
nificant negative effect of the late decompression time-point on the
difference in SCIM score 1 year after SCI ( p<0.019; Table 5).
Further, we tested the predictive effect of early versus late surgical
decompression on AIS conversion(AIS score improvement of at least
1 grade after 1 year) in a bivariate logistic regression analysis without
adjustment (model 1), adjusted for basal AIS score (model 2), and for
age, sex, and basal AIS score (model 3). All three models show
significantly increased odds (unadjusted model 1: odds ration [OR]:
3.368, p<0.025; adjusted model 2: OR: 8.971, p<0.005; adjusted
model 3: OR: 8.816, p<0.006) for an AIS conversion in patients who
received an earlier surgical intervention (Table 6).
Discussion
This study investigates the potential beneficial effect of early
surgical decompression (i.e., within the first 8 h) compared with
later decompression times on the functional outcome after acute
traumatic cervical SCI. Functional outcome was first assessed post-
operatively in the acute phase after trauma and then again 1 year
after the incident using the SCIM scale
21
and ISCNSCI examina-
tion. To the best of our knowledge, this study is the first to analyze
Table 3. Baseline and Demographic Characteristics
Characteristics
Overall
(n=70)
Early decompression
(n=35)
Late decompression
(n=35) Pvalue
Mean age [years (SD)] 51.0 (17.3) 51.9 (16.4) 50.1 (18.2) p<0.660 n.s.
Sex [n(%)]
Male 59 (84.3%) 26 (74.3%) 33 (94.3%) p<0.045 *
Female 11 (15.7%) 9 (25.7%) 2 (5.7%)
NASCIS [n(%)] 30 (42.9%) 17 (48.6%) 13 (37.1%) p<0.469 n.s.
Mean length of stay [d (SD)] 127 (58) 125 (46) 129 (69) p<0.828 n.s.
Baseline AIS grade [n(%)] p<0.899 n.s.
A 31 (44.3%) 14 (40.0%) 17 (48.6%)
B 10 (14.3%) 5 (14.3%) 5 (14.3%)
C 5 (7.1%) 3 (8.6%) 2 (5.7%)
D 24 (34.3%) 13 (37.1%) 11 (31.4%)
E 0 (0.0%) 0 (0.0%) 0 (0.0%)
Pre-operative SCC [mean (SD)] 25.7 (17.6) 21.3 (17.0) 23.6 (17.4) p<0.304 n.s.
Baseline neurological level [median (IQR)] C4 (1 segment) C5 (1 segment) C4 (2 segments) p<0.146 n.s.
Baseline sensory level [median (IQR)] C4 (1.25 segments) C5 (2 segments) C4 (2 segments) p<0.040 *
Baseline motor level [median (IQR)] C5 (1 segment) C5 (2 segments) C4 (2 segments) p<0.214 n.s.
Baseline TMS [mean (SD)] 34.7 (30.7) 38.6 (27.6) 30.8 (33.0) p<0.101 n.s.
Baseline UEMS [mean (SD)] 18.3 (13.8) 21.9 (12.2) 14.7 (14.4) p<0.019 *
Baseline pin prick [mean (SD)] 42.1 (36.1) 44.8 (33.5) 39.5 (38.3) p<0.119 n.s.
Baseline light touch [mean (SD)] 52.3 (34.5) 59.0 (29.9) 45.7 (37.4) p<0.036 *
Baseline SCIM [mean (SD)] 11.4 (20.8) 8.5 (14.7) 14.4 (25.4) p<0.604 n.s.
AIS, American Spinal Injury Impairment Scale; C, cervical; d, days; IQR, interquartile range (expressed in number of spinal segments); NASCIS,
National Acute Spinal Cord Injury Study; n.s., not significant; SCC, spinal canal compromise (percent); SCIM, Spinal Cord Independence Measure; SD,
standard deviation; TMS, Total Motor Score; UEMS, Upper Extremity Motor Score.
*p£0.05; **p£0.001.
Statistically significant parameters are in bold.
4 GRASSNER ET AL.

Table 4. Outcome at 1-year Follow-up
Characteristics/Variable
Overall
(n=70)
Early decompression
(n=35)
Late decompression
(n=35) Pvalue
AIS grade after 1 year [n(%)] p<0.006 **
A 20 (26.6%) 4 (11.4%) 16 (45.7%)
B 9 (12.9%) 7 (20.0%) 2 (5.7%)
C 5 (7.1%) 3 (8.6%) 2 (5.7%)
D 35 (50.0%) 21 (60.0%) 14 (40.0%)
E 1 (1.4%) 0 (0.0%) 1 (2.9%)
AIS Conversion [n(%)] p<0.029 *
0 47 (67.1%) 19 (54.3%) 28 (80.0%)
1 14 (20.0%) 10 (28.6%) 4 (11.4%)
2 5 (7.1%) 2 (5.7%) 3 (8.6%)
3 4 (5.7%) 4 (11.4%) 0 (0.0%)
Post-operative SCC [mean (SD)] 7.2 (13.6) 7.8 (13.9) 6.6 (13.3) p<0.514 n.s.
Difference in SCC [mean (SD)] 16.0 (19.5) 18.0 (21.1) 14.1 (17.6) P<0.590 n.s.
Last neurological level [median (IQR)] C5 (2 segments) C6 (2 segments) C4 (3 segments) p<0.014 *
Difference neurological level [mean (SD)] 0.8 (1.6) 1.1 (1.6) 0.4 (1.6) p<0.270 n.s.
Last sensory level [median (IQR)] C5 (3 segments) C6 (3 segments) C4 (3 segments) p<0.083 n.s.
Difference sensory level [mean (SD)] 0.9 (2.3) 1.2 (2.3) 0.7 (2.1) p<0.320 n.s.
Last motor level [median (IQR)] C6 (3 segments) C6 (2 segments) C5 (3 segments) p<0.003 **
Difference motor level [mean (SD)] 1.2 (1.8) 1.7 (1.9) 0.7 (1.5) p<0.227 n.s.
Last TMS [mean (SD)] 55.4 (37.1) 65.6 (31.0) 45.2 (40.1) p<0.025 *
Difference TMS [mean (SD)] 20.8 (21.5) 27.1 (23.6) 14.6 (17.0) p<0.007 **
Last UEMS [mean (SD)] 30.8 (17.3) 37.8 (12.7) 23.7 (18.4) p<0.002 **
Difference UEMS [mean (SD)] 12.5 (11.6) 15.9 (11.4) 9.1 (10.8) p<0.008 **
Last pin prick score [mean (SD)] 58.8 (36.6) 63.8 (31.0) 53.7 (41.5) p<0.173
Difference pin prick score [mean (SD)] 16.0 (29.9) 19.1 (32.6) 12.9 (26.5) p<0.452 n.s.
Last light touch score [mean (SD)] 68.3 (34.1) 76.1 (26.8) 60.3 (39.1) p<0.075 n.s.
Difference light touch score [mean (SD)] 14.3 (24.0) 17.1 (24.0) 11.5 (22.0) p<0.312 n.s.
Last SCIM score [mean (SD)] 47.9 (37.4) 54.3 (36.4) 41.5 (37.8) p<0.067 n.s.
Difference SCIM score [mean (SD)] 36.5 (30.3) 45.8 (30.5) 27.1 (27.1) p<0.005 **
AIS, American Spinal Injury Impairment Scale; C, cervical; d, days; IQR, interquartile range (expressed in number of spinal segments); NASCIS,
National Acute Spinal Cord Injury Study; n.s., not significant; SCC, spinal canal compromise (percent); SCIM, Spinal Cord Independence Measure; SD,
standard deviation; TMS, Total Motor Score; UEMS, Upper Extremity Motor Score.
*p£0.05; **p£0.001.
Statistically significant parameters are in bold.
FIG. 1. Baseline and follow-up AIS. Baseline (A) and follow-up (B) numerical AIS grades in patients who were surgically de-
compressed at early (<8 h) or at later time-points. (C) The ordinal AIS change after 1 year of both groups (early and late surgical
decompression). Tabularization of A–C is provided in D and E. AIS, American Spinal Injury Impairment Scale.
5

the effect of surgical timing after cervical SCI on the SCIM. In
accordance with our hypothesis that earlier surgical decompression
is advantageous, we found a significantly higher SCIM difference
(45.8 vs. 27.1, p<0.005) after 1 year in patients who underwent
surgical decompression and spinal fusion with the first 8 h after the
trauma. Further, the ‘‘early decompression’’ group also showed
better AIS grades ( p<0.006) and a higher AIS conversion rate
(p<0.029). Additionally, total motor performance ( p<0.025) and
upper extremity motor function ( p<0.002) were better in this
group after 1 year.
Further, we investigated if early or delayed surgical decom-
pression affects the function of the spinal cord also on a segmental
level. For this reason, we included only patients with cervical
trauma, because in these patients clinical examinations are more
sensitive to segmental changes over time. Moreover, gain or loss of
one or two segments of medullary function may have a tremendous
impact on the quality of life for the affected individual. For tetra-
plegics, regaining arm or hand function remains the highest priority
according to a published survey.
22
Robust pre-clinical data indicate that neurological impairment is
related to the time in which the spinal cord is exposed to pressure
and to the degree of spinal canal narrowing.
4
Compressive pressure
of around 30–35 mm Hg—as seen in clinically complete traumatic
spinal cord injuries
23
—leads to significant deficits after 2–6 h and
to severe paraparesis after 8–12 h in rodent models.
24,25
However, a
direct comparison of the effect of decompression time on tissue
damage between mice and humans is difficult. It is noteworthy that
ischemia is an essential part of the pathophysiology of SCI.
26
Cerebrovascular research (e.g., in stroke) indicates that in human
patients the therapeutic effect is strongly time-dependent and that
the optimal therapeutic window—as assessed in rodent models—
might be multiplied by the factor of 2–3.
27,28
Taken together, these data indicate that a surgical decompres-
sion after SCI (even earlier than 24 h) might have additional benefit.
We propose that an intervention before 8 h after acute traumatic
SCI could be a realistic goal and that this early treatment might
improve the therapeutic effect and, thus, functional outcome. For
these reasons, we set the threshold between early and late surgery at
8 h for the purpose of this study. As already discussed in the liter-
ature, an adequate health care system with prompt pre-hospital
emergency services could allow surgery at early time-points after
SCI.
29
It has been shown that if patients are immediately trans-
ported to an adequate trauma center, the vast majority reach the
hospital within 4 h, thus 8 h until surgical decompression could be
realistic in the Western world.
30
Interestingly, a new study under-
taken in the United States points out that the majority of the time
loss until surgery occurs after inpatient admission.
31
Strategies to
counteract these issues are highly needed.
In our cohort, surgical decompression was done as soon as pos-
sible (with specialized surgeons available around the clock). The
reason for the delay of surgery was, most of the time, first admission
to an institution not capable of performing the necessary procedures.
Of the patients who came directly to our center, only three were not
decompressed within the first 8 h. These delays were always due to
hold-ups in transportation and pre-hospital management. It should be
noted, however, that polytraumatized patients with concomitant
cervical spine injuries, who sometimes need postponement of sur-
gical management, were excluded from this study.
In our cohort, patients who underwent decompression earlier
showed a significantly higher gain in TMS (27.1–23.6 vs.
14.6 –17.0, p<0.007) and, additionally, in UEMS values
(15.9 –11.4 vs. 9.1 –10.8, p<0.008; Table 4). The minimal detect-
able difference plus the minimal clinically important difference is
suggested as an approximate 10-point increase in the UEMS.
21
However, as noted in the same article,
21
the segmental distribution of
the motor gain is probably more relevant for the patient than the
absolute value. In our cohort, the initial motor levels did not differ
between both groups, but were significantly more caudal in the early
decompression group after 1 year ( p<0.003). This indicates a
beneficial effect of early surgical intervention on the motor perfor-
mance and the segmental motor outcome for the affected patients. In
addition to this, patients from the early decompression groupshowed
a significantly more caudal neurological level (=combination of
motor and sensory level) after 1 year (p<0.014).
The SCIM scale is a global outcome measurement tool to assess
the capability of SCI patients to perform ADLs.
14,32
Our study
Table 5. Predictors of Differences in the SCIM Score after 1Year
Dependent variable
Predictor
variables Pvalue
Beta coefficients
(standardized)
B coefficients
(95% CI)
Difference in SCIM after 1 year Basal AIS 0.001 0.760 17.208 (12.393, 22.317)
Basal SCIM 0.005 -0.308 -0.450 (-0.759, -0.142)
Age 0.002 -0.290 -0.506 (-0.817, -0.196)
Early vs. late
decompression
0.019 -0.215 -13.042 (-23.836, -2.248)
AIS, American Spinal Injury Impairment Scale; CI, confidence interval; SCIM, Spinal Cord Independence Measure.
Table 6. Predictive Value of Surgical Timing for AIS Conversion
Dependent variable Model Predictor variables Pvalue Odds ratio CI (95%)
AIS conversion (at least
1 grade) after 1 year
1: unadjusted Early vs. late decompression 0.025 3.368 1.164, 9.744
2: adjusted for basal AIS score Early vs. late decompression 0.005 8.971 1.935, 41.597
3: adjusted for basal AIS score,
age, and sex
Early vs. late decompression 0.006 8.816 1.846, 42.055
AIS, American Spinal Injury Impairment Scale; CI, confidence interval.
6 GRASSNER ET AL.

shows a remarkable increase of the total SCIM value within the
follow-up period regardless of the decompression time. However,
patients who were operated on earlier showed a significantly higher
gain in the SCIM score compared with the other individuals
(45.8 –30.5 vs. 27.1 –27.1; Table 4). Although an increase of 10
points within the SCIM scale has been defined as a substantial
improvement, a minimal clinically important difference still needs
to be established.
21,33
As shown in Table 5, the initial AIS grade,
basal SCIM, age, and early or late decompression time are signif-
icant and independent predictors of a better functional outcome—
as assessed by the SCIM score—after 1 year. It should be noted,
however, that in our cohort two different versions of the SCIM
score were used (until December 2007 SCIM-II
17
and after that
SCIM-III
18
). Because these version differ only slightly in the dis-
tribution of the score points (see Supplementary Table 1 online at
http://www.liebertpub.com), we decided not to distinguish between
these two SCIM versions in our study.
Routine administration of methylprednisolone has not been
performed at our institution for several years. Nevertheless, sev-
eral patients of our cohort received methylprednisolone, espe-
cially during the early phase of the study. Interestingly,
methylprednisolone treatment according to the NASCIS scheme
(National Acute Spinal Cord Injury Study)
34
hadnosignificant
effect on the improvement of the AIS score; however, univariate
analysis showed a significant correlation between a received
cortisone treatment and an improvement in SCIM score 1 year
after SCI (correlation coefficient: 0.271, p<0.023). If we divide
our cohort according to whether the patients received cortisone
treatment or not, the difference in SCIM after 1 year is signifi-
cantly higher in patients who received methylprednisolone
(p<0.025). There was no significant correlation between the pre-
or post-operative spinal canal compromise and any of the other
analyzed variables. Because our center also performs early re-
habilitation measures after the acute surgical management, our
patient cohort had a relatively long length of stay (mean: 127 days
–58 days) compared with other studies.
13,35
Patients with acute traumatic central cord syndrome were ex-
cluded from this study, because this patient cohort usually consists
of older patients with more pre-existing co-morbidities and an al-
tered pathophysiology. However, this patient cohort is increasing
steadily over the last decades. The optimal time-point for surgical
management in these patients is under vigorous debate
36
as delayed
surgery has been shown to reduce mortality.
37
In contrast to other studies, the neurological ISNCSCI exami-
nations were performed strictly post-operatively (according to the
very acute or acute I phase of the EMSCI protocol). Most of the
delay (i.e., examination in the acute I phase) occurred due to the
fact that it is not possible to perform adequate neurological ex-
aminations in intubated and/or sedated patients. This circum-
stance weakens the comparability of our results to other studies,
in which the examination occurred preoperatively.
12,13
In our
study cohort, some recovery may have already occurred post-
operatively before the examination was performed for the first
time. This might explain the higher proportion of patients who did
not convert to a higher AIS grade compared with other stud-
ies.
12,13
Nevertheless, when we tested in our cohort the predictive
value of timing of surgical decompression for higher AIS con-
version via a bivariate logistic regression model, early decom-
pression was favored in all three models (unadjusted: p<0.025;
adjusted for basal AIS grade: p<0.005; and adjusted for basal AIS
grade, age, and sex: p<0.006) with high ORs (unadjusted: 3.368;
adjusted for basal AIS grade: 8.971; and adjusted for basal AIS
grade, age, and sex: 8.816; Table 5).
Because we focused on the investigation of segmental and func-
tional improvement, we also included patients with AIS D, who in
general have a low likelihood to convert to AIS E ( =no neurological
impairment). Despite this inclusion of higher initial AIS grades, the
AIS grades after 1 year were significantly different between both
cohorts, again favoring early decompression (Table 4). Also, a multi-
variate regression analysis of the predictive effect of early or late
decompression times on AIS conversion (i.e., an increase of AIS
score of at least 1) showed that late decompression has a negative
effect on conversion of AIS grade 1 year after SCI (Table 5).
When interpreting the results of this study, some limitations need
to be acknowledged. First, we have only included patients who
were treated at our institution in order to minimize potential con-
founding factors within our cohort group. However, because study
data were collected only at one center, it is more difficult to ex-
trapolate our results to other hospitals and settings. Furthermore,
we performed a retrospective study, which per se carries the dis-
advantage of missing values and exclusion of patients due to in-
complete datasets. The small number of patients is a further
limitation of our study. Therefore, prospective multi-center trials
such as the SCI-POEM study (Prospective, Observational Euro-
pean Multicenter study on the efficacy of acute decompression after
traumatic spinal cord injury)
38
will most likely deliver additional
valuable data regarding the optimal time-point of surgical de-
compression after SCI. However, a true randomized controlled trial
seems to be ethically challenging, as this study and others clearly
favor ‘‘early’’ decompression.
12,13,35
Although early decompression seems to show a beneficial effect
on functional outcome, there is still a significant amount of patients
with only minimal recovery. Therefore, research regarding addi-
tional benefit of interventions/treatment measurements such as
hypothermia,
39
expansion duroplasty,
40
and pharmacological
agents such as glibenclamide, riluzole, or minocycline
41–44
needs
to be further evaluated and may be implemented in patient care.
In conclusion, this study shows that early surgical intervention
after cervical traumatic SCI may lead to a better functional outcome
of affected individuals (SCIM and AIS scores). This is most likely
mediated by an improvement of the neurological outcome, pre-
sumably on the segmental level.
FIG. 2. SCIM change after 1 year. The difference in the SCIM score
between the first and last evaluation is shown for both groups (early and
late surgical decompression). SCIM, Spinal Cord Independence
Measure; S.E.M., Standard Error of the Mean.
**p£0.001.
FUNCTIONAL OUTCOME AFTER SURGERY FOR CSCI 7

Acknowledgments
The authors thank all colleagues at the Trauma Center Murnau
who were involved in patient care.
Author Disclosure Statement
No competing financial interests.
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Address correspondence to:
Lukas Grassner, MD
Center for Spinal Cord Injuries
Trauma Center Murnau
Prof. Ku
¨ntscherStraße 8
82418 Murnau, Germany
E-mail: lukas.grassner@googlemail.com
FUNCTIONAL OUTCOME AFTER SURGERY FOR CSCI 9